Thursday, 5 February 2015

Tutorial 5 February 2015

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5 February 2015.


  1.  
EMQ. Obstetric cholestasis 1

  1.  
EMQ. Obstetric cholestasis 2

  1.  
EMQ. Diabetes & pregnancy

  1.  
EMQ. Down syndrome screening.

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EMQ. BRCA1 & 2.

  1.  
Viva. CNST.

42. Obstetric cholestasis. (OC). 1.
Lead-in.
The following scenarios relate to the definition and diagnosis.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
gamma GT: gamma-glutamyl transferase
Option list.
A.             true
B.             false
C.             don’t be daft
D.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, raised bile acids and pale stools, all of which resolve postnatally
E.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids and pale stools, all of which resolve postnatally
F.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids, all of which resolve postnatally
G.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids and pale stools, all of which resolve postnatally
H.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids, all of which resolve postnatally
I.               levels do not usually rise in pregnancy
J.               mostly originates in the placenta
K.              levels vary with the time of day
L.              no information in the GTG
M.           none of the above

Scenario 1.
The international definition of OC was agreed at a conference in Tokyo in 1985.
Scenario 2.
What is the GTG’s definition of OC?
Scenario 3.
What is the incidence of pruritus in pregnancy?
Scenario 4.
Hepatitis B and C, but not hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.
Scenario 5.
Infection with the Ebstein Barr virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 6.
The cytomegalovirus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 7.
The herpes zoster virus may cause pruritus and abnormal LFTs in pregnancy.


Scenario 8.
Chronic active hepatitis and secondary biliary cirrhosis are included in the GTG’s list of conditions to be considered in the differential diagnosis.
Scenario 9.
Bilirubin levels are normally elevated in the early stages of OC and remain elevated until the condition resolves after delivery.
Scenario 10.
Liver function tests become abnormal as soon as the pruritus is noted.
Scenario 11.
Levels of bile acids commonly rise significantly after meals making fasting levels mandatory for diagnosis.
Scenario 12.
The upper limit of normal for transaminases, gamma GT and bile acids is about 20% lower in pregnancy.
Scenario 13.
Once a diagnosis of OC has been made, tests of liver function should not be repeated until the puerperium
Scenario 14.
LFTs should be checked weekly until they have returned to normal after delivery of the baby in a case of OC.
Scenario 15.
Once a diagnosis of OC has been made, the activated partial thromboplastin time (APTT) should be measured and a full coagulation screen done if it is prolonged.
Scenario 16.
Delivery at 37 weeks should be recommended because of the risk of FDIU in the later weeks of pregnancy.
Scenario 17.
What additional pre-labour monitoring of fetal welfare is advisable in the third trimester?
Scenario 18.
Prophylactic steroids should be offered at 28 weeks because of the risk of spontaneous premature labour.

43. Obstetric cholestasis. (OC). 2.
Lead-in.
The following scenarios relate to the prevalence of OC.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        0.1%
B.         0.5%
C.         0.7%
D.        1 – 1.2%
E.         1.2% to 1.5%
F.         1.5 – 2%
G.        2.4%
H.        3 – 3.5%
I.           5%
J.          7%
K.         15%
L.          white
M.      brown
N.        blue-green
O.        red-brown, striped
P.         no information in the GTG
Q.        none of the above

Scenario 1.
What is the overall prevalence in the UK population?
Scenario 2.
What is the overall prevalence in the Indian and Pakistani Asian populations?
Scenario 3.
What is the overall prevalence in Scandinavia?
Scenario 4.
What is the overall prevalence in Chile?
Scenario 5.
What is the overall prevalence in Araucanian Indians?
Scenario 6.
What is the overall prevalence in Eskimos?
Scenario 7.
What is the incidence of pruritus in pregnancy?
Scenario 8.
What colour of eggs do Araucanian chickens lay?

44. Diabetes in pregnancy.
Lead-in.
The following scenarios relate to diabetes in pregnancy.
For each, select the action from the option that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
ACE:      angiotensin converting enzyme.
ARA:      angiotensin II receptor antagonist.
GDM:    gestational diabetes mellitus.
OGTT:   oral glucose tolerance test.
Option list.
A.        advise postponement of pregnancy.
B.         normal antenatal care.
C.         refer to a joint diabetic / antenatal clinic.
D.        refer to the next joint diabetic / antenatal clinic.
E.         refer for a diabetic opinion.
F.         refer to a nephrologist.
G.        refer to a clinical psychologist.
H.        arrange referral for screening for diabetic retinopathy.
I.           screen for microalbuminuria.
J.          stop ACE inhibitor / ARA drugs and arrange for safer substitutes.
K.         advise to continue statin.
L.          asvise to stop statin.
M.      prescribe folic acid 5mg. daily and advise HbA1c , 6.1%, if not associated with untoward symptoms.
N.        stop oral hypoglycaemic drug and start insulin.
O.        discuss pros and cons of oral hypoglycaemic drug, but allow her to continue to take it.
P.         arrange fasting plasma glucose level and repeat monthly.
Q.        arrange HbA1c assay and repeat monthly.
R.         arrange a 75 gram OGTT now.
S.         arrange a 75 gram OGTT at 16 weeks
T.         arrange a 75 gram OGTT at 28 weeks.
U.        arrange a 100 gram OGTT now.
V.        arrange a 100 gram OGTT at 16 weeks
W.      arrange a 100 gram OGTT at 28 weeks.
X.         Resign, buy a yacht and sail to Bali.
Y.         none of the above
Z.          
Scenario 1.
A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 10.6 %. Her health is good. She last had screening for retinopathy 8 months ago. What is the most important advice you will give?
Scenario 2.
A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 5.4 %. She last had screening for retinopathy 8 months ago. What advice will you give about retinopathy screening?
Scenario 3.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her serum creatinine is 125 micromol/ litre.
Scenario 4.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her GFR is 60 ml./minute. What advice will you give about referral to a nephrologist?
Scenario 5.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her blood sugar levels are well controlled with diet and metformin. What advice will you give about metformin?
Scenario 6.
A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2nd. stage. She is keen to have the earliest possible diagnosis of recurrence.
Scenario 7
A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2nd. stage. She is keen to have the earliest possible diagnosis of recurrence but has needle phobia and an aversion to self-monitoring.
Scenario 8
A 25-year-old primigravida books at 10 weeks. Her health is good but her BMI is 28. What screening for hyperglycaemia will you arrange.
Scenario 9
A healthy para 1 books at 10 weeks. She takes a statin because of elevated cholesterol and triglyceride levels. Her blood pressure is 130/85. Otherwise she is well.

45. Screening for Down’s syndrome.
Lead-in.
The following scenarios relate to screening for Down’s syndrome.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
DS.        Down’s syndrome.
FASC:    Fetal Anomaly Screening Programme.
NSC:      National Screening Committee
Suggested reading.

Option list.
a.       1 in 2
b.      1 in 5
c.       1 in 10
d.      1 in 20
e.       1 in 40
f.        1 in 250
g.       1 in 400
h.      1 in 1,000
i.         5 mm.
j.         6 mm.
k.       7 mm.
l.         8 mm.
m.    10 mm.
n.      1%
o.      2%
p.      5%
q.      10%
r.        80%
s.       95%
t.        90%
u.      95%
v.       higher
w.     lower
x.       true
y.       false
z.       none of the above.

Scenario 1.
What is the age-related risk of DS at 20 years?
Scenario 2.
What is the age-related risk of DS at 30 years?
Scenario 3.
What is the age-related risk of DS at 35 years?
Scenario 4.
What is the age-related risk of DS at 40 years?
Scenario 5.
What is the age-related risk of DS at 45 years?
Scenario 6.
AFP levels are lower in Ds.
Scenario 7
Inhibin levels are raised in DS.
Scenario 8
Oestriol levels are raised in DS.
Scenario 9
β-hCG levels are raised in DS.
Scenario 10
1st. trimester PAPP-A levels are lower in DS.
Scenario 11
2nd. trimester PAPP-A levels are normal in DS.
Scenario 12
 What characteristic is described in relation to the occipital hairline in DS?
Scenario 13
 What characteristic is described in relation to the frontal hairline in DS?
Scenario 14
 What is the incidence of congenital heart anomaly in DS?
Scenario 15
 Which is the most common congenital heart anomaly in DS?
Scenario 16
 Which major haematological condition is more common in those with DS?
Answer. 
Scenario 17
 Which major neurological condition is more common in middle  age in those with DS?
Scenario 18
 Which spinal anomaly is more common in DS and of concern to anaesthetists?

46. BRCA1 & 2 carriers and risk of breast and ovarian cancer.
There is no option list – you have to produce your own numbers.
Scenario 1.
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 2.
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 3.
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 4.
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 5
The woman asks for the overall figure for lifetime risk of breast cancer in UK women for comparison with her risk.
What is the approximate figure?
Scenario 6
The woman asks for the overall UK figure for lifetime risk of ovarian cancer for comparison with her risk.
What is the approximate figure?
Scenario 7
Which of the following genes have mutations that increase the risk of female breast cancer?
Answer.
A
ATM
B
CDH1
C
CHEK1
D
FATHEAD
E
MARBELLA
F
NBENE
G
p45
H
p53.
I
PALB2
J
PNINE
K
PTEN
L
RADON50
M
RINT1
Scenario 8
A man of 30 has two sisters who developed breast cancer before the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of breast cancer. What is the approximate figure?
Scenario 9
A man of 30 has two sisters who developed breast cancer before the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of ovarian cancer. What is the approximate figure?
Scenario 10
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information about the value of prophylactic mastectomy. What advice will you give about efficacy?
Scenario 11
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy – her family is complete and her husband has had vasectomy. What is the approximate figure for the efficacy of salpingo-oophorectomy in relation to cancer?
Scenario 12
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy. What are the disadvantages of BSO?
Scenario 13
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy.  What alternatives should be discussed?
Scenario 14
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
Which drugs are of proven value in reducing breast cancer risk for women like her?
Scenario 15
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
Which drugs are of proven value in reducing breast cancer risk for women like her?
Scenario 16
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.
Which drugs are of proven value in reducing ovarian cancer risk for women like her?
Scenario 17
A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.
Which drugs are of proven value in reducing ovarian cancer risk for women like her?




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