Clinical Flashcards
1
Q
Asthma treatment pathway according to NICE?
A
1) SABA
2) low-dose ICS and SABA
3) add in LTRA
4) LABA with ICS (with or without LTRA)
5) MART with ICS
6) MART with higher dose ICS or trial additional drug such as antimuscarinic or theophylline
7) specialist
2
Q
Prescribing advice for LABA?
A
- only add if ICS failing
- do not initiate in rapidly deteriorating asthma
-introduce at a low dose - discontinue if no benefit
- not for exercise-induced asthma unless also using ICS
- review as appropriate with aim to step down
3
Q
Signs of theophylline toxicity?
A
Nausea and vomiting
4
Q
Why do asthma deaths still occur?
A
Underuse of ICS
Over use of B2 agonists
Failure to recognise symptoms
Failure to recognise severity of attack
Incorrect use of inhalers
Underuse of monitoring devices
Lacks of education and training
5
Q
What is classed as uncontrolled asthma?
A
3 or more days a week with symptoms or with SABA use or 1 or more nights awakening with asthma
6
Q
Key features of asthma?
A
Chronic airway inflammation
Cough
Wheeze
Breathlessness
Chest tightness
Reversibility
Trigger factors
7
Q
What is FEV1?
A
forced expiratory volume in 1 second the maximum amount of air that the subject can forcibly expel during the first second following maximal inhalation.
8
Q
Normal FEV1 for age 8-19 years?
A
85%
9
Q
Normal FEV1 for age 20-39 years?
A
80%
10
Q
Normal FEV1 for age 40-59 years?
A
75%
11
Q
Normal FEV1 for age 60-80 years?
A
70%
12
Q
Common types of asthma?
A
Allergic
Non-allergic
Late-onset
Asthma with fixed airflow limitation
Asthma with obesity
13
Q
Physiology of asthmatic airways?
A
Wall inflamed and thickened
Excess mucus production
Tightened airway muscles
Smaller lumen
Dysynchronisd cilia
14
Q
Immune cells involved in mild/moderate asthma?
A
Eosinophils
Macrophages
CD4+ T-cells
Mast cells
15
Q
Immune cells involved in severe refractory asthma?
A
Neutrophils
Macrophages
CD4+ T-cells
CD8+ T-cells
16
Q
Key mediators in mild/moderate asthma?
A
Eotaxin
IL-4
IL-5
IL-13
Nitric oxide
17
Q
Key mediators in severe refractory asthma?
A
IL-8
IL-5
IL-13
Nitric oxide
18
Q
Activators of asthma exacerbations?
A
Viruses
Bacteria
Allergens
Occupational exposure (chemicals)
Irritants (smoke, pollution)
Aspirin
Cold air
Exercise
19
Q
What causes airway inflammation?
A
Cytokines/chemokines
Cell adhesion
Cellular infiltrate/oedema
Increased mucus
IgE increase
20
Q
What happens when mast cells in the airways degranulate?
A
Already inflammation and bronchoconstriction
21
Q
What is Th2 imbalance in allergic asthma?
A
Normally it is an equal balance or favours Th1 but in asthma patients Th2 is greater
22
Q
Local side effects of ICS?
A
Dysphonia
Candidiasis
Cough
Pneumonia
23
Q
Systemic side effects of ICS?
A
Adrenal suppression
Growth suppression
Skin thinning
Osteoporosis
Cataracts
Glaucoma
Metabolic abnormalities
Psychiatric disturbance
24
Q
What are the two response stages of asthma?
A
Acute response
Late response
25
What is the acute asthmatic response?
Bronchoconstriction
Hypersecretion of mucus
Mucosal oedema
Caused by mast cell degranulation
Lasts around an hour
26
What is the late asthmatic response?
Eosinophils attract Th2 T-cells and neutrophils. Causes:
Inflammation
Tissue destruction
Tissue remodelling
2-8 hours after exposure and lasts 1-2 days
27
What are the most common cells to be affected in testicular cancer?
Germ cells
28
Risk factors for developing testicular cancer?
Family history
Cryptorchidism (undescended testicles)
Previous testicular cancer
Testicular carcinoma in situ
Ethnic background
HIV
29
Symptoms of testicular cancer?
Testicular lump that is usually painless
Lumbar back pain
Cough
Dyspnoea
Difficulty swallowing
CNS symptoms
30
How to diagnose testicular cancer?
Ultrasound
MRI
Chest X-ray
Blood tests: AFP, LDH, beta-HCG
31
What is stage 1 testicular cancer?
Tumour confined to testes
32
What is stage 2 testicular cancer?
Tumour spread to abdominal lymph nodes
33
What is stage 3 testicular cancer?
Tumour spread to lymph nodes above diaphragm
34
What is stage 4 testicular cancer?
Tumour invading organs other than lymph nodes
35
How to monitor treatment in testicular cancer?
Changes in tumour markers: AFP HCG
36
Drugs used to treat testicular cancer?
Bleomycin
Etoposide
Cisplatin
Ifosfamide
37
Bleomycin indication?
Metastatic testicular cancer
Non-Hodgkin lymphoma
38
Bleomycin route of administration?
Intramuscular
39
Side effects of bleomycin?
Rigors
Fever
Malaise
Interstitial pneumonia
Nausea and vomiting
Pulmonary fibrosis
40
Etoposide indication?
Carcinoma of bronchus
Testicular cancer
Lymphoma
41
Etoposide route of administration?
Intravenous infusion
42
Side effects of etoposide?
Hypertension
Nausea and vomiting
Abdominal pain
Diarrhoea
Fatigue
Alopecia
Cytopenias
43
Cisplatin indication?
Testicular cancer
Lung cancer
Cervical cancer
Bladder cancer
Head and neck cancer
Ovarian cancer
44
Cisplatin route of administration?
Intravenous infusion
45
Side effects of cisplatin?
Severe nausea and vomiting
Myelosuppression
Nephrotoxic
Hearing loss
Tinnitus
Peripheral neuropathy
Hyperurcaemia
Anaphylaxis
46
Ifosfamide indication?
Testicular cancer
47
Ifosfamide route of administration?
Intravenous infusion
48
Side effects of ifosfamide?
Nephrotoxic
Neurotoxic
Encephalopathy
Nausea and vomiting
Hypersensitivity
Haemorrhagic cystitis
49
Risk factors for cervical cancer?
HPV
Unprotected sex
Chemicals
Age
Smoking
Social deprivation
Muliparity
Early onset of sexual intercourse
50
What are CIN changes?
Cervical intraepithelial neoplasia changes
Grades abnormal cells that lead to cancer
51
Types of cervical cancer?
Squamous cell
Adenocarcinoma
Adenosquamous carcinoma
Small cell cancer
52
Symptoms of cervical cancer?
Unusual bleeding
Smelling vaginal discharge
Post-coital bleeding
Backache
Blood in urine
Bone pain
Weight loss
Loss of appetite
53
What type of test is a smear test?
Liquid-based cytology
54
How often are women aged 25-49 invited for cervical screening?
Every three years
55
How often are women aged 50-64 invited for cervical screening?
Every five years
56
What stage of cervical cancer is treated with chemotherapy?
4
57
Drugs used to treat cervical cancer?
Paclitaxel
Cisplatin/carboplatin
Topotecan
Bevacizumab
58
Paclitaxel indication?
Brest and cervical cancer
59
Paclitaxel route of administration?
Intravenous infusion
60
Side effects of Paclitaxel?
Bone marrow suppression
Neurotoxicity
Hypersensitivity (steroids and antihistamines should be given prior to treatment)
Extravasation
61
Topotecan indication?
Cervical cancer
Small cell lung cancer
Metastatic ovarian cancer
62
Topotecan route of administration?
Intravenous infusion
Oral capsules
63
Side effects of Topotecan?
Diarrhoea
Bone marrow suppression
Hypersensitivity
Sepsis
Alopecia
Mucositis
64
Bevacizumab indication?
Cervical cancer
Metastatic breast cancer
Metastatic colorectal cancer
Metastatic renal cancer
Ovarian cancer
65
Bevacizumab route of administration?
Intravenous infusion
66
Side effects of bevacizumab?
Osteonecrosis of the jaw
Fatigue
Pain
Lack of energy
GI effects
67
Monitoring required for bevacizumab?
Blood pressure
68
Three types of anaesthesia?
Local
Regional
General
69
What is local anaesthesia?
Localised response by inhibiting excitation of nerve endings or by blocking conduction in peripheral nerves. Usually used for minor procedures involving specific tissues
70
What is regional anaesthesia?
Usually involves a larger body area/region
71
What is general anaesthesia?
Involves most of the surgical procedures where patients need to be in an unconscious state
72
How do local anaesthetics work?
Bind reversibly and inactivate sodium channels
73
Examples of amino amide local anaesthetics?
Lidocaine
Prilocaine
Bupivacaine
74
Examples of amino ester local anaesthetics?
Cocaine
Procaine
Tetracaine
Benzocaine
75
Which type of local anaesthetics are more likely to cause hypersensitivity reactions?
Amino esters
76
Why can adrenaline be used with local anaesthetics?
Constricts the surrounds blood vessels to limit the diffusion of the anaesthetic agent, extending its duration of action
77
Contraindications of spinal anaesthesia?
Local infections
Sepsis
Bleeding disorders
Increased inter-cranial pressure
Hypovolaemia
78
What is the difference between spinal and epidural anaesthesia?
The main difference is the placement. With an epidural, anesthesia is injected into the epidural space. With a spinal, the anesthesia is injected into the dural sac that contains cerebrospinal fluid. The direct access means that a spinal gives immediate relief.
79
What adjuvants need to be added to general anaesthesia?
NMBA
Benzodiazepines
Opioids
Anti muscarinic agents
80
What is stage 1 of anaesthesia?
Stage of analgesia
Patient is still conscious but drowsy, usually exhibits a reduced response to painful stimuli
81
What is stage 2 of anaesthesia?
Stage of excitement
Occurs because inhibition is lost before consciousness
82
What is stage 3 of anaesthesia?
Surgical anaesthesia
Reflexes are lost, respiration becomes regular and a muscle tone eventually lost
83
What is stage 4 of anaesthesia?
Medullary depression
Respiratory and cardiovascular control is lost, usually resulting in death
84
What are the five main classes of general anaesthetic agents?
Intravenous anaesthetics
Inhaled anaesthetics
Intravenous sedatives
Synthetic opioids
Neuromuscular blocking drugs
85
Examples of group one general anaesthetics?
Etomidate
Propofol
Barbituates
86
How do group 1 anaesthetic agents work?
Actions mediated by a subset of GABA receptors
87
Examples of group two general anaesthetics?
Nitrous oxide
Xenon
Cyclopropane
Ketamine
88
How do group 2 anaesthetic agents work?
Potently inhibit NMDA receptors
89
Example of group 3 general anaesthetics?
Halogenated volatile anaesthetics
Isoflurane, halothane
90
How do group 3 anaesthetic agents work?
Positive modulation of GABA receptors
Activate 2P potassium channels and inhibit a variety of excitatory cation channels
91
Three main actions of anaesthesia?
Hypnosis
Analgesia
Relaxation
92
Symptoms of malignant hyperthermia?
Rapid rise in temperature
Increased muscle rigidity
Tachycardia
Acidosis
93
Malignant hyperthermia treatment?
IV dantrolene
94
Causes of nausea and vomiting?
Intracranial
Vestibular
Endocrine/metabolic
Radiotherapy
Psychogenic
Drug induced
Gastrointestinal
Surgery
Pain related
95
Receptors involved in nausea and vomiting?
Histaminergic H1
Cholinergic M1
Dopaminergic D2
Serotonergic 5HT3
Neurokinin-1 NK1
96
What is a volume disturbance?
When the volume of body fluids are altered
97
What is an osmolarity imbalance?
When the concentration of constituents in body fluids are altered
98
What is hypovolaemia?
Depletion of extracellular fluid. Concomitant loss of water and sodium
99
Cause of hypovolaemia?
Insufficient fluid intake
Haemorrhage
Diarrhoea
Burns
Vomiting
Endocrine imbalances
100
Symptoms of hypovolaemia?
Thirst
Weakness
Abdominal pains
Nausea
Hypotension
Elevated heart rate
Elevated respiratory rate
101
Treatment of hypovolaemia?
Volume replacement: crystalloids, colloids, blood products
102
What is hypervolaemia?
Excess extracellular fluid. Concomitant gain of water and sodium
103
Cause of hypervolaemia?
Excessive administration of fluids
Glucocorticoids
CKD
Liver disease
CCF
Endocrine imbalances
104
Symptoms of hypervolaemia?
Weight gain
Cough
Distended abdomen
Hypertension
Oedema
105
Treatment of hypervolaemia?
Diuretics
106
Normal plasma sodium range?
136-145mmol/l
107
What is hyponatremia?
Loss of sodium from body fluids or excessive gain of extracellular water
108
Cause of hyponatraemia?
Inadequate sodium intake
SIADH
Diuretic therapy
Adrenal insufficiency
Hypotonic solutions
Heart failure
Nephrosis
Cirrhosis
109
Symptoms of hyponatraemia?
Peripheral oedema
Hypotension
Nausea
Vomiting
Rapid heart rate
Cell swelling leads to cerebral oedema, headache and coma
110
Treatment of hyponatraemia?
Review diuretics
Treat cause
Administer/restrict electrolytes and fluids
V2 receptor antagonist (tolvaptan)
Demeclocycline
111
What is hypernatraemia?
Increased intake of sodium or excessive loss of water
112
Cause of hypernatraemia?
Excessive sodium intake
Corticosteroids
Renal insufficiency
113
Symptoms of hypernatraemia?
Hypotension
Tachycardia
Excessive thirst
Cell shrinking can lead to CNS irritability
114
Treatment of hypernatremia?
Treat underlying cause
IV fluids, such as glucose
Enteral water
115
Normal plasma potassium range?
3.6-5mmol/l
116
Cause of hypokalaemia?
Insufficient intake
Abnormal loss
Drugs: diuretics, corticosteroids, amphotericin, insulin
Endocrine imbalance
Trauma
Burns
117
Symptoms of hypokalaemia?
Mild: mostly asymptomatic
Severe: muscle weakness, ECG changes, arrhythmias
118
Treatment of hypokalaemia?
Potassium replacement, enteral or parenteral
119
Cause of hyperkalaemia?
Renal insufficiency
Increased tissue catabolism
Increase fragility of blood cells
Drugs: ACEi, potassium supplements, potassium-sparing diuretics
120
Symptoms of hyperkalaemia?
Life-threatening cardiac arrhythmias
121
Treatment of hyperkalaemia?
Mild: loop diuretics and NaCl infusion
Severe: calcium gluconate
Insulin/glucose infusion
B-2 agonist infusion
Cation exchange resins such as resonium/zirconium
Sodium bicarb, if acidosis present
122
What is hypocalcaemia?
Decrease calcium intake/absorption or increased calcium excretion
123
Cause of hypocalcaemia?
CKD
Deficient intake/absorption of calcium/vitamin D
Hypoparathyroidism
Hyperphosphataemia
124
Symptoms of hypocalcaemia?
Increased neuromuscular excitability
Prolonged action potentials in the heart
125
Treatment of hypocalcaemia?
IV calcium replacement
Oral calcium or vitamin D replacement
126
What is hypercalcaemia?
Increased calcium intake/absorption or decreased calcium excretion or movement of calcium from the bones to the extracellular fluid
127
Causes of hypercalcaemia?
Hyperparathyroidism
Thiazide diuretics
Excessive intake of calcium/vit D
Bone carcinomas
128
Symptoms of hypercalcaemia?
Nausea
Vomiting
Fatigue
Muscle weakness
Diminished reflexes
Cardiac arrhythmias
129
Treatment of hypercalcaemia?
Phosphates
Calcitonin
Bisphosphonates
Loop diuretics
130
Normal plasma calcium range?
2.15-2.65mmol/l
131
Normal plasma phosphate range?
1.12-1.45mmol/l
132
Main types of antiplatelet drugs?
Theinopyridines
Glycoprotein IIb/IIIa inhibitors
Others
133
Examples of theinopyridines?
Clopidogrel
Prasugrel
Ticlopidine
134
Examples of glycoprotein IIb/IIIb inhibitors?
Abciximab
Eptifibatide
Tirofiban
135
Examples of ‘other’ antiplatelet drugs?
Aspirin
Dipyridamole
Ticagrelor
136
What does the cycloxygenase enzyme produce?
Thromboxane A (TXA2)
Prostacyclin 2 (PGI2)
137
What does Thromboxane A (TXA2) do?
Promotes platelet aggregation
138
What does Prostacyclin 2 (PGI2) do?
Inhibits platelet aggregation
139
Low dose aspirin mode of action?
Irreversibly inhibits cyclooxygenase, which reduces the synthesis of thromboxane A for the life of the platelet
140
Common side effects of low dose aspirin?
GI irritation
Prolonged bleeding time
Allergy
141
Rarer side effects of low dose aspirin?
GI bleed
Intracranial bleed
142
Can low dose aspirin be used in pregnancy?
Category C in pregnancy
Low doses are considered safe but should be avoided where possible in the third trimester
143
Clopidogrel/prasugrel mode of action?
Block the platelet ADP receptor (P2Y12) which prevents activation of the platelet glycoprotein IIa/IIIb complex, preventing platelet aggregation and thrombus formation
144
When would clopidogrel be used alongside aspirin?
After having a CV event whilst on aspirin or after stenting
145
When should aspirin be taken with prasugrel?
In most cases
146
Comparison of prasugrel and clopidogrel in ACS after PCI?
Prasugrel superior in primary outcomes (death, stroke, MI) and secondary outcomes (stent thrombosis)
Prasugrel had an increased risk of bleeding
Overall mortality did not differ between the two groups
147
Prasugrel dose?
Loading dose of 60mg then 10mg daily. Reduced to 5mg daily if over 75 years old or less than 60kg
148
Dipyridamole mechanism of action?
Inhibits platelet function by inhibiting phosphodiesterase, thereby increasing cAMP, which blocks platelet response to ADP
149
Dipyridamole indications?
In combination with warfarin in patients with prosthetic heart valves
In combination with aspirin for the secondary prevention of stroke
150
Dipyridamole side effects?
Headache
Hot flushes
Hypotension
Tachycardia
Allergic reactions
151
Ticagrelor mechanism of action?
Binds reversibly to P2Y12 receptor inhibiting platelet aggregation
152
Ticagrelor indication?
For use in ACS with aspirin.
153
Ticagrelor with aspirin VS clopidogrel with aspirin?
Ticagrelor more effective in preventing CV events in ACS patients
Significant reduction in MI and vascular death but a non-significant increase in stroke noted
Total bleeding similar but rate if ICH higher with ticagrelor
Risk-benefit of ticagrelor less favourable when used with aspirin doses above 150mg daily
154
Side effects of ticagrelor?
Bleeding
Nausea
Diarrhoea
Headache
Non-cardiac chest pain
155
How are glycoprotein IIb/IIIa receptor inhibitors administered?
Intravenously
156
Mechanism of action of glycoprotein IIb/IIIa receptor inhibitors?
Prevent binding of fibrinogen to platelet by occupying platelet glycoprotein IIb/IIIa receptor, reducing platelet aggregation
157
Main groups of anticoagulants?
Indirect parenteral anticoagulants
Direct thrombin inhibitors
Vitamin K antagonists
Factor Xa inhibitors
158
Examples of indirect parenteral anticoagulants?
Heparin
LMWH
Danaparoid
159
Examples of direct thrombin inhibitors?
Dabigatran
Bivalirudin
160
Examples of vitamin K antagonists?
Warfarin
Phenindione
161
Examples of factor Xa inhibitors?
Apixaban
Edoxaban
Rivaroxaban
Fondaparinux
162
Heparin onset of action?
Almost immediate
163
Heparin mechanism of action?
Heparin binds to antithrombin III, causing a conformational change allowing antithrombin to rapidly
combine and inhibit thrombin
It also inactivates factor Xa
164
Can heparin be used in pregnancy?
Yes, it does not cross the placenta as it has a large molecular weight
165
How can heparin be administered?
IV or SC
166
Why can heparin not be administered intramuscularly?
Risk of haematoma
167
Heparin side effects?
Haemorrhage
Bruising or pain at injection site
HIT
Hypersensitivity reactions
168
Heparin monitoring?
Platelet count on days 0, 3, 5 and then on alternative days if treatment continued
APTT target range of 1.5-2.5 times of control
169
LMWH mechanism of action?
Enhance effects of antithrombin III but have a higher ratio for factor Xa than IIa, so has a more selective Xa activity
170
Which is more Xa selective LMWH or danaparoid?
Danaparoid
171
LMWH monitoring?
AntiXa levels but only in at-risk patients
172
LMWH vs heparin in regards to bleeding?
Similar incidences of bleeding but protamine only partially effective with LMWH
173
LMWH vs heparin in regards to renal impairment?
Incidence of bleeding higher with LMWH
174
LMWH vs heparin in regards to HIT?
Lower risk with LMWH but there is 90% cross-reactivity, so LMWH is not an alternative to heparin in a patient with HIT
175
LMWH vs heparin in regards to preventing VTE in general surgery patients?
Similar efficacy, but LMWH can be given once daily, although it is more expensive
176
LMWH vs heparin in regards to preventing VTE in orthopaedic patients?
LMWH seen to be more effective
177
LMWH vs heparin in regards to treating DVT?
LMWH are at least as effective as heparin in preventing recurrence and reducing overall mortality in hospital patients. LMWH is more expensive, but since monitoring is not required and can be used for outpatients, this may offset the cost
178
Warfarin mode of action?
Impairs utilisation of vitamin K and reduces the synthesis of some clotting factors and proteins. thought to interfere with clotting factor synthesis by inhibition of the regeneration of vitamin K1 epoxide
179
Which clotting factors and anticoagulant proteins does warfarin reduce the synthesis of?
2,7,9,10
Proteins C and S
180
Why does warfarin take time to exert its full anticoagulant effect?
It has not direct action on the coagulation factors present in the blood so the effects start once these factors are cleared. The factors have half-lives between 24 and 50 hours
181
Warfarin contraindications?
Bleeding disordered
Previous GI bleed
Haemorrhagic retinopathy
Intracerebral haemorrhage
Severe hypotension
Bacterial endocarditis
Alcoholism
Unsupervised dementia
Frequent falls
182
Warfarin in renal and hepatic impairment?
Cautioned
183
Warfarin in pregnancy?
Avoid- teratogenic and can cause placental haemorrhage
184
How can warfarin interact with other drugs?
Decreased hepatic synthesis of procoagulant factors
Inhibition of enzymatic metabolism of warfarin
Increased receptor affinity for warfarin
Decreased vitamin K synthesis
Displacement of warfarin from protein binding sites
Increased metabolism of warfarin
185
INR range for AF, DVT, PE and bio-prosthetic heart valves?
2.0-3.0
186
INR range for mechanical prosthetic heart valves?
2.5-3.5
187
How often is INR monitored?
2-3 times weekly until three consecutive readings are within 0.5 of each other, then weekly for four weeks and then every 4-6 weeks when stable
188
Warfarin counselling points?
?Do not change brands
Take at same time of day
Stabilise vitamin K intake
Avoid excessive alcohol intake
Care with OTC and herbal products
Warn about early signs of haemorrhage
189
Warfarin antidote?
Phytomenadione
190
How does dabigatran/bivalirudin work?
Binds directly to thrombin to block its effect
191
Which type of anticoagulants also have an antiplatelet affect?
Dabigatran
Bivalirudin
192
Dabigatran indications?
Prevention of VTE after elective hip or knee replacement
Treatment of acute VTE and prevention of subsequent VTE
Non-valvular AF and a high risk of stroke or systemic embolism
193
Common dabigatran drug interactions?
Clarithromycin
Verapamil
Ketoconazole
194
Common dabigatran side effects?
Gastritis
Dyspepsia
GI bleed
195
Dabigatran counselling points?
Importance of not missing doses
Do not open capsules or chew or crush as it can increase the risk of bleeding
Take at the same time of day
Monitor for signs of bleeding
196
Dabigatran reversal agent?
Idarucizumab
197
Factor Xa inhibitor mechanism of action?
Selectively inhibits factor Xa, blocking thrombin production, conversion of fibrinogen to fibrin and thrombus development
198
Can factor Xa inhibitors be used in valvular AF?
No
199
Common DOAC interactions?
Ketoconazole
Itraconazole
HIV protease inhibitors
Rifampicin
St Johns wort
Carbamazepine
200
When to consider DOACs over warfarin?
Lots of interacting medicines or frequent antibiotic courses
High alcohol intake
Unable to cope with variable dosing
201
Warfarin vs DOAC in renal impairment?
Warfarin clearance less affected by renal function
202
DOAC positives?
No INR monitoring
No known food interactions
203
DOAC negatives?
Cannot be used in valvular AF
High cost
Shorter half-life so greater effect with compliance issues
Less evidence for reversal agents
204
Warfarin positives?
Longer half-life so compliance less of an issue
Cheap
Lots of experience with its use
Can be used in valvular AF
Reversal agent
205
Warfarin negatives?
INR monitoring
Food interactions
206
Appropriate starting dose of beclometasone ICS in ages 5-16?
50mcg BD
207
Appropriate starting dose of beclometasone ICS in ages 17+?
100mcg BD
208
What is low-dose budesonide ICS in adults?
<400mcg daily
209
What is moderate-dose budesonide ICS in adults?
>400<800mcg daily
210
What is high-dose budesonide ICS in adults?
>800mcg daily
211
What is low-dose budesonide ICS in under 16s?
<200mcg daily
212
What is moderate-dose budesonide ICS in under 16s?
>200<400mcg daily
213
What is high-dose budesonide ICS in under 16s?
>400mcg daily
214
How often to clean a spacer?
Monthly
215
How often to change a spacer?
6-12 months
216
Difference between NICE and GINA?
NICE: LTRA after ICS
GINA: LABA after ICS
GINA does not recommend SABA alone
217
Why does NICE use LRTA second line?
Cost-effective, even though evidence shows LABA more effective
218
Chlamydia treatment?
Doxycycline 100mg BD for seven days
OR azithromycin 1g stat (useful in pregnancy)
219
Gonorrhoea treatment?
Ceftriaxone 500mg IM/IV stat AND azithromycin 1g stat OR doxycycline 100mg BD for 10 days
220
Early/late latent syphilis treatment?
Benzathine penicillin 1.8g IM stat OR procaine penicillin 1.5g IM daily for 10 days
221
Tertiary syphilis treatment?
Ben pen 1.8g every four hours for 15 days
222
Trichomoniasis treatment?
Metronidazole 2g stat OR tinidazole 2g stat
In relapse metronidazole 400mg BD for 5 days
223
First episode of genital herpes treatment?
Aciclovir 400mg TDS for 10 days
(Stop treatment after 5 days if worked)
224
Episodic genital herpes treatment?
Aciclovir 800mg TDS for two days
225
Prevention of genital herpes?
Aciclovir 400mg BD
226
Treatment of pubic lice?
Permethrin
227
Microbiological features of chlamydia?
Gram-negative (ish)
Lacks cell wall
Non-motile
Has two forms: elementary bodies, which are cocci, and articulate bodies, which are pleomorphic
228
Is chlamydia an intracellular or extracellular pathogen?
Intracellular
Grows in host cells as does not have genes for ATP production
229
What causes chlamydia?
Chlamydia trachomatis
230
Which form of chlamydia bodies are infective?
Elementary
231
Which form of chlamydia bodies can replicate and how?
Reticulate. Through binary fission within phagosomes
232
What cells can chlamydia infect?
Conjunctiva
Trachea
Bronchi
Urethra
Uterus
Anus
Rectum
233
Does chlamydia cause genital lesions?
Yes. Initially a lesion forms as bacteria multiply. This is I ften missed though, internal in women
234
How can chlamydia be transmitted?
Drops
Hands
Fomites
Flies
235
Chlamydia symptoms in women?
85% asymptomatic
Unusual vaginal discharge
Pain when urinating
Low abdominal pain
Bleeding between periods or after sex
Pain during sex
236
Chlamydia symptoms in men?
75% have symptoms
White/cloudy/watery discharge
Pain/burning when urinating
Testicular pain or swelling
237
Diagnosis of chlamydia?
Urine test or swab
238
Cause of gonorrhoea?
Neisseria gonorrhoeae
239
Microbiological features of gonorrhoea?
Gram-negative
Diplococci
True pathogen
240
What cells can gonorrhoea infect?
Genital mucosal membranes, urethra, digestive tract, cervix, uterus, rectum, pharynx, mouth
241
Gonorrhea secretes?
A protease that cleaver IgA
242
Gonorrhoea symptoms in men?
Usually symptomatic
Acute inflammation
Painful urination
Purulent discharge
Can cause infertility
243
Gonorrhoea symptoms in women?
Often asymptomatic
Often mistaken for bladder infection
Infects cervix
Can lead to pelvic inflammatory disease
244
Diagnosis of gonorrhoea?
Urine sample or swab
245
Why do athletes use drugs?
Legitimate therapeutic use
Performance continuation
Recreationally
Performance enhancement
246
What is WADA?
World anti-doping agency
247
Five main groups of performance enhancing drugs?
Stimulants
Anabolic steroids
Diuretics
Narcotic analgesics
Peptides/hormones
248
Activation of what receptors in the gut can cause nausea and vomiting?
5HT3
D2
NK1
249
Activation of what receptors in the chemoreceptor trigger zone can cause nausea and vomiting?
5HT3
D2
M1
250
Where is the chemoreceptor trigger centre found?
Area postrema
251
Activation of what receptors in the cerebral cortex can cause nausea and vomiting?
NK1
GABA
5HT
252
Activation of what receptors in the vestibular nuclei can cause nausea and vomiting?
M1
H1
253
Activation of what receptors in the vomiting centre can cause nausea and vomiting?
M1
H1
Mui opioid
5HT3
NK1
254
What gene is defective in CF?
CFTR
255
What does the CFTR gene stand for?
Cystic fibrosis transmembrane conductance regulator
256
What does the CFTR gene control?
Transport of chloride
257
Is CF dominant or recessive?
Recessive
258
What is the most common CFTR gene mutation?
Delta-F508
259
Common places to find CFTR channels?
Sweat glands
Lungs
Pancreatic duct
GI tract
260
How many functional mutation classes of CF are there?
Six
261
How is CF tested for in newborns and when?
Heel prick blood test on day six of life
262
Ways to diagnose CF?
Heel prick blood test
Sweat test
Genetic test
263
What type of sweat is produced in individuals with CF and why?
Hypertonic (salty) as since Cl- cannot be reabsorbed so to balance the electrical charges, neither is Na+
264
What is ASL in the lungs?
Airway surface liquid
265
What is airway surface liquid?
Salt containing, mucus gel layer that traps bacteria and foreign particles breathed in. Then wafted out by cilia
266
How is airway surface liquid affected by CF?
Excess Na+ reabsorbed from the ASL and water follows so it becomes sticky and dehydrated
267
Lung management in CF?
Chest physiotherapy
Mucus modifying drugs
Vibrating vest
Regular sputum samples
Prophylactic antibiotics
Bronchodilators
Transplant
Gene therapy
268
Effects of CF on the pancreas?
Pancreatic insufficiency
Nutrient malabsorption
Constipation
Bloating
Pancreatitis
Can lead to diabetes
Fats and fat-soluble vitamins not absorbed
269
Effects of CF on the liver bile duct?
Obstruction of liver bile duct
Biliary cirrhosis
Inflammation
Scarring
Fibrosis
270
Effects of CF on the GI system?
Malnutrition
Vitamin deficiency
Intestinal obstruction
Intussusception
271
Effects of CF on the reproductive system?
Infertility
272
Effects of CF on the sinuses?
Sinusitis
Nasal polyps
273
Why is reproduction affected in patients with CF?
98% of males have no vas deferens
Females have thick cervical mucus
274
What does HIV bind to?
CD4 antigens on lymphocytes, macrophage
275
What to monitor when using antiretrovirals?
Clinical status and compliance
HIV viral load
CD4 cell count
Toxicity through FBC, U and Es every three months
Cardiovascular risk
276
Common opportunistic infections in HIV?
PCP
CMV
MAC
277
What causes pubic lice?
Phthirus pubis
278
Drugs that target bacterial cell walls?
Beta-lactams
Glycopeptides
279
Antibiotics that target bacterial protein synthesis?
Aminoglycosides
Chloramphenicol
Fusidic acid
Clindamycin
Macrolides
Tetracyclines
280
Antibiotics that target folate synthesis?
Sulphonamides
Trimethoprim
281
Antibiotics that target transcription of bacterial RNA?
Rifampicin
282
Antibiotics that target bacterial DNA gyrase and topoisomerase IV?
Quinolones
283
How do penicillins work?
Bind to penicillin-binding proteins resulting in weakness of the cell wall and lysis
284
General penicillin spectrum of action?
Many Gram-positive organisms and gran-negative cocci
285
Which penicillin does not need to be taken on an empty stomach?
Amoxicillin
286
Examples of beta-lactam inhibitors?
Clavulanate
Tazobactam
287
Common side effects of penicillin?
Diarrhoea
Nausea
Superinfection
288
Rare side effects of penicillins?
Anaphylaxis
Bronchospasm
SJS
TEN
289
Common penicillin drug interactions?
Probenecid
Oral contraceptives
Anticoagulants
290
Benzylpenicillin spectrum of activity?
Neisseria meningitidis
Neisseria gonorrhoeae
291
600mg of benpen in units?
100 million units (1 mega unit)
292
Key points of benzathine penicillin?
Slowly released from IM injection site and is hydrolysed to benpen
Gives low serum concentrations for up to one month
Treatment for syphilis
293
Key points of procaine penicillin?
Mix of procaine and benpen
Procaine slows absorption of penicillin which gives a plateau-type blood level at four hours which gradually falls over the next 15-20 hours
294
First-generation cephalosporins?
Cefazolin
Cefalotin
Cefalexin
295
Second-generation cephalosporins?
Cefaclor
Cefoxitin
Cefuroxime
296
Third-generation cephalosporins?
Cefotaxime
Ceftriaxone
Ceftazidime
297
Fourth-generation cephalosporins?
Cefipime
298
Moderate spectrum cephalosporins?
Cefaclor
Cefalotin
Cefoxitin
Cefuroxime
Cefalexin
Cephazolin
299
Broad spectrum cephalosporins?
Cefepime
Cefotaxime
Ceftaroline
Ceftazidime
Ceftriaxone
300
What can happen with rapid IV administration of cephalosporins?
Seizures
301
Monitoring with cephalosporins?
Renal function and FBCs with high doses or prolonged therapy
302
What is the main macrolide used in STIs?
Azithromycin
