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September 17, 2013 Issue

Clinical Practice Points

Effects of Varenicline on Smoking Cessation in Adults With Stably Treated Current or Past Major Depression. A Randomized Trial

Patients with depression are more likely to become nicotine dependent and to have greater difficulty quitting smoking. This study found that varenicline increased smoking cessation rates in smokers with a history of depression.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below!
  • Use a brief review of this trial’s results to introduce a session on smoking cessation. After presenting the results, ask your residents why it is important to assess efficacy of smoking cessation interventions over time (look at Figure 2 to see how abstinence rates decreased).
  • Discuss the importance of and how to discuss smoking cessation with patients.
  • Review interventions that are effective for smoking cessation. You may use the already prepared teaching slides from In The Clinic: Smoking Cessation to show figures and tables.

Video Learning

Perioperative Risk Assessment – The Consult Guys

Watch this brief and entertaining TV talk-show-like discussion of perioperative cardiac risk assessment. Seasoned clinicians (and entertainers!) Geno Merli and Howard Weitz discuss the role of the medical consultant and pearls for evaluating who is and who is not at risk.


The Consult Guys logo

Use this video to:

  • Ask why we should not use the phrase, “Cleared for surgery.”
  • Use the teaching slides that accompany the video to review essential points after watching the video: What are the key variables to risk assessment? What algorithm may be used to efficiently evaluate a patient prior to surgery?
  • Answer the multiple-choice questions that are provided as a review at the end. And, log on and get CME for yourself! You’ve already done the work preparing and reviewing the material with your residents!

Ideas & Opinions

Acute HIV-1 Infection: A Call to Action

An estimated 50 000 persons in the United States are newly infected with HIV each year, yet the diagnosis is infrequently considered. This commentary discusses the diagnosis and treatment of acute HIV infection.

Use this paper to:

  • Review the symptoms and signs of acute HIV infection. Ask your residents what other diseases need to be considered.
  • Review how the diagnosis of acute HIV infection is made. Use the Figure as a guide.
  • Discuss the potential advantages to identifying acute HIV infection, both for an individual patient and for public health. What are the limitations to our current knowledge of the benefits of early treatment? The authors review recent study findings to answer this question.
  • Ask your residents if they think they will treat patients with acute HIV infection.

Humanism and Professionalism

The Evening Seminar

Take time to discuss the “art” of practicing medicine. Play the audio recording of this On Being a Doctor essay in which Dr. Donix describes being moved by a patient's story of how a few simple words from her physician made a world of a difference.

Use this essay to:

  • Ask your residents if they sit down when they go into a patient’s room. Why might it matter? Why is it hard to do?
  • Ask your residents whether they consciously make efforts to provide their patients with hope.

The Man Who Worked Too Hard

Play the audio recording of this On Being a Doctor essay in which Dr. Coates observes how a routine admission squandered resources and failed to adequately address true health concerns and opportunities for prevention.

Use this essay to:

  • Ask your residents whether they ever feel like “hapless worker bees in a buzzing but somehow misguided hive.”
  • How often are our routines “unnecessary and avoidable endeavors”?
  • Do they feel they have a role in changing these problems? How?

mksap16

A 46-year-old woman is evaluated during a routine examination. Her 72-year-old mother was just diagnosed with lung cancer, so the patient asks you for help with quitting smoking. She has a 27-pack-year smoking history. She made one previous quit attempt several years ago using over-the-counter nicotine gum, but she was unable to quit for more than a few days. Medical history is significant for seizure disorder. Review of systems discloses mild shortness of breath with exertion and occasional wheezing. Medications are a multivitamin and phenytoin.

On physical examination, vital signs are normal. Lung examination reveals occasional wheezing.

In addition to counseling regarding tobacco use, which of the following is an appropriate adjunct to increase her likelihood of successful smoking cessation?

A. A benzodiazepine
B. Bupropion
C. Electronic smokeless cigarette use
D. Nicotine replacement therapy

Answer:
D. Nicotine replacement therapy

Key Point:
Smoking cessation is achieved more effectively with a combination of counseling and anti-smoking medication use than with either intervention alone.

Educational Objective:
Counsel a patient regarding methods for smoking cessation.

Although both counseling and pharmacotherapy are effective strategies for smoking cessation, the combination of counseling with medication use is more effective than either intervention alone. Nicotine replacement is effective for smoking cessation; its availability in multiple formulations (gum, lozenge, patch, aerosol) allows for alternative options in patients who have not benefited from one type of therapy, as in this patient. Although centrally acting agents (bupropion, varenicline) are also effective treatment options, bupropion would be contraindicated in this patient with an underlying seizure disorder. The choice of cessation method is less important than that an effective method is used correctly by the patient; the array of treatment options allows for individualization based on patient preference, previous experience, cost, and potential side effects. Counseling may be brief or intensive; the two most effective counseling components include practical problem-solving skills and social support.

Many smokers indicate that stress reduction is a primary reason for their tobacco use. Although selected individuals with true anxiety disorders may benefit from anxiolytic therapy, the use of benzodiazepines as a smoking cessation medication has not been documented.

Electronic smokeless cigarettes deliver a warmed aerosol through a cigarette-like device that bears the appearance, physical sensation, and possibly the taste of tobacco smoke, with the intention of helping smokers maintain the activities associated with smoking but without the harmful effects. However, their use in smoking cessation has not been established.

Bibliography
2008 PHS Guideline Update Panel, Liasons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. 2008;53(9):1217-1222. PMID: 18807274

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.

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