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Tutorial 20th. July 2017

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20th. July  2017.

44
SBA. PARP inhibitors
45
EMQ. Montgomery & consent
46
EMQ. Endometrial cancer & FIGO
47
EMQ. Education
48
EMQ. Down’s syndrome

Question 44. PARP inhibitors in cancer.
Question 1.              
Lead-in
The following options relate to the meaning of “PARP”. Pick one option from the list.
Option List
A.       
“PARP” is a variant on the American “PERP” or ”criminal” and relates to oncogenic alleles
B.       
“PARP”  is an acronym for Poly ADP-Ribose Polymerase
C.       
“PARP”  is an acronym for Poly Adenosine-Ribose Polymerase
D.       
“PARP”  is an acronym for Post-Adjuvant Radiotherapy Platinum-therapy
E.        
none of the above
Question 2.              
Lead-in
Pick the correct option from the list.
Option List
A.       
PARP results from a wild-type mutation in BRCA1
B.       
PARP results from a wild-type mutation in BRCA2
C.       
PARP results from a wild-type mutation in p53
D.       
PARP results from a non-wild-type mutation in p53
E.        
none of the above.
Question 3.              
Lead-in
What is a “wild” allele?
Option List
A.       
it is the “normal” version of a gene
B.       
it is the version of a gene found  in sociopaths
C.       
it is any of the mutations of a gene that lead to serious disease, e.g. cancer
D.       
it is a variant of a human gene found in the great apes
E.        
none of the above
Question 4.              
Lead-in
What is the difference between germline and somatic mutations?
Pick the one correct answer from the option list.
Option List
A.       
germline mutations arise from viral infection of the nucleus of a cell
B.       
germline mutations can be passed to the next generation
C.       
somatic mutations are only found in tumour cells
D.       
somatic mutation can be passed to the next generation
E.        
none of the above
Question 5.              
Lead-in
Pick the correct option from the list.
Option List
A.       
PARP is a cytotoxic agent
B.       
PARP is an immunological therapy
C.       
PARP is not a therapeutic intervention
D.       
PARP is post-adjuvant radiotherapy psychotherapy
E.        
none of the above
Question 6.              
Lead-in.
Pick the best answer from the list in relation to the use of PARPIs in breast cancer.
Option List
A.       
The main use of PARPIs is in maintenance therapy in women with BRCA1 mutations
B.       
The main use of PARPIs is in maintenance therapy in women with BRCA2 mutations
C.       
The main use of PARPIs is in maintenance therapy in women with no BRCA mutations
D.       
The main use of PARPIs is in initial treatment of women with BRCA mutations
E.        
None of the above
Question 7.              
Lead-in.
Pick the best answer from the list in relation to the use of PARPIs in cervical cancer.
Option List
A.       
The main use of PARPIs is in women with BRCA mutations and stage I - III disease
B.       
The main use of PARPIs is in women with BRCA mutations and stage IV disease
C.       
The main use of PARPIs is in women with no BRCA mutations and stage I - III disease
D.       
The main use of PARPIs is in women with no BRCA mutations and stage IV disease
E.        
None of the above
Question 8.              
Lead-in.
Pick the best answer from the list in relation to the use of PARPIs in endometrial cancer.
Option List
A.       
The main use is in the management of recurrence in women with BRCA1 mutations
B.       
The main use is in the management of recurrence in women with BRCA2 mutations
C.       
The main use of PARPIs is in pre-surgical treatment
D.       
The main use of PARPIs is in treatment immediately after surgery
E.        
None of the above
Question 9.              
Lead-in.
Pick the best answer from the list in relation to the use of PARPIs in choriocarcinoma.
Option List
A.       
The main use is as an alternative to methotrexate in women who are allergic to it
B.       
The main use is as an alternative to methotrexate in those with BRCA1 mutations
C.       
The main use is as an alternative to methotrexate in those with BRCA2 mutations
D.       
The main use is as an alternative to methotrexate in those with no BRCA mutations
E.        
None of the above
Question 10.          
Lead-in
This question is about the interaction between PARPIs and cytochrome enzymes. Pick the correct answer from the option list.
Option List
A.       
the most important interaction is with cytochrome CYP3A
B.       
the most important interaction is with cytochrome CYP3X
C.       
the most important interaction is with cytochrome CYP450
D.       
the most important interaction is with cytochrome CYP451
E.        
none of the above
Question 11.          
Lead-in
This question is about the interaction between cytochrome enzymes and PARPIs
Option List
A.       
inhibitors of the most important cytochrome in question 10 ↓ PARPI levels
B.       
inhibitors of the most important cytochrome in question 10 ↑ PARPI levels
C.       
inhibitors of the most important cytochrome in question 10 do not affect PARPI levels
D.       
inhibitors of the most important cytochrome in question 10 only affect PARPI levels at night
E.        
none of the above
Question 12.          
Lead-in
This question is about the interaction between PARPIs enzymes and combined hormonal contraception (CHC).
Option List
A.       
the efficacy of CHC may be reduced by concomitant use of PARPIs
B.       
the efficacy of CHC is unaffected by concomitant use of PARPIs
C.       
PARPIs increase the risk of depression in women using CHC
D.       
PARPIs increase the risk of thromboembolism in women using CHC
E.        
none of the above

Question 45. Montgomery Ruling.
Abbreviations.
BMA:    British Medical Association.
GMC:    General Medical Council.
Question 13.          
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 14.          
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 responsible person in the patient’s situation would be likely to regards as significant


Question 46.  Endometrial cancer & FIGO.
Lead-in.
The following questions relate to endometrial cancer. There is no option list.
Scenario 1.
A histology report on endometrial curetting is of 95% adenocarcinoma with 5% solid, non-squamous areas. What is the FIGO grade?
Scenario 2.
A histology report on endometrial curetting is of 90% adenocarcinoma with 10% solid, non-squamous areas. What is the FIGO grade?
Scenario 3.
A histology report on endometrial curetting is of 50% adenocarcinoma with 50% solid, non-squamous areas. What is the FIGO grade?
Scenario 4.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 5% myometrial invasion. What is the FIGO staging?
Answer.
Scenario 5.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 25% myometrial invasion. What is the FIGO staging?
Scenario 6.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 60% myometrial invasion. What is the FIGO staging?
Scenario 7
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the endocervical endothelium. What is the FIGO staging?
Scenario 8
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 9
A woman undergoes surgery for carcinoma of the endometrium. Peritoneal washings are +ve but there is no other evidence of spread outside the uterus. There is no myometrial invasion. There is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 10
A woman undergoes surgery for carcinoma of the endometrium. There is no evidence of extension outside the uterus. There is myometrial invasion through to and including the serosa. What is the FIGO staging?
Scenario 11
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. There is no evidence of disease elsewhere. What is the FIGO staging?
Scenario 12
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. Positive pelvic nodes are found, but no other lymphatic involvement. There is no distant spread. What is the FIGO staging?
Scenario 13
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. The tumour involves the mucosa of the bladder. There is no lymphatic or distant spread. What is the FIGO staging?

Question 47. 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.

Question 48. Down’s syndrome screening.
Lead-in.
The following scenarios relate to screening for Down’s syndrome.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
DS.        Down’s syndrome.
FASC:    Fetal Anomaly Screening Programme.
NSC:      National Screening Committee
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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