Pulm Health and Society Flashcards
Who should be on a high-dose nicotine patch?
Anyone who smokes more than 1/2 a pack of cigarettes/day
According to survey data, the 3 most prevalent sympmtoms causing burden for CF patients were….
Cough
Shortness of Breath
Lack of Energy
What drug therapies increase risk factors for TB disease?
- TNF antagonist therapy
- Corticosteroid therapy
Both for acquiring new disease and activating latent TB
How soon before a paitent’s quit date should Varenicline be started?
At least 7 days
Is a skin rash a contraindication of use of the nicotine patch?
No - can place it elsewhere, or use a different maintenance therapy (Varenicline or Bupropion [Welbutrin])
What is the current median survival of age for CF?
48 years old
What factors influence a patient’s self-efficacy?
Experience
Modeling
Social persuasion
Psychological factors
What is the mechanism of action of bupropion (aka Wellbutrin)?
Blocks neural re-uptake of dopamine and/or norepinephrine
Contraindicated in patients with seizure history
What is “social protection” as a TB treatment/prevention strategy
TB is a disease of poverty and poor living conditions.
If you improve people’s lives by investing in wellfare/social safety net, TB cases and mortality go down.
When are we most susceptible to bias?
When we have less bandwidth
- High workload
- Time pressures
- Fatigue
What are the FDA-approved ad lib agents for tobacco cessation?
Treat the cravings
- Nicotine gum
- Nicotine lozenge
- Nicotine inhaler
- Nicotine nasal spray
- Nicotine patch (kind of both)
After insurance, a patient with CF can expect to pay ~_________ per year.
After insurance, a patient with CF can expect to pay ~ $60,000 per year.
($40,000 for health care + $20,000 for prescriptions)
What is the STAR method for creating a plan to quit smoking?
Which patients will benefit from this plan?
- Set a quit date
- Tell others
- Anticipate challenges
- Remove tobacco products
This is most effective for patients who are ready to quit - they will benefit from abrupt cessation
If patinets are not ready to quit, start nicotine replacement therapy before making a full-fledged quit attempt
Which pharmacologic smoking cessation agent is a nicotinic receptor antagonist?
Varenicline
What are the 5 A’s for motivated smokers?
(Motivated = motivated to quit)
- Ask about tobacco use
- Advise the patient to quit smoking
- Assess willingness to quit
- Assist in quit attempt
- Arrange follow-up
Of people with latent TB infections in the United States, who is prioritized for treatment?
Everyone
High priority for high-risk persons
- HIV positive
- Recent contact with persons with active TB
- Fibrotic changes on x-ray consistent with old TB
- Immunosuppressed
- Healthcare providers
If a patient can successfully quit smoking by using an e-cigarette, do the health benefits outweigh the risks of combustible cigarette use?
Yes, probably?
It is better to use an e-cigarette for the rest of your life than to smoke cigarettes
But would counsel evidence based therapies before recommending an e-cig
Are patients at an increased risk of heart attack if they smoke while using a nicotine patch?
No
Cystic fibrosis affects about _________ individuals in the US
Cystic fibrosis affects about 30,000 individuals in the US
Which patients who smoke should be offered pharmacotherapy to aid with smoking cessation?
All of them
Pharmacotherapy can double or triple quit rates
DONT’ NEED TO BE READY TO QUIT TO START TREATMENT!
Which key treatment belief had the most statistically significant effect on adherence to treatment?
- Importance of the treatment
- Motivation
- Self-efficacy
c. Self-efficacy
How is TB diagnosed in Sub-Saharan Africa?
How is it diagnosed in the United State?
- Sub-Saharan Africa = PCR
- Subsidized in resource-limited settings
- Ex: Xpert MTF/RIF
- Unites States = Sputum smears
- Although access to rapid PCR diagnosis is expanding
- Limited at first due to low disease burden
PCR is the better test. Was rolled out in high needs areas first
Of people with latent TB infections globally, who is the WHO prioritizing for treatment?
Children and people living with HIV
What social determinants increase one’s risk of TB infection?
- Access to healthcare
- Crowding
- Nutritional Status
- Prisons
- Housing
- Coexisting HIV and TB epidemics
What are the FDA approved maintenence therapies for tobacco cessation?
- Varenicline (Chantix)
- Bupropion (Welbutrin)
- Nicotine patch
What is the definition of a healthcare disparity?
Racial or ethnic difference in the quality of healthcare that is not due to:
- Access-related factors
- Clinical needs
- Preferences
- Appropriateness of treatment
Is counseling for smoking cessation effective?
Yes
Also; it is dose responsive. More counseling = more effective
The WHO estimates that _____% of the world population has a latent or active TB infection
The WHO estimates that 25% of the world population has a latent or active TB infection
(~1.7 billion people - 1/4 of the world population :| )
In order to combat implicit bias, should we promote or suppress our awareness of our own implicit biases?
Promote!
Recognizing our own implicit biases gives us the opportunity to enhance conscious efforts to overcome them
What is the general approach to pharmacologic tobacco cessation?
Maintenence therapy + Ad lib (for situational cravings)
- Maintenence
- Varenicline
- Bupropion (Welbutrin)
- Nicotine patch
- Ad lib
- Nicotine gum
- Nicotine lozenge
- Nicotine inhaler
- Nicotine nasal spray
Which 7 countries account for 64% of TB cases?
- India
- Indonesia
- China
- Philippines
- Pakistan
- Nigeria
- South Africa
Will Varenicline increase a patient’s desire to commit suicide?
No - People used to think this was true, but it is not
(Patients with neurotropic disease had increased neurotropic effects while quitting smoking on any therapy compared to people without neurotropic disease, but the pharmacologic therapy did not impact the neurotropic effects)
Which pharmacoogic smoking cessation agent blocks neural re-uptake of dopamine and/or norepinephrine?
Bupropion (aka Wellbutrin)
Which populations are at an increased risk of progressing from latent TB to active TB?
People with HIV who are not on prophylactic therapy to prevent immune function decline
What is the leading infectious disease cause worldwide?
Mycobacterium tuberculosis disease
What are the future needs of TB treatment?
- Raise the social and political profile of TB
- Point of care testing
- Enhanced TB treatment programs
- Increased social protection spending
- More effective therapies?
- Vaccines?
____________ is the main cause of death in patients with cystic fibrosis
Respiratory Failure is the main cause of death in patients with cystic fibrosis
Standard CF treatment regimens include…
- Oral medications
- Inhaled medications
- Airway clearance therapy
What is the WHO recommended public health approach for TB disease?
Directly observed treatment short course
Comprised of:
- Aggressive case detection
- Directly observed treatment of ALL cases with standardized treatment
- Ensure effective drug supply and management, free drugs
- Accurate monitoring and reporting of cases, cures, relapses, and now drug resistance
- Political will
What contributes to multidrug resistant (MDR) and extensively drug resistant (XDR) TB?
How does treatment differ?
Poor adherence to treatment and delayed recognition of resistance
Treatment requires multiple second line drugs (usually more toxic) and longer duration
How should you approach a patient’s ambivalence to smoking cessation?
Normalize ambivalence
Pushing back against it and trying to force the patient to want to quit is typically ineffective
Use the tennants of motivational inteviewing and shared decision making
What factors are contributing to the difference in quality of healthcare between minorities and nonminority?
- Dissimilarities
- Access to care
- Clinical need an appropriateness
- Patient preferences
- Disparities
- Healthcares systems
- Legal regulatory climate
- Discrimination
- Biases
- Stereotyping
- Uncertainty
What is the prevalence of cigarette smoking in the United States?
13.7%
What are the 5 strategies to mitigate the effect of implicit bias on care?
- Stereotype replacement
- Conter-stereotypic imaging
- Individuation
- Perspective taking
- Increasing opportunites for contact
What percentage of patients with CF screen positive for depression?
How does this affect treatment?
20%
Patients with a positive depression screen are twice as likely to report non-adherence to treatment
How soon before a patient’s quit date should Bupropion be started?
At least 7 days
About _______ million people will become ill
and ______ million people will die from tuberculosis every year
About 10 million people will become ill and
1.5 million people will die from tuberculosis every year
Which smoking cessation agent should be used for maintenence in patients with a history of siezures?
Varenicline or nicotine patch
(Bupropion is contraindicated)
What is the mechanism of action of Varenicline?
Varenicline is an antagonist (partial agonist) of the alpha-4-beta-2 subnit of the nicotinic Ach receptor
Varenicline blocks the binding of nicotine, but still promotes dopamine release.
Based on survey results, the mean time performing all treatments for CF was ____ minutes/day
Based on survey results, the mean time performing all treatments for CF was 108 minutes/day
The WHO estimates that ___% of people living in the United States have a latent or active TB infection
The WHO estimates that 4.7% of people living in the United States have a latent or active TB infection
What are the side effects of Varenicline?
Nausea, insomnia, dose adjustment in renal failure
What are the 5 R’s for reluctant smokers?
(Smokers reluctant to quit)
Discuss the following with your patient
- Relevance of tobacco cessation
- Risks of continued tobacco use
- Rewards of tobacco cessation
- Roadblocks to successful cessation
- Repeat all of the above regularly
