36.
|
Criticise
paper. RBC transfusion & infection
|
37.
|
Viva.
Operation waiting list prioritisation
|
38.
|
Role-play.
Dyspareunia referral.
|
39.
|
Role-play:
teach trainee fetal blood sampling.
|
40.
|
Role-play.
6/52 FU. FDIU. Normal pregnancy. PM: on 5th. centile for weight,
but no other anomaly found. All other investigations normal. Smokes. Didn’t
take folic acid. Now blames herself.
|
36.
Health Care–Associated Infection After Red Blood Cell Transfusion. A Systematic
Review and Meta-analysis
Jeffrey
M. Rohde, MD1; Derek E. Dimcheff, MD, PhD1;
Neil Blumberg, MD2; Sanjay Saint, MD, MPH1,3,4,5;
Kenneth M. Langa, MD, PhD1,3,4,5;
Latoya Kuhn, MPH3,4; Andrew Hickner, MSI1,3;
Mary A. M. Rogers, PhD1,3,5
Importance. The
association between red blood cell (RBC) transfusion strategies and health
care–associated infection is not fully understood.
Objective To
evaluate whether RBC transfusion thresholds are associated with the risk of
infection and whether risk is independent of leukocyte reduction.
Data
Sources.
MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of
Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov,
International Clinical Trials Registry, and the International Standard
Randomized Controlled Trial Number register were searched through January 22,
2014.
Study
Selection.
Randomized clinical trials with restrictive vs liberal RBC transfusion
strategies.
Data
Extraction and Synthesis Twenty-one randomized trials with 8735 patients
met eligibility criteria, of which 18 trials (n = 7593 patients)
contained sufficient information for meta-analyses. DerSimonian and Laird
random-effects models were used to report pooled risk ratios. Absolute risks of
infection were calculated using the profile likelihood random-effects method.
Main
Outcomes and Measures. Incidence of health care–associated infection such as
pneumonia, mediastinitis, wound infection, and sepsis.
Results. The
pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the
restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk
ratio (RR) for the association between transfusion strategies and serious
infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; Ï„2
<.0001). The number needed to treat (NNT) with restrictive strategies to
prevent serious infection was 38 (95% CI, 24-122). The risk of infection
remained reduced with a restrictive strategy, even with leukocyte reduction
(RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin
threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20
(95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI,
0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI,
0.28-0.95) in patients presenting with sepsis. There were no significant
differences in the incidence of infection by RBC threshold for patients with
cardiac disease, the critically ill, those with acute upper gastrointestinal
bleeding, or for infants with low birth weight.
Conclusions
and Relevance.
Among hospitalized patients, a restrictive RBC transfusion strategy was
associated with a reduced risk of health care–associated infection compared
with a liberal transfusion strategy. Implementing restrictive strategies may
have the potential to lower the incidence of health care–associated infection.
37.
Waiting list prioritisation. See document lower down.
38.
Dyspareunia referral.
GP
Referral Letter.
Dr.
P. Fella,
Green
Road Surgery,
Halcion
Street,
Bliss.
Re:
Margaret Smith.
Please
see Mrs Smith who complains of dyspareunia.
Candidate's
Instructions.
This
is a role-play station.
Take
a history and discuss appropriate investigation and management.
39. Role-play:
teach trainee fetal blood sampling.
Candidate's
Instructions.
This is a role-play station.
Dr. Jones has recently joined your team as a new trainee
in obstetrics & gynaecology.
The labour ward is quiet and the consultant has asked you
to teach Dr. Jones about fetal blood sampling.
40.
Roleplay. F/U after stillbirth.
Candidate's
Instructions.
This is a roleplay station.
Mrs. Brown has come for follow-up 6/52 after delivery of
a stillborn baby.
Reduced fetal movements had been noted at 38 weeks.
She was admitted and FDIU was confirmed.
The scan also showed IUGR.
She opted for induction of labour.
Prostin was used and she had a normal delivery 12 hours
later.
Effective analgesia was provided by epidural anaesthesia.
There were no complications.
Full investigation, including PM, was normal apart from
the birthweight, which was < 5th. centile.
Your task is to explain the results and advise about the
next pregnancy.
37. Waiting List Prioritisation.
Your consultant is away.
The waiting-list manager comes to see you.
The following patients have been listed by junior staff.
The waiting-list manager wants you to:
confirm the appropriateness of the proposed treatment,
decide the degree of urgency,
confirm the appropriateness of the proposed venue,
decide any special requirement(s) for each patient.
Name
|
Age
|
Clinical Problem
|
Proposed
operation
|
Venue
|
Special Needs
|
Urgency
|
JK
|
5
|
chronic discharge.
? foreign body
|
EUA
|
Main theatre
|
||
JM
|
32
|
1ry. infertility
|
Laparoscopy + tubal patency tests
|
Main theatre
|
||
GN
|
77
|
Vulval cancer. Coronary thrombosis x 2. Unstable
angina.
|
Radical vulvectomy agreed at MDT.
|
Main theatre
|
||
RU
|
55
|
PMB x1. Weight 20 stones. (127 kg.)
1 kg. = 2.2 lb.
1 stone = 14 lb.
|
D&C.
|
DCU.
|
||
LD
|
32
|
Menorrhagia. Fibroids. Anaemia.
|
Vaginal hysterectomy.
|
Main theatre.
|
||
DT
|
22
|
Does not want children.
|
Lap. Steril.
|
DCU
|
||
HB
|
14
|
Unwanted pregnancy at 10/52.
|
TOP
|
DCU. TOP
list.
|
.
|
|
JY
|
44
|
GSI.
|
Anterior colporrhaphy.
|
Main theatre.
|
||
JS
|
23
|
Vaginal discharge. Cervical ectropion.
|
Diathermy to cervix.
|
DCU
|
||
DT
|
55
|
3 cm. ovarian mass.
|
Laparoscopy ? proceed to Hyst + BSO.
|
Main theatre.
|
||
EV
|
32
|
CIN3.
|
Cone biopsy.
|
DCU
|
||
UW
|
34
|
Endometriosis
|
Laparoscopic ablation
|
DCU
|
||
HT
|
88
|
Cystocoele/ rectocoele/ 2nd. degree uterine
prolapse
|
Manchester
Repair.
|
Main theatre.
|
||
KN
|
58
|
Haematuria
|
Cystoscopy
|
DCU
|
||
JW
|
18
|
Menorrhagia & copes badly with menstrual hygiene.
Has Down’s syndrome. Sexually active.
|
Hysterectomy
|
Main theatre
|
||
TB
|
30
|
Menorrhagia. 2nd. degree uterine descent.
Been sterilised. Jehovah’s witness.
|
Vaginal hysterectomy and repair.
|
Main theatre.
|
||
BM
|
55
|
Stage Ib cancer cervix. Been discussed at MDT. For
Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.
|
Wertheim’s hysterectomy.
|
Main theatre.
|
||
NU
|
60
|
Recurrent rectocoele.
|
Posterior colporrhaphy.
|
Main theatre.
|
