Monday, 12 December 2016

Tutorial 12th. December 2016

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 12 December 2016.

37
EMQ. Chickenpox & pregnancy
38
EMQ. Haemophilia
39
EMQ. Education
40
EMQ. Down’s syndrome

37.         EMQ. Chickenpox & pregnancy
Abbreviations.
FVS:                     fetal varicella syndrome
NPV:                    negative predictive value
PPV:                    positive predictive value
VZV:                    varicella-zoster virus.
Question 1.
Lead-in
What type of virus causes chickenpox?                                                                      
Option List
A.       
avian virus
B.       
herpes virus
C.       
retrovirus
D.       
picovirus
E.        
pox virus
Question 2.
Lead-in
Which of the following best describes the chickenpox virus
Option List
A.       
DNA virus
B.       
RNA virus
C.       
Prion
D.       
All of the above
E.        
None of the above
Question 3.
Lead-in
What is the main reservoir of the chickenpox virus?
Option List
A.       
domestic chickens
B.       
chickens in battery farms
C.       
sparrows
D.       
humans
E.        
earthworms
Question 4.
Lead-in
How is the chickenpox virus spread?
Pick the option from option list that best fits.
Possible modes of spread.
A.      respiratory droplets
B.      direct contact with the fluid from the vesicles
C.      contact with fomites
D.      contact with stalactites
E.       from lavatory seats
Option List.
1.        
A
2.        
A + B
3.        
A +  C
4.        
A + B + C
5.        
A + B + C + D + E
Question 5.
Lead-in
Fomites - which of the following statements are true?
Statements.
A.       
fomites are bedclothes infested with bed bugs which can carry the chickenpox virus
B.       
“fomites” in Latin is the plural of “fomes”, the noun meaning “tinder” in English
C.       
fomites are inanimate objects that can effect the transfer of communicable diseases from the infected person to someone who is not infected
D.       
fomites are horizontal stalagmites, particularly found in the Dolomite mountains and capable of fostering the growth of viruses, including the chickenpox virus
E.        
fomites are the viral particles in vomit that form the aerosols particularly associated with the respiratory spread of viruses such as the chickenpox virus.
Option List
1.        
A + B + C + D + E
2.        
A + B + C + E
3.        
A + B + C + D
4.        
B + C + D
5.        
B + C + E
6.        
B + C
Question 6.
Lead-in
Which of the following are listed in GTG13 as examples of fomites?
A.      bathtubs used by person with chickenpox at the infectious stage
B.      bedding
C.      blood, fresh or dried, from person with chickenpox at the infectious stage
D.      clothing
E.       hair
F.       paper money
G.      skin cells
H.      viral remnants in vomit from person with chickenpox at the infectious stage
Option List
1.        
A + B + C + D + E + F + G + H
2.        
A + B + C + D + E + F
3.        
B + C + D + E + F + G
4.        
B + C + E + G
5.        
None of the above
Question 7.
Lead-in
With regard to the epidemiology of chickenpox in the UK, which of the following statements are true?
A
Chickenpox is endemic
B
Chickenpox is endemic with mini-epidemics every 3-4 years in the early part of the year
C
The main reservoir is chickens, particularly those that are reared intensively
D
The main reservoir is human sensory nerve root ganglia after primary infection
E
The main reservoir is fomites
Option List
1
A
3
A + C
4
A + D
5
A + E
2
B
6
B + C
7
B + C + D + E
7
B + C + D + E
Question 8
Lead-in
What proportion of the ante-natal population of the UK is immune to chickenpox?
Option List
A.       
   50%
B.       
   60%
C.       
   70%
D.       
   80%
E.        
   90%
F.        
≥ 90%
Question 9.
Lead-in
Which population of immigrant women is least likely to have immunity to chickenpox?
Option List
A.       
Middle-Eastern
B.       
Those from Antarctica
C.       
Those from the EEC
D.       
Those from tropical and sub-tropical Africa
E.        
One-eyed Mongolians with the bad habit of spitting in public
Question 10.
Lead-in
What is the incidence of chickenpox in pregnancy in the UK?
Option List
A.       
1 in 1,000
B.       
3 in 1,000
C.       
5 in 1,000
D.       
8 in 1,000
E.        
14 in 1,000
F.        
20 in 1,000
Question 11.
Lead-in
What is the usual presentation of chickenpox in a child?
Option List
A.       
Mild fever with malaise  then vesicles which appear after 2 days and  disappear after 4 – 5 days
B.       
Mild fever with malaise  then vesicles which appear after 2 days and  disappear after about 7 days
C.       
Mild fever, malaise, pruritic maculopapules that develop into vesicles and normally crust over within 5 days
D.       
Mild fever, malaise, pruritic maculopapules that develop into vesicles and normally crust over within 7 days
E.        
Mild fever, malaise, pruritic maculopapules that develop into vesicles and normally crust over within 10 days
Question 12.
Lead-in
What is the duration of infectivity after primary infection?
Option List
A.       
From the onset of fever until 48 hours after the vesicles form
B.       
From the onset of fever until 5 days after the vesicles form
C.       
From 48 hours before the development of the vesicles until 5 days later.
D.       
From 48 hours before the development of the vesicles until they crust over
E.        
From the development of the vesicles until 5 days later.
F.        
From the development of the vesicles until they crust over
Question 13.
Lead-in
A woman books at 8 weeks. Her 6-year-old son lives with her and has recently developed chickenpox? She is tested and found to be non-immune. What is her risk of infection from the domestic contact with her son?
Option List
A.       
50%
B.       
60%
C.       
70%
D.       
80%
E.        
90%
Question 14.
Lead-in
Which of the following contacts with a case of chickenpox would be significant?
        I.            contact with the mother of a child who has just developed the typical chickenpox rash
      II.            contact with the mother of a child who has not developed the typical chickenpox rash
    III.            a four-hour journey on a school bus with 20 children, one of whom develops the typical chickenpox rash the next day
    IV.            having a coffee with a neighbour who is having chemotherapy and has just developed shingles
      V.            visiting a neighbour who has developed ophthalmic shingles and has been admitted to an old-fashioned 20-bed ward
    VI.            having a coffee with an 80-year-old  neighbour who is in good health but has just had recurrence of thoracic shingles.
Option List
  1.  
all of the above
  1.  
I +  III + IV + V
  1.  
I +  III + IV + V
  1.  
II + III + IV + VI
  1.  
III + IV + V
Question 15.
Lead-in
In relation to shingles, which of the following statements are true ?
A.       
Shingles is due to reactivation of the virus which has lain dormant in the sensory nerve root ganglia
B.       
Shingles is due to reactivation of the virus which has lain dormant in the motor nerve root ganglia
C.       
Shingles is due to reactivation of the virus which has lain dormant in the autonomic nerve root ganglia
D.       
Shingles should always be regarded as infectious.
E.        
Shingles in the immuno-compromised should always be regarded as infectious.
F.        
Ophthalmic shingles should always be regarded as infections
Option List
1.        
A + D
2.        
A + E
3.        
A + E + F
4.        
B + D
5.        
C + E + F
Question 16. This is about chickenpox vaccine.
Lead-in
Which of the following statements are true? Pick the best option from the option list.
Statements.
A.      Chickenpox vaccine does not exist.
B.      Chickenpox vaccine uses a killed virus of the Okra strain.
C.      Chickenpox vaccine uses an attenuated virus of the Oka strain.
D.      All children who have not had chickenpox should be offered the vaccine after 1 year of age.
E.       Women should be screened for immune status as part of pre-pregnancy counselling or fertility treatment with ART
Option List
1.        
A.
2.        
B.
3.        
C.
4.        
B + D
5.        
B + D + E
6.        
C + D
7.        
C + D + E
8.        
None
Question 17. This relates to vaccination in early pregnancy
Lead-in
A 25-year-old woman is given varicella vaccine. Her period is due the next day, but does not occur. A pregnancy test a few days later is +ve. What should be the management?
Option List

A.       
She should be advised that there is a 5% risk of congenital varicella syndrome and be offered TOP.
B.       
She should be advised that there is a 10% risk of congenital varicella syndrome and be offered TOP.
C.       
She should be advised that the level of risk of congenital varicella syndrome after vaccination in early pregnancy is unknown and be offered TOP.
D.       
She should be advised that the level of risk of congenital varicella syndrome after vaccination in early pregnancy is unknown and be offered referral to a feto-maternal medicine expert.
E.        
She should be advised that the manufacturer has monitored occurrences of inadvertent vaccination for nearly 20 years and that no increase of the risk of congenital varicella syndrome has been identified after inadvertent vaccination in early pregnancy.
F.        
She should be advised that the vaccine contains no live virus and cannot cause fetal infection.
Question 18.
Lead-in
A woman has been referred to the booking clinic by her GP. Screening for immunity to chickenpox showed her to be seronegative. What advice would you give her?
Option List
A.       
Advise her that there is no risk unless she comes into contact with a case of chickenpox or shingles and to speak to GP or midwife if possible contact occurs..
B.       
Advise her to have the chickenpox vaccine because of the 10% risk and high mortality associated with varicella in pregnancy.
C.       
Advise her to have VZIG to reduce her risk of infection.
D.       
Advise her to take oral acyclovir until two weeks post-delivery.
E.        
None of the above.
Question 19.
Lead-in
A woman is referred to the booking clinic by her GP for urgent assessment as she was in contact with a case of chickenpox two days before. What action should be taken?
Possible actions.
        I.            take a detailed history to determine the significance of the contact and her history of and likely immunity to chickenpox.
      II.            check for VZV immunity if there is a history of a significant contact and possibility that she is not immune.
    III.            if the contact was significant and the tests for VZV immunity show her to be seronegative, offer oral acyclovir
    IV.            if the contact was significant and the tests for VZV immunity show her to be seronegative, offer VZIG.
      V.            if the contact was significant and the tests for VZV show her to be seronegative, discuss TOP.
Option List
A.       
I + II + III
B.       
I + II + III + IV
C.       
I + II + III + V
D.       
I + II  + IV
E.        
V
Question 20.
Lead-in
Which, if any, of the following statements about VZIG are correct?
        I.            VZIG is manufactured using recombinant technology
      II.            VZIG is effective in pregnancy when given within 10 days of the contact
    III.            If VZIG is given, the woman is potentially infectious for up to 28 days
    IV.            Repeat doses of VZIG should not be given in the event of repeated significant contact
      V.            There are reliable supplies of VZIG and no problems regarding availability
Option List
A.       
I + II + III
B.       
I + II + III + IV
C.       
I + II + III + IV + V
D.       
II + III
E.        
II + III + V
Question 21.
Lead-in
How does the administration of VZIG affect the duration of infectivity for the woman?
Option List
A.       
With no VZIG the woman is potentially infectious from day 8 to 28.
B.       
VZIG destroys virus and the woman is potentially infections from day 8 to 21.
C.       
VZIG does not alter the period in which the woman is potentially infections.
D.       
VZIG reduces the risk of shingles in later life
E.        
None of the above
Question 22.
Lead-in
With regard to established varicella in pregnancy, which, if any, of the following statements are true? Choose the best option from the option list.
        I.            the main risk to the mother comes from pneumonia, with an incidence of about 10%
      II.            the main risk to the mother comes from pneumonia, with an incidence of about 40%
    III.            hepatitis and encephalitis are more common compared to the non-pregnant state
    IV.            mortality from varicella pneumonia have fallen to < 15%
      V.            the death rate from varicella pneumonia is estimated to be 5 times greater than in the non-pregnant
Option List
A.       
I  + III + IV + V
B.       
II + III + IV + V
C.       
I + IV + V
D.       
II + IV + V
E.        
I + IV
Question 23.
Lead-in
A GP phones to say that a patient of his at 10 weeks’ gestation has developed the typical rash of chickenpox. Her son had proven chickenpox a couple of weeks previously. She had been tested and found to be non-immune, but declined VZIG. Which, if any of the following statements would you include in your advice to the GP.
        I.            admit the woman for assessment, VZIG and acyclovir after counselling re risks and benefits.
      II.            arrange for her to be seen in the next antenatal clinic.
    III.            advise re prevention of secondary bacterial infection of the lesions
    IV.            advise about her avoiding contact with susceptible individuals until at least 7 days after the lesions crust over
      V.            advise the GP of the criteria for hospital admission and the need for the woman to be informed of them.
    VI.            advise the GP to discuss the risks and benefits of acyclovir 800mg five times daily for seven days and to prescribe it if the woman agrees.
  VII.            advise that acyclovir is contraindicated once the rash appears
VIII.            advise that VZIG is ineffectual once the rash has appeared
Question 24.
Lead-in
What kind of drug is aciclovir?
There is no option list
Question 25.
Lead-in
How effective is aciclovir?
There is no option list.
Question 26.
Lead-in
Which, if any, of the following statements are true in relation to the diagnosis of fetal varicella syndrome?
Option List
A.       
detailed ultrasound examination by a fetal medicine expert should be offered
B.       
fetal MRI is superior to US examination and should be the 1ry test if available
C.       
amniocentesis should be offered as detection of varicella DNA makes FVS probable
D.       
amniocentesis should be done as early as possible, avoiding any varicella lesions
E.        
PCR which is –ve for varicella DNA in amniotic fluid has a strong NPV for FVS
F.        
PCR which is +ve for varicella DNA in amniotic fluid has a strong PPV for FVS
Question 27.
Lead-in
Which, if any, of the following statements are true in relation to fetal varicella syndrome?
Option List
A.       
FVS occurs in relation to 1ry. infection in-utero
B.       
FVS occurs in relation to 2ry. infection in-utero
C.       
the risk of FVS is ~ 5% when 1ry. infection in-utero  occurs < 13 weeks
D.       
the risk of FVS is ~ 10% when 1ry. infection in-utero  occurs between 13  and 20 weeks
E.        
the risk of FVS is greatest when 1ry. infection in-utero occurs within 4 weeks of birth
Question 28.
Lead-in
Which, if any, of the following statements are true in relation to administration of varicella vaccine in pregnancy.
Option List
A.       
varicella vaccine is a recombinant vaccine and licensed for use in pregnancy
B.       
varicella vaccine contains a live, attenuated vaccine and is contraindicated in pregnancy
C.       
varicella vaccine contains a live, attenuated vaccine and is safe to use after 12 weeks
D.       
varicella vaccine should not be given to women who are breastfeeding
E.        
TOP should be advised if varicella vaccine is given in the 1st. trimester
F.        
VZV immunoglobulin should be given if varicella vaccine is given in the 1st. trimester
Question 29.
Lead-in
Which, if any, of the following statements are true in relation to neonatal varicella (NV)
Option List
A.       
the risk of NV is 90% with fetal infection in the 1st. trimester
B.       
the risk of NV is 50% with fetal infection in the 2nd. trimester
C.       
the risk of NV is 10% with fetal infection in the 4 weeks before delivery
D.       
planned delivery should be delayed, if safe, until 7 days after start of the maternal rash
E.        
women with active chickenpox should not breastfeed until 10 days after the lesions crust

38.         Haemophilia 1.
Linguistics.
In relation to the possible genes, I use the terms “haemophilia gene” and “normal gene”. The use of the word “normal” in this way upsets some people. It can be taken to mean that the haemophilia gene is abnormal and that people with haemophilia are abnormal. This is not my intention and the use of “normal” just makes things easier rather than using “non-haemophilia gene” or some similar term, which could be confusing.
The key thing in answering these questions it to climb up the family tree to get to the common ancestor and then work back down to the individual we are talking about.
Lead-in.
The following scenarios relate to haemophilia A, factor VIII deficiency  (HA).
For each, select the most appropriate answer  from the option list.
Each option can be used once, more than once or not at all.
Scenario 1.
A woman attends for pre-pregnancy counselling. Her brother has haemophilia A. What is her risk of being a carrier?
Scenario 2.
A woman attends for pre-pregnancy counselling. Her father has haemophilia A. What is her risk of being a carrier?
Scenario 3.
If she is tested and found to be a carrier, what tests will you arrange for her partner?
Scenario 4.
If she is a carrier, what is the risk to her male offspring?
Scenario 5.
If she is a carrier, what is the risk to her female offspring?
Scenario 6.
If she is a carrier and her partner has haemophilia A, what are the risks to their female offspring?
Scenario 7.
If she is a carrier and her partner has haemophilia A, what are the risks to their male offspring?
Scenario 8.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter being a carrier.
Scenario 9.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter’s sons being affected.
Scenario 10.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter having an affected daughter.
Scenario 11.
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he is affected?
Scenario 12.
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he is not affected?
Scenario 13
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. What is the chance that she will have an affected son?

39.         Education.
Option list.
  1. brainstorming.
  2. brainwashing
  3. cream cake circle.
  4. Delphi technique.
  5. demonstration & practice using clinical model.
  6. doughnut round.
  7. interactive lecture with EMQs.
  8. lecture.
  9. 1 minute preceptor method.
  10. teaching peers / junior colleagues
  11. schema activation.
  12. schema refinement.
  13. small group discussion.
  14. snowballing.
  15. snowboarding.
  16. true
  17. false
Scenario 1.
A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?
Scenario 2.
You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?
Scenario 3.
You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?
Scenario 4.
You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?
Scenario 5.
Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?
Scenario 6.
You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?
Scenario 7
The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?
Scenario 8
Which of the listed teaching techniques is least likely to lead to deep learning?
Scenario 9
An interactive lecture with EMQs is the best method of teaching. True or false.
Scenario 10
Only 20% of what is taught in a lecture is retained. True or false.
Scenario 11.
The main role of the teacher is information provision. True or false.
Scenario 12.
The main role of the teacher is to be a role model.  True or false.


40.         EMQ. Down’s syndrome screening.
Option list.
a.       1 in 2
b.      1 in 5
c.       1 in 10
d.      1 in 20
e.       1 in 40
f.        1 in 250
g.       1 in 400
h.      1 in 1,000
i.         5 mm.
j.         6 mm.
k.       7 mm.
l.         8 mm.
m.    10 mm.
n.      1%
o.      2%
p.      5%
q.      10%
r.        80%
s.       95%
t.        90%
u.      95%
v.       higher
w.     lower
x.       true
y.       false
z.       none of the above.
Scenario 1.
What is the age-related risk of DS at 20 years?
Scenario 2.
What is the age-related risk of DS at 30 years?
Scenario 3.
What is the age-related risk of DS at 35 years?
Scenario 4.
What is the age-related risk of DS at 40 years?
Scenario 5.
What is the age-related risk of DS at 45 years?
Scenario 6.
AFP levels are lower in Ds.
Scenario 7
Inhibin levels are raised in DS.
Scenario 8
Oestriol levels are raised in DS.
Scenario 9
β-hCG levels are raised in DS.
Scenario 10
1st. trimester PAPP-A levels are lower in DS.
Scenario 11
2nd. trimester PAPP-A levels are normal in DS.
Scenario 12
What are the NSC’s standards for an acceptable screening test in terms of detection and screen +ve rates?
Option list.
A
DR > 70%; screen +ve rate < 5%
B
DR > 75%; screen +ve rate < 4%
C
DR > 80%; screen +ve rate < 3%
D
DR > 85%; screen +ve rate < 3%
E
DR > 90%; screen +ve rate < 2%
Scenario 13
Which of the following tests meet the NSC’s standards for detection and screen +ve rates?
There is no option list. Write the tests you know that fit.
Scenario 14
What are NICE’s current recommendations about Down’s syndrome screening?
There is no option list. Write down all the things you can think of.
Scenario 15
 What characteristic is described in relation to the occipital hairline in DS?
Scenario 16
 What characteristic is described in relation to the frontal hairline in DS?
Scenario 17
 What is the incidence of congenital heart anomaly in DS?
Scenario 18
Which is the most common congenital heart anomaly in DS?
Scenario 19
 Which major haematological condition is more common in those with DS?
Scenario 20
 Which major neurological condition is more common in middle age in those with DS?
Scenario 21
 Which spinal anomaly is more common in DS and of concern to anaesthetists?
Scenario 22
Lead in. I have added the following scenarios as I have been told by Deepak Bhenki that there were questions along these lines in the exam.
A woman aged 20 has a routine 1st. trimester DS screening test at 11 weeks. The midwife taking her details enters her age incorrectly on the form as 30 years. What effect will this have on the risk given when the result is available?
Scenario 23
A woman aged 40 has a routine 1st. trimester DS screening test at 11 weeks. The midwife taking her details enters her age incorrectly on the form as 20 years. What effect will this have on the risk given when the result is available?
Scenario 24
A woman aged 25 has a routine 1st. trimester DS screening test at 11 weeks. The laboratory has a problem with the assay for PAPP-A levels and ends up with a result that is half of what it should be. What effect will this have on the risk given when the result is available?







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