back to basics, 2008 population health (2): clinical presentations

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Back to Basics, 2008POPULATION HEALTH (2):

CLINICAL PRESENTATIONSN Birkett, MD

Epidemiology & Community Medicine

Based on slides prepared by Dr. R. Spasoff

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THE PLAN(2)

• About 1.5-2 hours of lectures

• Review MCQs for 60 minutes

• A 10 minute break about half-way through

• You can interrupt for questions, etc. if things aren’t clear

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THE PLAN (4)

• Session 2 (April 18)– Clinical Presentations

• Periodic Health Examination– More in session after this one (Dr. Wooltorton)– Focus here is on key conditions, risks and general issues

• Immunization• Occupational Health• Health of Special Populations• Disease Prevention• Determinants of Health• Environmental health

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077 PERIODIC HEALTH EXAMINATION (1)

• “Determine patient’s risks for common gender/age specific conditions”

• This would involve knowing something about prevalence of condition, as well as patient’s risk factors for it.

• Objectives identify certain common conditions for each age group

• Use periodic health exam for health promotion/disease prevention interventions.

• Case-finding and screening for disease & risky behaviours

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Conditions identified by MCCas examples (1)

• Infant/Toddler <3 years– Delayed growth & development– Abuse/neglect

• Child 3-12 years– Vision/hearing defect– “Accidents”– Delayed development– Abuse/neglect

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Conditions identified by MCC (2)

• Youth 13-24 years– MVA– Substance abuse– STDs– Contraception– Sedentary lifestyle– Female: rubella/HPV immunization– Eating disorders (don’t know why not included)

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Conditions identified by MCC (3)

• Adult 25-44 years– Substance abuse– Eating disorders– Family violence– Hypertension– Female: cervical cancer– Male: elevated cholesterol, MVA

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Conditions identified by MCC (4)

• Middle age 45-64 years– Lung cancer

– Colon cancer• Method of screening is controversial

• Screening colonoscopy has serious potential risks and low patient acceptance but can treat adenomas

– Skin cancer

– Female: osteoporosis, breast cancer

– Male: IHD, prostate cancer (55 and up)• Role of PSA screening is controversial

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Conditions identified by MCC (5)

• Seniors >64 yrs– Elder abuse– Falls– Drug-related morbidity– Nutrition– Cancer– Dementia (Should be on MCC list)

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077 PERIODIC HEALTH EXAMINATION (2)

• “Elicit information about ethnic, family, socio-economic, occupational, and lifestyle characteristics that are known to be at high risk for a particular condition.”

• Presumably means “…known to convey a high risk…”

• MCC provides a list for each age group

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Risk factors identified by MCC (1)

• Infant, Toddler, Child:– Risk factors at conception, pregnancy, birth– Familial factors– Existing signs of illness– Environment (missed immunization, diet,

passive smoke inhalation, skin protection)– Height, weight, head circumference, medical

status, developmental milestones

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Risk factors identified by MCC (2)

• Youth– Nutrition– Physical activity– Drug use– Sexual/social/peer activities– Emotional concerns– Communication with parents

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Risk factors identified by MCC (3)

• Adults:– Lifestyle patterns– Psychological, social and physical functioning– Symptoms of any illness– Situational factors affecting mood

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Risk factors identified by MCC (4)

• Seniors:– Past illness– Lifestyle factors– Mental function– Drug use– Physical and social activity– Emotional concerns– Social relations and support systems

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Risk factors identified by MCC (5)

• General:– Use lab tests only for specific to age and sex

concerns. Do not use the same battery of tests in all patients.

– Interpret results taking into account age/gender, etc.

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077 PERIODIC HEALTH EXAMINATION (3)

• “Conduct an effective plan of management”• All patients:

– Encourage patient control over health– Follow recommendations of CTFPHC (

http://www.ctfphc.org/ )

• Patient with risk factors:– Counsel about risk factor reduction, using

health belief model, stages of change model, etc.

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077A NEWBORN ASSESSMENT/NUTRTION

• Developmental surveillance– Anticipatory guidance to new parents

• Nutritional issues– Importance of breast-feeding– Bottle feeding; solid foods

• Well-newborn care– Bathing, skin care

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077B INFANT & CHILD IMMUNIZATION (1)

• “Discuss the population health benefits of immunization programs”

• Probability of contracting communicable disease depends on probability that contacts have the disease, or are carriers

• If sufficient proportion of population is immune, then disease will not spread (herd immunity)

• Prevention is usually cheaper and more effective than treatment (if treatment even exists)

• Possibility of eradicating some diseases• Implications for school attendance (Ontario)

– Mandatory choice vs. mandatory immunization– Exclusion from school for non-immunized children

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Standard immunizations(2007)Age 0-16

• Diphtheria

• Tetanus

• Pertussis

• Polio

• H. influenzae

• Mumps

• Measles

• Rubella• Hepatitis B• Chickenpox

(varicella)• Pneumococcus C• Meningococcus C• Influenza• HPV (girls only)

Taken from: Canadian Immunization Guide, 2007

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IMMUNIZATION: HPV

• Protects against 4 strains of HPV– Type 16/18 (linked to 70% of cervical cancer)– Type 6/11 (linked to 90% of anogenital warts)

• Approved for use in women aged 9-26.• Need three doses (0, 2 and 6 months)• 1st dose prior to initial sexual contact

– Age 9-13• Ontario

– Offered free on voluntary basis to all Grade 8 girls• Why only women?

– NO RCT’s in men (drug companies)– Rectal cancer– Genital warts– STD & shared responsibility for interrupting transmission

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077B INFANT & CHILD IMMUNIZATION (2)

• “State that a lapse in immunization schedule does not require re-instituting the initial series, merely giving it at the next visit”

• Done!

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077B INFANT & CHILD IMMUNIZATION (3)

• “Communicate to patients and parents about vaccine benefits and risks”

• Obtain an immunization history on all children• Late immunization is still very effective• Immigrants require special attention

– Depends on availability of good records– Countries have different immunization coverage– Were the previous vaccines ‘potent’?

• Travel– Update regular vaccinations– Follow legal requirements

• Yellow fever

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077B INFANT & CHILD IMMUNIZATION (3)

• “Discuss misconceptions about immunization contraindications”

• Following are not contraindications:– Mild/moderate local reactions to previous dose– Mild acute illness with or without fever– Taking antibiotics– Allergy to penicillin, duck, molds, pollens– Positive Mantoux TB skin test– Breast feeding– Asplenia– Prior febrile seizure reaction (consider prophylactic

acetaminophen)

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077B INFANT & CHILD IMMUNIZATION (4)

• “List possible complications of immunization”

• Seizures (secondary to fever)• Anaphylaxis• Neurological damage (rarely, if ever)

– Most evidence is due to diagnostic correlations, not causation

– Use acellular pertussis

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077B INFANT & CHILD IMMUNIZATION (5)

• “Discuss immunization of immuno-compromised children (e.g., asplenia, chronic diseases or seizures)”

• Avoid live (attenuated) vaccines; use killed vaccines• Splenectomy (surgical or congenital/functional)

– Not a contra-indication to vaccination• Immuno-suppression

– Avoid live vaccines– Follow regular immunization schedule– High dose steroids can mute immune response

• Congenital immunodeficiency– Read the Guide!

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Communicable disease controlTime scale

ExposureIncubation period(personal surveill.)

Clinical onsetPeriod of infectivity (isolation)

“Cure”time

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Communicable disease controlApproaches

• Enhance host resistance– Active or passive immunization

• Interrupt transmission– Isolate cases until no longer infectious– Contact tracing; observe until incubation period

is over– Individual measures (hygiene, barriers)

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077C PRE-OPERATIVE MEDICAL EVALUATION

• Come on … This is population health?

• Opportunity for case-finding/screening

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077D WORK-RELATED HEALTH ISSUES

• “Elicit history of patient’s occupation and possible exposure and identify potential relationship to patient presentation

• “Counsel patients about safety issues and report findings to affected patients as well as employers (considering medical confidentiality issues)”

• Consider underlying medical conditions and work risk• Importance in Canada

– 920 work place deaths in 2001– 373,216 lost time injuries in 2001

Well covered in UTMCCQE, except 2 topics

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Work-related Health Issues (2)• Under provincial jurisdiction except for 16 federal

regulated industries (e.g. banks, airports, highway transport).– 90% of workers are under provincial jurisdiction

• Ontario: Occupational Health and Safety Act– Defines rights of workers: participate, know, refuse and stop.

• Ontario: Workplace Safety and Insurance Act– Establishes WSIB to oversee work-site injuries/disease– Funded by employers– Non-fault protection but no right to sue– MD must submit medical report to WSIB; no need for patient

waiver.– MD must report exposure to designated substances

• Asbestos, arsenic, benzene, lead, mercury, vinyl chloride, etc.

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Essential responsibilities of an Occupational Health Program

• Health evaluation of employees• Diagnosis/treatment of occup injuries or illnesses• Emergency treatment of other injury or illness• Education of employees re: occupational hazards• Evaluation of programs for the use of indicated

personal protective devices• Assist management in providing a safe and

healthful work environment. Inspect workplace.

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WHMISWorkplace Hazardous Materials

Information System

• Informs workers of hazards that they face

• Labels

• MSDS (Materials Safety Data Sheets)

• Worker education

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Work-related Health Issues (3)

• Categories of occupational hazards– Chemical

• Dusts, heavy metals, gasses, second-hand smoke

– Physical• Noise, temperature, air pressure, radiation

– Biological– Mechanical

• Repetitive strain, trauma

– Psychosocial stress

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Work-related Health Issues (4)• Work place safety issues can affect family

members as well as the workers.• Asbestos

– Causes asbestosis and lung cancer in miners and other workers.

– Asbestos in the air adheres to work clothing, even if the clothes are brushed

– Cleaning of clothes at home liberates asbestos fibers and has been shown to cause cancer in family members.

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077E HEALTH OF SPECIAL POPULATIONS

“When providing periodic health examination to a person belonging to one of the [following] groups, evaluate conditions common to the group and determine whether evidence exists that the individual has such a condition”

MCC lists four populations and several conditions

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Special populations (1)

• Aboriginal peoples– Trauma/poisoning/SIDS/ALTE (Apparent Life

Threatening Event Syndrome)• also suicide, substance use

– Circulatory diseases (incl rheumatic fever)– Neoplasms– Respiratory diseases– Infection (gastroenteritis, otitis media,

infectious hepatitis)– Diabetes

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Special populations (2)

• Seniors:– Musculoskeletal

• includes falls & injuries

– Hypertension/heart diseases– Respiratory diseases– Dementia– Polypharmacy

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Special populations (3)

• Children in poverty– Low birth weight– trauma/poisoning– Mouth problems (abnormalities in teeth and

jaws)– Fever/infectious diseases– Psychiatric problems

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Special populations (4)

• People with disabilities– No specifics listed

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Two priests, a Dominican and a Jesuit met for their regular Monday morning walk. They got into a discussion about whether it was a sin to smoke and pray at the same time. The Jesuit was sure that it wasn’t a sin while the Dominican was sure that it was. Unable to resolve it, they decided to ask their superiors.

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The next week, they met again.

Dominican: What did your superior say?Jesuit: He said that it definitely was not a sin.Dominican: That’s strange because mine said that it was a sin.Jesuit: What did you ask him?Dominican: Whether it was a sin to smoke while praying.Jesuit: I asked if it was a sin to pray while smoking.

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077F POPULATION (1)Disease Prevention

• “Discuss the 3 levels of disease prevention and strategies for health promotion (e.g., education, communication/behaviour change, social marketing, healthy public policy, community development and organization, community-wide prevention, and diffusion of innovation)”

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Levels of Prevention

• Categories are not black and white.• Primary prevention:

– Strategies applied BEFORE disease starts.– E.g. Immunization

• Secondary prevention:– Early identification of disease– Screening; thrombolytic therapy of MI– Some people suggest secondary prevention relates to reducing the

severity of disease.

• Tertiary prevention:– Treatment and rehabilitation of disease

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Screening

• Can either:– Detect pre-disease states (e.g. dysplasia)– Detect the disease at an early stage

• Criteria for when screening is useful– Disease related

• Significant cause of ‘illness’• Early detection can alter the course of the disease

– Test related• High sensitivity (and specificity if possible)• Safe, rapid, cheap, acceptable

– Healthcare System related• Adequate capacity for follow-up/treatment

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Strategies for Prevention (1)High Risk Approach

• Identify individuals at high risk and attempt to reduce their risk

• Requires testing entire population (costs, false positives)

• Asks targeted people to act differently from their peers

• Misses most cases (which occur in lower risk people)

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Strategies for Prevention (2)High Risk Approach

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Strategies for Prevention (3)Population Approach

• Attempts to shift distribution of risk factor in whole population

• Gets to root of the problem

• Shades into health promotion

• Benefits everyone

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Strategies for Prevention (4)Population Approach

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077F POPULATION (2)Determinants of Health

• “Explain that factors such as geographic location, gender, and ethnic origin influence some of the determinants of health, but health status is in turn influenced by differential allocation and distribution of some of the determinants of health”

See below…

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Determinants of Health(Useful list from MCC Objectives)

• Income and social status• Social support network• Education• Personal health practices and coping skills• Healthy child development• Health services (access and barriers to access)• Employment and working conditions• Physical environment• Biology and genetic endowment

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Differential distribution of determinants of health

• Poverty is associated with increased occurrence of nearly all health problems, often working through known determinants/risk factors, e.g.., smoking

• Income inequality appears to be associated with worse overall health in the population, perhaps through decreased social cohesion, community investment, etc.

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077F POPULATION (3) Health Promotion

• “Select (identify) population health issues better managed by means of health promotion rather than traditional medical interventions”

• Physical or social environmental hazards, (e.g., pollution, poverty)

• Environmental interventions are usually more effective than behavioural ones

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077G ENVIRONMENT (1)

• “Describe clinical presentations caused or aggravated by environmental exposures that are virtually indistinguishable from ones caused by other conditions (e.g., headache from CO poisoning is similar to tension headache or migraine; asthma)”

• Done. You have to identify them from the history.

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077G ENVIRONMENT (2)

• “In patients whose immediate (e.g. allergic reaction), subacute (e.g. asthma) or delayed (e.g. pneumoconiosis) presentation may be linked to environmental exposure, elicit and environmental history and identify a/the potential source of the problem”

• Need to know when presentation may link to environmental agent.

• Consider list of candidate agents (later)

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077G ENVIRONMENT (3)

Four areas to focus on for environmental history

1. Determine whether symptoms are worse:– at home,– at work– at leisure activities– on weekends or week days

– And what is relationship to recent or past exposures (e.g. fumes, dusts, chemicals, radiation, etc.)

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077G ENVIRONMENT (4)

2. Determine whether an illness is occurring in an unexpected person (e.g. lung cancer in a non-smoker) or whether symptoms developed without a clear etiology

3. Determine presence of nearby industrial plants, commercial businesses or dump sites.

– ‘nearby’ needs to consider hydrology, weather patterns, etc.

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077G ENVIRONMENT (5)

4. Obtain information about:– Home insulation (UFI),– Home heating and cooling systems– Cleaning agents used– Pesticide use– Water supply and leaks– Recent renovations– Air pollution– Hobbies– Hazardous waste contamination, spills, etc.

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077G ENVIRONMENT (6)

• “Interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation and diagnosis.

• Doesn’t really say a whole lot.• Main point is to learn where to get

information and help in dealing with environmental issues (next 2 slides)

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077G ENVIRONMENT (7)

• “Select and consult labels or Material Safety Data Sheets (MSDS), poison control centers, consultants, agencies, and other references for information.”

• Sources of help: Ministry of Labour, occupational health clinics (not many freestanding ones)

• MSDS are available on the web. Find one you like and book-mark it for use in your practice.

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077G ENVIRONMENT (8)

• “Select consultants (environmental medicine specialists, toxicologists, governmental agencies, industrial hygienists, etc.) for the purpose of documenting and quantifying exposure.”

• Industrial (occupational) hygienists: usually chemical engineers with post-graduate training in measurement and control of environmental hazards

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077G ENVIRONMENT (9)

• “Select laboratory tests for the patient to establish exposure or select investigations to establish the presence of adverse health effects in target organs:– Blood lead levels to access exposure– Serum creatinine to look for effect on kidney

function.

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077G ENVIRONMENT (10)

• “If evidence supports, or a strong suspicion exists for, a causal connection between exposure and the clinical presentation, notify the appropriate authorities to inspect the site and thereafter to decrease and eliminate exposure.

• Your responsibility lies beyond the specific patient.

• Who do you contact? Next slide

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ENVIRONMENT (11)• Environmental Health Jurisdiction

– Public Health Unit• Sanitation, reportable diseases, local hazard assess

– Municipal• Garbage disposal, recycling

– Province/territory• Toxic waste disposal, air/water standards

– Federal• Food regulations, designating toxic substances

– International• Treaties like Kyoto

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ENVIRONMENT (12)• Risk assessment/management• Epidemiology vs. toxicology

– Air• Includes climate change

– Water• Biological & chemical risks

– Soil– Food

• Biological & chemical risks

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ENVIRONMENT (13)• AIR

– Particulates– Ground-level ozone– Carbon monoxide– Sulphur dioxide, nitrogen dioxide– Biological agents (e.g. moulds, mites)– Organic compounds (e.g. benzene)– Heavy metals– Radiation– Global warming

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ENVIRONMENT (14)• WATER

– Biological agents• Mainly animal and human waste• Very high risk in aboriginal Canadians

– Chemical agents• Organic compounds• Chlorination byproducts.

• SOIL– Lead, pesticides, industrial waste– Infants/toddlers are at highest risk

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ENVIRONMENT (15)• FOOD

– Biological Contaminants• Salmonella• Campylobacter• E. Coli• Listeria monocytogenes• Clostridium botulinum• BSE• Avian flu• Viruses, mould, parasites

– Chemical Contaminants• PCBs, dioxins/furans, pesticide residues (e.g. DDT), endocrine

disruptors, food additives• antibiotics