Tutorial 16 September 2021

 

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57	EMQ. Obesity and endometrial cancer
58	EMQ. Gestational trophoblastic disease
59	SBA.   Coeliac disease & pregnancy
60	EMQ. Mayer-Rokitansky-Küster-Hauser syndrome
61	EMQ. Caldicott guardian
62	EMQ. Listeriosis

 

57.        Obesity and endometrial cancer.

Abbreviations.

EC:           endometrial cancer.

Question 1.            What is the definition of ‘overweight’?

Option list.

A	BMI > 25
B	BMI > 30
C	BMI > 35
D	BMI > 40
E	BMI > 45
F	BMI > 50
G	Body shape causing distress or mirth when viewed in a full-length mirror
H	Body shape causing strangers to stop and gawp
I	None of the above

Question 2.            What is the definition of ‘obesity’?

Option list.

A	BMI > 25
B	BMI > 30
C	BMI > 35
D	BMI > 40
E	BMI > 45
F	BMI > 50
G	Body shape causing distress or mirth when viewed in a full-length mirror
H	Body shape causing strangers to stop and gawp
I	None of the above

Question 3.            What is the definition of ‘morbid obesity’?

Option list.

A	BMI > 25
B	BMI > 30
C	BMI > 35
D	BMI > 40
E	BMI > 45
F	BMI > 50
G	Body shape causing distress when viewed in a full-length mirror
H	Body shape causing strangers to stop and gawp
I	Obesity as the confirmed cause of death
J	None of the above

Question 4.            Approximately what percentage of UK women are overweight or obese?

Option list. There is none: just write your answer.

Question 5.            Approximately what percentage of UK women were obese in 2018?

Option list. There is none: just write your answer.

Question 6.            Approximately what percentage of UK women are morbidly obese?

Option list. There is none: just write your answer.

Question 7.            What is the life-time risk of endometrial cancer?

Option list.

A	< 1%
B	3%
C	5%
D	5 - 10%
E	10 - 15%
F	16 - 20%

Question 8.            What is the life-time risk of endometrial cancer in the morbidly obese?

Option list. Use the list for the previous question

Question 9.            What are the main risk factors for endometrial cancer?

Option list. There is none. Just write as many as you can think of.

Question 10.        Which, if any, of the following best describes the ↑ in the life-time risk of EC and increasing BMI ?

Option list.

A	the risk ↑ by about 10% with each 5 kg/m2 ↑ in BMI
B	the risk ↑ by about 20% with each 5 kg/m2 ↑ in BMI
C	the risk ↑ by about 30% with each 5 kg/m2 ↑ in BMI
D	the risk ↑ by about 40% with each 5 kg/m2 ↑ in BMI
E	the risk ↑ by about 50% with each 5 kg/m2 ↑ in BMI
F	None of the above.

Question 11.         

What is the approximate percentage of endometrial cancer attributable to obesity?

Option list. There is none: just write your answer.

 

58.        Gestational trophoblastic disease.

Gestational Trophoblastic Disease (GTD)

Abbreviations.

APSN:           atypical placental site nodule.

BWS:             Beckwith-Wiedemann syndrome.

CCGTDS:       Charing Cross Gestational Trophoblast Disease Service.

CHM:            complete hydatidiform mole.

COC:             combined oral contraceptive.

EMA/CO:      etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine (oncovin).

EPT:              epithelioid tumour.

FIGOSS:        FIGO GTD Scoring System. Included in FIGO Cancer Report 2018: Ngan H et al: “Update on the diagnosis and management of gestational trophoblastic disease”.

Gynecology & Obstetrics 2018 Volume143, IssueS2 Special Issue; Pages 79-85.

FSRHCAP:     FSRH’s guideline: “Contraception after Pregnancy”.

GI:                 gastro-intestinal.

GTD:             gestational trophoblastic disease.

GTDTC:         gestational trophoblastic disease treatment centre.

GTG38:         RCOG’s Green-top Guideline 38: “Gestational Trophoblastic Disease”. 2020.

GTN:             gestational trophoblastic neoplasia.

HM:               hydatidiform mole.

IFAP:             interval from antecedent pregnancy in months.

IPI:                inter-pregnancy interval.

LGA:              large for gestational age.

NIUP:            negative intra-uterine pressure.

PHM:            partial hydatidiform mole.

POC:              products of conception.

PSTT:            placental site trophoblastic tumour.

TTC:              trophoblastic tumour centre

UKMEC:        UK Medical Eligibility for Contraceptive Use

UPD:             uniparental disomy.

US:                ultrasound.

 

Option list.

A.	100%.
B.	20%.
C.	15%.
D.	10%.
E.	5%.
F.	2.5%.
G.	1.5%.
H.	0.5%.
I.	1 in 35.
J.	1 in 55.
K.	1 in 65.
L.	1 in 700.
M.	1 in 1,000.
N.	Ö64.
O.	pr2.
P.	increased.
Q.	reduced.
R.	increased by a factor of 2.
S.	increased by a factor of 5.
T.	increased by a factor of 10.
U.	increased by a factor of 20.
V.	increased by a factor of 30.
W.	increased by a factor of > 100.
X.	hydatidiform mole, both partial and complete.
Y.	hydatidiform mole, both partial and complete and placental site tumour.
Z.	partial mole, complete mole, invasive and metastatic mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour.
AA.	choriocarcinoma invasive and metastatic mole and epithelioid trophoblastic tumour.
BB.	true
CC.	false
DD.	None of the above.

Scenario 1.             List the conditions included in the term GTD. There is no option list, just make a list.

Scenario 2.           What is the difference between GTD and GTN? Pick one option from the list below.

Option list.

A	GTD comprises the non-malignant conditions, i.e. complete and partial moles. GTN comprises the malignant conditions: invasive mole, choriocarcinoma and PSTT
B	GTD comprises all the trophoblastic conditions; GTN comprises the malignant conditions
C	GTD comprises all the trophoblastic conditions; GTN comprises persistent GTD
D	GTD comprises all the trophoblastic conditions; GTN comprises malignant and potentially malignant conditions, including atypical placental site nodules
E	none of the above

Scenario 3.           What is the incidence of GTD in the UK?

Scenario 4.           Which of the following statements, if any, are true of complete molar pregnancy?

A	are usually diploid and with all the chromosomal material of paternal origin
B	are usually triploid, with 2 sets of paternal haploid genes + 1 set of maternal haploid genes
C	are usually triploid, with 1 set of paternal haploid genes + 2 sets of maternal haploid genes
D	are tetraploid or mosaics in up to 10% of cases
E	up to 80% are due to duplication of a single sperm in an egg devoid of maternal chromosomes
F	up to 80% are due to duplication of a single sperm in a normal egg
G	usually result from dispermic fertilisation of a normal egg
H	usually result from dispermic fertilisation of an egg devoid of maternal chromosomes
I	usually has 46XX makeup
J	usually has 46XY makeup
K	the presence of fetal red blood cells defines a mole as partial
L	mitochondrial DNA is maternal
M	mitochondrial DNA is paternal

Scenario 5.           Which of the following statements, if any, are true of partial molar pregnancy?

Option list.

A	are usually diploid and with paternal chromosomal material
B	are usually triploid, with 2 sets of paternal haploid genes + 1 set of maternal haploid genes
C	are usually triploid, with 1 set of paternal haploid genes + 2 sets of maternal haploid genes
D	are tetraploid or mosaics in up to 10% of cases
E	up to 80% are due to duplication of a single sperm in an egg devoid of maternal chromosomes
F	up to 80% are due to duplication of a single sperm in a normal egg
G	usually result from dispermic fertilisation of a normal egg
H	usually result from dispermic fertilisation of an egg devoid of maternal chromosomes
I	usually has 46XX makeup
J	usually has 46XY makeup
K	the presence of fetal red blood cells defines a mole as partial
L	mitochondrial DNA is maternal
M	mitochondrial DNA is paternal

Scenario 6.           What is the ratio of complete: partial moles?

Scenario 7.           What is the risk of molar pregnancy at age < 15 compared to age 30?

Scenario 8.           What is the risk of molar pregnancy at age > 45 compared to age 30?

Scenario 9.           What is the risk of molar pregnancy in a pregnancy after a complete mole?

Option list.

A	< 1%
B	1-2%
C	3-5%
D	6-10%
E	11-20%
F	> 20%

Scenario 10.       What is the risk of molar pregnancy in a pregnancy after a partial mole?

Use the option list from the previous question.

Scenario 11.       Which, if any, of the following are more common in pregnancy after a molar pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A	anaemia
B	eclampsia / severe PET
C	intrauterine growth retardation
D	miscarriage
E	premature labour
F	PPH
G	pulmonary embolism
G	none of the above

Scenario 12.       Which, if any, of the following statements about hCG are true?

A	is a glycoprotein
B	shares its α sub-unit with FSH, LH & TSH
C	shares its α sub-unit with FSH & LH but not TSH
D	shares its β sub-unit with FSH, LH & TSH
E	shares its β sub-unit with FSH & LH but not TSH
F	β-core exists as a sub-type of β-hCG
G	nicked free-β exists as a sub-type of β-hCG
H	c-terminal peptide exists as a sub-type of β-hCG
I	hCG β core fragment may lead to false –ve results with urine pregnancy tests
J	heterophile antibodies may give false +ve hCG results
K	heterophile antibodies are not found in urine

Scenario 13.       Which, if any, of the following statements are true in relation to the diagnosis of molar pregnancy ?

A	definite diagnosis is usually made by ultrasound
B	definitive diagnosis requires a +ve test for P57KIP2
C	definitive diagnosis requires an hCG level > twice the median value for gestation
D	definite diagnosis requires histological examination
E	none of the above

Scenario 14.       Cystic placental spaces in the placenta and a ratio of transverse to anterioposterior

measurements of the gestation sac <1.5 are strongly suggestive of a partial mole. True / False.

Scenario 15.       Which, if any, of the following statements are true about twin pregnancy with a viable pregnancy and a CHM?

A	the woman should be referred to a feto-maternal specialist
B	the woman should be referred to a GTDTC
C	fetal karyotyping should be done
D	the rate of early fetal loss is about 20%
E	the rate of preterm birth is about 40%
F	the rate of preeclampsia is 20%
G	the incidence of GTN in doubled if the pregnancy goes beyond 24 weeks

Scenario 16.       Which, if any, of the following statements are true about preparation of the cervix before evacuation of molar pregnancy?

A	medical preparation is of proven efficacy in making suction evacuation easier
B	medical preparation with prostaglandins ↑ trophoblastic embolisation
C	medical preparation with prostaglandins ↑ the risk of needing chemotherapy
D	GTG 38 recommends the use of laminaria tents
E	none of the above

Scenario 17.       Which, if any, of the following statements are true about evacuation of molar pregnancies?

A	medical management is recommended for both CMs and PMs to ↓ the risk of bleeding
B	medical management is recommended for both CMs and PMs to ↓ the risk of dissemination of trophoblastic tissue
C	medical management is recommended for both CMs and PMs to ↓ the risk of uterine perforation
D	suction evacuation is recommended for both CMs and PMs
E	suction evacuation is recommended for CMs
F	suction evacuation is recommended for PMs so long as fetal parts are not too big
G	mifepristone + misoprostol treatment is an acceptable alternative to suction evacuation.
H	oxytocin administration after suction evacuation is recommended to ↓ bleeding
I	none of the above

Scenario 18.          Which, if any, of the following statements are true about urinary hCG testing in relation to molar pregnancy?

A	testing should be done 3 weeks after medical evacuation of complete moles
B	testing should be done 3 weeks after surgical evacuation of complete moles
C	testing should be done 3 weeks after medical evacuation of partial moles
D	testing should be done 3 weeks after surgical evacuation of complete moles
E	testing should be done 3 weeks after medical evacuation of ‘failed’ pregnancy
F	testing should be done 3 weeks after surgical evacuation of ‘failed’ pregnancy
G	testing should be done 3 weeks after medical evacuation of ‘failed’ pregnancy, but only if POC have not been sent for histological examination
H	testing should be done 3 weeks after surgical evacuation of ‘failed’ pregnancy, but only if POC have not been sent for histological examination
I	testing should be done 3 weeks after medical evacuation of incomplete miscarriage
J	testing should be done 3 weeks after surgical evacuation of incomplete miscarriage
K	testing should be done 3 weeks after medical evacuation of incomplete miscarriage, but only if POC have not been sent for histological examination
L	testing should be done 3 weeks after surgical evacuation of incomplete miscarriage, but only if POC have not been sent for histological examination
M	none of the above

Scenario 19.          Which, if any, of the following statements are true in relation to histological examination of POC after TOP?

A	it should be done in all cases to exclude GTD
B	it should be done in all cases that have not had pre-op ultrasound examination in case the pregnancy was an unsuspected ectopic. Absence of trophoblastic tissue on histology will raise suspicion of the diagnosis
C	it should be done in all cases where ultrasound has not shown a viable pregnancy
D	it should be done in all cases where ultrasound has not shown fetal parts.
E	none of the above

Scenario 20.          Which, if any, of the following statements are true in relation to RhD and TOP?

A	CHMs have no RhD
B	PHMs have no RhD
C	Anti-D should be withheld until histological results are available
D	‘C’ is true, but only in relation to CMs
E	‘C’ is true, but only in relation to PMs
F	none of the above

Scenario 21.       Which, if any, of the following statements are true in relation to GTN?

A	always arises from molar pregnancy
B	may occur after normal pregnancy and livebirth
C	may arise as primary ovarian neoplasia
D	the incidence after complete molar pregnancy is greater than after partial molar pregnancy
E	the incidence after livebirth is estimated at 1 in 50,000

Scenario 22.       Which, if any, of the following statements are true in relation to p57^KIP2?

A	it is a tumour suppressor gene, found in complete and partial moles but not choriocarcinoma
B	takes us to the world of genomic imprinting
C	is an example of uniparental disomy
D	is a gene found in chromosomes of maternal origin, but not paternal
E	is a gene found in chromosomes of paternal origin, but not maternal
F.	can help to distinguish complete and partial moles
G.	none of the above

Scenario 23.       What is the risk of persistent GTD after a complete mole?

Scenario 24.          What is the risk of requiring chemotherapy after a complete mole?

Scenario 25.          What is the risk of persistent GTD after a partial mole?

Scenario 26.       What is the risk of requiring chemotherapy after a partial mole?

Scenario 27.       What is the risk of requiring chemotherapy with hCG level > 20,000 i.u. 4⁺¹ weeks after evacuation?

Scenario 28.       What is the overall risk of requiring chemotherapy after molar pregnancy in the UK?

Scenario 29.       What is the risk of requiring chemotherapy in the USA compared with the UK?

Scenario 30.       Which, if any, of the following are grounds for offering chemotherapy after hydatidiform mole?

Scenario 31.       What are the risk factors included in the FIGO scoring system?

Scenario 32.       Which, if any, of the following statements is true about the recommended treatment of low-risk GTN?

A	low risk is defined as WHO score < 5
B	low risk is defined as WHO score < 6
C	low risk means that no treatment is necessary
D	treatment of low risk GTN is methotrexate
E	treatment of low risk GTN is folic acid
F.	treatment of low risk GTN is folinic acid

Scenario 33.       Which, if any, of the following is the most common side-effect of methotrexate?

A	alopecia
B	anaemia
C	aphasia
D	nausea
E	myelosuppression
F.	none of the above.

Scenario 34.          Which, if any, of the following statements are true about the use of folic acid / folinic acid in methotrexate treatment regimens? This is not a true EMQ as there may be > 1 answer.

A	folic acid must be converted to tetrahydrofolate to be biologically active
B	folic acid must be converted to folinic acid to be biologically active
C	dihydrofolate reductase converts folic acid to folinic acid
D	dihydrofolate reductase converts folic acid to tetrahydrofolate
E	dihydrofolate reductase converts folinic acid to tetrahydrofolate
F	folinic acid is use in preference to folic acid as it reaches higher levels in plasma
G	folate therapy is used to reduce GI tract damage from methotrexate
H	folate therapy is used to reduce hepatic damage from methotrexate
I	folate therapy is used to reduce neurological damage from methotrexate
J	folate therapy is used to reduce renal damage from methotrexate
K	none of the above.

Scenario 35.       Which, if any, of the following statements are true about the recommended duration of follow-up after GTD? This is not a true EMQ as there may be > 1 correct answer.

A	6 months from the time the hCG falls to normal
B	6 months from the date of evacuation of the GTD if the hCG falls to normal within 56 days
C	6 months from the date of the hCG falling to normal if it does so within 56 days
D	6 months from the date of evacuation of the GTD if the hCG falls to normal after 56 days
E	6 months from the date of the hCG falling to normal if it does so after 56 days
F.	56 days after the first full moon after the evacuation of the GTD

Scenario 36.       Which, if any, of the following statements are true about the recommended duration of follow-up after GTD? This is not a true EMQ as there may be > 1 correct answer.

A	6 months from the time the hCG falls to normal
B	6 months from the date of evacuation of the GTD if the hCG falls to normal within 56 days
C	6 months from the date of the hCG falling to normal if it does so within 56 days
D	6 months from the date of evacuation of the GTD if the hCG falls to normal after 56 days
E	6 months from the date of the hCG falling to normal if it does so after 56 days
F.	56 days after the first full moon after the evacuation of the GTD

Scenario 37.       What is the approximate cure rate for GTN with a FIGO risk score <6?

A	70%
B	80%
C	90%
D	95%
E	98%
F.	100%

Scenario 38.       What is the approximate cure rate for GTN with a FIGO risk score >7?

A	70%
B	80%
C	90%
D	95%
E	98%
F.	100%

Scenario 39.       When should the possibility of persistent GTD be investigated after non-molar pregnancy?

A	if there is abnormal bleeding
B	if there is persistent abnormal bleeding
C	if there is cough
D	if there is new-onset dyspnoea
E	if there is pleurodynia

Scenario 40.       A woman wishes to become pregnant after a pregnancy with GTD. Which, if any, of the following statements are true about the advice she should be given about an appropriate inter-pregnancy interval?

A	not before follow-up is complete
B	not for at least 3/12 after completion of follow-up
C	not for at least 6/12 after completion of follow-up
D	not for at least 12/12 after completion of follow-up
E	she should be advised not to become pregnant if chemotherapy was needed
F	not for at least 6 months after completion of follow-up if chemotherapy was needed
G	none of the above

Scenario 41.       Which of the following statements are true about combined hormonal contraception use after GTD?

A	it may increase the risk of GTN if used before hCG levels have returned to normal
B	is not associated with additional risk
C	intra-uterine contraceptives are preferable

Scenario 42.       Which, if any, of the following statements are true about the long-term issues for women who have needed chemotherapy for GTN?

A	the menopause is likely to be earlier
B	the risk of other cancers is not increased
C	there is evidence of ↑ risk of breast cancer
D	there is evidence of ↑ risk of colon cancer
E	there is evidence of ↑ risk of myeloid leukaemia
F	there is evidence of ↑ risk of melanoma
G	there is evidence of ↑ risk of breast cancer
H	there is no evidence of addition risk with HRT

Scenario 43.       A woman had a complete mole in her first pregnancy. She is pregnant for the second time. What is the risk that it is another molar pregnancy?

Scenario 44.       A woman has had two molar pregnancies. What is the risk of molar pregnancy if she becomes pregnant again?

Scenario 45.       A woman has had three molar pregnancies. What is the risk of molar pregnancy if she becomes pregnant again?

Scenario 46.       Which, if any, of the following statements are correct in relation to recurrence of molar pregnancy?

A	the histological type is likely to be the same
B	the histological type in recurrent mole after a complete mole is likely to be partial mole
C	the histological type in recurrent mole after a partial mole is likely to be complete mole
D	the histological type after PSTT is likely to be choriocarcinoma
E	none of the above

Scenario 47.       A woman has a normal pregnancy after treatment for hydatidiform mole. Which, if any, of the following statements are true about the need for hCG testing 6 weeks after the pregnancy?

A	testing is optional
B	testing is only needed for women with persisting GTD
C	testing is only needed for women with persisting GTN
D	testing is only needed for women who have needed chemotherapy
E	testing should be offered to all women who use hair dye

Scenario 48.       What proportion of women remain fertile after treatment for GTN?

A	80%
B	70%
C	60%
D	50%
E	40%

Scenario 49.       What proportion of women will reach the menopause by age 40 after chemotherapy for GTN?

A	10%
B	20%
C	30%
D	40%
E	50%

 

FSRHCAP has a SBA. It is open access, to reproduced here. It is not well written, but highlights some of the key points.

With gestational trophoblastic disease (GTD), which statement is false?

A. After complete hydatidiform mole, 15–20% women develop GTD needing chemotherapy

B. After partial hydatidiform mole, 30–35% women develop GTD needing chemotherapy

C. Intrauterine contraception is unsuitable while human chorionic gonadotropin is still detectable

D. Combined hormonal contraception can be used if gestational trophoblastic neoplasia develops

 

59.        Coeliac disease & pregnancy.

Abbreviations.

AGA:        anti-gliadin antibodies 

CD:          coeliac disease.

DGP:        IgG deamidated gliadin peptide.

EMA:       IgG endomysial antibodies. 

FGR:        Fetal growth restriction.

HLA:        Human leucocyte antigen.

IgA:          immunoglobulin A. 

tIgA:        total immunoglobulin A.

tTGA:       IgA tissue transglutaminase antibody.

vLBW:      very low birth weight.

vPTB:       very pre-term birth (<30/52).

Question 1. What is coeliac disease?

Option List

A.	allergy to gluten
B.	malabsorption due to large bowel inflammation
C.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the descending colon in individuals with a genetic predisposition
D.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the gastric mucosa in individuals with a genetic predisposition
E.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the small bowel in individuals with a genetic predisposition

Question 2. What is the prevalence of coeliac disease in women of reproductive age?

Option List

A.	0.1%
B.	0.5%
C.	1%
D.	2-5%
E.	5-10%

Question 3. 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. 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. 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. 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.	tIgA + tTGA

Question 8. Which, if any, of the following statements are true in relation to the woman due to have testing for suspected CD?

Option List

A.	continue with a diet that includes gluten ≥ once daily for at least 1 month
B.	continue with a diet that includes gluten ≥ once daily for at least 6 weeks
C.	continue with a diet with ≥ 10 gm. gluten daily for at least 1 month
D.	continue with a diet with ≥ 10 gm. gluten daily for at least 6 weeks
E.	follow a strict gluten-free diet for at least 3 months

Question 9. What advice should be given to those who have gone on to a gluten-free diet in the month before testing?

Option List

A.	the gluten-free diet may render the serological tests –ve, but not intestinal biopsy
B.	the gluten-free diet may render the intestinal biopsy –ve, but not the serological tests
C.	the gluten-free diet may render all the tests -ve
D.	if she is happy with the gluten-free diet, there is no  point in testing
E.	she is not qualified to make medical decisions and should not be so stupid on future occasions

Question 10. 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 11. What recommendation does NICE make about the information to be provided to healthcare professionals with the results of serological tests for CD?

Option List

A.	the results alone should be provided
B.	the results with the local reference values for children, adult men and adult women
C.	the results with the local and national reference values for children, adult men and women
D.	the results with interpretation of their meaning
E.	the results with interpretation of their meaning + recommended actions

Question 12. 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 13. Which skin condition is particularly associated with CD?

Option List

A.	atopic eczema
B.	dermatitis herpetiformis
C.	dermatitis multiforme
D.	dermatographia
E.	psoriasis

Question 14. 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 15. 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 16. Which of the following do not contain gluten?

Option List

A.	barley
B.	oats
C.	rapeseed oil
D.	rye
E.	wheat

 

60.        Mayer-Rokitansky-Küster-Hauser syndrome.

Mayer-Rokitansky-Küster-Hauser syndrome.

Note. Some of the questions are not true EMQs as there may be more than one correct answer – this is me being lazy and saving typing.

Mayer–Rokitansky–K

¨

uster–Hauser

syndrome: diagnosis and management

With regard to the MRKH syndrome,

61. there is failure of development of the

mesonephric ducts. T F

62. the phenotype and genotype are female. T F

63. studies have established a link between the

syndrome and the use of diethylstilbestrol in

pregnancy. T F

With regard to the anatomical abnormalities seen in

MRKH syndrome,

64. symmetrical uterovaginal aplasia is found in

type I disorders. T F

65. renal abnormalities are seen in more than

half of cases. T F

66. skeletal abnormalities are reported in up to

one-fifth of cases. T F

67. up to one-quarter of women have a

malformed ear or auditory canal. T F

68. the close proximity of the m

¨

ullerian and

wolffian duct derivatives to the metanephric

duct in the developing embryo explains the

higher association of malformations of the

kidneys with this condition. T F

69. vaginal agenesis is caused by failure of the

caudal part of the m

¨

ullerian duct system to

develop. T F

Regarding the diagnosis of MRKH syndrome,

70. magnetic resonance imaging is the gold

standard tool. T F

71. two-dimensional ultrasound scanning is not

useful for associated renal tract

abnormalities. T F

72. complete androgen insensitivity syndrome is

an important differential diagnosis. T F

73. the presence of cyclical abdominal pain will

rule out the diagnosis, as it indicates the

presence of functioning endometrium. T F

With regard to the creation of a neovagina,

74. it is recommended that treatment is initiated

as soon as the diagnosis is made. T F

75. psychological support to women undergoing

this procedure is of the utmost importance. T F

76. vaginal dilators are acceptable as an option

for first-line therapy. T F

77. Ingram’s modified Frank’s technique involves

the use of vaginal dilators. T F

With regard to the surgical creation of a neovagina,

78. in the Davydov procedure the neovagina is

lined with peritoneum. T F

With regard to fertility in women with the MRKH

syndrome,

79. transvaginal egg retrieval is recognised to be

difficult during in vitro fertilisation. T F

80. the condition has been shown to be

transmissible to the offspring. T F

Abbreviations.

AIS:          androgen insensitivity syndrome

AMH:       anti- Müllerian hormone

MRKH:    Mayer-Rokitansky-Küster-Hauser syndrome

MURCS:  Müllerian duct aplasia, renal dysplasia and cervical somite anomaly syndrome.

Question 1.            What are the main features of MRKH? There is no option list to make life harder.

Question 2.            Which, if any, are the main secondary features associated with MRKH?

Option list.

A	anosmia
B	attention-deficit-hyperactivity syndrome
C	auditory anomalies
D	neural tube defects
E	renal anomalies
F	skeletal anomalies

Question 3.            How does MRKH syndrome usually present?

Option list.

A	cyclical pain due to haematometra
B	delayed puberty
C	precocious puberty
D	premature menopause
E	primary amenorrhoea
F	recurrent otitis media
G	recurrent urinary tract infection
H	secondary amenorrhoea

Question 4.            Which of the following chromosome patterns are typical of MRKH?

Option list.

A	45XO
B	45YO
C	46XX
D	46XY
E	47XXX
F	47XXY

Question 5.            What is the approximate incidence of MRKH in newborn girls?

Option list.

A	~ 1 in 1,000
B	~ 1 in 2,000
C	~ 1 in 4,000
D	~ 1 in 6.000
E	~ 1 in 8,000
F	~ 1 in 10,000
G	~ 1 in 100,000
H	the figure is unknown
I	it does not occur

Question 6.            What is the approximate incidence of MRKH in newborn boys?

Option list.

A	~ 1 in 1,000
B	~ 1 in 2,000
C	~ 1 in 4,000
D	~ 1 in 6.000
E	~ 1 in 8,000
F	~ 1 in 10,000
G	~ 1 in 100,000
H	the figure is unknown
I	it does not occur

Question 7.            Which of the following statements are correct in relation to urinary tract anomalies associated with MRKH?

Option list.

A	absent bladder
B	absent kidney
C	ectopic ureter
D	horseface kidney
E	hypospadias
F	urinary tract anomalies are not part of the syndrome

Question 8.            Which of the following statements are correct in relation to skeletal anomalies associated with MRKH?

Option list.

A	absent thumb
B	absent big toe
C	developmental dysplasia of the hip
D	Klippel-Feil anomaly
E	ulnar hypoplasia
F	vertebral fusion
G	skeletal anomalies are not part of the syndrome

Question 9.            Which of the following statements are correct in relation to auditory anomalies associated with MRKH?

Option list.

A	absent ear
B	absent stapes
C	acoustic neuroma
D	conductive deafness
E	inductive deafness
F	stapedial ankylosis
G	auditory anomalies are not part of the syndrome

Question 10.        What is the recommended first-line management for creation of a neovagina.

Option list.

A	digital dilatation
B	marriage to a virile husband
C	vaginal balloons
D	vaginal dilators
E	vaginoplasty
F	there is no recommended 1st. line management

Question 11.        What are the key features of Davydov vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 12.        What are the key features of McIndoe vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 13.        What are the key features of Vecchietti vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 14.        What are the key features of Williams vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

TOG CPD questions.

With regard to the MRKH syndrome.

1.     there is failure of development of the mesonephric ducts.

2.     the phenotype and genotype are female

3.     studies have established a link between the syndrome and the use of diethylstilboestrol in pregnancy.

With regard to the anatomical abnormalities seen in MRKH syndrome.

4.     symmetrical uterovaginal aplasia is found in type I disorders

5.     renal abnormalities are seen in more than half of cases.

6.     skeletal abnormalities are reported in up to one-fifth of cases.

7.     up to one-quarter of women have a malformed ear or auditory canal.

8.     the close proximity of the Müllerian and Wolffian duct derivatives to the duct in the developing embryo explains the higher association of malformations of the kidneys with this condition.

9.     vaginal agenesis is caused by failure of the caudal part of the Müllerian duct system to develop.

Regarding the diagnosis of MRKH syndrome,

10.   magnetic resonance imaging is the gold standard tool.

11.   two-dimensional ultrasound scanning is not useful for associated renal tract abnormalities.

12.   complete androgen insensitivity syndrome is an important differential diagnosis.

13.   the presence of cyclical abdominal pain will rule out the diagnosis, as it indicates the presence of functioning endometrium.

With regard to the creation of a neovagina,

14.   it is recommended that treatment is initiated as soon as the diagnosis is made.

15.   psychological support to women undergoing this procedure is of the utmost importance.

16.   vaginal dilators are acceptable as an option for first-line therapy.

17.   Ingram’s modified Frank’s technique involves the use of vaginal dilators.

With regard to the surgical creation of a neovagina,

18.   in the Davydov procedure the neovagina is lined with peritoneum.

With regard to fertility in women with the MRKH syndrome,

19.   transvaginal egg retrieval is recognised to be difficult during in vitro fertilisation.

20.   the condition has been shown to be transmissible to the offspring.

 

61.        Caldicott guardian.

Question 1. Which, if any, of the following statements is true of the Caldicott Guardian?

Option List

A	it is a large lizard, unique to the Galapagos Islands
B	it is the Trust Board member responsible for child safeguarding procedures
C	it is the Trust Board member responsible for complaint procedures
D	it is the person within a Trust responsible for patient confidentiality in relation to information
E	it is the person within a Trust responsible for dealing with bullying

Question 2. The Caldicott Report identified 6 basic principles. What are they?

Option list. There is none. Imagine that there is information about you stored on the computers of the local NHS Trust. What conditions would you want to lay down about sharing of that information within the Trust, with other NHS organisations and with non-NHS organisations?

Question 3. The Caldicott Report made numerous recommendations. Which was particularly important for major NHS organisations such as Trusts?

Option List

A.	the need to appoint a Caldicott Guardian
B.	the need to create a Caldicott Register
C.	the need to create a Caldicott Police Department
D.	the need to create a link between the Caldicott Department and the DOH
E.	none of the above.

Question 4. What is the definition of the key role deriving from the answer to question 3?

Option List. There is none lest it give you the answer to question 3!

 

62.        Listeriosis.

Abbreviations.

Lm:                Listeria monocytogenes.

TOC:              test of cure.

Scenario 1.              

Which organism is responsible for human listeriosis?

A	Listeria diogenys
B	Listeria frigidaire
C	Listeria hominis
D	Listeria monocytogenes
E	Listeria xenophylus

Scenario 2.              

Which, if any, of the following statements are true about Lm? This is not a true EMQ as there may be >1 correct answer.

Option list.

A	it is a small, Gram -ve rod
B	it is a Gram +ve coccus
C	it is flagellated
D	it has no cell wall
E	it is an obligate aerobe
F	it functions within host cells
G	it can easily be mistaken for commensal organisms
H	none of the above

Scenario 3.              

Which of the following are associated with an increased risk of contracting listeriosis? This is not a true EMQ as there may be >1 correct answer.

A	age > 60 years
B	age < 1 year
C	blond hair
D	pregnancy
E	strabismus

Scenario 4.              

Which of the following is true of the susceptibility of pregnant women to Lm? This is not a true EMQ as there may be >1 correct answer.

Option list.

A	they are not more susceptible
B	they are more susceptible x 2
C	they are more susceptible x 5
D	they are more susceptible x 10
E	they are more susceptible x 20
F	they are > 20 times more susceptible
G	none of the above.

Scenario 5.              

When does Lm most often occur? This is not a true EMQ as there may be >1 correct answer.

Option list.

A	1st. trimester
B	2nd. trimester
C	3rd trimester
D	1st. + 2nd. trimesters
E	2nd. + 3rd trimesters
F	all trimesters equally
G	puerperium
H	none of the above

Scenario 6.              

What is the incubation period for Lm?.

Option list.

A	7±3 days
B	7±5 days
C	10±3 days
D	10±5 days
E	14±3 days
F	14±5 days
G	none of the above.

Scenario 7.              

What is the significance of Granulomatosis Infantisepticum ?

Option list.

A	it is a fabrication by the author and of no significance
B	it is pathognomonic of Lm infection
C	it is the cause of vertical transmission of Lm
D	I refuse to answer Latin questions as they make me think of Boris Johnson
E	none of the above

Scenario 8.              

Which of the following are accurate about cervico-vaginal infection? This is not a true EMQ as there may be >1 correct answer.

Option list.

A	Lm is as often found in the cervix as in the bowel.
B	Lm is as often found in the vagina as in the bowel.
C	Lm is less often  found in the cervix than in the bowel.
D	Lm is less often  found in the vagina than in the bowel.
E	Lm is more often  found in the cervix than in the bowel.
F	Lm is more often  found in the cervix than in the bowel.
G	no one knows and no one cares

Scenario 9.              

A GP phones about a primigravida at 28 weeks’ gestation. She has possibly ingested food contaminated by Lm. She is asymptomatic and afebrile. What advice will you give?

Option list.

A	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 2 weeks
B	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 4 weeks
C	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 6 weeks
D	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 8 weeks
E	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
F	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
G	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
H	admit to hospital for investigation and intensive treatment if Lm infection found
I	none of the above

Scenario 10.           

A GP phones about a primigravida at 28 weeks’ gestation. She has possibly ingested food contaminated by Lm. She has mild symptoms but is afebrile. What advice will you give?

Option list.

A	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 2 weeks
B	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 4 weeks
C	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 6 weeks
D	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 8 weeks
E	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
F	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
G	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
H	admit to hospital for investigation and intensive treatment if Lm infection found
I	none of the above

Scenario 11.           

A GP phones about a primigravida at 28 weeks’ gestation. She has possibly ingested food contaminated by Lm. She is symptomatic and her temperature is 38.2^oC. What advice will you give?

Option list.

A	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 2 weeks
B	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 4 weeks
C	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 6 weeks
D	reassure and advise her about avoiding exposure and to reattend if she develops signs or symptoms within 8 weeks
E	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
F	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
G	prescribe appropriate antibiotic(s) for 7 days with follow-up for TOC
H	admit to hospital for investigation and intensive treatment if Lm infection found
I	none of the above

Scenario 12.           

Which, if any, of the following would be appropriate for consideration as 1^st. line treatment of Lm in pregnancy? This is not a true EMQ as there may be more than 1 correct answer.

Option list.

A	ampicillin
B	ampicillin + gentamycin
C	ampicillin + streptomycin
D	amoxicillin + clavulanic acid
E	clarithromycin
F	erythromycin
G	erythromycin + metronidazole
H	trimethoprim
I	none of the above

Scenario 13.           

Is listeriosis a notifiable infection in the UK? Yes/No.