Monday 24 August 2015

Tutorial 24th. August 2015


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24 August 2015.

48
EMQ. Endometrial cancer & FIGO
49
SBA. Needle-stick & related injuries
50
EMQ. Turner’s syndrome.
51
EMQ. Drugs in pregnancy. 1
52
EMQ. Drugs in pregnancy. 2

48. EMQ. Endometrial cancer & FIGO
Lead-in.
The following scenarios relate to endometrial cancer.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
Scenario 1.
A histology report on endometrial curetting is of 95% adenocarcinoma with 5% solid, non-squamous areas. What is the FIGO grade?
Scenario 2.
A histology report on endometrial curetting is of 90% adenocarcinoma with 10% solid, non-squamous areas. What is the FIGO grade?
Scenario 3.
A histology report on endometrial curetting is of 50% adenocarcinoma with 50% solid, non-squamous areas. What is the FIGO grade?
Scenario 4.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 5% myometrial invasion. What is the FIGO staging?
Answer.
Scenario 5.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 25% myometrial invasion. What is the FIGO staging?
Scenario 6.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 60% myometrial invasion. What is the FIGO staging?
Scenario 7
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the endocervical endothelium. What is the FIGO staging?
Scenario 8
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 9
A woman undergoes surgery for carcinoma of the endometrium. Peritoneal washings are +ve but there is no other evidence of spread outside the uterus. There is no myometrial invasion. There is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 10
A woman undergoes surgery for carcinoma of the endometrium. There is no evidence of extension outside the uterus. There is myometrial invasion through to and including the serosa. What is the FIGO staging?
Scenario 11
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. There is no evidence of disease elsewhere. What is the FIGO staging?
Scenario 12
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. Positive pelvic nodes are found, but no other lymphatic involvement. There is no distant spread. What is the FIGO staging?
Scenario 13
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. The tumour involves the mucosa of the bladder. There is no lymphatic or distant spread. What is the FIGO staging?

49. SBA. Needle-stick & related injuries
Background.
I am told that there have been MRCOG questions on this topic. I could not find a really helpful source of information until the excellent article mentioned below appeared in the BMJ. The authors are Anna Riddell, SpR in infectious diseases and virology, Ioana Kennedy, Consultant occupational health physician and C Y. William Tong, Consultant virologist, exactly the kind of mix you would want to get a good exposition of the topic.
Abbreviations.
CMV:    cytomegalovirus
GBCV:   GB virus C
HAV:     hepatitis A virus
HBV:     hepatitis B virus
HCV:     hepatitis C virus
HDV:     hepatitis D virus
SOE:      significant occupational exposure to blood-borne infective agent. This includes exposure to potentially infected body fluids from injuries from “sharps” and splash events and bites, which, I hope are rare!.
VL:         viral load.

Question 1.
Lead-in
Approximately how many SOEs are reported annually in the UK?
Option List

A.       
~    100
B.       
~    250
C.       
~    500
D.       
~ 1,000
E.        
~ 5,000

Question 2.
Lead-in
Who was Ignac Phillip Semmelweis?
Option List

A.       
the person credited with demonstrating the infective nature of puerperal sepsis
B.       
the horticularist who first grew the white flower subsequently popularised in the musical, “The sound of music”, naming it after his first wife, Eidel.
C.       
the person who first used antisepsis in aerosol form to reduce the risk of infection during  C section.
D.       
the inventor of catgut sutures
E.        
the inventor of the Dalkon shield

Question 3.
Lead-in
Why does the name of Semmelweis’s colleague Kotecha live on in medical history?
Option List
A.       
he was the first doctor to perform hysterectomy
B.       
he was the first doctor know to undergo transgender surgery
C.       
he died of infection akin to puerperal sepsis after a SOE
D.       
he performed the first successful repair of a 3rd. degree perineal tear
E.        
none of the above

Question 4.
Lead-in
Which of the following have been described as causing infection after a SOE.
Infective agents
1.        
hepatitis A virus
2.        
hepatitis B virus
3.        
hepatitis C virus
4.        
human T cell leukaemia virus
5.        
malaria parasites
Option List
A.       
1 + 2 + 3 + 4 + 5
B.       
1 + 2 + 3 + 5
C.       
2 + 3 + 4 + 5
D.       
2 + 3 + 4
E.        
2 + 3 + 5

Question 5.
Lead-in
Which are the main causes of infection to cause concern in the UK in relation to SOEs?
Infective agents.
1.        
hepatitis A virus
2.        
hepatitis B virus
3.        
hepatitis C virus
4.        
HIV
5.        
treponema pallidum

Option List

A.       
1 + 2 + 3 + 4 + 5
B.       
1 + 2 + 3 + 4
C.       
1 + 2 + 3 + 5
D.       
2 + 3 + 4 + 5
E.        
2 + 3 + 4

Question 6.
Lead-in
Which group features most in the list of those reporting SOEs?
Option List
A.       
doctors
B.       
midwives
C.       
phlebotomists
D.       
nurses
E.        
other healthcare workers.

Question 7.
Lead-in
Which clinical activity generates most SOEs?
Option List
A.       
acupuncture
B.       
assisting in the operating theatre
C.       
intramuscular drug / vaccine injection
D.       
subcutaneous drug / vaccine injection
E.        
venepuncture

Question 8.
Lead-in
Approximately how many cases of HIV seroconversion after SOE were recorded in the UK between 2004 and 2013?
Option List
A.       
0
B.       
1
C.       
20
D.       
100
E.        
500

Question 9.
Lead-in
Rate the following body fluids as: high or low risk in relation to infectivity.
Option List
A.       
amniotic fluid
B.       
blood
C.       
breast milk
D.       
cerebro-spinal fluid
E.        
faeces
F.        
peritoneal fluid
G.       
saliva
H.       
urine
I.         
urine – blood stained
J.         
vaginal fluid
K.        
vomit

Question 10 .
Lead-in
Rate the following types of contact with body fluids as:
high-risk
low-risk
minimal or zero risk
Option List
A.       
exposure to faeces: not bloodstained
B.       
exposure to saliva: not bloodstained
C.       
exposure to urine: not bloodstained
D.       
exposure to vomit: not bloodstained
E.        
exposure via broken skin
F.        
exposure via intact skin
G.       
injury deep, percutaneous
H.       
exposure via mucosa
I.         
injury superficial
J.         
needle not used on source’s blood vessels
K.        
needle used on source’s blood vessels
L.        
sharps old
M.     
sharps recently used
N.       
sharps with blood not visible
O.      
sharps with blood visible sharps

Question 11.
Lead-in
Rate the following types of sources of potentially infective body fluids as:
high-risk
low-risk
minimal or zero risk
Option List
A.       
infected but VL and treatment details unknown
B.       
recent blood test negative for all relevant viruses
C.       
source has known risk factors but recent tests negative
D.       
viral status not known but source has known risk factors
E.        
viral status not known but source has no known risk factors
F.        
VL detectable
G.       
VL not detectable
H.       
VL unknown but on treatment with good adherence

Question 12.
Lead-in
Approximately how many cases of HBV seroconversion after SOE have been recorded in the UK since 1997?
Option List
A.       
0
B.       
1
C.       
20
D.       
100
E.        
500

Question 13.
Lead-in
Approximately how many cases of HCV seroconversion after SOE have been recorded in the UK since 1997?
Option List
A.       
0
B.       
1
C.       
20
D.       
100
E.        
500

Question 14.
Lead-in
What is the usually quoted figure for the risk of transmission of HAV in cases of SOE.
Option list.
A.       
1 in 100
B.       
1 in    50
C.       
1 in    33.3
D.       
1 in    10
E.        
1 in      2
F.        
none of the above

Question 15.
Lead-in
What is the usually quoted figure for the risk of transmission of HBV in cases of SOE.
Option list.
A.       
1 in 100
B.       
1 in    50
C.       
1 in    33.3
D.       
1 in    10
E.        
1 in      2

Question 16.
Lead-in
What is the usually quoted figure for the risk of transmission of HCV in cases of SOE.
Option list.
A.       
1 in 100
B.       
1 in    50
C.       
1 in    33.3
D.       
1 in    10
E.        
1 in      2

Question 17.
Lead-in
What is the usually quoted figure for the risk of transmission of HIV in cases of SOE.
Option list.
A.       
1 in 100
B.       
1 in    50
C.       
1 in    33.3
D.       
1 in    10
E.        
1 in      2

Question 18.
Lead-in
What is the estimated risk of transmission of infection of HBV in an SOE involving sharps in a patient +ve for HBe antigen?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less

Question 19.
Lead-in
What is the estimated risk of transmission of infection of HCV in an SOE involving sharps?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less

Question 20.
Lead-in
What is the estimated risk of transmission of infection of HIV in an SOE involving sharps?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less

Question 21.
Lead-in
What is the estimated risk of transmission of infection of HIV in an SOE involving mucosal splashing?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less

Question 22.
Lead-in
Which of the following carries the highest risk of transmission of an infective agent after a SOE.
Option List
A.       
a bite on the bottom by an HIV-infected patient who finds your buttocks irresistible
B.       
deep injury from a scalpel wielded by a psychopathic surgeon
C.       
deep needle-stick after venepuncture
D.       
spitting by a patient with HIV
E.        
splash SOE from beating a disagreeable patient round the head with a frozen turkey because you are sick to death of their whingeing and perennial misery

Question 23.
Lead-in
List the steps you would take in relation to immediate first aid, including the things that might be suggested but you know are contraindicated.

Question 24.
Lead-in
Which tests should be performed on the source after obtaining consent?
List what you think should be done.
Option List
A.       
HBV surface antigen
B.       
HCV antibody
C.       
HCV RNA
D.       
HIV antigen and antibody (fourth generation HIV immunoassay)
E.        
TTV antibody

Question 25.
Lead-in
What consent is required from the source individual?
Option List

A.       
consent to having the tests
B.       
consent to having the results given to the occupational health department
C.       
consent to having the results given to the person who sustained the SOE
D.       
consent to having the results given to the hospital’s legal team
E.        
consent to notifying the hospital staff if the results are +ve.

Question 26.
Lead-in
What tests should be done on the person who has sustained the SOE and there is a significant risk of infection?
Option List

A.       
a baseline sample should be taken and stored for possible future use
B.       
HBV surface antibody
C.       
HCV antibody
D.       
HIV antigen and antibody

Question 27.
Lead-in
If there is a significant risk of HIV transmission, which of the following statements are correct in relation to when should PEP be given?
Option List
A.       
before the results of the tests done on the source are available
B.       
after the results of the tests done on the source are available
C.       
as soon as is practical
D.       
within 24 hours
E.        
within 72 hours

Question 28.
Lead-in
What are the recommended drugs for PEP in the UK?
Option List
A.       
Kaletra (200 mg lopinavir and 50 mg ritonavir)
B.       
Raltegravir 400 mg twice daily
C.       
Rifampicin 450-600mg daily as a single dose 
D.       
Tenofovir + lamivudine or emtricitabine
E.        
Truvada (245 mg tenofovir disoproxil fumarate and 200 mg emtricitabine)

Question 29.
Lead-in
Which of the following statements are correct in relation to PEP in early pregnancy
Option List
A.       
PEP is contraindicated until after 12 weeks
B.       
PEP should be started as for the non-pregnant
C.       
PEP should be started, but TOP should be offered
D.       
PEP should be started, but not until the puerperium

Question 30.
Lead-in
Which of the following statements is true in relation to reducing the risk of HCV infection.
Option List
A.       
HCV vaccine is safe in pregnancy and should be offered immediately
B.       
HCV vaccine is a live vaccine and contraindicated in pregnancy
C.       
acyclovir is an effective drug for prophylaxis
D.       
there is no known effective prophylactic drug
E.        
early treatment of HCV infection is effective, so SOE staff should be closely followed up for evidence of infection.

50. EMQ. Turner’s  syndrome.
This is supposed to be an EMQ, but some of the questions are MCQs with “True” and “False” answers. But it includes everything I think you might be asked about Turner’s.
Abbreviations.
DDH
developmental dysplasia of the hip

Option list 1.
1.        
1 in   500
2.        
1 in 1,000
3.        
1 in 1,500
4.        
1 in 2,000
5.        
1 in 2,500
6.        
1 in 3,000
7.        
1 in 10,000
8.        
1 in 50,000
Option list 2.
A.       
0%
B.       
0.1%
C.       
1 %
D.       
2%
E.        
5%
F.        
10%
G.       
15%
H.       
20%
I.         
30%
J.         
40%
K.        
50%
L.        
60%
M.     
70%
N.       
80%
O.      
90%
P.        
> 90%
Q.      
Most common
R.       
2nd. most common
S.        
True
T.        
False
U.       
Answer not on this option list.

Questions.
Option list 1 is for question 2, option list 2 is for all the others that are not True/False.

1.  TS is due to 45XO.                                                                                                         True /False
2.  What is the incidence of TS?                                                                                      
3.  The incidence of TS rises with maternal age?               .                                          True /False
4.  Most cases of TS are due to loss of a paternal chromosome.                                            True /False
5.  How common is monosomy X in TS?              
6.  How common is monosomy Y in TS?              
7.  What % of miscarriages are due to TS?                         
8.  What % of TS pregnancies miscarry?              
9.  ↑ NT is a feature of TS                                                                                                 True /False
10.↑ NT is more common in foetuses with congenital heart disease                     True /False
11. Low birth weight is a feature of TS.                                                                          True /False.
12. If TS is suspected, but the neonate’s karyotype from blood testing is normal, the diagnosis is   Noonan’s syndrome.                                                                                                       True /False.
13. Neonates with TS are at normal risk of DDH.                                                         True /False
14. Immune hydrops is more common in TS.                                                               True /False
15. Cystic hygroma is more common in TS.                                                                   True /False
16. What is the approximate risk of malignancy if there is XY mosaicism in TS?             
17. How common is webbing of the neck in TS?              
18. How common is a low occipital hairline in TS?                         
19. How common is congenital heart disease in TS?       
20. Dissecting aortic aneurysm is more common in TS.                                              True /False
21. How common is lymphoedema in TS?                         
22. How common is kidney disease in TS?                         
23. Short stature in TS has been linked to the TS gene.                                              True /False
24. What % of adolescents with TS have scoliosis.           .
25. Inverted nipples are more common in TS.                                                              True /False
26. 1ry. amenorrhoea occurs in all cases.                                                                     True /False
27. Adrenarche occurs at a normal time.                                                                                     True /False
28. Cubitus valgus is more common in TS.                                                                    True /False
29. Cleft palate if a feature of TS.                                                                                    True /False
30. Micrognathia is a feature of TS.                                                                                True /False
31. Abnormalities of teeth and nails are more common in TS.                                 True /False
32. Otitis media is more common in TS.                                                                        True /False
33. Intelligence is usually lower in TS, especially verbal skills.                                   True /False
34. Women with TS have higher mortality rates than other women.                      True /False
35. Oestrogen should be started on diagnosis to promote bone growth.                              True /False
36. Oestrogen-only HRT is appropriate for bone protection.                                    True /False
37. Women with TS have an ↑ risk of hypertension.                                                 True /False
38. Women with TS have an ↑ risk of coeliac disease.                                              True /False
39. Women with TS have an increased risk of Crohn’s disease and ulcerative colitis.  True /False
40. Women with TS have an ↑ risk of diabetes                                                           True /False
41. Women with TS have an ↑ risk of hyperthyroidism. True /False                      True /False
42. Women with TS have an ↑ risk of deafness.              .                                                         True /False
43. Women with TS have an ↑ risk of osteoporosis.                                                  True /False
44. Women with TS have similar rates of red-green colour blindness to men.                True /False
45. Women with TS have a normal incidence of ptosis.                                             True /False
46. Women with TS cannot have children.                                                                    True /False
47. The “short stature homeobox” (SHOX) gene has been implicated in TS.              True /False

51. EMQ.
Drugs in O&G 1.
Lead-in.
The following scenarios relate to drugs & hypertension in pregnancy.
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.
ACEI:             angiotensin-converting enzyme inhibitor.
ARA:              angiotensin II receptor antagonist.
MAOI:           monoaminoxidase inhibitor.
Option list.
A.       
False.
B.       
True.
C.       
5
D.       
10
E.        
15
F.        
18
G.       
20
H.       
24
I.         
contraindicated in the months before pregnancy
J.         
contraindicated in the 1st. trimester
K.        
contraindicated in the 2nd. trimester
L.        
contraindicated in the 3rd. trimester
M.     
contraindicated in all trimesters
N.       
not contraindicated in pregnancy
O.      
contraindicated in breastfeeding
P.        
not contraindicated in breastfeeding
Q.      
an acute, severe illness like rheumatoid arthritis
R.       
an acute, severe illness with encephalopathy and acute fatty liver
S.        
an acute, severe illness with gastro-intestinal tract bleeding.
T.        


Scenario 1.
When are ACE inhibitors contraindicated in pregnancy?
Scenario 2.
When are ARAs contraindicated in pregnancy?
Scenario 3.
Can St. John’s Wort (SJW) be used in pregnancy?
Scenario 4.
Methyl dopa is an acceptable option for the treatment of gestational hypertension. True / False.
Scenario 5.
Spironolactone is contraindicated in pregnancy. True/False
Scenario 6.
Furosemide is an acceptable option in the management of gestational hypertension. True / False.
Scenario 7.
When are thiazide diuretics contraindicated in pregnancy?
Scenario 8.
Salbutamol is contraindicated for the management of premature labour. True / False.
Scenario 9.
Ergometrine is an integral part of active management of the 3rd. stage.  True / False.
Scenario 10.
When is aspirin contraindicated in pregnancy & the puerperium?
Scenario 11.
When are NSAID’s contraindicated in pregnancy and why?
Scenario 12.
Pethidine:       adverse neonatal effects are most likely if the drug is administered in the six hours before birth. True / False.
Scenario 13.
Pethidine:       what is the half-life in the mature neonate?
Scenario 14.
Pethidine:       is contraindicated in those taking MOAIs or who have taken them in the previous 2 months.
Scenario 15.
Pethidine:       is relatively contra-indicated when there is significant blood loss.
Scenario 16.
Pethidine:       has greater analgesic effect in labour than Diamorphine.
Scenario 17.
What is Reye’s syndrome?

52. EMQ. Drugs in Pregnancy. 2
Lead-in.
The following scenarios relate to some common drugs used in pregnancy.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
NSAID.  non-steroidal anti-inflammatory drug.
Option list.
I have not given one to make you think! And, in the exam, you should be deciding your answer before you check the option list.
Scenario 1.
What is the generic name for Prostin?
Scenario 2.
What kind of drug is Prostin?
Scenario 3.
What is the generic name for Misoprostol?
Scenario 4.
What kind of drug is Misoprostol?
Scenario 5.
What is the generic name for Gemeprost?
Scenario 6.
What kind of drug is Gemeprost?
Scenario 7
What is the generic name for Mifepristone?
Scenario 8
What king of drug is Mifepristone?
Scenario 9
What are the constituents of a 1 ml. ampoule of Syntometrine?
Scenario 10
What is the generic name for Carbetocin?
Scenario 11
What kind of drug is Carbetocin?
Scenario 12
What is the generic name for Hemabate?
Scenario 13
What kind of drug is Hemabate?
Scenario 14
What is the generic name for Atosiban?
Scenario 15
What kind of drug is atosiban?
Scenario 16
What if the generic name for Cervagem?
Scenario 17
What kind of drug is Cervagem?
Scenarion 18
What is the cost of 1mg. of Prostin E2 gel and what are its storage requirements?
Scenarion 19
What is the cost of a 1mg. Gemeprost pessary and what are its storage requirements?
Scenarion 20
What is the cost of 200 mcg. of misoprostol and what are its storage requirements?


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