Public Health 5

Last updated on June 14, 2020 at 16:30

1. Importance of non-communicable diseases in developed countries (mortality, morbidity, trends)

  • Most important non-communicable diseases in high-income countries
    • CVD
    • Cancer
    • Chronic respiratory disease
  • NCD
    • cause more than 75% of deaths in high-income countries yearly
    • are more important in high-income than low-income countries
      • due to diet, social status
    • are becoming more important in low-income countries as well (as communicable diseases are becoming less of a problem)
    • In all ages:
      • CVD 48%
      • Cancer 21%
      • Others 16%
    • < 60 year olds
      • CVD 35%
      • Cancer 28%
      • Others 26%
  • Disease adjusted life years (DALY)
    • One DALY is one lost year of “healthy” life
    • DALY = years of life lost + years lost due to disability
    • Most DALYs are in high-income countries
  • Top causes of death in world
    • Ischaemic heart disease – 7 million per year – 13%
    • Stroke, cerebrovascular disease
    • Lower respiratory tract infections
  • Top causes of death in low-income countries
    • Lower RTI
    • Diarrhoeal diseases
    • HIV/AIDS
  • Morbidity – the disease burden in a population
    • Incidence and prevalence of a disease
  • Mortality – the occurrence of death in a population
  • Communicable diseases are less important in high-income countries due to vaccines, treatment, etc

2. Epidemiology of ischaemic heart disease

  • Leading cause of death in US and the world
  • Higher risk in men than women
  • Rising tendency in developing countries
  • Accounts for nearly 30% of all disability cases
  • Especially affects middle aged population
  • Proposed theories
    • Lipid theory
      • Decreasing blood cholesterol decreases IHD
      • Oxidized LDL enters vessel wall
    • Blood coagulation theory
      • Increased coagulation tendency
      • Evidence:
        • Increased plasma fibrinogen
        • Increased thromboxane A2/prostaglandin ratio
        • Increased lipoprotein(a) (inhibits fibrinolysis)
    • Blood vessel wall theory
      • Collagen increases, elastic fibres decrease
      • Increases microthrombi formation and lipid infiltration
  • Pathomechanism of atherosclerosis
    • Endothelial dysfunction
      • HT
      • Smoking
      • Diabetes
      • High LDL
      • Aging
    • Leukocyte migration into tunica intima
    • Proliferation of smooth muscle cells in tunica intima
    • Oxidized LDL accumulates, macrophages transform into foam cells
    • Foam cells and smooth muscle cells produce collagen -> forms fibrous plaque
    • Inflammation in fibrous plaque weakens the fibrous cap
    • Plaque ruptures, exposing thrombogenic material

3. Main modifiable risk factors of coronary heart disease

  • Hypertension
  • Abnormal blood lipids
    • High serum cholesterol
    • High LDL
    • Low HDL
  • Tobacco use
    • Worse risk for women
    • Genetical sensitivity
  • Physical inactivity
    • > 150 minutes /week of moderate intensity
    • Muscle-strengthening activities
  • Obesity
  • Unhealthy diet
  • Diabetes mellitus

Seven countries study

  • First major study to investigate diet and lifestyle as risk factors for CVD
  • 1958
  • Included countries with different cultures and standards

European guidelines for cholesterol

  • Total cholesterol < 5 mM
  • LDL < 3 mM
  • HDL > 1 mM
  • Triglycerides < 1,7 mM
  • US guidelines less strict

Cholesterol content of certain foods

  • Chicken liver 750mg / 100g
  • Egg 500mg / 100g

Olive oil

  • Decreases LDL, TG
  • Decreases BP
  • Inhibits LDL oxidation

Decrease TC and LDL:

  • Reduce dietary saturated fat
  • Reduce dietary trans fat
  • Eat phytosterols
  • Reduce dietary cholesterol

Decrease TG

  • Reduce body weight
  • Reduce alcohol intake
  • Reduce mono and disaccharide intake

Increase HDL

  • Reduce trans fat
  • Increase physical activity
  • Reduce body weight

Metabolic syndrome

  • 3 of the following
    • Abdominal circumference
      • Male > 94
      • Female > 80
    • Hypertension
    • Triglycerides
    • Low HDL
    • High fasting blood glucose

4. Other modifiable risk factors of coronary heart disease

  • Low socioeconomic status
  • Mental ill health
    • Depression
  • Psychosocial stress
    • Social isolation
    • Anxiety
  • Heavy alcohol use
    • One or 2 drinks per day reduces heart disease
    • J-shaped curve
  • Certain medications
    • Oral contraceptives
    • Hormonal replacement therapy
  • Lipoprotein(a)
  • Left ventricular hypertrophy

5. Risk factors of coronary heart disease (excluding main and other modifiable risk factors)

  • Non-modifiable risk factors
    • Advanced age
      • Risk of stroke doubles every decade after age 55
    • Family history
      • Increased risk if first-degree had cardiovascular disease at < 55 or <65 years
    • Gender
      • Increased risk for CHD in men
      • Stroke similar for genders
      • Protective effect of oestrogen
        • Increases HDL
        • Decreases LDL
        • Decreases Homocysteine
        • Inhibits NF-kB
    • Ethnicity
      • Stroke increased in
        • Blacks
        • Hispanics
        • Chinese
        • Japanese
      • Cardiovascular increased in
        • South Asian
        • American blacks
  • Novel risk factors
    • Hyperhomocysteinaemia
      • Occurs in folic acid, pyridoxine or B12 deficiency
      • MTHFR – enzyme involved in homocysteine homeostasis
        • Increased risk in those with lower activity
    • Inflammation
      • High-sensitivity CRP
    • Abnormal blood coagulation
      • Increased fibrinogen, other clotting markers

6. Epidemiology and prevention of cerebrovascular diseases

  • Stroke
    • Ischaemic 80%
      • Thrombotic 50%
      • Embolic
    • Haemorrhage 20%
      • Intracerebral
        • Hypertension
      • Subarachnoid
        • Aneurysms
        • Occurs at any age
        • Different epidemiology than other stroke types
    • Symptoms
      • Sudden numbness or weakness
      • Sudden confusion, trouble speaking
      • Sudden blindness
      • Sudden trouble walking
      • Sudden severe headache
  • Epidemiology
    • 10% of ischaemic strokes -> death in 30 days
    • 40% of haemorrhagic strokes -> death in 30 days
    • Leading cause of long-term disability in US
    • 3rd cause of death in US
  • Risk factors
    • Hypertension x2 risk
    • Atherosclerosis
    • Heart disease
      • 1/10 will develop stroke in 6 years
    • Coagulation disorders
    • Previous TIA, stroke, ami
    • Diabetes
    • Smoking x10 haemorrhagic stroke risk
    • Alcohol
    • Age
    • Genetics

7. Epidemiology and prevention of hypertension

  • Hypertension
    • Systolic > 140 mmHg
    • Diastolic > 90 mmHg
    • Most are primary
    • Symptom-free
  • Epidemiology
    • Most prevalent in eastern Europe, southern Africa
    • More prevalent in blacks
    • More prevalent in lower socioeconomic classes
    • Prevalence increases with age
    • < 50: more frequent among men
    • > 65: more frequent among women
  • Risk factors
    • Familial factors
    • Nutritional
      • Salt intake > 5g/day
        • Hungary has extremely high salt intake (17 g per day)
      • Soft water
      • High tyramine content – sympathetic activation
      • Alcohol
    • Obesity
      • 12% risk increase for each unit BMI
    • Body weight
      • 10 kg increase – 2 systolic, 1 diastolic
    • Physical inactivity
    • Modern lifestyle
      • Lots of stress
    • Diabetes
  • Prevention
    • BMI < 25
      • 5 – 20 mmHg reduction per 10 kg
    • DASH diet
      • Lots of vegetables, fruits
      • Grains
      • Lean meat, low fat dairy
      • Oils, beans, nuts
      • Little sweets
      • reduces 8 – 14 mmHg
    • Salt < 5g/day
      • reduces 2 – 8 mmHg
    • Increase Ca, K, Mg
    • Moderate alcohol consumption
      • reduces 2 – 4 mmHg
    • Stop smoking
    • Physical activity
      • reduces 4 – 9 mmHg
  • Treatment
    • < 5% risk and no organ damage
      • Lifestyle changes for 6 months
        • If successful -> annual control
        • If unsuccessful -> therapy may be necessary
    • < 5% risk with organ damage
      • Lifestyle changes + therapy

8. Cardiovascular diseases: risk assessment and prevention

  • Risk assessment
    • SCORE risk estimation system
    • Framingham risk scoring
      • Not used in Europe, not so important
      • Points for
        • Age
        • total cholesterol
        • HDL
        • Systolic BP
        • Smoking
      • Sum of points gives risk
  • Prevention
    • Primordial – activities which reduce or remove risk factors
      • Improve public transport availability
      • Opportunities for recreational activities
      • Increased socioeconomic development
      • Smoke-free restaurants
    • Primary – reducing the population’s exposure to risk factors
      • Health education programs
      • Anti-smoking campaigns
      • Sports programs
      • Nutritional counselling
    • Secondary – screening
      • Regular check-ups
        • Cholesterol
        • Lipids
        • Glucose
    • Tertiary – prevention of recurrence and treatment of symptomatic patients
      • 5 – 7 x higher risk in those with previous CVD
  • Recommended targets
    • Very high CV risk (SCORE > 10%)
      • LDL < 1,8 mM
    • High risk SCORE > 5%
      • LDL < 2,5 mM
    • Moderate risk
      • LDL < 3,0 mM

9. Morbidity and mortality of malignant diseases

  • Morbidity
    • Most common for men
      • Prostate
      • Lung
      • CRC
    • Most common for women
      • Breast
      • Lung
      • CRC
  • Mortality
    • Cancer is second leading cause of death globally
    • 10 million deaths in 2018
    • 1 in 6 deaths
    • 70% of deaths in low and middle income countries
    • Most common causes of cancer death in men
      • Lung
      • CRC
      • Prostate
    • Most common causes of cancer death in women
      • Lung
      • Breast
      • CRC
    • Cancer-related death similar now as 50 years ago
    • 20 – 30% of deaths of non-communicable diseases

10. Role of infectious diseases in tumour development

  • H. pylori
    • Half of the world has it
    • Most commonly gastro-oral or feco-oral transmission
    • Causes chronic gastritis -> gastric cancer
  • HPV
    • 16, 18, 31, 33 -> carcinogenic (high risk)
    • 6, 11 -> not carcinogenic (low risk)
    • Most common cause of cervical cc
    • Also a cause for throat cancer
    • Recombinant vaccines
      • Bivalent
      • Quadrivalent
  • HBV
    • Causes HCC
    • Vaccine
  • HCV
    • Causes HCC
    • No vaccine
  • EBV
    • Burkitt lymphoma
    • No vaccine
  • HIV
    • Kaposi sarcoma
    • Non-Hodgkin lymphoma
    • Increased risk for many other cancers

11. Risk factors of malignant diseases

  • Preventable causes of cancer
    • Poor diet is the most common cause of cancer
    • 30% of cancers due to high BMI, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use
    • Diet
      • Fat intake -> breast cancer
      • Salt intake -> stomach, CRC
      • Spicy food intake -> stomach
      • Omega-6 intake -> prostate cancer
    • Tobacco
      • Responsible for 22% of cancer deaths
      • Initiator
      • DNA adduct
      • 2nd hand smoke
        • Sidestream smoke – doesn’t pass through filter
        • Mainstream smoke – exhaled smoke
    • Infections
      • 25% of cancers in low and middle-income countries
      • H. pylori
      • HPV
      • HBV
      • HCV
      • EBV
      • HIV
      • HSV
    • Sexual behaviour
    • Inactivity
    • Occupation
      • Asbestos
      • Chimney sweeper
    • Alcohol
      • Cirrhosis
      • Oral, oesophagus, stomach
  • Non-preventable risk factors
    • Family history
    • Aging
    • Gender
    • Ethnicity

12. Screening of malignant diseases

  • CRC
    • Begins at age 50
    • Sigmoidoscopy
    • Colonoscopy
    • CT colonography (virtual colonoscopy)
    • Faecal occult blood test
  • Breast
    • Yearly mammogram after 40
    • Clinical breast exam every 3 years after 20
    • Breast self exam
  • Prostate
    • Controversial screening
      • May lead to treatment of cases which wouldn’t have been bothersome anyway
    • For high-risk people
      • BRCA
      • Black
      • History of prostate cc
    • PSA
    • DRE
  • Cervical
    • 21 – 30
      • Pap smear every 3 years
    • 30 – 65
      • Pap smear every 5 years
      • HPV test every 5 years
    • Over 65
      • Not tested
    • Vaccinated women should also be screened
    • High risk screened more often

13. Epidemiology and prevention of lung cancer

  • Epidemiology
    • Second most common cancer for each gender
    • Causes most cancer deaths in both genders
    • Mainly affects elderly
    • Males > females
  • Etiology
    • 90% caused by smoking
      • Half of all smokers in hungary will die as a result of smoking
      • Nicotine
      • PAH
      • N-nitrosamines
    • Non-smoking causes
      • 2nd hand smoke
      • Radon
        • Natural in soil
      • Air pollution
      • Occupation
        • Asbestos exposure
  • Prognosis
    • 5 year-survival 15%
    • Mortality 92%
  • Prevention
    • Beta carotene increases cancer risk
    • Stop smoking
    • Reduce air pollution
    • Prevent occupational exposure

14. Epidemiology and prevention of colorectal cancer

  • Epidemiology
    • Third most common cancer worldwide
    • Second and third most common causes of cancer deaths in men and women, respectively
    • Males = females
    • Half could be prevented with correct prevention
  • Etiology
    • Majority are sporadic 
    • Minority are hereditary
      • APC, K-RAS, p53
    • Familial
      • FAP
      • Peutz Jeghers syndrome
    • Risk factors
      • Red meat
      • Low dietary fibre
      • Obesity
      • Smoking
      • High energy intake
  • Protective factors
    • Calcium
    • Vitamin D
    • Fruit, vegetables
    • Physical activity
    • High fibre intake
  • Prognosis
    • 5-year survival: 65%
  • Prevention
    • Improve diet
    • Screening (recommendations)
      • Begins at age 50
      • Sigmoidoscopy
      • Colonoscopy
      • CT colonography (virtual colonoscopy)
      • Faecal occult blood test

15. Epidemiology and prevention of breast cancer

  • Epidemiology
    • Most common cancer in females
    • Second most common cause of cancer-death in female
  • Etiology
    • Age
    • High fat intake
    • Ethnicity
      • Caucasian > black > asian
    • Increase oestrogen exposure
      • Late menopause
      • Early menarche
      • Late first pregnancy
      • Nulliparity
      • Oral contraceptive
      • Overweight
    • Not breastfeeding
    • Radiation
    • Physical inactivity
    • Familial
      • BRCA1 and 2
  • Prognosis
    • High 5-year survival: 85%
      • Much lower in Asian women
  • Prevention
    • Screening
      • Yearly mammogram after 40
      • Clinical breast exam every 3 years after 20
      • Breast self exam
    • Prevent obesity
    • Physical activity

16. Epidemiology and prevention of prostate and cervix cancer

Prostate

  • Epidemiology
    • Most common cancer in men
    • Third most common cause of cancer death in men
    • Incidence increased recently
    • A disease of elderly
  • Etiology
    • Old age
    • Ethnicity
      • Black > white
    • Family history
    • Androgen exposure
    • Diet
      • Omega-6 intake
    • Obesity
    • Smoking
    • STD
  • Prognosis
    • Mortality stable
    • 5-year survival: 80%
  • Prevention
    • Prevent obesity
    • Increase omega-3, reduce omega-6
    • Don’t smoke
    • Screening
      • For high-risk people
        • BRCA
        • Black
        • History of prostate cc
      • PSA
      • DRE

Cervix

  • Epidemiology
    • 4th most common cancer in females
    • 6th most common cause of cancer death in females
    • In 35 – 50 years old
    • Deaths mainly occur in countries without access to screening and vaccines
  • Etiology
    • HPV 95% of cancers
    • Increased number of pregnancies
    • Early start of sexual life
    • Higher number of sexual partners
    • Smoking
    • Obesity
  • Prognosis
    • Screening decreased mortality
    • 5-year survival: 20%
  • Prevention
    • Safe sex
    • No smoking
    • Prevent obesity
    • Vaccination against HPV
    • Screening
      • 21 – 30
        • Pap smear every 3 years
      • 30 – 65
        • Pap smear every 5 years
        • HPV test every 5 years
      • Over 65
        • Not tested
      • Vaccinated women should also be screened
      • High risk screened more often

17. Epidemiology and prevention of liver-, pancreas- and gastric cancer

Gastric

  • Epidemiology
    • Was most common cancer in 1970s, but now much less common
      • Perhaps due to decreased prevalence of H. pylori
    • Male > female
    • Strong geographical differences in incidence
      • High incidence in Korea and Japan
      • Declining incidence in Western countries
  • Etiology
    • Male gender
    • Old age
    • Diet
      • Salt
      • Smoked food
      • Nitrites, nitrates
    • Smoking
    • Obesity
    • Chronic gastritis
      • H. pylori
  • Prognosis
    • 5 year survival: 15%
  • Prevention
    • Treat H. pylori
    • Improve diet
    • Stop smoking
    • Treat gastritis
    • Prevent obesity

Pancreas

  • Epidemiology
    • Rare but fatal cancer
    • Male > female
    • Age of onset: 60 – 80
    • Accounts for only 3% of cancers in US
  • Etiology
    • Old age
    • Men
    • Blacks
    • Smoking
    • Obesity
    • Chronic pancreatitis
    • Cirrhosis
    • Binge drinking
    • Family history
  • Prognosis
    • 5 year survival: 5%
    • Highest lethality of all cancers
  • Prevention
    • Avoid avoidable risk factors

Liver

  • Epidemiology
    • Male > female
    • Age of onset in Western countries: 70 years
    • Highest incidence in Asia, Africa
      • Due to endemic HBV, HCV
  • Etiology
    • In developing countries
      • HBV
      • HCV
      • Aflatoxin
    • In developed countries
      • HCV
      • Promiscuity
      • Chronic alcoholism
      • Non-alcoholic fatty liver disease
      • Low socioeconomic status
  • Prognosis
    • 5-year survival < 50%
  • Prevention
    • Avoid alcohol
    • Avoid obesity
    • Safe sex
    • Screening
      • In high-risk patients (cirrhosis, chronic hepatitis)
      • HBV, HCV serology
      • AFP

18. Epidemiology and prevention of head and neck cancers and skin cancers

Head and neck

  • Epidemiology
    • Explosive growth in incidence of head and neck tumors in 20th century
    • Accounts for 3% of cancers in Western world
    • Male > female
  • Etiology
    • Smoking
    • High alcohol intake
    • “Smokeless” tobacco
    • Poor oral hygiene
    • Oral infections
    • HPV 16, 18
  • Prognosis
    • Death rate 4x increase in last 30 years in hungary
    • 5-year survival 20%
  • Prevention
    • Stop smoking
    • Improve oral hygiene
    • HPV vaccination

Non-melanoma skin cancer

  • Epidemiology
    • Non-melanoma incidence increasing
    • Male > female
    • More common than melanoma
    • Highest incidence in Australia, US, Europe
    • Lowest in dark-skinned populations
  • Etiology
    • Sun exposure
    • Tanning beds
    • Skin types I and II
      • Light skin
      • Blue eyes
      • Blond hair
      • Easily sunburnt
    • Arsenic exposure
  • Prognosis
    • 5-year survival almost 100%
  • Prevention
    • Sunscreen
    • Clothes in the sun
    • Don’t do tanning beds

Melanoma

  • Epidemiology
    • Only 2% of cancer incidence
  • Etiology
    • Sun exposure
      • Especially sunburn in childhood
    • Tanning bed
    • Congenital nevi
    • Skin types I and II
      • Light skin
      • Blue eyes
      • Blond hair
      • Easily sunburnt
  • Prognosis
    • Vary variable depending on stage at diagnosis
    • 5-year survival
      • T1 > 90%
      • N1, M0 20 – 40%
      • M1 < 5%
  • Prevention
    • Sunscreen
    • Clothes in the sun
    • Don’t do tanning beds

19. Epidemiology and prevention of diabetes

Diabetes mellitus type 1

  • Epidemiology
    • 5% of all diabetes cases
    • Onset in childhood
    • Most prevalent in white
  • Etiology
    • Genetic factors
    • Autoimmune disease
    • Viral infections
  • Protective factors
    • Breast feeding
    • Vitamin D
  • Prevention
    • Secondary
      • Screening of relatives or high-risk populations
    • Tertiary
      • Glucose control

Diabetes mellitus type 2

  • Epidemiology
    • Worldwide prevalence rising
    • Becoming more and more of a problem in developing countries as well
    • Prevalence: 9% of US
      • Rising
    • Onset > 40, but age of onset is decreasing
    • Hispanics, native americans, Asians, blacks > whites
  • Etiology
    • Associated with metabolic syndrome
    • Family history
    • Obesity
    • High calorie diet
    • Physical inactivity
    • Dyslipidaemia
    • Hypertension
    • Genetic factors
      • LPL
      • Insulin receptor
      • Glucose transporter
    • Socioeconomic factors
  • Scoring systems
    • Gives the risk of developing type 2 diabetes
    • FINDRISK
    • AUSDRISK
  • Prevention
    • Primary
      • Population-based health programmes
      • Prevention of obesity
      • Reduce fat
      • Reduce sugar
      • Increase fruit, vegetables
    • Secondary
      • Screening
    • Tertiary
      • Management of cardiovascular risk factors
      • Glucose control

20. Epidemiology and prevention of osteoporosis

  • Epidemiology
    • 4x in women
      • Women mostly primary osteoporosis
      • Men mostly secondary osteoporosis
    • Age of onset 50 – 70
    • Asian, Hispanic, European > black
  • Etiology
    • Female
    • White
    • Old age
    • Malnutrition
      • Poor protein, calcium, vitamin D intake
    • Family history
    • Smoking
    • Alcohol
  • Diagnosis:
    • DEXA scan, which measures the bone mineral density (BMD)
    • T-score: the number of standard deviations the patient’s BMD is away from the BMD of a young female adult
      • Osteopaenia: T-score -2,5 <-> -1
      • Osteoporosis: T-score < -2.5
    • Z-score: the number of standard deviations the patient is away from a similarly aged adult
  • Prognosis
    • 30 – 50% of women will experience fracture related to osteoporosis during lifetime
  • Prevention
    • Avoid alcohol
    • Avoid smoking
    • Sufficient intake of Ca
    • Sufficient intake of vitamin D
    • Physical activity – strength training
    • Bisphosphonates

21. Epidemiology and prevention of chronic obstructive pulmonary disease

  • Epidemiology
    • Fourth most common cause of death worldwide
    • Leading cause of morbidity in developed countries
    • Male > female
    • 6% prevalence in US
  • Etiology
    • Smoking
      • 20 – 30 pack years gives 80-90% risk
    • Passive smoking
    • Air pollution
    • Occupational exposure to dust
    • Respiratory tract infections
    • Premature birth
    • Asthma
    • Low socioeconomic status
    • Physical inactivity
    • Alpha-1-antitrypsin deficiency
  • Diagnosed by spirometry
    • Decreased Tiffeneau index < 70%
    • <12% amelioration by bronchodilators
  • Scoring
    • GOLD – groups according to risk and symptoms
    • BODE index – prognosis
    • mMRC dyspnoea scale
  • Prevention
    • Primary
      • Health education
      • Promote smoking prevention
      • Air pollution control
    • Secondary
      • Screening for A1ATD – family members too
      • Screening of high-risk individuals
    • Tertiary
      • Stop smoking
      • Oxygen therapy
      • Pulmonary rehabilitation
      • Vaccination
        • Influenza
        • Pneumococcus
      • Exercise

22. Epidemiology and prevention of asthma

  • Epidemiology
    • Prevalence: 7% in world
      • Increasing
    • Black > white
    • Mostly in children
    • Allergic asthma – childhood onset
    • Nonallergic asthma – adulthood onset
  • Etiology
    • For allergic asthma
      • Atopy
        • Allergic rhinitis
        • Eczema
      • Air pollution
      • Allergies
        • Mold
        • Dust mite
    • For non-allergic asthma
      • Respiratory infections in childhood
    • Both
      • Smoking or second-hand smoke
      • Low socioeconomic status
      • Obesity
      • Occupational air pollution exposure
  • Prognosis
    • Developing countries have fewer medications and options for treatment -> higher mortality and morbidity
    • Therapy is expensive
    • 80% of deaths in low income countries
  • Prevention
    • Primary
      • Prevention of development of atopy
      • Breastfeeding
      • Prevention of passive smoking
      • Adequate control of childhood infections
    • Secondary
      • Screen high-risk 
    • Tertiary
      • Avoid triggers
      • Get vaccinations
      • Effective medication and management

23. Epidemiology and prevention of allergic rhinitis

  • Epidemiology
    • Prevalence 10 – 30% of industrialized countries
    • Most frequent disease among children and teens
      • 80% of cases 0 – 20 years
    • Prevalence increasing, especially in urban areas
  • Forms
    • Seasonal – outdoor allergens
      • Pollen
        • Ragweed
        • Grass
        • Tree
      • Mold
        • Fungus
    • Perennial – indoor allergens
      • Pets
      • Dust
      • Mites
      • Molds
  • Etiology
    • Second hand smoke
    • Exposure to allergens
    • Atopy or family history of it
    • Male gender
    • Urbanization
  • Prevention
    • Breastfeeding
    • Elimination, avoiding allergen
      • Avoid dust mites
        • Reduce indoor humidity
        • Wash bed sheets
        • Use bedding encasements
    • Medical treatment

24. Epidemiology and prevention of hepatic cirrhosis

  • Epidemiology
    • 0,02% prevalence
    • 10th leading cause of death for men
    • 10-year mortality: 50%
    • Men > women
    • In developed countries – mostly due to alcohol, non-alcoholic fatty liver disease
    • In developing countries – mostly due to HBV, HCV, aflatoxin
  • Etiology
    • Alcohol liver disease
      • 70% of cases
      • 40 – 80g/day for 20 years
      • Especially large amounts occasionally
    • HBV
    • HCV
    • Non-alcoholic fatty liver disease
      • Obesity
      • Diabetes type 2
    • Aflatoxin
    • Alpha-1 antitrypsin deficiency
  • Prognosis
    • Good in compensated cirrhosis
    • Poor in decompensated cirrhosis
  • Prevention
    • Primary
      • Prevention of alcohol abuse
      • HBV vaccination
      • Needle exchange programme – give clean needles to IV drug users
      • Safe sex
      • Promote healthy diet
    • Secondary
      • Screen high-risk groups
    • Tertiary
      • Treat underlying disease
      • Prevention of complication

25. Epidemiology and prevention of ulcer disease

  • Epidemiology
    • Men > women
    • 25 – 60 years
    • Duodenal ulcers 4x more common than gastric, more common in younger
    • Incidence dropping globally
  • Aggressive factors
    • HCl
    • Pepsin
    • Decreased motility
    • H. pylori
      • 6 – 10x increased risk in H. pylori
      • 50% of the world is infected
      • Lifetime risk 10% in H. P negatives and 20% in positives
  • Protective factors
    • Thanks to prostaglandins
    • Mucosal blood flow
    • Mucin
    • Bicarbonate secretion
    • Restitution
    • Regeneration
  • Etiology
    • Old age
    • Long-term NSAID
    • Long-term steroid
    • Smoking
    • Alcohol
    • H. pylori infection
    • Stress
  • Prevention
    • Primary
      • Enhancement of protective factors
      • Elimination of aggressive factors
      • Increased fibre
      • Avoid spicy food
      • Decrease caffeine
      • Decrease alcohol
      • Prevent smoking
    • Secondary – screening
      • Urea breath test
      • Blood antibody test
      • Gastroscopy
    • Tertiary – treatment
      • PPIs, H2 blockers
      • Eradicate H. pylori
      • Stop NSAIDs, steroids
      • Improve diet
      • Stop smoking

26. Epidemiology and prevention of inflammatory bowel diseases

  • IBD
    • Epidemiology
      • More common in urbanized areas of Western countries
      • Higher incidence in northern than southern countries
      • White, Ashkenazi Jews
      • Age of onset 15 – 30
      • Women = men
    • Etiology
      • Physical inactivity
      • Diet
        • Low intake of fibre
        • High intake of fat
        • Vitamin D deficiency
      • Hygiene hypothesis
        • Extremely hygienic environments predispose to immunological diseases
      • Family history
      • High socioeconomic status
      • Urbanization
      • Drugs
        • Contraceptives
        • NSAIDs
    • Prognosis
      • No cure
      • Mortality similar to healthy
      • Needs a lifetime of care
      • Requires many physician visits, hospitalizations
      • Major cause of disability
    • Prevention
      • Tertiary
  • Crohns
    • Epidemiology
      • Prevalence: 300 / 100 000
      • Incidence: 24 / 100 000
    • Specific risk factors
      • Smoking
      • NOD2
    • Prognosis
      • 75% require surgery
  • UC
    • Epidemiology
      • Prevalence: 500 / 100 000
      • Incidence: 12 / 100 000
    • Specific risk factors
      • Not smoking
    • Prognosis
      • 25% require surgery

27. Epidemiology and prevention of suicide

  • Epidemiology
    • 1 million worldwide every year
    • 3rd leading cause of death in 15 – 24 age group
    • 80% occur in low and middle income countries
    • Peak incidence: 45 – 65
    • 25 attempts for each success
      • 3:1 in older
      • 100:1 in younger
    • Male > female
    • Suicide attempts more common in women
    • >90% have psychiatric illness or substance abuse disorder
    • 20 – 50% have alcohol or drug use problems
  • Countries
    • Korea
    • Hungary
    • Russia
    • Japan
    • China
  • Individual risk factors
    • Mood disorders
      • Depression
    • Alcoholism
    • Previous attempt
    • Schizophrenia
    • Life crisis
    • Partner problems
    • Chronic pain or illness
    • Impulsivity
    • Isolation
    • Trauma or abuse
  • Socio-cultural risk factors
    • Lack of social support
    • Stigma associated with seeking help
    • Decreased access to health care
    • The belief that suicide is noble
    • Copycat effect
  • Protective factors
    • Easy access to mental health care
    • Strong connection to friends and family
    • Restricted access to means of suicide
    • Problem-solving skills
    • Sense of belonging
    • Positive self-esteem
  • Prevention
    • Restrict access to means of suicide
    • Low-threshold access to help
    • Hotlines
    • Improve social circumstances
    • Programmes in school
    • Screening for mental well-being at GP

28. Epidemiology and prevention of depression and mood disorders

  • Epidemiology
    • Depression is the most common mood disorder
    • 20 million people every year
    • Female > male
    • Major cause of disability in young
  • Criteria for major depression
    • Depressed mood
    • Diminished interest
    • Weight changes
    • Sleep disturbances
    • Loss of energy
    • Feelings of worthlessness
    • Feelings of excessive guilt
    • Problems concentrating
  • Risk factors
    • Biological factors
      • Genetic predisposition (concordance 50%)
      • Dysfunction of HPA
      • Increased level of stress hormones
    • Psychosocial factors
      • Trauma
      • Stress
      • Learned helplessness
    • Comorbidities
      • Chronic illnesses
      • Chronic pain
  • Prevention
    • Teach problem-solving skills
      • Break problems into smaller chunks
    • Teach emotion-coping skills
      • Challenge irrational thoughts
      • Acknowledge and express emotions
    • Decrease stigma associated with depression
    • Increase availability of help services

29. Epidemiology and prevention of anxiety disorders

  • Epidemiology
    • Common in adolescents
    • Most prevalent psychiatric disorders
    • 22% of young people
    • Impairment, high health-care utilization, economic burden
    • Women > men
  • Risk factors
    • Neurobiological factors
    • Substance abuse
    • Stress
    • Smoking
    • Psychological trauma
    • Comorbidities
  • Subtypes
    • Generalized anxiety disorder
      • Most common in elderly
    • Post-traumatic stress disorder
    • Panic disorder
      • Most common in middle-aged
    • Social anxiety disorder
      • Most common in young
    • Specific phobias
  • Treatment
    • Cognitive behavioural therapy
    • Medication

30. Epidemiology and prevention of schizophrenia and dementias

  • Schizophrenia
    • Epidemiology
      • Males = females
      • Onset in 20s – 30s
    • Clinical features
      • Positive and negative symptoms
    • Risk factors
      • Stress
      • Psychosocial factors
      • Cannabis abuse
      • Family history
    • Treatment
      • Avoid validation of delusions
      • Avoid confronting patients about delusions
    • Prevention
      • Maintaining healthy relationships and friendships
      • Avoiding cannabis
      • Seeking therapy for depression early
      • Teach stress and anxiety coping
      • Promote exercise
  • Dementia
    • Epidemiology
      • Disease of elderly
      • Female > male
    • Causes
      • Neurodegenerative disease
      • Cerebrovascular disease
    • Risk factor
      • Age
      • Female
      • Family history
      • CVD risk factors
      • Lack of physical activity
    • Prevention
      • No smoking
      • Healthy weight
      • Exercise
      • Healthy diet
      • Reduce comorbidity
      • Stay mentally alert
      • Maintain social relationships

31. Epidemiology and prevention of addictions

  • Addiction = Chronic problem which causes drug seeking, despite harmful consequences
  • Addictions cause accidents, violence, abuse
  • Epidemiology
    • 6% of the world
    • Most drug-related deaths are in North America
  • Physical dependence
    • Avoidance of withdrawal
  • Psychological dependence
    • Drug-seeking behaviour
  • Comorbidity of addiction
    • Depression
    • Suicide
    • Antisocial personality disorder
    • Infections

Smoking

  • Epidemiology
    • One of the most important public health issues
    • Most smoking in Eastern Europe
      • Greece
      • Serbia
      • Croatia
      • Etc.
    • Male > female
    • Almost all adult smokers had their first cigarette before 20
  • Risk factors
    • Low socioeconomic status
    • Peer pressure
    • Family who smokes
  • Fagerstrøm nicotine dependence scale
  • 5 A of smoking cessation
    • Ask – about tobacco use
    • Advise – tobacco users to quit
    • Assess – readiness to attempt quitting
    • Assist – with quitting
    • Arrange – follow up care
  • 5 R’s – for patients unwilling to quit at this time
    • Relevance – tailor advice to each patient
    • Risks – inform of risks of continuing
    • Rewards – inform of rewards of stopping
    • Roadblocks – identify roadblocks
    • Repetition – repeat messages
  • Prevention
    • Primary
      • Campaigns
      • Ban advertisements
      • Decrease availability
      • Encourage cessation
      • Decrease second hand smoking
      • School programs
    • Secondary
      • Ask patient about substance disorder
    • Tertiary
      • Support groups
      • Bupropion
      • Nicotine replacement

Alcohol

  • Epidemiology
    • Alcohol consumption causes 3 million deaths every year
    • Excessive alcohol consumption is the 2nd most important epidemiological problem after smoking
    • More common in minorities
    • Peak incidence 20s – 30s
    • Male > female
  • AUDIT test – alcohol use disorders identification test
    • Gives points based on risk
  • There is no safe amount of alcohol
  • Risk factor
    • High and low socioeconomic status (not middle)
    • Depression
    • Anxiety
    • Abuse of other substances
  • Prevention
    • Legislation
    • Taxes
    • Mental health promotion
    • No ads
    • Awareness campaign

Other drugs

  • Designer drugs
  • 4% of worlds adult population used psychoactive substances
  • Cannabis, amphetamines, cocaine, opioids

32. Recommended and compulsory screening methods for non-communicable diseases (excluding cancers)

  • DM2 screening in children
    • Recommended by ADA
    • In those who are overweight for their age and gender, and who have any of the following risk factors
      • Family history
      • Specific ethnicity
      • Signs of insulin resistance
    • Begin at age 10, repeat every 2 years
  • CVD in adults
    • BP, cholesterol, weight, waist, glucose, smoking, physical activity, diet
    • Start at 20
    • Every 2 – 4 years
  • Diabetic eye screening
    • Annually to people with diabetes
  • Osteoporosis
    • Bone mineral density measurement by DEXA
    • In women > 65, or younger if they have risk factors
  • Abdominal aortic aneurysm
    • For men > 65
    • With ultrasound
  • Cognitive impairment
    • No universal recommendation for screening
  • Depression
    • Adults > 18
    • Screening with simple screening questions
  • Antenatal screening
    • Haemoglobinopathies
    • Down syndrome
    • Infectious diseases
      • Syphilis
      • HBV
      • HIV
      • Rubella
  • Newborn screening
    • Hearing loss
    • Metabolic diseases


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