Monday, 23 November 2015

Tutorial 23rd. November 2015

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23rd. November 2015.

6
SBA. Menopause. NG23. Diagnosis & definitions
7
EMQ.  Mode of inheritance
8
SBA. Placenta accreta, increta & percreta
9
EMQ.  Cervical cancer staging
10
Communication skills.

6.     Menopause. NG23. Diagnosis & definitions.
             
Abbreviations.
AMH:    anti-Müllerian hormone.
FSH:      follicle-stimulating hormone.
LH:         luteinising hormone.
NG23:   NICE Guideline 23. “Menopause: diagnosis and management.” November 2015.
POF:      premature ovarian failure.
POI:       premature ovarian insufficiency.

Some of the questions have no option list to make them harder.

Question 1.
Lead-in
Which adjective did NICE use in relation to ideal care in recommendation 1.1.1 of NG23?
Option List
A.       
best
B.       
holistic
C.       
individualised
D.       
personalised
E.        
privatised

Question 2.
Lead-in
What is the average age at the menopause?
Option List
A.       
49 years
B.       
50 years
C.       
51 years
D.       
52 years
E.        
53 years

Question 3.
Lead-in
What age limit is used for the diagnosis of premature ovarian insufficiency?
Option List
A.       
30 years
B.       
35 years
C.       
37 years
D.       
40 years
E.        
45 years

Question 4.
Lead-in
What is the approximate incidence of premature ovarian insufficiency?
Option List
A.       
0.1%
B.       
0.5%
C.       
1%
D.       
2%
E.        
5%

Question 5.
Lead-in
What is the definition of the perimenopause?

Question 6.
Lead-in
What is the definition of the postmenopause?

Question 7.
Lead-in
What is the definition of premature ovarian insufficiency?
Option List
There is none.

Question 8.
Lead-in
A healthy physics teacher of 35 is diagnosed as menopausal. There is no obvious explanation. Which of the following conditions could be the undiagnosed hereditary cause?

Option List
A.       
Cystic fibrosis carrier status
B.       
Elliptocytosis
C.       
Fragile X carrier status
D.       
Galactosaemia
E.        
Polycythaemia vera

Question 9.
Lead-in
A healthy woman of 52 presents with amenorrhoea for 15 months and vasomotor symptoms. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause.

Option List.
A.       
FSH
B.       
FSH & LH
C.       
FSH & oestradiol
D.       
AMH
E.        
None of the above

Question 10.
Lead-in
A healthy woman of 46 presents with vasomotor symptoms and irregular periods. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause?
Option List.
A.       
FSH
B.       
FSH & LH
C.       
FSH & oestradiol
D.       
AMH
E.        
None of the above

Question 11.
Lead-in
Which tests does NICE say should not be used to diagnose the menopause and perimenopause in women > 45 years?

List of possible investigations.
A.       
AFCA
B.       
MH
C.       
CT scan of pituitary fossa
D.       
inhibin A
E.        
inhibin B
F.        
oestradiol
G.       
ovarian volume
H.       
prolactin
I.         
thyroid function tests
Option list.
There is none.

Question 12.
Lead-in
What does NICE recommend with regard to the use of FSH in relation to diagnosis of the menopause?

Question 13.
Lead-in
What does NICE recommend with regard to the use of FSH in relation to diagnosis of the perimenopause?

Question 14.
Lead-in
What does NICE say about the cost of FSH assay?

Question 15
Lead-in
What does NICE recommend with regard to the use of oestradiol assay in relation to diagnosis of the menopause and perimenopause?

Question 16.
Lead-in
What does NICE recommend in relation to the diagnosis of POI?

7.           Mode of inheritance.
Lead-in.
The following questions relate to the mode of inheritance – some not quite to “mode”, but I am sure you will indulge me!
For each question, write what you think is the mode of inheritance or appropriate answer. There is no option list.
Comment.
You are expected to know a lot of basic genetics and it is hard to remember the details. A list to go over in the days before the exam makes sense. Use this one and add anything else you can think of – and let me know of your additions so I can add them to this list. Don’t add a load of rare syndromes – you will just end up confused. But add anything that you know has featured in the exam.

List of questions.
1.        
achondrogenesis.
2.        
achondroplasia.
3.        
acute fatty liver of pregnancy (AFLP).
4.        
adreno-genital syndrome
5.        
adult polycystic kidney disease.
6.        
androgen insensitivity syndrome.
7.        
albinism.
8.        
Angelman syndrome.
9.        
Apert syndrome.
10.    
Becker muscular dystrophy.
11.    
Beckwith-Wiedemann syndrome.
12.    
BRCA 1.
13.    
BRCA2.
14.    
Cavanan syndrome.
15.    
Charcot-Marie-Tooth disease.
16.    
chondrodystrophy.
17.    
Christmas disease.
18.    
congenital adrenal hyperplasia.
19.    
Cowden syndrome.
20.    
cri-du-chat syndrome. 
21.    
cystic fibrosis.
22.    
Dandy-Walker syndrome.
23.    
developmental dysplasia of the hip.
24.    
Down’s syndrome.
25.    
Duchenne muscular dystrophy
26.    
Dwarfism. See isolated growth hormone deficiency.
27.    
Edward’s syndrome.
28.    
exomphalos.
29.    
Ehlers-Danlos syndrome
30.    
Fanconi anaemia
31.    
Fitz-Hugh-Curtis syndrome.
32.    
Fragile X syndrome.
33.    
galactosaemia.
34.    
gastroschisis.
35.    
glucose-6-phosphatase deficiency. G6PD.
36.    
glucose-6-phosphate dehydrogenase deficiency. G6PDD.
37.    
haemochromatosis.
38.    
haemosiderosis..
39.    
haemophilia A:
40.    
haemophilia B:
41.    
Hunter syndrome.
42.    
Huntington’s disease.
43.    
ichthyosis.
44.    
isolated growth hormone deficiency.
45.    
juvenile polycystic kidney disease.
46.    
Kallmann’s syndrome.
47.    
Klinefelter’s syndrome.
48.    
Lesch Nyhan syndrome.
49.    
Lynch syndrome (HNPCC).
50.    
Malignant hyperthermia.
51.    
Maple syrup urine disease. 
52.    
Marfan’s syndrome.
53.    
Martin-Bell syndrome.
54.    
Mayer-Rokitansky-Kuster-Hauser syndrome.
55.    
McCune-Albright syndrome.
56.    
Meckel-Gruber syndrome.
57.    
Medium-chain acyl-CoA dehydrogenase deficiency.
58.    
mucopolysaccharidosis type I.
59.    
Myotonic dystrophy.
60.    
neurofibromatosis.
61.    
Niemann-Pick disease.
62.    
Noonan syndrome.
63.    
ocular albinism.
64.    
osteogenesis imperfecta.
65.    
osteoporosis.
66.    
Patau’s syndrome.
67.    
Perrault syndrome.
68.    
phenyketonuria.
69.    
polydactyly.
70.    
porphyria.
71.    
Potter’s syndrome.
72.    
Prader-Willi syndrome. 
73.    
Prune-belly syndrome
74.    
pyruvate kinase deficiency.
75.    
sickle cell disease.
76.    
spherocytosis.
77.    
Syndrome X.
78.    
Tay-Sach’s disease.
79.    
Thalassaemia.
80.    
Thrombophilia.
81.    
Triple X syndrome.
82.    
Turner’s syndrome.
83.    
Swyer’s syndrome.
84.    
Uniparental disomy.
85.    
VACTERL.
86.    
vitamin D resistant rickets
87.    
von Willebrand’s disease.
88.    
A mother has spina bifida. What is the risk of a child being affected? 
89.    
A mother has had a child with spina bifida, what is the risk of the next child being affected?   
90.    
A mother has had two children with spina bifida. What is the risk of the next child being affected?
91.    
A mother has grand-mal epilepsy. What is the risk of her child having epilepsy?
92.    
A mother and her partner both have grand-mal epilepsy. What is the risk of their child having epilepsy?
93.    
A mother has insulin-dependent diabetes mellitus. What is the risk of a child being affected?
94.    
A mother has congenital heart disease. What is the risk of a child being affected? 
95.    
A mother takes lithium for bi-polar disorder throughout her pregnancy. What is the risk of the child having congenital heart disease?
96.    
A mother has a nuchal translucency scan at 11 weeks. The result is 6 mm. What is the risk of the fetus having congenital heart disease?

8.     Placenta accreta, increta & percreta.
This topic has been chosen to remind you of the existence of UKOSS and the various Reports it has produced as they would make perfect EMQs or SBAs.

Question 1.
Lead-in
Choose the best option from the option list for the definition of placenta accreta.
Option List
  1.  
Placenta which is difficult to remove, but can be separated digitally
  1.  
Placental villi  invade the decidua, but not the myometrium
  1.  
Placental villi  invade the decidua and myometrium but not the serosa
  1.  
Placental villi  invade the decidua, myometrium and serosa
  1.  
Placental villi  invade adjacent organs, e.g. the bladder

Question 2.
Lead-in
Choose the best option from the option list for the definition of placenta increta.
Option List
  1.  
Placenta is difficult to remove, but can be separated digitally
  1.  
Placental villi  invade the decidua, but not the myometrium
  1.  
Placental villi  invade the decidua and myometrium but not the serosa
  1.  
Placental villi  invade the decidua, myometrium and serosa
  1.  
Placental villi  invade adjacent organs, e.g. the bladder

Question 3.
Lead-in
Choose the best option from the option list for the definition of placenta percreta.
Option List
  1.  
Placenta is difficult to remove, but can be separated digitally
  1.  
Placental villi  invade the decidua, but not the myometrium
  1.  
Placental villi  invade the decidua and myometrium but not the serosa
  1.  
Placental villi  invade the decidua, myometrium and serosa
  1.  
Placental villi  invade adjacent organs, e.g. the bladder

Question 4.
Lead-in
What is the approximate incidence of placenta creta in the UK?
Option List
  1.  
1-2 per   1,000 deliveries
  1.  
1-2 per   1,000 maternities
  1.  
1-2 per   5,000 deliveries
  1.  
1-2 per   5,000 maternities
  1.  
1-2 per 10,000 deliveries
  1.  
1-2 per 10,000 maternities

Question 5.
You need to be able to define “maternity” and know why it is important.
Lead-in
What is a “maternity”?
Option List
  1.  
Any pregnancy, including ectopic pregnancy
  1.  
Any pregnancy, excluding ectopic pregnancy
  1.  
Any pregnancy resulting in a live birth
  1.  
Any pregnancy resulting in live birth or stillbirth
  1.  
Any pregnancy ending from 24 completed weeks plus any pregnancy resulting in a live birth.

Question 6.
Lead-in
Why is the term “maternity” important.
Option List
  1.  
We should take best possible care of our pregnant patients
  1.  
It is used as the denominator in calculations of the maternal mortality rate
  1.  
It is used as the numerator in calculations of the maternal mortality rate
  1.  
It is used as the denominator in calculations of the maternal mortality ratio
  1.  
It is used as the numerator in calculations of the maternal mortality ratio

Question 7.
This question relates to risk factors for placenta accreta
Lead-in
Match each of the risk factors  listed below with an adjusted odds ratio from the Option List. Each option can be used once, more than once or not at all.
Note that some of the adjusted odds ratios show a reduced risk.

Risk factors and adjusted odds ratio.
Risk factor
Adjusted odds ratio
BMI > 30

Cigarette smoking in pregnancy

Ethnic group non-white

IVF pregnancy

Maternal age > 35

Parity ≥ 2

PIH or PET

Placenta previa diagnosed pre-delivery

Previous Caesarean section > 1

Previous Caesarean section x 1

Previous uterine surgery – not C. section






Option List
Adjusted odds ratio
0.53
0.57
0.66
0.9
1.0
2.0
3.06
3.4
3.48
10
14
16.31
32.13
65.02
102

Question 8.
Lead-in
This question relates to estimated incidence of placenta creta for various risk factors.
Match the risk factors with the estimated incidence in the option list. Each option can be used once, more than once or not at all.

Risk factors and estimated incidence per 10,000 maternities.
Risk factor
Estimated incidence
No previous C section

≥ 1 C section

Placenta previa not diagnosed pre-delivery

Placenta previa diagnosed pre-delivery

Previous C section but placenta previa not diagnosed pre-delivery

Previous C section + placenta previa diagnosed pre-delivery




Option List
0.3
0.6
1
3
5
9
108
577
1,000

9      EMQ.  Cervical cancer staging.
EMQ Paper 1 , Question 6 . Ca Cx staging.
Lead-in.
The following scenarios relate to cervical cancer staging.
For each, select the most appropriate staging.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 2.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 3.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 4.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There is no evidence of extension outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 5.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is nulliparous and wishes to retain her fertility.
Scenario 6.
A woman of 38 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR scan shows involvement of the lymphatic nodes in the left of the pelvis.
Scenario 7.
A woman of 45 has carcinoma of the cervix. It extends into the parametrium, but not to the pelvic side-wall. It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic node involvement.
Scenario 8.
A woman of 55 has carcinoma of the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of the vagina. She has a secondary on the end of her nose.
Scenario 9.
A woman of 55 has carcinoma of the cervix. It involves the bladder mucosa.
Scenario 10.
A woman of 35 has a proven cancer of the cervix with extension into the right parametrium, but not to the pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on IVP and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.
Scenario 11.
A woman of 25 has a cone biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is 5 mm in width. The margins of the biopsy are clear. There is evidence of lymphatic vessel involvement. There is no evidence of spread outside the uterus.

Option list.
Micro-invasive cervical cancer.
Stage Ia1
Stage Ia2
Stage Ia3
Stage Ib1
Stage Ib2
Stage Ib3
Stage IIa
Stage IIb
Stage IIc
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Stage IVc
Stage Va
Stage Vb
Stage Vc
None of the above.

This question illustrates the problems surrounding staging. If you are not a cancer specialist, it is not something that you think about very often, if ever. So you have to put it into your list of things to revise in the days before the exam. If you haven’t started this list, do so now.

10.   Communication skills.


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