Monday, 29 April 2019

Tutorial 29 April 2019


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How to prepare. What to read. Revision system. Study buddies. Statistics. Urogynaecology. 
EMQ. Mycoplasma genitalium 
EMQ. Cystic fibrosis. 
EMQ. Montgomery & consent. 
SBA.   Cowden syndrome. 
EMQ. Uterine transplant. 

1.  How to prepare.

2.  Mycoplasma genitalium. Question.
Lead-in.
Many of the questions are not true EMQs as they have more than one correct answer.
Abbreviations.
BASHHMG: British Association for Sexual Health and HIV’s “National guideline for the management of infection with Mycoplasma genitalium”. 2018
BASHHNGU:     British Association for Sexual Health and HIV’s. “ UK National Guideline on the management of non-gonococcal urethritis”.  2015, updated 2018.
MG:              Mycoplasma genitalium.
MP:               Mycoplasma pneumoniae.
NHSCS:        NHS Cervical Screening Programme
PCB:              postcoital bleeding.
PMB:            postmenopausal bleeding.
PID:               pelvic inflammatory disease.
PTB:              preterm birth.
SARA:           Sexually-Acquired Reactive Arthritis.
Which, if any, of the following statements are true in relation to MG? This is not a true EMQ as there may be more that one correct answer.
Option list.

A
MG was first isolated in 2001
B
MG was first isolated from men with non-gonococcal urethritis (NGU)
C
MG belongs to the Cutemollies class
D
MG is the smallest known yeast with the ability to self-replicate
E
MG is the smallest known bacterium with the ability to self-replicate
F
MG has an unusual, double-layered cell wall
G
MG has an unusual protrusion at one end
H
MG’s protrusion enables it to adhere to epithelial cells
I
MG’s protrusion enables it to invade epithelial cells
J
MG is best seen on a Gram stain

Scenario 2.             
Which, if any, of the following statements are true in relation to Mycoplasmas?
Option list.
A
are the largest known bacteria
B
have no cell wall
C
have no nuclei
D
are resistant to ß-lactam antibiotics
E
are resistant to sulphonamides
F
colonies show a ‘scrambled egg’ appearance on culture on agar
Scenario 3.             
Which, if any, of the following statements are true in relation to Mg?
Option list.
A
when the organism was originally found, culture took 50 days
B
Mg is facetious
C
Mg is a facultative aerobe
D
Mg is a facultative anaerobe
E
Mg is a facultative aerobe & anaerobe
F
Mg is fastidious
Scenario 4.             
Which, if any, of the following are true in relation to the approximate prevalence of MG?
Option list.
A
it is ~ 0.1%
B
it is ~ 1.0%
C
it is ~ 5.0%
D
it is ~ 5-10%
E
it is > 10%
F
none of the above
Scenario 5.             
Which, if any, of the following is true in relation to screening for MG? This is a true EMQ with only one correct answer.
Option list.
A
screening for MG is now included in the NCSP
B
screening for MG is now offered as part of the NHSCS
C
screening should be offered to all sexually active women < 30 years old
D
screening should only be offered to those with symptoms suggestive of infection
E
screening should be offered to all partners of those with MG infection
F
none of the above
Scenario 6.             
Which, if any, of the following are included in BASHHMG as risk factors for infection with MG?
Option list.
A
Cigarette smoking
B
Multiple dancing partners
C
Multiple sexual partners
D
Non-white ethnicity
E
Younger age
F
None of the above
Scenario 7.             
Which of the following statements is true in relation to MG and co-infection with other organisms?
Option list.
A
MG excretes bactericidal toxins and co-infection is rare
B
MG co-infection is most often with chlamydia
C
MG co-infection is most often with E. coli
D
MG co-infection is most often with HIV
E
MG co-infection is most often with TB
F
None of the above
Scenario 8.             
Which of the following statements is true in relation to MG and men?
Option list.
A
It is the most common cause of NGU
B
It is the most common cause of epididymitis
C
It is the most common cause of prostatitis
D
It is a well-recognised cause of male sub-fertility
E
Most men with MG infection are asymptomatic
E
None of the above
Scenario 9.             
Which, if any, of the following statements are true in relation to MG and women?
Option list.
A
MG is linked to an risk of cervicitis
B
MG is linked to an risk of endometritis
C
MG is linked to an risk of female infertility
D
MG is linked to an risk of miscarriage
E
MG is linked to an risk of otitis media
F
MG is linked to an risk of pelvic inflammatory disease
G
MG is linked to an risk of postcoital bleeding
H
MG is linked to an risk of postmenopausal bleeding
I
MG is linked to an risk of preterm birth
J
MG is linked to an risk of damage to Fallopian tube cilia
K
MG is linked to an risk of puerperal psychosis
L
MG is linked to an risk of puerperal sepsis
M
Most infected women are asymptomatic
N
None of the above
Scenario 10.         
Which, if any, of the following statements are true in relation to current concerns about Mg?
Option list.
A
It could become a ‘superbug’, resistant to most antibiotics, within a decade
B
Infection is often misdiagnosed as chlamydia with risk of antibiotic resistance
C
‘superbug’ status would be likely to lead to an in renal failure
D
‘superbug’ status would be likely to lead to an in female infertility
E
‘superbug’ status would be likely to lead to an in male infertility
Scenario 11.         
Which, if any, of the following methods are used in the recommended test for MG infection in women?
Option list.
A
blood testing for MG IgG
B
blood testing for MG IgM
C
cervical smears checked microscopically for the diagnostic intracellular inclusion bodies
D
culture and sensitivity of cervical swab specimens using MG-specific culture medium
E
culture and sensitivity of 1st. void MSSU using MG-specific culture medium
F
culture and sensitivity of vaginal swab specimens using MG-specific culture medium
G
NAATs that detect the MG G-antigen
H
NAATs that detect MG DNA
I
NAATs that detect MG RNA
J
serum testing for MG-specific antigen
K
vaginal swabs taken by the woman
L
none of the above
Scenario 12.         
Which, if any, of the following statements are true in relation to testing for antibiotic resistance after initial tests are +ve for MG?
Option list.
A
test for resistance to cephalosporins
B
test for resistance to macrolides
C
test for resistance to penicillin
D
test for resistance to quinolones
E
test for resistance to macrolides
F
test for resistance to streptomycin
F
test for resistance to sulphonamides
F
test for resistance to tetracyclines
G
None of the above
Which, if any, of the following statements are true in relation to estimates of antibiotic resistance in current strains of MG in the UK?
Option list.

A
20% are resistant to cephalosporins
B
40% are resistant to macrolides
C
50% are resistant to penicillin
D
50% are resistant to quinolones
E
10% are resistant to streptomycin
F
90% are resistant to sulphonamides
F
40% are resistant to tetracyclines
F
None of the above

Scenario 14.         
Which, if any, of the following is BASHHMG’s recommended 1st. line treatment of uncomplicated MG?
Option list.
A
azithromycin 1 gram daily for 7 days
B
doxycycline 100 mg twice daily for 7 days
C
doxycycline 100 mg twice daily for 10 days
D
doxycycline 100 mg twice daily for 7 days
E
doxycycline 100 mg twice daily for 7 days then azithromycin 1 gram daily for 2 days
F
moxifloxacin 400mg orally once daily for 7 days
G
moxifloxacin 400mg orally once daily for 10 days
H
none of the above
Scenario 15.         
Lead-in
Which, if any, of the following is BASHHMG’s recommended 1st. line treatment of complicated MG?
Option list.
A
doxycycline 100 mg twice daily for 10 days
B
doxycycline 100 mg twice daily for 14 days
C
moxifloxacin 400mg orally once daily for 10 days
D
moxifloxacin 400mg orally once daily for 14 days
E
none of the above
Scenario 16.         
Lead-in
This is not an EMQ or SBA!
Fill in the gaps in the table below, using option list.
Option list.
A
aminoglycoside
B
cephalosporin
C
macrolide
D
penicillin
E
quinolone
F
tetracycline
Table.
Drug name
Category of drug
azithromycin

doxycycline

moxifloxacin

Scenario 17.         
Which, if any, of the following statements is true in relation to test of cure (TOC) after treatment of MG?
Option list.
A
TOC should be offered to everyone who has been treated for MG
B
TOC should only be offered to those who had signs of infection before treatment
C
TOC should only be offered to those who had symptoms of infection before treatment
D
TOC should only be offered to those who had signs and symptoms before treatment
E
TOC should only be offered to those who continue to have signs or symptoms two weeks or more after the start of treatment
F
none of the above
Scenario 18.         
Which, if any, of the following statements are true in relation to the timing of test of cure (TOC) after treatment of MG?
Option list.
A
TOC is best done at 3 weeks after start of treatment
B
TOC is best done at 4 weeks after start of treatment
C
TOC is best done at 5 weeks after start of treatment
D
TOC is best done at 6 weeks after start of treatment
E
TOC should not be done < 2 weeks from the start of treatment
F
TOC should not be done < 3 weeks from the start of treatment
G
TOC should not be done < 4 weeks from the start of treatment

3.  This question is about cystic fibrosis.
And, to make you behave in a model fashion, there is no option list, so you have to decide the correct answer without help.
Question 1.
A woman is 8 weeks pregnant and known to be a carrier of cystic fibrosis.
Her husband is Caucasian. What is the risk of the child having cystic fibrosis?
Question 2.
A healthy woman attends for pre-pregnancy counselling. Her brother has cystic fibrosis.
Her husband is Caucasian. He has been screened for cystic fibrosis. The test was negative.
What is the approximate risk of them having a child with cystic fibrosis?
Question 3.
A healthy woman is a known carrier of cystic fibrosis. She attends for pre-pregnancy counselling. Her husband has cystic fibrosis.What is the risk of them having a child with CF?
Question 4.
A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with cystic fibrosis. What is her risk of being a carrier?
Question 5.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
What is the risk that she is a carrier?
Question 6.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
The partner’s risk of being a carrier is 1 in X. What is the risk that she will have a child with CF?
Question 7.
A healthy Caucasian woman is 10 weeks pregnant. Her husband is a known carrier of cystic fibrosis.
Which test would you arrange?
Question 8.
A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?
Question 9.
A woman and her husband are known carriers of cystic fibrosis.
What is the risk of them having an affected child?
Question 10.
A woman and her husband are known carriers of cystic fibrosis.
What can they do to reduce the risk of having an affected child?
Question 11.
A woman and her husband are known carriers of cystic fibrosis.
Can CVS exclude an affected pregnancy?
Question 12.
A woman with cystic fibrosis is planning pregnancy. Her husband is a carrier of cystic fibrosis. What is the risk of having an affected child?
Question 13.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption.
Is this advice correct?
Question 14.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium.
Is this advice correct?

4.  Montgomery Ruling.
Abbreviations.
BMA:    British Medical Association.
GMC:   General Medical Council.
Question 1.           
Which, if any, of the following statements are true?
Lead-in
A.       
The Montgomery ruling largely replaces the Bolam ruling
B.       
The Montgomery ruling largely replaces the Chester ruling
C.       
The Montgomery ruling largely replaces the Sidaway ruling
D.      
The Montgomery ruling is being contested in the European Court by the GMC as it infringes the rights of doctors
E.       
The Montgomery ruling is being contested in the European Court by the BMA as it infringes the rights of doctors
Question 2.           
Which, if any, of the following statements are true?
Lead-in
A.       
the level of risk, however small, must be disclosed if a patient requests it
B.       
the level of risk of damage from a procedure need not be disclosed if < 1%
C.       
the level of risk of damage from a procedure need not be disclosed if < 10%
D.      
a material risk is one that would be reflected in damages > £100,000 if negligence were proved in court
E.       
a material risk is one that would be reflected in damages > £1,000,000 if negligence were proved in court
F.        
a material risk is one that involves anatomical damage, not emotional or psychological
G.      
a material risk is one that a reasonable person in the patient’s situation would be likely to regards as significant

5.  Cowden syndrome.
Scenario 1.
Lead in.
Which feature is associated with Cowden syndrome?
Option list.
A.     albinism
B.     hamartoma
C.     hammer-toe
D.     hypertrichosis
E.     stammer
Scenario 2.
Lead in. Which condition has the highest risk of occurrence in women with Cs?
Option list.
A.     breast cancer
B.     bowel cancer
C.     congenital absence of Müllerian tract derivatives
D.     hypertension
E.     hypothyroidism
Scenario 3.
Lead in. Which gynaecological cancer is a particular risk for women with Cs?
Option list.
A.     Bartholin’s gland cancer
B.     cervical cancer
C.     choriocarcinoma
D.     endometrial cancer
E.     vulval cancer
Scenario 4.
Lead in. Which cancer is more common in men with Cs?
Option list.
A.     breast cancer
B.     colon cancer
C.     melanoma
D.     renal cancer
E.     thyroid cancer
F.     all of the above

6.  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 2018?
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-Küster-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.             
Has successful transplant occurred using a dead donor?
Option list.
A
No
B
Yes
Scenario 7.             
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 8.             
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 9.             
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 10.         
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 11.         
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 12.         
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



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