Tutorial 16th. February 2017

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16 February 2017.

78	Urogynae. Deepa Gopinath.	16	February	2017
79	EMQ. Chlamydia trachomatis	16	February	2017
80	EMQ. Diabetes	16	February	2017

Question 78       Urogynaecology. Deepa Gopinath.

The documents for the tutorial are in the Dropbox folder “Materials for the tutorials

Question 79.     EMQ. Chlamydia.

Abbreviations.

EIA:             enzyme immunoassay

FCU:           first-catch urine specimen

FHCs:          Fitz-Hugh Curtis syndrome.

MSM:         Men who have sex with men.

NAAT:        nucleic acid amplification test.

NGC:           UK national guideline for the management of infection with Chlamydia trachomatis. 2015. 

PID:            pelvic inflammatory disease

POCT:         point-of-care testing

VVS:           vulvo-vaginal swab.

WSW:         Women who have sex with women.

Scenario 1.                

What kind of organism is Ct?

Option list.

A	gram –ve enterococcus
B	gram +ve enterococcus
C	gram –ve diplococcus
D	gram +ve diplococcus
E	obligate intracellular Gram –ve bacterium
F	obligate intracellular diplococcus
G	obligate intracellular bacteriophage

Scenario 2.                

Which, if any, of the following statements are true?

Statements.

I	Ct genital infection is due to serotypes D-K
II	Ct genital infection is due to serovars L1 – L3
III	LGV is due to Ct serotypes D-K
IV	LGV is due to Ct serovars L1 – L3
V	Granuloma inguinale is due to serotypes A - E
VI	Granuloma inguinale is due to serovars L4 – L6
VII	Trachoma is due to serotypes A - C
VIII	Trachoma is due to serovars L4 – L6

Option list.

A	I + III + V + VII
B	I + III  + V + VI
C	I + IV + V + VIII
C	I + IV + VI + VIII
D	I + IV + VII
E	II + III + V + VII
F	II + III  + V + VI
G	II + IV + V + VIII
H	II + IV + VI + VIII
I	II + IV + VII

Scenario 3.                

Which, if any, of the following groups have the highest prevalence of Ct infection?

Groups.

I	sexually-active men, aged 15-24
II	sexually-active women, aged 15-24
III	sexually-active men, aged 25-30
IV	sexually-active women, aged 25-30

Option list.

A	I
B	II
C	I + II
D	III
E	IV
F	I + II
G	I + III
H	II + III
I	III + IV

Scenario 4.                

Which, if any, of the following statements are true?

Statements.

I	Ct. detection rates were higher for sexually-active men, aged 15-19 than those aged 20-24
II	Ct. detection rates were higher for sexually-active women, aged 15-19 than those aged 20-24
III	Ct. detection rates were higher for sexually-active men, aged 20-24 than those aged 25-30
IV	Ct. detection rates were higher for sexually-active women, aged 20-24 than those aged 25 -30

Option list.

A	I + II + III + IV
B	I + III + IV
C	II + III
D	II + III + IV
E	III + IV

Scenario 5.                

What proportion of chlamydial infections in UK occur in the highest risk group?

Option list.

A	< 20%
B	20 - 29%
C	30 - 39%
D	40 – 49%
E	50 – 59%
F	60 – 69%
G	70 – 79%
H	80 – 89%
I	≥ 90%

Scenario 6.                

What did the NSSAL estimate the prevalence rates for the highest risk group to be?

Option list.

A	< 1%
B	< 5%
C	5 – 10%
D	10 – 15
E	15 – 20%
F	none of the above

Scenario 7.                

What is the risk of recurrence after treatment in young adults?

Option list.

A	5 – 10%
B	10 – 20%
C	10 – 30%
D	20 – 30%
E	20 – 40%
F	none of the above

Scenario 8.                

What % of untreated Ct genital tract infections will resolve spontaneously by 12 months?

Option list.

A	<5%
B	5 - 10%
C	10 – 20%
D	20 – 30%
E	30 – 40%
F	50%

Scenario 9.                

What is the estimated risk of transmission between partners when one has Ct genital tract infection?

A	10 – 20%
B	20 – 30%
C	30 – 40%
D	40 – 50%
E	50 – 60%
F	60 – 70%
G	> 70%
H	> 80%
I	> 90%

Scenario 10.            

Which, if any, of the following statements are true in relation to symptoms in cases of chlamydial infection?

A	vaginal discharge may be present
B	intermenstrual bleeding may be present
C	postcoital bleeding may be present
D	dysuria may be present
E	dyspareunia may be present
F	most are asymptomatic

Scenario 11.            

What is the incidence of rectal infection in women with chlamydial genital tract infection?

A	10 – 20%
B	20 – 30%
C	30 – 40%
D	40 – 50%
E	50 – 60%
F	unknown

Scenario 12.            

What is the incidence of pharyngeal infection in women with genital tract Ct infection?

A	< 5%
B	5 – 9%
C	10 – 20%
D	20 – 30%
E	30 – 40%
F	unknown

Scenario 13.            

What is the incidence of conjunctival infection in women with genital tract Ct infection?

A	< 5%
B	5 – 9%
C	10 – 20%
D	20 – 30%
E	30 – 40%
F	unknown

Scenario 14.            

Which of the following are possible consequences of genital tract Ct infection?

A	ectopic pregnancy
B	endometritis
C	Fitz-Hugh Curtis syndrome
D	PID
E	salpingitis
F	SARA
G	tubal infertility

Scenario 15.            

What is the rate of occurrence of PID after genital tract Ct infection in women?

A	< 5%
B	5 – 9%
C	10 – 20%
D	20 – 30%
E	30 – 40%
F	unknown

Scenario 16.            

What is the rate of occurrence of SARA after genital tract Ct infection in women?

A	< 5%
B	5 – 9%
C	10 – 20%
D	20 – 30%
E	30 – 40%
F	unknown

Scenario 17.            

Which, if any of the following statements are true in relation to SARA?

A	means sudden amnesia related to alcohol
B	means sexually acquired reactive arthritis
C	is the name of my youngest daughter
D	was originally described in relation to Yersinia infection
E	is a complication of cutaneous leprosy

Scenario 18.            

One of the following statements is true. Which is it?

A	culture and sensitivity done on an endocervical swab is the recommended test
B	EIS done on an endocervical swab is the recommended test
C	NAAT done on an endocervical swab is the recommended test
E	EIS done on a FCU is the recommended test
F	NAAT done on a FCU is the recommended test
G	EIS done on a VVS is the recommended test
H	NAAT done on a VVS is the recommended test
I	POCT using enhanced EIS on a VVS is the recommended test
J	POCT using NAAT on a VVS is the recommended test
K	none of the above

Scenario 19.            

Which, if any, of the following statements are true in relation to NGC’s view of an ideal treatment?

A	it  should be administered as a single oral dose
B	it should have a microbiological cure rate > 85%
C	it should have a microbiological cure rate > 90%
E	it should have a microbiological cure rate > 95%
F	it should have a microbiological cure rate > 98%
G	it should have little by way of side effects
H	none of the above

Scenario 20.            

A 35-year-old woman is found to have genital chlamydial infection. She has a copper IUD.

Should she be advised to have it removed and use alternative contraception?  Yes / No.

Scenario 21.            

Which, if any, of the following statements are true about the recommended treatment regimens for uncomplicated Ct genital tract infection?

A	doxycycline 100 mg tds for 7 days is a recommended 1ry. treatment
B	azithromycin in a single dose of 1 gm. orally is a recommended 1ry. treatment
C	amoxicillin 250 mg. tds for 7 days is a recommended 2ry. treatment
D	erythromycin 500 mg bd for 10-14 days is a recommended 2ry. treatment
E	ofloxacin 200 mg bd or 400 mg od for 7 days is recommended 2ry. treatment
F	doxycycline is preferred to azithromycin in the treatment of Ct proctitis
G	azithromycin is linked to tendon rupture in rare cases
H	azithromycin is contraindicated in pregnancy and during breastfeeding
I	doxycycline is contraindicated in pregnancy and during breastfeeding
J	side-effects limit the usefulness of erythromycin
K	none of the above

Scenario 22.            

Which, if any, of the following statements apply to the treatment of Ct urogenital infection in pregnant women?

Statements.

A	amoxicillin 500 mg. tds for 7 days is a recommended treatment
B	azithromycin in a single dose of 1 gm. orally is a recommended treatment
C	doxycycline 100 mg tds for 7 days is a recommended treatment
D	erythromycin 500 mg twice daily  for 10-14 days is a recommended treatment
E	erythromycin 500 mg four times daily for 7 days is a recommended treatment
F	ofloxacin 200 mg bd or 400 mg od for 7 days is a recommended treatment

Scenario 23.            

Which, if any, of the following statements about test of cure (TOC) are true in relation to Ct urogenital infection?

Statements.

A	TOC is not usually done
B	TOC should be done when a pregnant woman is treated
C	TOC should be done if LGV is present or suspected
D	TOC should not be done earlier than 3 weeks after the treatment is finished
E	none of the above

Scenario 24.            

Which, if any, of the following statements are in relation to neonatal Ct?

Statements.

A	mother-to-baby transmission (MTBT) is mainly intrauterine
B	mother-to-baby transmission is mainly intrapartum from direct contact with the infected maternal genital tract
C	ophthalmia neonatorum and meningitis are the most common results
D	Ct infection should be excluded in all cases of conjunctivitis occurring < 30 days
E	antibiotic eye drops are the treatment of choice if conjunctivitis is the only sign of infection
F	none of the above

Question 80.     EMQ. Diabetes.

Diabetes in pregnancy.

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.          advise 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

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 1^st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2^nd. 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 1^st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2^nd. 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.