so we intervene with treatment to shorten the evolution and to reduce the

severity of the evolution of the disease but if we think of the natural evolution of
the condition as how it would develop and change over time without intervention
now incubation is a term which really describes the period from when someone is
infected with a microorganism to when clinical features develop so the incubation
period is two talking about infectious communicable disease from when the
person is exposed to the microorganism and that gets into the person's tissues in
some way up until clinical features develop the incubation period and it's
important to remember that in many conditions the patient will be infectious in
the incubation period an HIV is a classic example of this the incubation period
prior to seroconversion can be many months but the patient can be infectious
during that time when the patient has no knowledge that they have the disease
because they're feeling fine they're in the incubation period other incubation
periods can be much shorter so for example with food poisoning the incubation
period might just be an hour or two before the patient starts feeling unwell now
in some conditions especially those were the slow onset or a slow evolution there
is a prodromal phase there is a prodrome now the prodromal phase is when the
patient feels unwell but the disease is not localized to any part of the body and
very often what you find is that the disease becomes progressively localized over
time so initially the patient just reports that they're not feeling very well they're in
a program or phase and then after time we realize it was caused by a respiratory
infection or were you in a retract infection as the features localize and the
infection becomes obvious and then with hindsight we can see that the
prodromal features were in fact caused by a developing you're in a retract
infection or whatever it turned out to be remission so multiple sclerosis is an
absolutely classic example it's a disease characterized by relapses and remissions
when the person relapses they relapse back into the disease and they develop
features of the disease again or we might think about patient that has been an
alcoholic and they stop drinking and then one day they start drinking again they
relapse into alcoholism or bipolar disorder where a person is cyclo thalmic very
often alternating between periods of normality but they can become hypomanic
manic or depressed so they can have periods of normality then they relapse into
depression or relapse into mania and recently some people with the bola fever in
Africa who it was believed had got better they relapsed again for a period of time
after the symptoms of the disease had apparently gone away so relapses the
return of a disease or the return of clinical features of a disease in an actual fact
the disease had never quite gone away now the converse of relapse is remission
in remission the condition goes into respite or abeyance and we normally use the
term remission where the disease goes away to indicate a temporary state of
affairs so a disease that is in remission may well come back again so the patient
could suffer from a disease for a period of time then go into remission and then
it's possible that the condition would relapse again a good example is Crohn's
disease so the person can go into remission for a period of time apparently having
no features of Crohn's disease but then they can relapse potentially with a severe
complication such as a gastrointestinal perforation or we often talk about cancers
going into remission so we might say that Paige's leukemia is in remission the
leukemia might not absolutely gone away they might not be cured but they're not
suffering from features of leukemia at that period of time therefore we could say
the new Kimia is in remission and that's the same for quite a few malignant
diseases the patient can go into remission we can't say it's all clear that the
definite cured but they are for that period of time in remission free from clinical
features now exacerbation refers to a worsening or an increase in severity of a
condition and the condition has to be there already for it to get worse so it's
when a pre-existing condition gets worse so an exacerbation factor is something
that is going to aggravate the disease so for example the patient's asthma might
be exacerbated by air pollution patient chronic obstructive pulmonary disease
could be exacerbated by an acute bacterial infection the patient's achy joints
could be exacerbated by the cold weather is something that's making it worse
now convalescence refers to a period of recuperation a period of recovery and it's
normally gradual so in convalescence is really referring to the period of time from
when the clinical features of the disease abate to when the clinical features of the
disease go to the time where the patient returns to normal duties and normal
levels of activity there's going to be a period of recovery so in the surgical
situation of a patient's had an operation they discharged from hospital they're
probably not going to go back to work straightaway especially if they have a heavy
manual job they're going to need a period of convalescence before they can
return to normal duties and during any period of convalescence the patient is
probably going to need food they're going to need rest and they're going to need
psychological support and company to aid in their convalescence to return to
normal levels of activity after a period of illness now sequela a sequela well
actually technically it would be one sequela sequela you would be plural what this
means is it is a condition which is a consequence of a previous condition or a
complication so for example sequela of myocardial infarct action might include
left ventricular failure and pulmonary edema it's a condition which complicates an
original condition a sequelae of some streptococcal infections of the throat might
be lemuria nephritis as the quality of diabetes could be the development of
chronic kidney disease or diabetic retinopathy or peripheral vascular disease
sequelae of stroke could include dysphasia difficulty in speech dysphagia difficulty
in swallowing and hemiparesis or hemiplegia a weakness or paralysis down one
side of the body sequela of a major trauma might be a post-traumatic stress
disorder or after a head injury sequani could include headaches anxiety
depression motor dysfunction as a complication of the head injury so the sequela
are complications that come after and are caused by a particular condition as a
consequence of that condition now a terminal disease is one which is going to
result in the death of the individual where we would not expect the patient to
recover it's going to be terminal and it's going to be the cause of the patient's
death now there's quite a lot of conditions patients can die with but a terminal
condition is one they will die from so quite a lot of many of their 80s who died will
probably have prostate cancer but not die from prostate cancer they will die with
prostate cancer but they might die from congestive heart failure or from cerebral
vascular accident or from myocardial infarction or from a myeloid leukemia or
whatever the terminal disease is now prognosis means how the disease will do in
the future so when we give a patient a prognosis we tell them how the disease is
likely to evolve in the future and sometimes we can give a patient a good
prognosis so if a patient has an acute bacterial infection such as a cellulitis we
treat that with flucloxacillin can say the prognosis here is excellent you have a
good prognosis it's overwhelmingly likely you will make a full recovery but
unfortunately sometimes the prognosis can be bad where we're not expecting a
good outcome for example the patient presents with a bronchogenic primary
carcinoma especially in the later stages the prognosis is not going to be good
there's going to be a bad prognosis other times you might describe the prognosis
as being guarded basically that saying well we don't know what's going to happen
we kind of hope for the best but we're not giving you any guarantees in this
situation other times of course the prognosis is excellent so a patient might report
with a common cold and we can say well don't worry the prognosis here is
excellent you're probably going to have a runny nose and feel unwell for five or
six days and then you're going to be better and return to normal activity fairly
quickly so the problem notice is what is likely to happen in the future evolution of
this condition now in this section I want to think about some epidemiological
terms epidemiology is the study of the distribution of disease and this is
important because allows us to track the health of the population looking at the
amount of disease in a population and the distribution of that disease can tell us
all sorts of things about what causes the disease and how we can manage the
disease and minimize it and minimize the impact of that disease and the first term
is incidence now the incidence is the rate at which new cases of the disease occur
in the population so we would normally talk about the incidence of disease over a
year period so in a particular population there are so many new cases of a
particular disease over a one year period and this is important because it
describes the risk that an individual is likely to contract a particular disease now
some diseases are going to have relatively low incidence while other diseases
have relatively high incidence so for example I wonder what the of common cold
is in the north of England at the moment well most people get a cold at least once
a year so I would imagine the incidence of common cold in the north of England is
about 900 cases per thousand per year so there might be a few people don't get a
cold in a year but most people will so I have a high incidence now prevalence is
different because prevalence is the number of cases in a particular area at a
particular time so incidence is the number of new cases prevalence is the number
of cases at one point in time the number of cases of multiple sclerosis in a
particular city today and that would be called the point prevalence and we can
give that as a percentage so point prevalence can be useful how many people are
suffering from a particular condition in a particular area today but an alternative is
what we call period prevalence that would be the number of people that suffer
from a particular condition over a period of time so for example a study was done
a British women between the ages of 30 and 39 and it was found over a 12-month
period that thirty three point six of them suffered from lower back pain at some
point during that 12 months so that would be a period prevalence so point
prevalence how many people have got the condition today period prevalence
how many people suffer from a condition over a period of time and prevalence
can actually also be defined as the incidence multiplied by the average duration of
a condition so the number of people with a condition in a particular population is
going to depend on how many new cases and how long the person suffers from
the condition so what we normally find is acute conditions have a high incidence
but a lower prevalence because they don't last for very long but chronic
conditions will have a lower incidence compared to their prevalence so the
patient develops chronic bronchitis and emphysema for example they're going to
suffer from that condition for a long period of time so the prevalence is going to
be relatively high but hopefully the number of new cases per year is going to be
much lower than that or it will be much lower than that and hopefully as low as
possible now the term morbidity relates to the burden of disease in a population
so morbidity is relating to disease so we could identify factors in populations
which are increasing or decreasing morbidity the amount of people suffering
from a particular disease and the burden of that disease to a particular society but
mortality is specific to death so mortality is talking about what is causing death in
a particular population now we could talk about crude death rates and crude
death rates just records the number of deaths per year in a population but that
doesn't tell us too much because it's not telling us about the cause of those
deaths and it's not telling us about the age at which people died or it's not telling
us about the sex of the people that died so another way we can do it is to give
mortality figures in terms of a condition and again we can have a crude death rate
for a condition that just tells us the overall figures so between 1985 and 1989 the
crude mortality for people dying of lung cancer in the UK was 1034 per million of
the population per year so that tells us that crude death rate for a particular
condition but it were much more interesting to know at what age people were
dying and what sex people were dying and these further studies have been done
and this gives us more specific death rates related to age and related to sex now
correlation studies are where two variables are recorded so for example a
variable might be the amount of alcohol consumed and the amount of alcoholic
cirrhosis in a population or the number of cigarettes smoked with the incidence of
lung cancer or myocardial infarction in a population and what we would normally
find in these situations is that these two variables were positively correlated the
more people smoke the more lung cancer we would expect to see the more
people drink the more alcoholic cirrhosis we were likely to see so two variables
are positively correlated when one increases as the other increases but another
type of correlation could be a negative correlation that two factors are negatively
correlated and what this means is that as one variable goes up the other variable
will go down so for example if the amount of vaccination against a particular
disease in the population goes up we would expect the incidence of new cases of
that infectious disease to go down if people take more exercise in a population
we would expect the prevalence of obesity to reduce so we would expect a
negative correlation between exercise and obesity other times when we look at
two variables we find that they're not really correlated at all and in that case the
result would simply show that there was no correlation or there might be small
degrees of correlation and again these could be negative or positive correlations
now screening is where we go out and look for early signs of a disease in the
general healthy population so for example women should be screened for the
development of cervical cancer because from when the cells first start changing
to when they become malignant there's usually a few years where we can
intervene to prevent the malignancy so screening is looking at healthy members
of the population looking for early signs of disease in order to prevent disease so
everyone should have their blood pressure done everyone should be screened for
the development of hypertension because we've got very good drugs for treating
hypertension and preventing the hypertension and we know that if we prevent
the hypertension we're going to prevent the long term complications of
hypertension such as heart failure or renal disease or atherosclerosis but what
we're not so good at is treating those conditions once they have occurred so
much better to prevent rather than cure and those we're screening comes in now
a sporadic disease just occurs irregularly there might be irregular intervals or it
only occurs in a few apparently random places it might be scattered or isolated
and because it's random we can't really correlate the causality of the condition so
very often the causes are not apparent it's not a regular it's not a constant
presentation of disease it's just sporadic odd isolated cases from time to time so
for example we get sporadic occurrences of creutzfeldt-jakob disease you might
get a case there you might get a case somewhere else no apparent connection
between them is just sporadic now our cluster is where you get an aggregation of
cases at a particular place or a particular time when you get more cases than
would be expected in that particular place or time so for example you might get a
cluster of hemolytic uremic syndrome caused by E coli o157 and then of course
the challenge is to isolate the origin of that outbreak to identify the cause of the
cluster now an epidemic refers to a sudden increase in the incidence of a disease
there is an outbreak of a particular condition so there might be an outbreak of
influenza causing an epidemic this could be a localized epidemic or it could be a
national epidemic of disease endemic means that can do is always present in the
population so whenever you look there's going to be some cases of that disease
so unfortunately malaria is endemic in Africa there's always going to be a certain
amount of cases although many people are struggling valiantly to reduce the
number of cases in the UK you're always going to get some diabetes in fact in
many societies perhaps virtually all societies in the world now you're going to get
some diabetes has become endemic but pandemic means it's spreading all over
the globe so a pandemic is like an international epidemic so HIV is a recent
example of a pandemic where it's spread all around the world affecting many
countries pandemic doesn't have to be a communicable disease we can actually
say that there's a pandemic of diabetes or a pandemic of obesity in the world at
the moment whereas these conditions are spreading or these conditions are now
appearing in many areas of the world now we want to think about the types of
treatment that we can give our patients and ideally everyone would receive a
curative treatment that means we give our treatment preferably for a short
period of time preferably without side effects and as a result we're able to
eliminate the disease condition we cure the patient and the patient will then live
the rest of their lives because we have cured them and actually examples of
absolute cure in healthcare are rather difficult to think of because there's not that
many actually but we do have some for example a patient might suffer from an
infection and providing we give antibiotics at an early stage we can completely
eradicate that infection hopefully we will have eradicated the infection before the
patient's tissues are damaged the patient then goes on and lives the rest of their
life with no relapse of that disease condition another example is wolff-parkinson-
white where the patient can get reentry tachycardias the interventional
cardiologists can apply the ectopic conducting focus the abnormal lesion they just
get rid of it altogether they can cry o it or they can get rid of it with
radiofrequency ablation and they just get rid of it and the patient carries on and
lives the rest of their life with no relapse into that disease State or some
nutritional deficiencies for example of a patient reports with edema as a result of
protein deficiency we give an adequate amount of protein in the diet and then
the edema goes away in the patient is cured because we have eliminated the
particular nutritional deficiency causing the disease State so we always aim to
cure our patients but unfortunately the converse of curable is incurable and in an
incurable condition we either can't cure the condition we can't get rid of it we
don't have a treatment to manage it or we do manage it but there's a possibility
that the patient may relapse and there's so many long-term conditions that we
manage we don't cure them so prior to nineteen twenty to everyone who
developed type one diabetes would die it was an automatic death sentence the
only question was how long would it take but now we can manage people with
insulin for years decades and the newly diagnosed patient with type one diabetes
can look forward to many decades of healthy life because we manage the
condition but the insulin doesn't cure it if we stopped administering the insulin
the patient would relapse into absolute insulin deficiency develop diabetic
ketoacidosis and they would die of the condition so many diseases are incurable
but we're fortunately able to manage them effectively and how patients respond
to treatment is interesting some people are good responders or they respond well
to a treatment so for example someone has epigastric pain we give an antacid the
pain goes away that this epigastric pain was in fact caused by gastroesophageal
acid reflux and we were able to manage that and the fact that the patient
responded well to that is an indication that we made the correct diagnosis or on
patient suffers some crushing central chest pain on exercise we give glycerin try
nitrate and a very short time after that the pain is gone indicating that yes the
glycerine try nitrate probably was dilating the arterial vessels probably was
dilating the coronary arteries restoring the blood supply to the ischemic
myocardium oxidizing the lactic acid and getting rid of the pain indicating that the
condition probably was in fact what we suspected because of how it responded to
the treatment but other times patients may respond badly indicating that we are
probably given the wrong treatment or giving a treatment which is not efficacious
for that particular condition all other times patients might respond for a period of
time there might be transient responders again indicating what is possibly wrong
with the patient by the way that they respond to the treatment that we give now
other treatments are symptomatic now a symptomatic treatment is treating the
symptoms as opposed to treating the cause so symptomatic treatments actually
are the converse of causal curative treatments and actually it's not very hard for
us as healthcare professionals to improve patient symptoms on many occasions
so analgesics for example are symptomatic treatments we can give a lot of
analgesic drugs taking away the symptom of pain and in the vast majority of cases
that is a good thing to do but there are other conditions where it's easy for us to
treat the symptoms and that is not necessarily benefiting the cause of the disease
and indeed it can be making the cause of the disease worse so for example any
patient who has an infection induce fever it's very easy for us to get rid of that
with paracetamol or ibuprofen and we can bring the patient's temperature back
down to normal really quickly within about 20 minutes or half an hour after giving
a gram of paracetamol and the patient will feel much better and they'll think
you're very clever for making them feel better so quickly but of course what
you've actually done by bringing the patient's body temperature down is reduce
the efficiency of their immune system that can mean that the microorganism
might proliferate more than it would otherwise have done so yes you've made
the patient feel better you've relieved the symptoms but what have you done to
the underlying cause of the disease well nothing or you've made it worse or again
if patients have diarrhea is very easy for us to give symptomatic treatments we
can give vomiting or various anti motility agents we could even give opiates and
we can stop the diarrhea that's not hard to do but if the diarrhea was caused by
infections such as bacteria or amoeba then those infectious organisms or indeed
viruses those infectious organisms will be stuck in the lumen of the
gastrointestinal tract they're no longer being washed out by the diarrhea like
they're supposed to be really into flow the microorganisms should be washed out
in the flow of diarrhea but by blocking the diarrhea you have prevented the
excretion of the microorganisms from the lumen of the gut that means they're
free to proliferate making the infection worse potentially making the patient
septic or potentially for example amoeba could migrate of the biliary system
causing a me big liver abscesses so treating the symptoms isn't hard but it's not
always appropriate sometimes it is but we've got to decide when it is appropriate
virtually all inflammatory skin conditions will respond to hydrocortisone cream
but if that inflammatory skin condition is caused by a virus or by a fungal infection
that's the last thing we want to do that will be contraindicated because when we
take away the inflammatory response we are stopping the body's natural
localized immunological response from combating that viral infection or that
fungal infection or that bacterial infection yes it will work straight away yes it'll
make you look good the patient often you're clever for a short period of time but
actually in the long run you're making them worse and indeed you are even
putting their life a danger so always consider is a symptomatic treatment
appropriate or not sometimes it will be sometimes it won't you have to decide
that giving antiemetics is another good example if we give unto your metics we
can stop the patient vomiting but again does that mean that we are leaving
microorganisms in the gut which will proliferate making the infection worse if so
don't give the antiemetics now the final type of treatment we'll want to consider
at the moment is palliative treatment now palliative care ideally should be
multidisciplinary and it is aimed at symptom relief it is not aimed at a causative
cure or treatment we are not trying to make this patient better we're trying to
take away suffering and we're trying to improve the quality of the patient's life
and indeed include the quality of the family members lives as well so this is my
involved treatment of pain it might involve treatment of mental and physical
stress and distress or treatment of nausea or indeed we could give surgical
palliative treatments such as debulking a fungating tumor it's not going to take
away all the cancer from the body but it's going to make the patient feel a lot
better because we're taking away the fungating tumor it is improving the quality
of life by treating the symptoms the aim of palliative care is good quality of life
the aim of palliative care is not to cure the disease we would if we could but we
can't it comes from the latin word polari and polari means to cloak or to cover up
and that's what palliative care is doing it is covering up the symptoms it is not
curing the individual on this occasion