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MD3001 > Week 11 > Flashcards

Week 11 Flashcards

1
Q

Describe Asthma?

A
  • Recurrent, reversible airway obstruction
  • Attacks of wheezing, shortness of breath
  • Often nocturnal dry cough
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2
Q

What is the pathogenesis of asthma in genetically susceptible people?

A

Activation of the Th2 profile of cytokine production

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3
Q

What happens when the Th2 are activated in asthma?

A
  • Attracts inflammatory granulocytes (eosinophil) to mucosal surface
  • IL-5 & GMCSF cause eosinophils to produce cysteinyl leukotrienes & release granule proteins
  • IgE synthesis is promoted, as is expression of IgE receptors on mast cells and eosinophils
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4
Q

What are the important mediators in the pathogenesis of asthma?

A
  • Leukotriene B4 & cysteinyl-leukotrienes (C4 & D4)
  • Interleukins IL-4, IL-5, IL-13
  • Tissue damaging eosinophil proteins
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5
Q

What does GMCSF mean?

A

Granulocyte macrophage colony stimulating factors

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6
Q

What would the cross section of a bronchiole in severe asthma show?

A
  • Dilated blood vessels
  • Thickened BM
  • Mucus plug with eosinophils & desquamated epithelial cells
  • Infiltration of inflammatory cells (mononuclear, eosinophils etc)
  • Oedema
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7
Q

How is the treatment for asthma measured?

A

Measuring the Peak expiratory flow rate.

also forced expiratory volume, oxygen saturation & arterial blood gases

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8
Q

What are the eliciting agents of the Immediate phase of allergic asthma and what cells do they stimulate?

A
  • Allergen, Non-specfic stimulus

- Stimulates Mast cells, mononuclear cells

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9
Q

What happens in the Immediate phase of allergic asthma?

A

Bronchospasm

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10
Q

How is the Immediate phase of allergic asthma reversed/treated?

A
  • Beta2-adrenoceptor agonists
  • CysLT-receptor antagonists
  • Theophylline
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11
Q

What are the eliciting agents of the Late phase of allergic asthma?

A

Chemotaxins & chemokines from immediate phase allergic asthma

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12
Q

What happens in the late phase of allergic asthma?

A
  • Infiltration of cytokine-releasing Th2 cells & monocytes
  • Activation of inflammatory cells (eosinophils)
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13
Q

What is the result of late phase allergic asthma?

A
  • Airway inflammation
  • Airway hyper-reactivity
  • Bronchospasm, wheezing, coughing
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14
Q

How is the late phase of allergic asthma reversed/treated?

A

Glucocorticoids

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15
Q

What are the 5 different types of treatment / preventative medicines for asthma?

A
  1. Beta2 adrenoceptor agonists (SABA, LABA)
  2. Anti-inflammatory agents
  3. Cysteinyl leukotriene antagonists (LTRA)
  4. Methylxanthines
  5. Anti-IgE treatment
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16
Q

How do Beta-adrenoreceptor agonists work?

A

Dilate bronchi via smooth muscle B2 receptors

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17
Q

What does Short acting (SABA) do?

ie. Salbutamol

A
  • Given by inhalation
  • Immediate effects & lasts 3-5hrs
  • “Rescue remedy” treats wheeze in patients
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18
Q

What does Long acting (LABA) do?

ie. Salmeterol

A
  • Lasts 8-12hrs

- Prevents bronchospasm (at night/during exercise) in patients requiring long-term therapy

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19
Q

What are the main drugs used for anti-inflammatory action in asthma?

A

Glucocorticoids (ICS)

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20
Q

What do Glucocorticoids do and don’t do?

A
  • Prevent progression on chronic asthma

- Don’t prevent immediate response to allergen

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21
Q

What do Glucocorticoids decrease?

A
  • Formation of cytokines (released by Th2 lymphoctyes)
  • Vasodilators such as prostaglandins by inhibiting COX
  • Activation of eosinophils
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22
Q

What do you give in deteriorating asthma?

A

Oral (prednisolone) or IV (hydrocortisone)

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23
Q

What is the main inhaled Glucocorticoid?

A

Beclometasone

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24
Q

How do cysteinyl-leukotriene receptor antagonists work?

A
  • Cloned cysteinyl-leukotriene receptors CysLT1 & CysLT2 are expressed on respiratory mucosa and infiltrating inflammatory cells
  • Lukast drugs antagonize only CysLT1
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25
Q

Give an example of a Lukast drug?

A

Montelukast

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26
Q

What do Lukast drugs do?

A
  • Decrease exercise-induced asthma and decrease early & late phase responses
  • Relax airways in mild asthma
  • Mainly used as add-on to ICS & LABAs
  • Decrease acute reactions to aspirin
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27
Q

Give an example of a Methylxanthine?

A

Theophylline

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28
Q

What is Theophylline and what does it do?

A
  • Cyclic nucleotide phosphodiesterase inhibitor

- Increases cyclic nucleotides in the cell to relax smooth muscle

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29
Q

What drug used to treat COPD comes under the Methylxanthine family?

A

Uniphyllin

oral sustained release formulations used in addition to steroids

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30
Q

What Methylxanthine drug is rarely used as an IV drug in acute severe asthma?

A

Aminophylline

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31
Q

What is the immediate treatment for acute severe asthma?

A
  • Oxygen (maintain SpO2 at 94-98%)
  • Salbutamol or terbutaline + ipratropium via nebuliser
  • IV hydrocortisone or prednisolone tablets
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32
Q

What would you do if patient was still not improving with immediate treatment for acute severe asthma?

A
  • IV magnesium sulphate

- Switch nebulised to IV salbutamol or aminophylline

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33
Q

Describe Ipratropium?

A
  • Its a SAMA for COPD
  • Rarely used for asthma
  • Used for cough by irritant stimuli
  • Decreases augmentation of mucous secretion & increase clearance of bronchial secretions
  • Not effective against allergen challenge
  • Not selective for 1 muscarinic receptor type
  • Used for bronchospasm precipitated by beta-blocker
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34
Q

What is Tiotropium?

A

LAMA version of Ipratropium

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35
Q

When constructing a clinical question what does PICO stand for?

A
  • Patient/Population/Problem
  • Intervention
  • Comparison (if any)
  • Outcome
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36
Q

What is the “Anatomy” of a good question?

A
  1. Define precisely who the question is about
  2. Define which option you are considering and possible comparison
  3. Define the desired outcome
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37
Q

What do systematic reviews/meta-analyses come under in information resources?

A

Secondary sources of information vetted by independent researchers and clinicians

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38
Q

What are Clinical Practice Guidelines?

A

Reviews covering large disease groups & treatment strategies (NICE & SIGN guidelines)

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39
Q

What do you look at when trying to answer a clinical question?

A
  1. Start with- Cochrane Reviews, NICE & SIGN guidelines

2. Then use- Medline (Ovid, PubMed), google Scholar

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40
Q

What is a “Null Hypothesis”?

A

Two sets of data are from the same population and not different

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41
Q

What is an “Alternative Hypothesis”?

A

Two sets of data are from different populations and are different

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42
Q

What is discrete quantitative data?

A

Can only have certain numerical values (number of children)

43
Q

What is continuous quantitative data?

A

Do not have discrete steps (height & weight)

44
Q

What are nominal (unordered) categorical variables?

A
  • Male/female
  • Green/blue eyes
  • Alive/dead
45
Q

What are ordinal (ordered) categorical variables?

A
  • Objective: heavy, moderate or light drinkers, grade of breast cancer
  • Subjective: health status questionnaires (good, average, terrible)
46
Q

How do we test the hypothesis?

A
  • Assume the null hypothesis

- Determine the probability that the null hypothesis is correct (P Value)

47
Q

What is the P value?

A

P value of 0.1 means there is a 0.1 probability/10% chance/1 in 10 chance that the null hypothesis is correct

48
Q

What is the P value cut off that indicates the null hypothesis should be rejected?

A

If P < 0.05 then there is a statistically significant difference (1 in 20 chance)

49
Q

What does a P value > 0.10 mean?

A
  • Greater than 10%
  • No evidence against the null hypothesis
  • Data consistent with null hypothesis
  • Not significant
50
Q

What does a P value > 0.05 mean?

A
  • Greater than 5%
  • Weak evidence against null hypothesis in favour of alternative
  • Not significant
51
Q

What does a P valve < 0.05 mean?

A
  • Less than 5%
  • Moderate evidence against null hypothesis in favour of alternative
  • Significant
52
Q

What does a P value < 0.01 mean?

A
  • Less than 1%
  • Strong evidence against the null hypothesis in favour of alternative
  • Highly significant
53
Q

What does a P value < 0.001 mean?

A
  • Less than 0.1%
  • Very strong evidence against null hypothesis in favour of alternative
  • Very highly significant
54
Q

What is a Type I error?

A
  • Rejecting the null hypothesis when it is true (false positive)
  • Concluding there is an effect when there isn’t
  • P is small
55
Q

What is a Type II error?

A
  • Not rejecting the null hypothesis when it is false (false negative)
  • Concluding there is no effect when there is
  • P is large
56
Q

What is the relationship between analyte concentration and null hypothesis?

A

No difference in analyse concentration between healthy and sick

57
Q

What is the relationship between analyte concentration and alternative hypothesis?

A

Difference in analyte concentration between healthy and sick

58
Q

What is the Power of a test?

A
  • Its ability to reject the null hypothesis when it is false

- Capacity to detect an effect if one is present

59
Q

What is the treatment for an STEMI and anteroseptal transmural MI?

A

Primary Percutaneous Coronary Intervention (PPCI)

60
Q

What is the pathogenesis of AMI (acute myocardial infarction)?

A
  • Atherosclerotic plaque destabilisation
  • Rupture/erosion
  • Platelet adherence & aggregation
  • Intracoronary coagulation
61
Q

What are the characteristics of an Unstable Plaque?

A
  • Few SMCs
  • Thin fibrous cap
  • Inflammatory cells
  • Eroded endothelium
  • Activated macrophages
62
Q

What are the characteristics of a Stable Plaque?

A
  • More SMCs
  • Thick fibrous cap
  • Lack of inflammatory cells
  • Foam cells
  • Intact endothelium
63
Q

What is the drug treatment for a MI?

A
  • Aspirin
  • Ticagrelor
  • Ramipril
  • Bisoprolol
  • Simvastatin
64
Q

What can cariogenic shock be secondary to?

A
  • Ventricular septal rupture
  • Acute mitral valve regurgitation (papillary muscle necrosis)
  • Acute LV rupture
65
Q

What is a Bradycardia?

A

Heart block

66
Q

What is a Tachycardia?

A
  • Atrial fibrillation
  • Ventricular tachycardia
  • Ventricular fibrillation
67
Q

What can be the cause of Myocardial death?

A
  • Pericarditis
  • VSD
  • Free wall rupture
  • Papillary muscle necrosis
68
Q

What are the different heart failures?

A
  • Pump failure
  • LV dilatation
  • LV aneurysm
69
Q

How do you know if someone is dead?

A
  • Cessation of the circulation (no pulses, no cardiac activity)
  • Cessation of respiration
  • Cessation of cerebral function (fixed dilated pupils)
70
Q

What do you need to do after pronouncing someone is dead?

A
  • Inform family
  • Inform coroner/procurator before certification of death
  • Leave all lines/tubes devices in place
71
Q

Give some examples of deaths that should be reported to the coroner?

A
  • Cause of death unknown
  • Death was violent or unnatural
  • Death was sudden
  • Deads within 24hrs of hospital admission
  • If there is a possibility that the person took their own life
72
Q

What is the pathology of MI?

A
  • Myocyte death
  • Coagulation
  • Inflammation (neutrophil recruitment, monocyte & macrophage formation, digestion & removal of debris)
  • Granulation and scar formation
73
Q

Describe asthma as a chronic condition and its statistics?

A
  • 7-10% children, 5% adults
  • Psychological and physical morbidity
  • Societal costs
  • Morbidity & mortality increasing
74
Q

What is the SIGN 141 policy?

A
  • British guidance on the management of asthma

- Covers asthma control with different client groups and outlines helpful interventios

75
Q

What are the different types of assessments for asthma?

A
  • Royal College of Physicians of London 3 questions

- Asthma Control Test (ACT)

76
Q

Why are Psychological factors of asthma important?

A
  • Impact on disease process due to adherence to treatment and taking in information
  • Depression & anxiety
  • Consistently reduced quality of life
77
Q

What are the psychological factors in asthma control?

A
  • Convincing evidence of association of psychological factors with asthma related deaths, near fatal asthma, brittle asthma, non-compliance and A&E visits
  • Depression, anxiety, panic and denial
78
Q

What are the 3 psychological emotions asthmatic patients can have?

A
  • Depression
  • Panic
  • Denial
79
Q

What are the psychological cognitive factors asthmatic patient can have?

A
  • Reduced confidence

- Beliefs around vulnerability

80
Q

Define Anxiety?

A

State of intense apprehension, uncertainty, and fear resulting from the anticipation of a threatening event or situation, often to a degree that normal physical and psychological functioning is disrupted

81
Q

What are the psychological cues of anxiety?

A
  • Thoughts that something bad is going to happen
  • Fear of losing control
  • Sense of dread, impending doom
  • Loss of confidence
82
Q

What are the behavioural cues of anxiety?

A
  • Fidgeting
  • Hesitation
  • Avoidance
  • Shaking
83
Q

What are the cognitive cues of anxiety?

A
  • Difficulties with concentration and attention

- Memory problems, forgetful

84
Q

What is breathlessness a symptom of?

A

Both respiratory disease & panic attacks

85
Q

List some models testing asthma control?

A
  • Impairment Disability Triad (WHO)
  • International classification of function- Interaction of concepts (WHO 2001)
  • Biomedical model
  • Biopsychosocial model (Engel, 1977)
  • Leventhal’s Self-regulation model/Common Sense Model
86
Q

Describe the different elements of Illness representation in the Common Sense Model/Leventhal’s self-regulation?

A
  1. Identity- name, signs & symptoms
  2. Cause- internal or external
  3. Consequences- physical, recurrent, chronic
  4. Time-line- acute, recurrent, chronic
  5. Cure/Control
87
Q

Why do asthmatic patients need to be able to self manage their illness?

A
  • Fluctuating nature of asthma means patients need to acquire decision-making skills to respond appropriately to changes in symptom control
  • Patients need to be aware of bodily changes and to respond accordingly
88
Q

What is a confidence interval?

A

Gives estimated range of values which is likely to include an unknown population parameter, the estimated range being calculated from a given set of sample data

89
Q

Why are confidence intervals better than hypothesis tests?

A

More informative than hypothesis tests since they provide range of plausible values for the unknown parameter

90
Q

What is the point estimate?

A
  • Usually the mean
  • Indicates magnitude of the effect of the experimental intervention compared to the control intervention
  • Confidence interval describes the uncertainty of this estimate
91
Q

What does the confidence interval describe?

A

Describes the range of values within which we can be reasonably sure that the true affect actually lies

92
Q

What does a narrow confidence interval tell you?

A

The level of confidence in result is higher

93
Q

What does a wide confidence interval tell you?

A

The level of confidence in results is lower

94
Q

Why are confidence intervals better than P values?

A
  • Give a range of possible effect sizes
  • Embrace the value of no difference between treatments
  • Help interpret clinical trail data by placing upper an lower bounds on the true effect size
  • Statistically significant does not mean clinically important, the size of the effect determines importance
95
Q

What does SIR mean?

A

Standardised infection rate

96
Q

What are the 3 ways you can measure the effectiveness of interventions?

A
  1. Number needed to treat (NNT)
  2. Relative risk (RR)
  3. Odds ratio
97
Q

What is the number needed to treat (NNT)?

A

Treatment specific and describes the difference between treatment and control in achieving a particular clinical outcome

98
Q

Describe the NNT & ARR of this example:

100 people given an analgesic tablet- 70 have pain relieved
Same 100 given placebo- 20 had pain relieved.

A
  • Analgestic is responsible for 70-20= 50 of the 100 people obtaining pain relief
  • Absolute risk reduction (ARR) is 50/100
  • NNT is the reciprocal of ARR ie. 100/50
  • NNT is 2, meaning 2 people have to be treated for one to obtain effective pain relief!
99
Q

What 7 elements are in a forest plot?

A
  1. List of individual studies
  2. Each square represents an individual study
  3. Line of no effect
  4. X-axis scale: logarithmic for ratios (odds, risk ratio). Linear for differences
  5. Combined results for all the studies
  6. Length of the horizontal line is the 95% confidence interval
  7. Size of square is proportional to the study weight
100
Q

What are the 5 key EBM concepts?

A
  1. Evidence pyramid
  2. Clinical research study designs (strengths & weaknesses)
  3. Asking questions and finding answers
  4. Basic statistics (variable types, P values & confidence intervals)
  5. Effectiveness of interventions (NNT, RR, odds ratio & forest plots)
101
Q

What is a Forest plot?

A

Graphical representation of a meta-analysis

102
Q

What % of confidence interval do we use in medicine?

A

95%

103
Q

What is the equation for the probability?

A

Number of favourable outcomes / Total number of possible outcomes

104
Q

What is the equation for the odd?

A

Number of favourable outcomes (successes) / Number of unfavourable outcomes(failures)

MD3001 (15 decks)

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