Basic Physician Training MCQs
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  • Nicotine is highly addictive substance: Essentially it signals via the central nicotinic receptors in the ventral tegmental area --> nucleus accumbens --> prefrontal cortex via dopamine release, crucial in reward pathways
  • Therefore tobacco uses aim to maintain steady state of nicotine concentration in blood - prevent withdrawal, maintain pleasure/ arousal/ modulate mood
  • Users self titrate by taking more frequent ciggs/ smoke more intensely (deeper breaths)
  • A 2 pronged problem - should therefore look at both these aspects
    • Physiological effects of nicotine on reward pathways
    • Behavioural aspects of addiction --> behavioural therapies
  • Pharmacological treatment
    • NRT
    • partial nicotine receptor agonists
      • varenicline
      • cytisine
    • psychotropics
      • sustained release bupropion
  • Information regarding trials in smoking cessation
    • patients recruited tend to be more motivated, cognitive therapy tends to be more intensive
    • Drug treatment only trialled for 12 weeks, but dependency is a chronic disease
  • Note in patients who are <50, smoking is often the only and most important risk factor, with similar prevalence between gender
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  • It is often thought that NRT is contraindicated after a myocardial infarction
    • patients with cardiovascular disease were often excluded in the efficacy trials
    • From retrospective reviews, NRT does not appear to elicit cardiovascular events in healthy patients, increase risk of first MI or increase 1 year mortality in ACS patients
    • Bupropion is well tolerated and safe in ACS patients - there is one small study in outpatients that yielded positive results
    • With respect to varenicline, there was a study of 714 patients with stable cardiovascular disease that yielded positive results. verenicline did not increase cardiovascular mortality or all-cause mortality but some cardiovascular events were more common
  • In terms of neuropsychatric effects - see EAGLES trial published in LANCET 2016. 
    • Essentially trial was done because neuropsychiatric effects were generalised from post marketing data, observational studies and patients with neuropsychiatric comorbidities were excluded from the study
    • There was no increased mod-severe neuropsychiatric effect in either of NRT/ varenicline/ buproprion in people with or without a past/ present history of psychiatric comorbidity. 
    • There was NO increase in suicidal ideation or behaviour
    • This study recruited patients who were STABLE and not unstable
    • Buproprion does have medication interactions and can lower the seizure threshold
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  • About
  • Written
    • Respiratory Medicine
    • Medical Oncology >
      • Colorectal Cancer
      • Lung Cancer
      • Urogenital Cancers
      • Emergencies
      • Melanoma
      • Breast
    • Haematology >
      • Anaemia
      • Coagulation
      • Malignancy
    • Cardiology >
      • General Cardiology
      • Coronary Artery Disease
      • Heart Failure
      • Valvular Heart Disease
      • Arrhythmia
    • Endocrinology >
      • General Endocrinology
      • Reproduction
      • Pituitary
      • Diabetes
    • Clinical Immunology
    • Clinical Toxicology
    • Genetics
    • Geriatrics
    • General Medicine
    • Statistics
    • Gastroenterology >
      • Pancreas
      • Inflammatory Bowel Disease
      • Oesophageal Diseases
      • Stomach and Small Intestine
      • Liver
    • Infectious Diseases >
      • Viruses
      • Bacteria
      • Parasites
      • Fungus
    • Neurology >
      • Anatomy
      • Nystagmus
      • Myopathies
      • Stroke
      • Neurodegenerative Disorders
      • Neuropathy
    • Nephrology >
      • Glomerulonephritis
      • General Nephrology
      • Chronic Kidney Disease
    • Psychiatry
    • Palliative Care
    • Pharmacology
    • Rheumatology >
      • Rheumatoid Arthritis
      • Connective Tissue Diseases
      • Spondyloarthropathies
      • Crystal Arthropathy
  • Clinical
    • Short Cases >
      • Haematology
      • Endocrine
      • Neurology
      • Rheumatology
      • Renal
      • Gastroenterology
      • Cardiology
      • Respiratory
    • Long Cases >
      • Addiction & Psychiatry
      • Cardiology
      • Endocrinology
      • Geriatrics
      • Gastroenterology
      • Renal
      • Haematology
      • Infectious Diseases
      • Oncology
      • Rheumatology
      • Respiratory
      • Neurology
      • Set pieces
  • Medical Students
  • Respiratory
    • Asthma >
      • Acute Exacerbation
    • COPD >
      • Exacerbations
    • Lung Cancer >
      • Targeted therapy
    • Tobacco
    • Questionnaires