Monday, 11 June 2018

Tutorial 11th. June 2018

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24
EMQ. Swyer’s syndrome
25
EMQ. Antenatal steroids.
26
SBA.   Cancer incidence & mortality
27
EMQ. Cervical cancer staging
28
SBA.   Coeliac disease & pregnancy

24.   EMQ. Swyer’s syndrome
Scenario 1.                
Who described Swyer’s syndrome?
Option list.
A
Andrew P. Swyer
B
Mary Elizabeth Swyer
C
Antonia Margaret Swyer
D
Gerald Isaac MacDonald Swyer
E
John Ambrosia Swyer
Scenario 2.                
Which, if any, of the following statements apply to Swyer’s syndrome?
Option list.
A
chromosomal disorder
B
gonadal agenesis
C
gonadal dysgenesis
D
trinucleotide repeat disorder
E
mitochondrial disorder
F
X-linked recessive
Scenario 3.                
What is the approximate prevalence of Swyer’s syndrome?
Option list.
A
1 in 1,000
B
1 in 5,000
C
1 in 10,000
D
1 in 50,000
E
1 in 100,000
F
1 in 250,000
Scenario 4.                
Which, if any, of the following are key features of Swyer’s syndrome?
Option list.
A
ambiguous genitalia at birth
B
androgen resistance
C
anlagen
D
insulin resistance
E
oestrogen resistance
F
height above average
G
height below average
H
xenophobia
Scenario 5.                
Which, if any, of the following are true of Swyer’s syndrome in the adult?
Option list.
A
gonadotrophin levels are high
B
gonadotrophin levels are low
C
gonadotrophin levels are normal
D
oestrogen levels are high
E
oestrogen levels are low
F
oestrogen levels are normal
G
testosterone levels are high
H
testosterone levels are low
I
testosterone levels are normal
J
prolactin levels are high
K
prolactin levels are low
L
prolactin levels are normal
M
17-hydroxyprogesterone are high
N
17-hydroxyprogesterone are low
O
17-hydroxyprogesterone are normal
Scenario 6.                
Which malignancy most commonly develops in the gonads in Swyer’s syndrome?
Option list.
A
dysgerminoma
B
embryonal carcinomas
C
endodermal sinus tumour
D
gonadoblastoma
E
yolk-sac tumour
F
none of the above
Scenario 7.                
What is the risk of malignancy developing in the gonads in Swyer’s syndrome?
Option list.
A
10%
B
20%
C
30%
D
40%
E
>50%
F
the figure is not known
Scenario 8.                
Which, if any, of the following are true about pregnancy in Swyer’s syndrome?
Option list.
A
it is possible but requires egg donation
B
it is possible but requires embryo donation
C
it is possible but requires uterine transplant
D
it is not possible due to uterine hypoplasia
E
the uterus does not develop as the chromosomes are 46XY
F
none of the above

25.   EMQ. Antenatal steroids

Abbreviations.
ANC:            antenatal corticosteroids.
ANS:            antenatal steroids.
NG25:           NICE’s Guideline 25: “Preterm labour and birth”. November 2015.

Lead-in.
There are no option lists: you have to decide your answers without help.
Scenario 1.
What are the benefits to the neonate of appropriate administration of antenatal steroids?
Scenario 2.
At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?
Scenario 3.
At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?
Scenario 4.
What advice is contained in NG25 about ANS and very early gestations?
Scenario 5.
What advice is contained in NG25 GTG about antenatal steroids and Caesarean section?
Scenario 6.
What advice is given in the NG25 about ANS in relation to the fetus with FGR at risk of premature delivery?
Scenario 7
What advice is given in NG25 about ANS for women with IDDM?
Scenario 8
What advice is in the NG25 about adverse effects of ANS on the fetus?
Scenario 9
What advice is in the GTG in relation to short-term maternal adverse effects?
Scenario 10
What contraindications to ANS are cited in NG25?
Scenario 11
What is the recommended drug regime for ANS administration?
Scenario 12.
What is the time-scale for maximum effect of ANS in reducing RDS?
Scenario 13.
When should repeat courses of ANS be given?
Scenario 14.
Who was the great pioneer of antenatal steroids to accelerate lung maturation?
Scenario 15.
Which country was this great pioneer from and which animal did he use for his early research?
Answer. New Zealand and sheep.
Scenario 16.
Why is the story of this pioneer’s work a cautionary tale for O&G?
Scenario 17.
Which international organisation has immortalised his work in its logo?
Scenario 18.
When may antenatal steroids be beneficial to the fetus apart from accelerating lung maturation?

26.   EMQ. Cancer incidence & mortality
Abbreviations.
NHL:      non-Hodgkin Lymphoma
Question 1.
Lead-in
Which is the most common female cancer?
Option List
A.       
Bowel
B.       
Breast
C.       
Cervix
D.       
Endometrium
E.        
Lung
Question 2.
Lead-in
Which is the 2nd. most common female cancer?
Option List
A.       
Bowel
B.       
Breast
C.       
Cervix
D.       
Endometrium
E.        
Lung
Question 3.
Lead-in
Which is the 3rd. most common female cancer?
Option List
A.       
Bowel
B.       
Breast
C.       
Cervix
D.       
Endometrium
E.        
Lung
Question 4.
Lead-in
Which is the 4th. most common female cancer?
Option List
A.       
Bowel
B.       
Cervix
C.       
Endometrium
D.       
Lung
E.        
Pancreas
Question 5.
Lead-in
Which is the 5th. most common female cancer?
Option List
A.       
Cervix
B.       
Malignant melanoma
C.       
Non-Hodgkin’s lymphoma
D.       
Ovary
E.        
Vulva
Question 6.
Lead-in
Which is the 6th. most common female cancer?
Option List
A.       
Cervix
B.       
Malignant melanoma
C.       
Non-Hodgkin’s lymphoma
D.       
Ovary
E.        
Vulva
Question 7.
Lead-in
Where does cervical cancer feature in the list of the most common female cancers?
Option List
A.       
10th.
B.       
11th.
C.       
13th.
D.       
14th.
E.        
20th.
Question 8.
Lead-in
Where does vulval cancer feature in the list of the most common female cancers?
Option List
A.       
10th.
B.       
12th.
C.       
16th.
D.       
20th.
E.        
none of the above
Question 9.
Lead-in
Which is the most common cancer causing female death in the UK?
Option List
A.       
Breast
B.       
Bowel
C.       
Lung
D.       
Ovary
E.        
Pancreas
Question 10.
Lead-in
Which is the 2nd. most common cancer causing female death in the UK?
Option List
A.       
Breast
B.       
Bowel
C.       
Lung
D.       
Ovary
E.        
Pancreas
Question 11.
Lead-in
Which is the 3rd. most common cancer causing female death in the UK?
Option List
A.       
Breast
B.       
Bowel
C.       
Lung
D.       
Ovary
E.        
Pancreas
Question 12.
Lead-in
Which is the 4th. most common cancer causing female death in the UK?
Option List
A.       
Brain
B.       
Oesophagus
C.       
Ovary
D.       
Pancreas
E.        
Uterus
Question 13.
Lead-in
Which is the 5th. most common cancer causing female death in the UK?
Option List
A.       
Brain
B.       
Oesophagus
C.       
Ovary
D.       
Pancreas
E.        
Uterus
Question 14.
Which is the 6th. most common cancer causing female death in the UK?
Option List
A.       
Brain
B.       
Oesophagus
C.       
Ovary
D.       
Pancreas
E.        
Uterus
Question 15.
Lead-in
The incidence of cervical cancer has fallen from the late 1970s until now. What is the approximate figure for the fall?
Option List
A.       
10%
B.       
25%
C.       
50%
D.       
60%
E.        
75%
Question 16.
Lead-in
Which, if any, of the following statements are true in relation to CIN.
Option List
A
there were ~ 20,000 new cases of CIN in 2015
B
there were ~ 30,000 new cases of CIN in 2015
C
there were ~ 50,000 new cases of CIN in 2015
D
incidence rates for new cases of CIN are highest in women aged 19 - 24
E
incidence rates for new cases of CIN are highest in women aged 25 - 29
F
incidence rates for new cases of CIN are highest in women aged 30 - 39
G
incidence rates for new cases of CIN ↑ by ~ 10 % since the 1990s
H
incidence rates for new cases of CIN ↑ by ~ 20 % since the 1990s
I
incidence rates for new cases of CIN ↑ by ~ 30 % since the 1990s
J
incidence rates for new cases of CIN ↑ by ~ 5 % in the past decade
K
incidence rates for new cases of CIN ↑ by ~ 10 % in the past decade
L
incidence rates for new cases of CIN ↑ by ~ 15 % in the past decade
Question 17.
Lead-in
Which, if any, of the following statements describes the change in incidence of cervical cancer in the past decade.
Option List
A.       
↑ by 5%
B.       
↓ by 5%
C.       
↑ by 10%
D.       
↓ by 10%
E.        
↑ by 15%
F.        
↓ by 15%
G.       
↑ by 20%
H.       
↓ by 20%
I.         
↑ by 25%
J.         
↓ by 25%
Question 18.
Lead-in
What is the peak age at which cervical cancer is diagnosed in the UK?
Option List
A.       
20-24
B.       
25-29
C.       
30-34
D.       
35-39
E.        
40-44
F.        
45-49
G.       
50-54
H.       
55-59
I.         
≥60
Question 19.
Lead-in
What proportion of cervical cancer is diagnosed in women < 45 years?
Option List
A.       
20%
B.       
30%
C.       
40%
D.       
50%
E.        
60%
Question 20.
Lead-in
The mortality rate from cervical cancer has fallen from the late 1970s until now. What is the approximate figure for the fall?
Option List
A.       
10%
B.       
25%
C.       
50%
D.       
60%
E.        
75%
Question 21.
Lead-in
The mortality rate from cervical cancer has fallen in the past decade. What is the approximate figure for the fall?
Option List
A.       
10%
B.       
25%
C.       
50%
D.       
60%
E.        
75%
Question 22.
Lead-in
The mortality rate from cervical cancer has fallen in the past decade. What is the approximate figure for the fall?
Option List
F.        
10%
G.       
25%
H.       
50%
I.         
60%
J.         
75%
Question 23.
Lead-in
When was routine HPV vaccination of girls introduced in the UK?
Option List
A.       
2000
B.       
2002
C.       
2004
D.       
2006
E.        
2008
Question 24.
Lead-in
From what year might we expect to see a reduction in cervical cancer incidence as a result of the HPV vaccination programme?
Option List
A.       
2020
B.       
2025
C.       
2030
D.       
2040
E.        
2050
Question 25.
Lead-in
When was routine HPV vaccination of boys introduced in the UK?
Option List
A.       
2010
B.       
2011
C.       
2012
D.       
2014
E.        
None of the above

27.   EMQ. Cervical cancer staging
Option list.
A
Micro-invasive cervical cancer.
B
Stage Ia1
C
Stage Ia2
D
Stage Ia3
E
Stage Ib1
F
Stage Ib2
G
Stage Ib3
H
Stage IIa
I
Stage IIb
J
Stage IIc
K
Stage IIIa
L
Stage IIIb
M
Stage IIIc
N
Stage IVa
O
Stage IVb
P
Stage IVc
Q
Stage Va
R
Stage Vb
S
Stage Vc
T
None of the above.
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.

28.   SBA. Coeliac disease & pregnancy
Abbreviations.
AGA:                            anti-gliadin antibodies 
CD:                              coeliac disease.
EMA:                           anti-endomysial antibodies. 
FGR:                            Fetal growth restriction.
IgA:                              immunoglobulin A IgG. 
tTGA:                           anti-tissue transglutaminase antibody.
Question 1.
Lead-in
What is coeliac disease?
Option List
F.        
allergy to gluten
G.       
malabsorption due to large bowel inflammation
H.       
an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the descending colon in individuals with a genetic predisposition
I.         
an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the gastric mucosa in individuals with a genetic predisposition
J.         
an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the small bowel in individuals with a genetic predisposition
Question 2.
Lead-in
What is the prevalence of coeliac disease in women of reproductive age?
Option List
A.       
0.1%
B.       
0.5%
C.       
1-2 %
D.       
2-5%
E.        
5-10%
Question 3.
Lead-in
Which of the following groups have an increased risk of CD?
Option List
A.       
1st. degree relatives of those with CD
B.       
those with type 1 diabetes
C.       
those with iron deficiency anaemia
D.       
those with osteoporosis
E.        
those with unexplained infertility
Question 4.
Lead-in
Which of the following are features of CD in the non-pregnant population?
Option List
A.       
abdominal bloating and pain
B.       
amenorrhoea
C.       
anaemia
D.       
recurrent miscarriage
E.        
unexplained infertility
Question 5.
Lead-in
How do pregnant women with CD present most commonly?
Option List
A
anaemia
B
failure to gain weight in pregnancy
C
intra-uterine growth retardation
D
low BMI
E
no recognised abnormality
Question 6.
Lead-in
Which of the following commonly occur in pregnant women with CD?
Option List
A
anaemia
B
failure to gain weight in pregnancy
C
intra-uterine growth retardation
D
low BMI
E
no recognised abnormality
Question 7.
How should the woman with suspected CD be investigated initially?
Option List
A.       
jejunal biopsy
B.       
IgA EMA
C.       
IgA tTGA
D.       
IgA EMA + IgA tTGA
E.        
rectal biopsy
Question 8.
Lead-in
Which, if any, of the following statements are true in relation to the woman due to have testing for suspected CD?
Option List
F.        
continue with a normal diet.
G.       
continue with a normal diet that includes a minimum of 5 gm. gluten daily
H.       
continue with a normal diet that includes a minimum of 10 gm. gluten daily
I.         
follow a strict gluten-free diet for at least 1 month
J.         
follow a strict gluten-free diet for at least 3 months
Question 9.
Lead-in
Which of the following conditions should make consideration of testing for CD sensible?
Option List
A.       
amenorrhoea
B.       
Down’s syndrome
C.       
epilepsy
D.       
recurrent miscarriage
E.        
Turner’s syndrome
F.        
unexplained infertility
Question 10.
Lead-in
How is the diagnosis of CD confirmed after +ve serological testing?
Option List
A.       
colonoscopy
B.       
enteroscopy
C.       
gastroscopy
D.       
rectal biopsy
E.        
small bowel  biopsy
Question 11.
Lead-in
Which skin condition is particularly associated with CD?
Option List
A.       
atopic eczema
B.       
dermatitis herpetiformis
C.       
dermatitis multiforme
D.       
dermatographia
E.        
psoriasis
Question 12.
Lead-in
Which of the following are likely to be absorbed less well than normally in women with CD?
Option List
A.       
carbohydrate
B.       
fat
C.       
folic acid
D.       
protein
E.        
vitamins B12, D & K
Question 13.
Lead-in
What is the appropriate treatment of CD?
Option List
A.       
antibiotics: long-term in low-dosage
B.       
azathioprine
C.       
cyclophosphamide
D.       
rectal steroids
E.        
none of the above
Question 14.
Lead-in
Which of the following do not contain gluten?
Option List
A.       
barley
B.       
oats
C.       
rapeseed oil
D.       
rye
E.        
wheat


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