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Hello, everyone. I'll give uh a couple more minutes for everyone to show up, show up and then we'll uh we'll make a start. Ok? So, um if you guys don't mind, since I'm the only one from code blue at the moment here, could you guys let me know if you can see the presentation and hear me, please just in the chat box, if that's all right. Just so I know that I'm not speaking with a empty screen. No, you can't see the presentation. Yeah, but ok, wonderful. So welcome everyone. Uh This week we are gonna be doing a session on chronic breathlessness. Uh It's the same lay out where we'll have 45 minutes of pure teaching and then an hour for you guys to go to the breakout rooms and practice the skills. Um As per usual, please don't forget about the feedback forms. These are the forms that will allow you to access the slides afterwards. Hopefully, we don't experience any technical difficulties this time around and everything should run smoothly. Um So you guys know our partners and all that. So the learning objectives for this week are primarily gonna be surrounding taking a focused history, um, on the topic of chronic breathlessness. Um, looking at specific findings that can help reach specific diagnosis is, um, I'm not gonna be specifically talking about the conditions themselves. This is, uh, something that's possibly best for you to go and look at in your own time. It is more about taking a good history that will help you pass your OS station. Uh, we're also gonna be looking at smoking and history taking specifically for smoking as well as sh the sharing information station. So what is considered chronic breathlessness? You have been learning about acute and subacute for the past two weeks. Can anyone uh hazard a guess about what time periods we're talking about when we're saying chronic, anyone got any ideas chronic, specifically in medical terminology usually reverse refers to something that's weeks um or more so acute. We were talking about minutes, subacute, we were talking about hours to days and then chronic is specifically in respiratory conditions signifying over four weeks duration. Um What differentials can you think of when I say chronic breathlessness, what could be causes of chronic breathlessness if you guys can just put them all the different types that you can think of into the chat. So any breathlessness that's been going on for more than four weeks, you can think of respiratory conditions, you can think of cardiology, any other conditions that you can think of. Anyone got any ideas? Yeah, COPD, heart failure brilliant. So, Valeria is named a few. Uh the list is quite ex uh extensive. So the ones we've got pulmonary, cardiac and other causes, um, out of the pulmonary causes, the ones in red are the ones that I would specifically, uh, that specifically are the University of Manchester ones. They're the ones that they want you to know for this week. Um But other than that, the rest of these are causes of chronic breathlessness. One second, we've got a message, uh uh can everyone else not see the slides or is this, uh it should be a slide that's called causes of chronic breathlessness. Can people see that or no? All right. Let me no. OK. You can't see the slides. How about now guys? Is that better? Brilliant? OK. So these are all the causes of chronic breathlessness, as I mentioned, uh we'll be concentrating on the pulmonary ones. Um Specifically the first three are the obstructive pathology that you guys would have known. So COPD asthma bronchiectasis and the ones in the red, as I mentioned are the ones at the University of Manchester want you to know. And the other ones are good conditions to bear in mind when you're taking a chronic breathlessness history there important to ask when you're trying to differentiate your diagnosis and you're doing a review, review of systems. OK. So, uh as with any consultation, right, with um a presenting complaint. So we're gonna ask with the generalized open question about what the patient in. After you ask the generalized broad question, get straight to the nitty and gritty and everyone's recommending you guys use Socrates. I'm not gonna stay far away from that. I also recommend Socrates. Um, sight is not very applicable in this case because it's breathlessness onset. You want to make sure that you find out specifically when it started uh the time frame that it's been going on for, um, to help differentiate whether with acute subacute or chronic, uh, obviously, no radiation or character associated symptoms, we'll have a chat about in a second. Um, but associated symptoms is a option and a chance for you guys to ask your red flags and timing. Again, you wanna ask about timing to differentiate conditions like asthma because asthma has uh some variation, for example, it tends to be a bit worse in the morning and better in the evening. You can ask about um, um, nocturnal dyspnea, which is when people with heart failure wake up gasping for air. This will help differentiate between the types of causes of chronic, um, breathlessness, exacerbating or relieving factors is always important. Asthma exac is exacerbated by many things. Uh, relieving factors could be that a patient sleeps with a couple of pillows in cases of orthopnea and severity. Uh I would suggest using the MRC dyspnea scale. This is uh a scale that, ok, sorry, you guys, I don't understand why the I'm gonna have to if the presentation it gets stuck again. Please do. Let me know and I'll keep just stopping it and moving on again. Uh Severity of the um breathlessness is great to quantify using a scale that patients can uh explain themselves. The MRC dyspnea scale is used for COPD patients and it helps to quantify how much their activities of daily living are impacted by their breathlessness. So this is a g a great easy way to help people understand um sort of and help you quantify uh their impact on their life. So let's go back to the associated symptoms uh in terms of chronic breathlessness. So a patient comes in 65 year old male, a 65 year old male comes in says I have a two year history of struggling to walk up the stairs. I used to be uh really fit or really healthy and now I can't walk up the stairs. I get breathless and this has been getting worse and worse over the past two years. What other symptoms can you think of that? You can ask in regards to this uh patient and maybe if you guys can throw in some red flags, that would be really good. Yeah. So coughing, you can ask a cough, how long the cough has been going if it's productive? What color weight loss? That's a great red red flag to always ask about anything else anyone can think of? Ok, so that there is no issue, right? Can you guys see the associated symptoms? Um, unless I get a notification that you can't, I'll assume you guys can. So associated symptom symptoms you can ask about are cough, like we said, in chronic cases and sort of sinister causes most of the time with cancer. It will be a nonproductive chronic cough with heart failure. You'll have a frothy pink cough which is not hemoptysis. Uh You can ask specifically about whether they've ever seen blood in their sputum, which is hemoptysis. That's a big red flag. You can ask about wheezing, that can help signify sort of an obstructive picture such as you would get an asthma, chest tightness or pain. This can move you to sort of the cardiac reasoning, headaches, finger, finger clubbing, frequent respiratory infections, weight loss, appetite loss, fatigue, night sweats, all everything that you can think of. I would ask this in your history of presenting complaints. It's important that you show the examiner that you're thinking about these symptoms. The presenting complaint and history of presenting complaint is where you sh you should be spending majority of your time, the medica past medical history and the medication history is not that important in the long run. The diagnosis will be in the associated symptoms that you get and the history of presenting late um in clinical scenarios as well. When you're speaking to a consultant, they are gonna want to know as much as they can about the history of presenting, they can look at the past medical history later unless it's obviously something super super duper um applicable to the scenario. The associated symptoms in red are, are red flags. These are the things that you must not miss and that you must ask about um when you're asking for your history of presenting complaint. All right, just so I know you guys are on the same slide as me. We've got the MRC scale. This is what I was talking about. This is the COPD uh dyspnea scale that can help uh people understand and help you quantify the impact of uh the breathlessness on a person. Um After the presenting complaint and history of presenting complaints, it's important that you um ask the patient ice so the ice can help understand and guide your consultation. Make sure that you don't miss out on marks about what people are actually concerned about with chronic breathlessness. Know when something is going wrong with their body and most of the time that gets them worried and they will tell you about how their parents died from lung cancer or that they've been a smoker their whole life and they're worried about lung cancer. And ice allows you to sort of gather your thoughts about what's going on. It lets you slow down, it lets you understand, right. Um This was the symptoms that he gave me and the history of presenting complaint. Now, I'm gonna try to tailor the rest of my um I'm gonna try to tailor the rest of tailor the rest of the consultation towards what he's told me. Right? Can you guys see the slides of past medical history and medication history? If I don't get told otherwise, I'm gonna assume you are, you can, bro. Thank you, Adrian. So because you're running out of time in a sy station, always ask about specific conditions and then generalize it. So when we're talking chronic breathlessness, these conditions that you guys already spoke about, have you got any past medical history of COPD and any sort of lung disease, any uh bronchiectasis, bronchiectasis, they might not know that they have it, but it could be signified by the fact that they had recurrent chest infections when they were younger and this causes stretching of the bronchi and this causes mucus build up and you get bronchiectasis specifically as well with chronic breathlessness, it's important to look at autoimmune conditions because things um such as sarcoidosis and vasculitis can be a in what's it called can be a risk factor for lung fibrosis. And so asking autoimmune conditions that either like rheumatoid arthritis or sle can help point you into the direction of this being a autoimmune condition. If you ask people if they have any auto immune conditions and they say they have an Alpha One Antitrypsin disorder, you might be considering CO PD in a younger patient. So it's just getting the brain sort of thinking in that, uh, scenario ask about any cancers because cancers frequently metastasize to the lungs. Um, there is a list of the most frequently metastasized cancers to the lungs. So it's quite important to ask, um, in oy scenarios, they will probably tell you, um, and they'll tell you quite clearly in real patients, you will probably have to ask a couple of times. Um, again with medication history, same thing, start specific, then move general um, in chronic breathlessness, medication history is important because there is specific medications. The ones that you see on your screen that increase the risk of lung fibrosis. We've got amiodarone. Does anyone, uh does anyone know what amiodarone is used for? I'll give you guys a little second to see if anyone knows for that matter if you. Uh Yes. So it's an antiarrhythmic medication. Bleomycin is a type of anti. Yeah, brilliant guys. Yeah. So Bleomycin is a type of antibiotic. Um, cyc uh cyclophosphamide is a type of um immunosuppressant also used in chemotherapy. Methotrexate is also an immunosuppressant and Nitrofuran is a antibiotic that is used to treat uh UTI S. So, these are uh 55 medications that I would specifically ask about when we're talking about chronic breathlessness, they increase your risk of lung fibrosis. Incredibly. And so when a person comes in and says I've been taking methotrexate, which they tend to take for a very long period of time, I've been taking methotrexate for a very long period of time. Your bells should be ringing that. Ok. This could be a picture of lung fibrosis, family history. Again, this is the same thing where you want to think about genetic conditions that could be important to the presenting complaint. Um Most of the time in a stations, they will uh tell you specifically about any family conditions that are important to the case. Um But as mentioned before, things like Alpha One Antitrypsin disorder can um mean that if it runs in the family, it could mean that a person that gets early onset COPD. If somebody tells you about the type of medical condition that runs in the family, clarify at what age it developed if family members had died, clarified what was the cause of death and what age did they die at? So maybe they have early onset lung cancer and that would be important in a chronic breathlessness picture. Now, one of the most important things when we're talking about chronic breathlessness is the social history and it's not just the smoking history, it's the general and occupational history that's as important in these cases. Um So in general can see the slides. Thank you very much. Is that better? Sorry guys don't know what's going on. I'll try to remember as much as I can to go off and on. Um Thanks Sarah. So in general, ask about the living conditions. Uh people in England specifically tend uh we have high humidity in England. It tends to get quite moldy in the house. People also tend not to take care of the houses. Mold can grow. Mold is a big factor for um, lung fibrosis and pets or hobbies like bird keeping also increases risk of um, lung fibrosis. So you see where I'm going with this, it's, it's all very important for you to ask these specific questions because it shows the examiner that you're thinking about what could be the cause of the chronic breathlessness. Um Smoking history, we'll talk about smoking history uh later in the presentation. But you know, the drill ask about how long they've been smoking, what they've been smoking, how many they've been smoking? Get to the bottom of the smoking history so that you could show the examiner that you've thought about. Uh not just ask. Oh, have you ever been a smoker? No, but um that you've thought and dive dealt, uh, dived deeply into the history and occupation. Occupation and chronic breathlessness is important. Plumbers have higher chance of being exposed to asbestos, bakers, flour dust, and enzyme additives also increase lung, uh lung fibrosis and farmers, they tend to be present around larges, large amounts of hay dust and different types of mold, which also increases the risk of lung fibrosis. All right, we'll do. Oh OK. I know you guys can't see this slide very well. This is a system. Um Systemic review. This is every sort of um thing that I can think of to put onto a systemic review. This is where fill in the feedback at the end of the slides and we'll be able to send these off to you so that you guys have them on hand. I didn't think it was too necessary for us to go through them one by one. So systemic review, make sure to just ask some generalized questions. Um but leave it to the end because it's not as important as your history of presenting complaint. And finally, don't ever forget to ask about allergies. That's important in asthmatic patients specifically. Ok. Let's go through some practice cases. So I'm gonna stop this so that I definitely know that you guys can see this. Ok? So we've got a 65 year old male. This is the type of history I was telling you about earlier 65 year old male and he is presenting with a two year history of increasing shortness of breath. He used to be an avid walker now struggling to get to the shop. He's had no weight loss, no hemoptysis, no night sweats. He's had increased fatigue recently and a dry cough. His past medical history includes Crohn's disease for which he takes methotrexate. And um he's got no family history and in terms of his social history, he's worked as a business consultant. Has a 25 pack year history, doesn't take, doesn't drink any alcohol or take recreational drugs and lives in a house with a large mold issue. So what uh differential diagnosis is? Can you guys think of, throw any different type of diagnosis that you can think of into the chat realistically in a SCU station, they're gonna want you to present at least four, I would say four diagnoses. So throw in whatever you guys can think of this could be any ideas anyone. So even your basic ones in the his in the history of chronic breathlessness you guys gave me, what kind of conditions could be causing this? Yeah, fibrosis. Brilliant. That's one. What other conditions can you think of that can cause an increased shortness of breath over two years. Co pd brilliant. Anything else? Yes. Aspergillosis. Exactly. Adrian. Anything else that anyone can think of that fits in this picture? What would be a must not miss diagnosis in this kind of um presenting complaint? What's the one thing you would not want to rule out lung cancer? Exactly. OK. So you guys have got it all pretty much, I'm gonna stop this presentation, make sure it's all working. Uh So the things that I've highlighted and read are that uh are risk factors that you guys should pick up on when you're looking at these sorts of vignettes. So we've got a male, a male increases your chance of lung fibrosis. That's a risk factor, increasing shortness of breath. So this is progressive. Um We've got increased fatigue that's also quite a red flag, I would say. Um, and a dry cough means that it's probably less towards the bronchiectasis or pneumonia picture and, and more towards a chronic sort of COPD or heart failure or lung cancer or lung fibrosis. M methotrexate. That's one of the drugs that causes lung fibrosis, 25 pack year history, smoking increases your chance of respiratory disease in general and mold issue as well. So this is the kind of way you need to be tackling vignettes. And um the diagnosis in this case was lung fibrosis. But um I would say COPD, heart failure and lung cancer are differentials that you could be giving them. Ok. Um, we've got another case. So we've got a 72 year old male presenting with a six month history of increasing shortness of breath. He noticed that he gets short of short of breath when walking up the stairs. He used to be very active and it's recently started to be painful for him to take deep breaths. He's noticed that his trousers are loose. He regularly has to change bedsheets because of night sweats and he has had flu like symptoms for nearly six months. He has hypertension for which he takes amLODIPine. No family history. 25 year uh years work as a plumber and he lives at home with his wife has a 40 year pack history. It doesn't drink or take recreational drugs. So based on this vignette can you guys provide me with some differential diagnoses that you can think of for this. Um, 72 year old chap here, lung cancer. If anyone can tell me what lung cancer specifically you would be worried about in this check, that would be bonus points if I could give you bonus points. Yeah, Angus. Brilliant, brilliant guys. Yeah. Mesothelioma. Me, mesothelioma. Sorry. Um, ok. Don't, um, what's it called? Don't get blindsided by the lung cancer. What other things can you think of? Maybe it's not lung cancer yet, what other things can asbestos cause cause? So, asbestos can also cause asbestosis. So that's just the inflammation of the pleura around the lungs. It can cause pleural plaques that can also cause pleuritic chest pain. What else can be causing flu like symptoms and pain? Uh, and pleuritic pain when taking a deep breath could be things like pneumonia. Longstanding chronic pneumonia that doesn't really get treated, could be providing a picture. Um, that looks something like this. So, yes, it's very easy to see that in a case like this. It's obvious that it's lung cancer. TB Brilliant. Yes, you could ask about um, foreign travel. So in a case, please try to keep your options open and try to give your examiners as many things as you can for differentials because it's very easy with the vignettes that they give to go up. That's definitely meso, he's been a, a plumber for 25 years. But, or for example, in the case of TB, he comes back from uh Egypt, which has a high prevalence of TB. And uh all of a sudden he's got hemoptysis. So again, with the same thing as we had previously, I've just written the risk factors and read, highlighted them in red. So the 72 year old male, so, um, me mesothelioma, which was the correct diagnosis in this case presents uh in the seventh TTH about the, in the seventh decade of life. This is because it's got a very long history when you guys read about it for it to actually become mesothelioma before that it has to go through asbestosis, pleural plaques, et cetera, et cetera. Trousers is a weight loss, night sweats and flu like symptoms are things that are be uh are things that are classic when you see mesothelioma, flulike symptoms is what everyone explains it like. Um And obviously smoking and working as a plumber. Ok, brilliant, well done guys that was smashing. So now we are going to move on to the smoking cessation consultation. Uh So smoking cessation consultations, most of the times in a scenarios are gonna be a sharing information station. They're gonna be asking you to provide information to patients. They're gonna be asking you to um answer their questions, ask sort of their concerns and it's, it's a station I struggle with because you need a lot of time. Um And you don't have it. You have six minutes or eight minutes, whatever, depending on the university that you're at. So for this station, this is the sort of layout that I would suggest people to use. Um, you wanna ask a brief history of their s um, in this case of their smoking? So specifically about what's brought them in, why have they decided that they need to speak to the doctor about their smoking? Maybe the doctor said that they need to speak, um, that it's vital that they start to get their smoking under control. Figure out why have they gotten a diagnosis? What's going on? Um Understanding, figure out why, what the patient knows about smoking already. This is a great way to start to make sure that you're on the same level. Um, as the patient, um, this will help you not seem like you're being, oh, well, I can tell you everything I know about smoking, blah, blah, blah. No, you don't want to make the patient feel that you're patronizing them. That's not gonna earn you very good marks. So by asking them what they already know, it's a good way to level the uh the playing field a little bit again, concerns always gonna a uh, ice things ask about concerns specifically about their smoking. Is it that they're worried they're gonna get lung cancer? Is it, they're worried about how they're gonna quit. And finally, this is what I mean by timing only at this point, would you start to provide some sort of information about how to quit and what um support there is to, to quit what pharmacological therapies there are to quit. So there's a lot to get through by the time um that you have to actually share the information that you know, finally summarize um and refer them to the next steps because that's important with uh motivational interviewing specifically uh with sharing information stations. Another big thing that I would suggest is chunk and check. So a good way to do this is after every single little bit that you tell a patient. So they, you've told them about the risks of smoking, just check with them, make sure that uh they still, if I've taken in what you've said again, try not to be patronizing. It is quite hard but saying something along the lines of, I hope um Just so I know that I've made sense in what I'm saying. Do you guys do, would you mind uh repeating back to me what I've said? So I know that we're on the same page. OK. So when is the appropriate timing to speak to patients about quitting smoking? Always every consultation counts. I know we're talking about husky scenarios. But in general, if you have a patient on the ward or in a GP practice, which smokes use that opportunity to try to talk to them about quitting, it's uncomfortable. It's a hard conversation, but it's gonna prepare you for your Aussies. Um As with any sort of oy station, you're gonna come in, wash your hands even when you're just sharing information, make it a point of going and putting some hand sanitizer in your hands. Introduce yourself, confirm the patient's name and date of birth and start with the reasoning. So get the brief history from the patient about what's brought them in. Finally, don't forget your um motivational interviewing skills that's asking open questions, giving affirmations again, try not to make them sound crazy. Um what's called over the top. So saying something along the lines of the fact that you guys are, the fact that you're here talking about, it is already a great first step reflections. Um That's letting the patient reflect on what they've said. So for example, a patient can come in and say, um I've been thinking about quitting smoking, but it's not something I've ever wanted to do if you repeat to them back what they said. So you said that this is never something you wanted to do? Why is that that allows them to reflect on something that they've just said themselves. This helps with their own deeper sort of um the motivation behind quitting summaries always summarize, helps, gives you time to think about what you wanna say next. Summaries, never gonna be too many of them. So I mentioned earlier to do ice, this will help understand the sort of barriers that could be preventing people from quitting smoking. Um, and using Dawn Cat is another helpful to, uh, helpful tool that can help understand the desires that people have to quit smoking. So, when I say desires, I mean, they will say, uh, I've been wanting to recently because I know how, uh, bad my cough has gotten and it just keeps getting in the way. Or I'm sick and tired of spending money on cigarettes when you hear these things, you know, that a patient is telling you and sort of, uh, laying out clues that they are thinking about quitting smoking ability. Um, they will might talk about previous quitting attempts. This means that you can understand how confident they feel about quitting. How were the previous attempts? This all gives you indications about things to speak about in your consultation reasons? That's the sort of stuff I spoke about earlier reasons can be intertwined with concerns. So, are they worried about cancer? Are they worried about heart issues? Their cardiovascular risk need? Maybe this is a diagnosis that they got? Maybe this is something that, uh, has been impacting their day to day life and they want to change this. Uh, commitment is things that could signify that the patient has already decided that they want to quit. So this can help you prevent from asking or repeating things that they've already thought about. So commitment things could be, um, they will say something along the lines of, well, yes, I've decided that actually starting next week, I'm gonna be buying a packet less of cigarettes every week. Um, sometimes phrases like that means that the patient just wants an extra nudge. And activation means they will say things like I will start tomorrow or, uh I'm ready to start today and taking steps is that they've take, gotten some patches or thrown away their packet of cigarettes. Ok. So now that we sort of looked at how you would structure this session, what are some important questions that you want to ask a patient when you're covering a smoking history, I'm leaving this up to you guys. So what are some questions that you would want to know when you're asking about a smoking history specifically in terms of motivational interviewing, not your social histories that you do at any type of consultations in a motivational interview. What's important for you to elicit about the pa uh person and their smoking, any ideas? So, ok, so I'll give you guys a little idea and then maybe that will prompt you guys to um thing for yourself. So you could ask specifically about um what is a trigger for them to go smoking? So, is it stress, uh is it drinking? A lot of people tend to want to have a cigarette when they've had a drink? So understanding the stresses can really help you picture sort of their smoking habit and what are some barriers that you could possibly tackle any other ideas about some of the questions you could ask in the smoking history. OK. Motivating factors. Yeah, brilliant sir. So what are some things that they can think of themselves? Um that could be motivating them to quit? So this is Adrian, you just from there? So, OK, so these are some of the questions that I would say are important aspects to cover. Um and that brief history that we talked about in the Bucs sort of acronym. So how long has the patient been smoking? That's a given. How much does this patient smoke in? What situations do they smoke? How does the smoke can make them feel? Does it make them feel relaxed? Does it make them feel like they can get control over the life? Does it make them feel like they can go outside for five minutes during a busy working day? Um explore relationships in terms of smoking. Uh Does the patient have other people in their life that smokes uh that smoke? Do they live in a house with smoking? Um Ask about the finances. Smoking is expensive, specifically in England. It's very expensive. It's about 15 lbs a packet here. And so exploring their financial situation and how they get through it is very important. It can help you uh use it as a motivating factor. Sarah said you can talk about how much money they would save. Uh It's important to also clarify previous quit attempts. Um Expe what kind of withdrawal symptoms they had because these are withdrawal symptoms that maybe you can target through counseling or through the uh pharmacological therapies. So understanding a patient again will help understand how to help them. Ok, sorry guys making sure everything's working. So in terms of past medical history and medication history, I would skim over this so quickly in a sharing information station because the simulated patients will tell you straight away if they think there's something that you need to know because you cannot waste time on this scenario. You have so much to get through, ask about preexisting lung conditions, any cardiovascular risk factors and hospital admissions and surgery. And this is a good chance to also ask about any medication or treatment that they used previously to help quit, help them quit because we run through this in a husky scenario. I'm running through this now as well. Same thing goes for family and social history. You can elicit questions about whether family members smoke. This can help understand sort of uh pathological needs to smoke or psychological needs to smoke people that grew up in a household where they were a really little child and their mother used to smoke around them. It could be something nostalgic, it could be something that their respiratory system has already been affected from a very young age. Those people that grew up in a smoking household tend to have very high risk factors for things like bronchiectasis. Um This will help understand the rationale um for smoking as well. And this could be something that you can target in your counseling sessions or just in your conversations to help a patients uh quit alcohol intake and recreational drugs go hand in hand with smoking. So it's important to find out about them. Um, and then work family and stress specifically about how this affects the patient. This could all be contributing to their need to smoke. Ok. So, 01 2nd, so this sort of summarizes the principles that we have smoked. Uh smoked. Spoken about um advice here in this specific case is talking about the consequences that the patient. Oh, sorry, I don't know. Hm I don't know what's happened to that slide. Uh Advice here could be the risks and long term effects of smoking. Uh You can also commend the patient for coming in and speaking to you about it, um assess the patient's motivation, um assess the patient's views on everything that you've spoken about and assist. So assist, this is where at the very end you're able to provide the information for the patient. And the most important thing is follow up or in your ay scenario, say that you would like to follow up in 1 to 2 weeks after this visit. Ok. So this is something that University of Manchester and uh the World Health Organization uh strongly believe in this is called the Star method. This is specifically for quitting smoking. So this is not just a motivational interviewing tool, this is specifically for quitting smoking. So s stands for a set of quit date, the shorter the, the sooner the quit date, the better. So, ideally, within two weeks, as we said, if you set a quit date with them as well, it means that there's not really anywhere for them to hide. Um tell friends and family, this will help keep uh accountability and this will help a patient understand that it's not just them, they will feel support, they will feel like they're being heard again. Anticipate challenges for the upcoming quit attempts. So this is where having a good history is important. You understand their motivation, you understand their barriers and this will be critical um to help them overcome these challenges in the first couple of weeks when it's uh really difficult and removing all tobacco pro uh products from the house. So this is where understanding their social life is important. Do other people smoke? How hard realistically is it gonna be to get all the smoking or tobacco products out of the house? And finally, they'll just quickly run through the pharmacological therapies that are to s uh to quitting smoking. So, as you guys know, there is the nicotine replacement therapy. So these are patches, gums sprays, um they're very useful, they release nicotine slowly um and help side effects of withdrawal. It can make people feel a little bit sick if and can make people feel a little bit dizzy sometimes. Um But it can also help people if they've had a cigarette while they're, we wearing a patch, it can make them most of the time throw up. So it could be quite a revolting process. And that's um then you start to build associations with negative things in smoking. Uh vus, excuse my pronunciation, but I still don't know how to pronounce drugs to save my life. Um Varenicline uh is one of the most effective treatments that we have. Um It helps to reduce the cravings. It helps um to re in increases your cessation by nearly twice. Uh the amount that you would without using anything else, you do have to take it for a little bit while you're still smoking. Uh But then you do a 12 week course and you're done with them. Uh buPROPion is a antidepressant. This helps the sort of irritability, the anxiety, all these things that come along when you're having nicotine withdrawals. So this is all the kind of things that you could share with the patient discuss. What seems more interesting to them. Obviously, the um medicinal side of verline and uh Bupron um is a 12 week course. So that would involve them taking a pill every day. Are they happy with that? Commit commitment? Do they want to commit to that? Um Nicotine replacement therapy is a little bit easier. You stick a patch, you take a gum and then you're done. Finally, I'm not gonna go into the details of the counseling for smoking cessation. There is multiple of options available on the NHS. Um Just be aware of them, be able to explain them to a patient, be able to explain what that would work better for them and explore some of the barriers that they have. So for example, if they work a 9 to 5 maybe group counseling might not be as easy for them or telephone counseling might not work for them because they feel embarrassed to have to do this at work or in any other environment. Um So counseling uh for smoking cessation specifically, just be aware about it, be able to speak to patients about them. Ok. Um That is it. Thank you very much for um being here for the presentation. We're now going to split away into the breakout rooms. So if the volunteers could be so kind as to move to the breakout rooms and then I will send all the people that are left behind to the breakout rooms if they fancy joining. Ok. Um Ashok, could you please go to Alisa's room? Adrian? Can you please go to Mare's room? Aha. Could you please go to Reja's room? And Angus, could you please go to um Zoe's room? I've just gotten the chart. Is there a feedback form if you guys can't? Sorry. This is the feedback form. Hope you guys can see it um I will send it through to the charts to the ones that weren't able to be there. But yeah, if you scan the QR code, you should get a feedback form there. Let me know if it doesn't work and you will also be sent a feedback form on your emails. Ok, Angus, I think I've sent you to Zoe's. You're the last one I had, right? Uh Ben, can you please go to uh Aba's Room Beta? Can you please go to Mre's room? I'm so sorry if I pronounce your names wrong guys. Uh go, can you please go to Ravi's room, Janella? Can you please go to Zo uh Zoe's room? Paul, can you go to Aisha's Room? Samia? Can you go to ma's room and Tar, can you please go to Ravi's room and Valeria? Can you please go to Zoe's room? Ok. Thank you very much guys and we will see you next week. Hope you enjoy your ay practice.