Monday, 19 January 2015

Tutorial 19 January 2015

Website.
Contact us.

There was no tutorial as only one person attended.
We will used these materials in the next tutorial on Monday 26th. January as there is quite a lot to discuss.
There will be no tutorial - Valerie and I are attending a dinner for an old colleague who is leaving Stepping Hill hospital.

19 January 2015.

37.    
Green-top guideline development
38.    
Non-invasive prenatal testing NIPT
39.    
Risk management. Reporting problems
40.    
Education
41.    
Viva. PMB.

1. Green-top guideline development.
This question relates to the Green-top and other RCOG guidelines and how evidence is evaluated and given importance and the strength of recommendations is graded.
This is the sort of esoteric stuff that could be included in an EMQ or SAQ.
Question 1.
Lead-in
Which of the following statements, if any, are true.
  1. CNST requires consultants to follow the advice in GTGs
  2. CNST requires consultants to follow the advice in GTGs, unless the consultant has phoned the CNST to obtain permission for alternative management
  3. Consultants deviating from the advice in a GTG should send details to the hospital lawyer
  4. Consultants are responsible for the decisions they make about patient care and can choose to deviate from the advice in GTGs.
  5. A consultant choosing different care for a patient to that in a guideline should fully document the decision at the time it is made.
Pick the option from the list below that best fits.
Option List


  1.  
i

  1.  
ii

  1.  
iii

  1.  
iii + iv

  1.  
iv + v

Question 2.
Lead-in
Grade A recommendations have specific requirements. Choose the option from the list below that best fits.
Option List

  1.  
a positive Cochrane review is a requirement for a Grade A recommendation

  1.  
a Grade A recommendation can be based on high-quality systematic reviews of case series

  1.  
a Grade A recommendation can be based on a single systematic review or RCT.

  1.  
a Grade A recommendation must include a meta-analysis or systematic review of RCTs

  1.  
a Grade A recommendation can be an extrapolation from studies graded 2++ or better.

Question 3.
Lead-in
Which, if any, of the following statements are true about Grade A recommendations.
  1. ≥ 1 meta analysis or systematic review can be sufficient for a Grade A recommendation
  2. ≥ 1 RCT rated 1++ and applicable to the target population can be sufficient for a Grade A recommendation
  3. a systematic review of RCTs can be sufficient for a Grade A recommendation
  4. studies rated as 1+ which are applicable to the target population and with consistent  results can be sufficient for a Grade A recommendation

Option List


  1.  
i

  1.  
i + ii

  1.  
i + iii

  1.  
all of the above

  1.  
none of the above

Question 4.
Lead-in
What other grades are there?

Question 5.
Lead-in
What criteria are associated with these other grades?

2. Non-invasive prenatal testing.
Abbreviations.
CAH:           congenital adrenal hyperplasia
DSD:           disorder of sexual development
IBGRL:        International Blood Group Reference Laboratory 
NIPD:          non-invasive prenatal diagnosis
NIPT:          non-invasive prenatal testing
RAADP:      routine antenatal anti-D prophylaxis.
RAPID:       http://www.rapid.nhs.uk/about-rapid/
SIP15:         RCOG’s Scientific Impact Paper No. 15: “Non-invasive Prenatal Testing for Chromosomal Abnormality using Maternal Plasma DNA”. March 2014.
UKGTN:      UK Genetic Testing Network

Question 1.
Lead-in
What is the definition of NIPT?
Option List

A.       
any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother
B.       
any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother, excluding TVS
C.       
any test for fetal chromosomal anomaly that does not involve invasive testing of the mother
D.       
any test for fetal chromosome or genetic anomaly that does not involve invasive testing of the mother.
E.        
none of the above

Question 2.
Lead-in
What is the potential of NIPT using cffDNA and RNA?
Option List

A.       
description of the full fetal genome
B.       
description of the full fetal genome with the exception of disorders arising from mitochondrial DNA
C.       
description of the full fetal genome with the exception of disorders arising from mitochondrial RNA
D.       
description of the full fetal genome and most structural anomalies
E.        
none of the above

Question 3.
Lead-in
Which of the following statements is true?
Option List

1.        
cffDNA is found in maternal serum in greater quantities than maternal cell-free DNA
2.        
cffDNA is found in maternal serum in  lesser quantities than maternal cell-free DNA
3.        
the quantity of cffDNA rises throughout pregnancy, peaking at placental separation
4.        
cffDNA diminishes after placental delivery but remains detectable for at least 6 weeks
5.        
cffDNA diminishes after placental delivery but remains detectable for at least 1 year

Question 4.
Lead-in
Which, if any, of the following statements are true?
Statements.
1.       cffDNA is usually detectable from 4-5 weeks’ gestation
2.       cffDNA is not usually detectable at gestations < 12 weeks
3.       the quantity of cffDNA rises throughout pregnancy, peaking at placental separation
4.       cffDNA diminishes after placental delivery but remains detectable for at least 6 weeks
5.       cffDNA diminishes after placental delivery but remains detectable for at least 1 year
Option List

A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 3
G.       
1 + 4
H.       
1 + 5
I.         
2 + 3
J.         
2 + 4
K.        
2 + 5

Question 5.
Lead-in
Which, if any, of the following statements is true about cffDNA in maternal blood?
Statements.
1.       cffDNA originates in the placenta, not the fetus
2.       cffDNA originates in fetal squames
3.       cffDNA originates in fetal blood cells
4.       cffDNA occurs in maternal blood due to trans-membrane osmosis
5.       cffDNA occurs in maternal blood due to feto-maternal transfusion
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 4
G.       
2 + 4
H.       
2 + 5
I.         
3 + 5

Question 6.
Lead-in
Which. if any, of the following statements are true?
Statements.
1.       tests using cffDNA are based on detecting paternally-derived fetal DNA in maternal blood.
2.       tests using cffDNA are based on detecting maternally-derived fetal DNA in maternal blood.
3.       tests using cffDNA are based on detecting DNA from the fetal Y chromosome.
4.       tests using cffDNA may involve shotgun sequencing.
5.       tests using cffDNA may involve shotgun nuptials.
Option List

A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 4
G.       
1 + 5
H.       
2 + 4
I.         
2 + 5
J.         
3 + 4
K.        
3 + 5

Question 7.
Lead-in
Which. if any, of the following statements are true?
Option List

A.       
detection of the SRY sequence in cffDNA means that the fetus is female
B.       
detection of the SRY sequence in cffDNA means that the fetus is male
C.       
detection of the SRY sequence in cffDNA means that the fetus is male unless it has a DSD
D.       
detection of the SRY sequence in cffDNA means that the fetus has Klinefelter’s syndrome
E.        
detection of the SRY sequence in cffDNA means that the fetus has 45X0/46XY mosaicism.

Question 8.
Lead-in
Which. if any, of the following statements are true?
Option List
There is none.

A.       
Rhesus D status can be determined accurately from 12 weeks’ gestation using cffDNA
B.       
Rhesus D pseudogene is more common in Africans than Caucasians
C.       
People with the RhD pseudogene are at risk of isoimmumisation.
D.       
People with the RhDu blood type may be identified as Rh-ve or Rh+ve on routing testing
E.        
People with the RhDu blood type are particularly prone to isoimmunisation

Question 9.
Lead-in
Which. if any, of the following statements are true in relation to cffDNA in maternal blood?
Option List

A.       
Checking the fetal RhD status is best left until > 16 weeks’ gestation
B.       
Checking the fetal Kell status is not yet routinely available
C.       
Checking the fetal Kell status is best left until > 20 week’s gestation
D.       
Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 10%
E.        
Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 40%

Question 10
Lead-in
List the other situations in which cffDNA in maternal serum can be used for clinical benefit.

Other questions.
1.     cffDNA levels in maternal blood are raised in pregnancies affected by Down’s syndrome.
True / False
2.     screening for Down’s syndrome using cffDNA has both sensitivity and specificity close to 100%
True / False
3.     What is the value of cffDNA in women at risk of having a baby with CAH?
4.     How might cffDNA be used to screen for conditions such as cystic fibrosis?
5.     What is the role of amniocentesis if a cffDNA screen for a condition such as cystic fibrosis proved +ve?
6.  cffDNA screening for achondroplasia and thanatophoric dysplasia is now available on the NHS for women at risk of an affected baby.   True / False
7.     What is meant by “contingent” screening using cffDNA in relation to Down’s syndrome?
8.     What is an “allele”?
9.     What is a “wild-type” allele?
10.   What is the alternative to a “wild-type” allele?

3. Risk Management/ disciplinary procedures.
Lead-in.
The following scenarios relate to risk management / disciplinary procedures.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
BMA:    British Medical Association
DOH:    Department of Health.
GMC:    General Medical Council
MDU:    Medical Defence Union

Option list.
A.             allow the practice to continue
B.             stop the practice until a full investigation has been done
C.             stop the practice permanently
D.            arrange an investigation by a senior consultant from another hospital
E.             decide the practice does not involve added risk
F.              declare the risk to be acceptable
G.            cancel admissions for surgery
H.            arrange adverse incident analysis
I.               arrange audit
J.               arrange research
K.             arrange a formal warning for the doctor
L.              arrange retirement for the doctor
M.          arrange dismissal for the doctor
N.            consult the on-call consultant
O.            consult the Clinical Director
P.             consult the Educational Supervisor / College Tutor
Q.            consult the Medical Director
R.             consult the Chief Executive
S.              consult the Postgraduate Dean.
T.             consult the hospital’s lawyer
U.            write to Her Majesty at Buckingham Palace
V.             consult your Medical Defence Body
W.          consult the British Medical Association
X.             consult the RCOG
Y.             report the matter to the GMC
Z.              allow return to work
AA.        allow return to work, but offer support
BB.         arrange a “return to work” package specific to the doctor
CC.         none of the above

Scenario 1
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a broken arm sustained in a skiing accident. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 2
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a severe bereavement reaction to the suicide of a family member. He sends you a certificate from his GP to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 3
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 6 months after having a coronary thrombosis. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 4
You are the Clinical Director. A 62-year-old Consultant has returned to work after four months’ sick leave after a coronary thrombosis. He has three cases on his first operating list and all have complications reported by the Sister on the gynaecology ward. What action will you take?
Scenario 5.
A Consultant has been in her first consultant post for two months. Three of the four patients on a single operating list develop post-operative wound infections. What action will you take?
Scenario 6.
You have recently been appointed Clinical Director. A consultant has been in post for ten years and prefers to operate with the same nurse assistant. No complications have been reported. What action will you take?
Scenario 7.
You are the Clinical Director. A consultant has an operating  list in a peripheral unit 20 miles from the main hospital. There is no resident doctor with post-operative care being provided by nurses. The cases dealt with on the list traditionally were minor, day-cases.  You have been told that the consultant, who was appointed 6 months ago, has recently been doing hysterectomies and prolapse repairs to get the waiting list down.  What action will you take?
Scenario 8.
You are the Clinical Director. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases.
What action will you take?
Scenario 9.
You are the on-call SpR. It is 8 pm. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases.
What action will you take?
Scenario 10.
An SpR is half an hour late for starting his duties on three occasions in one week. His consultant wishes to have this dealt with as a disciplinary matter to “nip it in the bud” and teach him a lesson. He reports it to you, the Clinical Director asking you to discipline the doctor. What action will you take?
Scenario 11
An SpR gets into an argument with the senior midwife on the labour ward and in the heat of the moment slaps her across the face. You are the Clinical Director and the matter is reported to you next day.
Scenario 12
Your consultant is the Clinical Director and a nasty man. You apply 6 months in advance for study leave for the week before the written part of the Part Ii MRCOG exam. He tells you that he plans to go on holiday at that time and you are not going to get any leave. In addition, he tells you that if you complain about this he will give you a terrible reference and tell all his consultant friends that you are a waste of space in order to ruin your career. What action can you take?
Scenario 13
A SpR fails an OSATS, but falsifies his records to indicate that it has been completed satisfactorily. You are the Educational Advisor and this is brought to your attention. What action will you take ?>
Scenario 14
A SpR2 uploaded reflective practice putting him in a good light after a case which had been handled sub-optimally by him.
Scenario 15
You are an FY2 and assist the senior consultant at a hysterectomy. The operation goes well initially, but then there is a lot of bleeding and a ureter is cut. The consultant urologist attends and repairs the ureter. The woman bleeds vaginally that evening and is taken back to theatre by another consultant and ends up in the ICU. You became convinced during the operation that you could smell alcohol on the consultant gynaecologist’s breath. What are your responsibilities?
Scenario 16
When do you need to inform the Consultant on-call?
Scenario 17
When do you need to inform the Clinical Director?
Scenario 18
When do you need to inform the Medical Director?
Scenario 19
When do you need to inform the GMC?
Scenario 20
What are the roles of the BMA and MDU?
Scenario 21
What are the differences between verbal and written warnings?

4. Education.
Lead-in.
The following scenarios relate to medical education
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EMQ:    extended, matching question.
PBL:       problem-based learning.
Scenario 1.
A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?
Scenario 2.
You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?
Scenario 3.
You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?
Scenario 4.
You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?
Scenario 5.
Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?
Scenario 6.
You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?
Scenario 7
The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?
Scenario 8
Which of the listed teaching techniques is least likely to lead to deep learning?
Scenario 9
An interactive lecture with EMQs is the best method of teaching. True or false.
Scenario 10
Only 20% of what is taught in a lecture is retained. True or false.
Scenario 11.
The main role of the teacher is information provision. True or false.
Scenario 12.
The main role of the teacher is to be a role model.  True or false.

Option list.
  1. brainstorming.
  2. brainwashing
  3. cream cake circle.
  4. Delphi technique.
  5. demonstration & practice using clinical model.
  6. doughnut round.
  7. interactive lecture with EMQs.
  8. lecture.
  9. 1 minute preceptor method.
  10. teaching peers / junior colleagues
  11. schema activation.
  12. schema refinement.
  13. small group discussion.
  14. snowballing.
  15. snowboarding.
  16. true
  17. false




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