Thursday, 27 September 2018

Tutorial 27th. September 2018


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12
Viva. C section scar pregnancy. 2
13
EMQ. Uterine transplant.
14
Role-play. Break bad news. Primigravida. 8 weeks. Some bleeding.
15
EMQ. Clue cells, koilocytes etc.
16
SBA.   Lynch syndrome
17
EMQ. Maternal Mortality definitions

12. C section scar pregnancy 2.
This is a continuation of last week’s viva. The examiner will ask 12 questions.

13. Uterine transplant.
Abbreviations.
ET:         embryo transfer.
UT:        uterine transplant
Scenario 1.                
When was the 1st. human uterine transplant performed?
Option list.
A
2000
B
2015
C
2010
D
2011
E
2012
F
2013
G
2014
H
2015
I
2016
J
2017
Scenario 2.                
When was the 1st. livebirth after human uterine transplant?
Option list.
A
2000
B
2015
C
2010
D
2011
E
2012
F
2013
G
2014
H
2015
I
2016
J
2017
Scenario 3.                
How many live births had occurred worldwide after UT up to the end of 2017?
Option list
A
< 5
B
5 - 10
C
11 - 20
D
21 - 50
E
51 - 100
F
> 100
Scenario 4.                
For which of the following conditions is UT a possible treatment?
Option list.
A
Androgen Insensitivity syndrome. AIS.
B
Congenital Adrenal hyperplasia. CAH.
C
Kallmann’s syndrome. KS.
D
Mayer-Rokitansky-K├╝ster-Hauser syndrome. MRKH.
E
McCune-Albright syndrome. MCAS.
F
Swyer’s syndrome. SS.
G
Turner’s syndrome. TS.
Scenario 5.                
Which, if any, of the following are commonly used for donor selection?
Option list.
A
absence of adenomyosis
B
absence of fibroids
C
age < 65 years
D
good general health
E
negative cervical smear and no high-risk HPV
F
no cancer in past 5 years
G
parous
H
vaginal length > 7 cm.
Scenario 6.                
What is the rate of graft survival at 1 year, failure being the need for hysterectomy?
Option list.
A
< 10%
B
11 – 20%
C
21 – 30%
D
31 – 40%
E
41 – 50%
F
51 – 60%
G
> 60%
H
the figure is unknown
Scenario 7.                
Which of the following statements is correct?
Option list.
A
donor surgery is more extensive than recipient surgery
B
donor surgery is less extensive than recipient surgery
C
donor surgery is as extensive as recipient surgery
Scenario 8.                
What are the risks to the donor in addition to the usual ones of bleeding,  infection, haematoma and thrombosis? There is no option list.
Scenario 9.                
Which condition has been the reason for recipients needing uterine transplant and which complication is more likely in addition to the usual ones of bleeding,  infection, haematoma and thrombosis? There is no option list.
Scenario 10.            
When is IVF and cryopreservation of eggs done?
Option list.
A
before uterine transplantation
B
at the time of uterine transplantation
C
12 months after uterine transplantation to ensure graft rejection does not occur
D
when the recipient chooses
E
none of the above
Scenario 11.            
Which maintenance therapy was used immediately before embryo transfer in the first case resulting in livebirth?
Option list.
A
azathioprine + corticosteroids + tacrolimus
B
azathioprine + ciclosporin + corticosteroids + mycophenolate mofetil
C
azathioprine + corticosteroids + mycophenolate mofetil + tacrolimus
D
azathioprine + corticosteroids + tacrolimus
E
ciclosporin + corticosteroids + mycophenolate mofetil + tacrolimus
F
ciclosporin + mycophenolate mofetil + tacrolimus
G
corticosteroids + mycophenolate mofetil + tacrolimus
H
corticosteroids + tacrolimus

14. Break bad news. Primigravida. 8 weeks. Some bleeding..
Candidate’s instructions.
You are the SpR in the ante-natal clinic. The Consultant who was in clinic has been asked to assist her Consultant colleague in the labour ward theatre. She is unlikely to return for some time as the case is one of massive PPH and hysterectomy may be necessary. 
One of the midwives asks you to see a patient who has just had a scan in the EPU.  She is primigravid and the gestation is 8 weeks. She has had some bleeding.   
An ultrasound scan = IUP.  CRL = 12 mm.  No fetal heart activity.  No adnexal masses.

15. Clue cells, koilocytes etc.
Lead-in.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
Ct:                     Chlamydia trachomatis
FPA:                  Family Planning Association
HSV:                 Herpes simplex virus
LGV:                 lymphogranuloma venereum
Ng:                    Neisseria gonorrhoeae
Tv:                    Trichomonas vaginalis
Option list.
A
Actinomyces
B
Bacterial vaginosis
C
Bacteroides
D
Chlamydia trachomatis
E
Chlamydial infection of the genital tract
F
Herpes Simplex
G
Human Papilloma Virus
H
Lymphogranuloma venereum
I
Monilia
J
Neisseria gonorrhoeae
K
Trichomonas vaginalis
Scenario 1
Which option or options from the option list best fit with “clue cells”
Scenario 2
Which option or options from the option list best fit with “fishy odour”?
Scenario 3
Which option or options from the option list best fit with “flagellate organisms”?
Scenario 4
Which option or options from the option list best fit with “inflammatory smear”?
Scenario 5
Which option or options from the option list best fit with “koilocytes”?
Scenario 6
Which option or options from the option list best fit with “non-specific urethritis in the male”?
Scenario 7
Which option or options from the option list best fit with “strawberry cervix”?
Scenario 8
Which option or options from the option list best fit with “thin grey/ white discharge”?
Scenario 9
Which option or options from the option list best fit with “white, curdy discharge”?
Scenario 10
Which option or options from the option list best fit with “frothy yellow discharge”?
Scenario 11
Which option or options from the option list best fit with “protozoan”?
Scenario 12
Which option or options from the option list best fit with “obligate intracellular organism”?
Scenario 13
Which option or options from the option list best fit with “blindness”?
Scenario 14
Which option or options from the option list best fit with “LGV”?
Scenario 15
Which option or options from the option list best fit with “multinucleated cells”?
Scenario 16
Which option or options from the option list best fit with “serotypes D–K”?
Scenario 17
Which option or options from the option list best fit with “serovars L1-L3”?
Scenario 18
Which of the following are true in relation to Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
flagellate organism present on microscopic examination of vaginal fluid
E
pH ≤ 4.5
F
pH > 4.5
G
thin, grey-white, homogeneous discharge present
H
frothy, yellow-green discharge present
I
fishy smell on adding alkali (10%KOH)
J
fishy smell on adding acid (10%HCl)
K
koilocytes present
L
absence of vulvo-vaginal irritation
Scenario 19
Which of the following are true in relation to Nugent’s Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
pH ≤ 4.5
E
pH > 4.5
F
count of lactobacilli
G
count of Gardnerella and Bacteroides
H
count of white cells
Scenario 20
Garnerella vaginallis can be cultured from the vagina of what proportion of normal women?
A
< 10%
B
11 - 20%
C
21 - 30%
D
31 - 40%
E
41 - 50%
F
> 50%

16. Lynch syndrome.
Abbreviations
CRC:              colorectal cancer.
EC:                 endometrial cancer.
HNPCC:         hereditary non-polyposis colo-rectal cancer.
IBD:               inflammatory bowel disease: Crohn’s & ulcerative colitis.
IDDM:           insulin-dependent diabetes mellitus.
Ls:                  Lynch syndrome.
Question 1.              
Lead-in
What is Lynch syndrome?
Option List
A
auto-immune condition leading to reduced factor X levels in blood
B
hereditary condition which increases the risk of many cancers, particularly breast
C
hereditary condition which increases the risk of many cancers, particularly breast & colorectal
D
hereditary condition which increases the risk of many cancers, particularly colorectal & endometrial
E
none of the above
Question 2.              
Lead-in
How  is Lynch syndrome inherited?
Option List
A
it is an autosomal dominant condition
B
it is an autosomal recessive condition
C
it is an X-linked dominant condition
D
it is an X-linked recessive condition
E
none of the above
Question 3.              
Lead-in
Which, if any, of the following genes can cause Lynch syndrome?
Genes.
A
MLH1
B
MLH2
C
MOH1
D
MSH1
E
MSH6
Option List
A
MLH1 + MLH2 + MOH1
B
MLH1 + MLH2 + MSH1
C
MLH1 + MLH2 + MSH6
D
MLH1 + MSH2 + MSH6
E
None of the above
Question 4.              
Lead-in
Mutations of which 2 of the following genes cause the majority of cases of Lynch syndrome?
Genes.
A
MLH1
B
MLH2
C
MOH1
D
MSH1
E
MSH6
Option List
A
MLH1 + MLH2
B
MLH1 + MSH1
C
MLH1 + MSH2
D
MLH2 + MSH1
E
MLH2 + MSH2
Question 5.              
Lead-in
What is the approximate prevalence of Ls in the UK population?
Option List
A.       
1 in 50
B.       
1 in 100
C.        
1 in 1,000
D.       
3 in 1,000
E.        
none of the above
Question 6.              
Lead-in
Approximately what % of individuals with Ls have had the diagnosis established?
Option List
A.       
< 5%
B.       
5 -10%
C.        
10-20%
D.       
20-30%
E.        
>30%
Question 7.              
Lead-in
Which, if any, of the following conditions are associated with an ↑ risk of Lynch syndrome?
Conditions
acromegaly
Addison’s disease
anosmia
coeliac disease
IBD
IDDM
Option List
A
acromegaly + Addison’s disease + coeliac disease + IBD + IDDM
B
acromegaly + disease + anosmia + coeliac disease + IBD
C
acromegaly + IBD + IDDM
D
acromegaly + IBD
E
Addison’s disease + anosmia + coeliac disease + IBD + IDDM
F
acromegaly + Addison’s disease + anosmia + coeliac disease + IBD + IDDM
G
acromegaly + Addison’s disease + anosmia + coeliac disease + IBD + IDDM
H
none
Question 8.              
Lead-in
Which 2 cancers are most likely in women with Lynch syndrome?
Cancers.
A
breast
B
bowel
C
cervix
D
endometrium
E
ovary
F
pancreas
Option List
A
breast + bowel
B
breast + pancreas
C
breast + endometrium
D
bowel + cervix
E
bowel + endometrium
F
bowel + ovary
G
bowel + pancreas
H
endometrium + ovary
Question 9.              
Lead-in
What does NICE recommend about screening for Lynch syndrome for the population with no personal history of colorectal cancer?
Option List
A
offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B
offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C
offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D
offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E
none of the above
Question 10.          
Lead-in
What does NICE recommend in relation to screening for Lynch syndrome in those with a new diagnosis of colorectal cancer?
Option List
A
offer screening to everyone, regardless of age and family history
B
offer screening to those aged < 50 years at diagnosis
C
offer screening to those aged < 60 years at diagnosis
D
offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E
offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1st.O relative
Question 11.          
Lead-in
What does NICE recommend about screening for Lynch syndrome for the population with no personal history of thyroid cancer?
Option List
A
offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B
offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C
offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D
offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E
none of the above
Question 12.          
Lead-in
What does NICE recommend in relation to screening for Lynch syndrome in those with a new diagnosis of thyroid cancer?
Option List
A
offer screening to everyone, regardless of age and family history
B
offer screening to those aged < 50 years at diagnosis
C
offer screening to those aged < 60 years at diagnosis
D
offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E
none of the above
Question 13.          
Lead-in
What does NICE recommend about screening for Lynch syndrome for the population with no personal history of endometrial cancer?
Option List
A
offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B
offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C
offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D
offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E
none of the above
Question 14.          
Lead-in
What does NICE recommend in relation to screening for Lynch syndrome in those with a new diagnosis of endometrial cancer?
Option List
A
offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B
offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C
offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D
offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E
none of the above
Question 15.          
Lead-in
What does NICE recommend about screening for Lynch syndrome for the population with no personal history of colorectal cancer?
Option List
A
offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B
offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C
offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D
offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E
none of the above
Question 16.          
Lead-in
What does NICE recommend in relation to screening for Lynch syndrome in those with a new diagnosis of colorectal cancer?
Option List
A
offer screening to everyone, regardless of age and family history
B
offer screening to those aged < 50 years at diagnosis
C
offer screening to those aged < 60 years at diagnosis
D
offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E
offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1st.O relative
Question 17.          
Lead-in
What relationship, if any, exists between Ls and acromegaly?
Option List
A
the risk of Ls is ↓ in those with acromegaly compared with the general population
B
the risk of Ls is ↑ in those with acromegaly compared with the general population
C
the risk of Ls is unchanged in those with acromegaly compared with the general population
D
the risk of Ls in unknown in those with acromegaly
Question 18.          
Lead-in
What is the effect of aspirin consumption on the risk of EC and CRC?
Option List
A
aspirin reduces the risk of EC and  CRC
B
aspirin reduces the risk of EC but not CRC
C
aspirin reduces the risk of CRC but not EC
D
aspirin does not reduce the risk of EC or CRC
E
aspirin reduces the risk of EC and CRC, but the risks outweigh the benefits
Question 19.          
Lead-in
A healthy woman of 35 years is diagnosed with Ls? What are the key elements of the National Screening Programme for people with Ls?
There is no option list – just write down everything you know.

17. Maternal mortality definitions.
The following scenarios relate to maternal mortality.
Pick the option that best answers the question in each scenario.
Each option can be used once, more than once or not at all.
Option List.
A.      Death of a woman during pregnancy and up to 6 weeks later, including accidental and incidental causes.
B.      Death of a woman during pregnancy and up to 6 weeks later, excluding accidental and incidental causes.
C.       Death of a woman during pregnancy and up to 52 weeks later, including accidental and incidental causes.
D.      Death of a woman during pregnancy and up to 52 weeks later, excluding accidental and incidental causes.
E.       A pregnancy going to 24 weeks or beyond.
F.       A pregnancy going to 24 weeks or beyond + any pregnancy resulting in a live-birth.
G.      Maternal deaths per 100,000 maternities.
H.      Maternal deaths per 100,000 live births.
I.         Direct + indirect deaths per 100,000 maternities.
J.        Direct + indirect deaths per 100,000 live births.
K.       Direct death.
L.       Indirect death.
M.    Early death.
N.      Late death.
O.      Extra-late death.
P.       Fortuitous death.
Q.      Coincidental death.
R.      Accidental death.
S.       Maternal murder.
T.       Not a maternal death.
U.      Yes
V.      No.
W.    I have no idea.
X.       None of the above.
Abbreviations.
MMR:      Maternal Mortality Rate.
MMRat:  Maternal Mortality Ratio.
SUDEP:    Sudden Unexplained Death in Epilepsy.            
Scenario 1.
What is a Maternal Death?
Scenario 2.
A woman dies from a ruptured ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?
Scenario 3.
A woman dies from a ruptured appendix at 10 weeks’ gestation. What kind of death is it?
Scenario 4.
A woman dies from suicide at 10 weeks’ gestation. What kind of death is it?
Scenario 5.
A woman with a 10-year-history of coronary artery disease dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?
Scenario 6.
A woman has gestational trophoblastic disease, develops choriocarcinomas and dies from it 24 months after the GTD was diagnosed and the uterus evacuated. What kind of death is it?
Scenario 7
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 18 months old. What kind of death is it?
Scenario 8
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 6 months old. What kind of death is it?
Scenario 9
What is a “maternity”.
Scenario 10
What is the definition of the Maternal Mortality Rate?
Scenario 11
What is the Maternal Mortality Ratio?
Scenario 12
A woman is diagnosed with breast cancer. She has missed a period and a pregnancy test is +ve. She decides to continue with the pregnancy. The breast cancer does not respond to treatment and she dies from secondary disease at 38 weeks. What kind of death is it?
Scenario 13
A woman who has been the subject of domestic violence is killed at 12 weeks’ gestation by her partner. What kind of death is it?
Scenario 14
A woman is struck by lightning as she runs across a road. As a result she falls under the wheels of a large lorry which runs over abdomen, rupturing her spleen and provoking placental abruption. She dies of haemorrhage, mostly from the abruption. What kind of death is it?
Scenario 15
A woman is abducted by Martians who are keen to study human pregnancy. She dies as a result of the treatment she receives. As this death could only have occurred because she was pregnant, is it a direct death?
Scenario 16
Could a maternal death from malignancy be classified as “Direct”.
Scenario 17
Could a maternal death from malignancy be classified as “Indirect”.
Scenario 18
Could a maternal death from malignancy be classified as “Coincidental”?
Scenario 19.
A pregnant woman is walking on the beach at 10 weeks when she is struck by lightning and dies. What kind of death is this?
Scenario 20.
A woman is sitting on the beach breastfeeding her 2-month old baby when she is struck by lightning and dies. What kind of death is this.




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