Friday 31 January 2014

Tutorial 30th. January 2014

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Tonight we had an EMQ and 5 essay plans.
Essay 71 is an example of a topic that you probably don't know much about.
Try to produce and answer without looking up references.
You may get a topic like this is the exam and it is good to have practised how to scratch around for enough marks to pass - you will surprise yourself by how much you manage to come up with.

16
EMQ. Education
69
Critically evaluate the uses of the levonorgestrel intra-uterine system, LNG-IUS.
70
You have been asked to review your departmental policy for the use of anti-D.
1. Justify how you will go about the process.                           8 marks.
2. Outline the key issues to be included in the document.  12 marks.
71
A woman attends the antenatal clinic at 36 weeks. She had read an article in a woman’s magazine about the merits of umbilical cord blood banking and would like to have this done.
1. Justify the history you will take.                       4 marks
2. Justify the investigations you will arrange.    2 marks
3. Justify your management.                               14 marks
72
You have been asked to write a protocol for the diagnosis and management of umbilical cord prolapse.
1. Justify the steps you will take.                                               6  marks
2. Justify the key advice you will include in the protocol.   14 marks
73
You have been asked to prepare a lecture on risk management in gynaecology for the trainees in your department.
Critically evaluate the key messages you will include in the presentation.

Education.
I am not an expert in this topic and offer this as some help to working out answers if you get a question on teaching methods, which apparently has happened. If you are an expert and can help to improve what follows, that will be much appreciated.
If you get a question in the exam, please try to remember as much as possible, particularly the option list and send it to me.
There are often a variety of different techniques that could be used. I would guess that the exam committee will take care to restrict the option list so that it is clear which is the best option.
Lead-in.
The following scenarios relate to medical education
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EMQ:     extended, matching question.
PBL:       problem-based learning.
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.

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



Tuesday 28 January 2014

Tutorial 27 January 2014

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Tonight we had a tutorial by Julie Morris on medical statistics.
The questions she discussed were:




Statistics Questions

1.      Weight gain in pregnancy was measured in a sample of 1000 women. Summary statistics of the weight gain were calculated.  (Answer yes/no to each statement)-

A     The median is the weight gain value which occurs most frequently
B     If weight gain was found to have a positively skewed distribution, the mean will be less than the median.
C     The interquartile range is unaffected by outliers
D     A large positive outlier will increase the mean
E     The median is affected by outliers

2.      For a cohort of babies, birthweight was considered to be Normally distributed with a mean of 3000g and a standard deviation of 500g. It follows that: (Answer yes/no to each statement)-

A     All birthweights must be less than 4500g
B     The distribution of birthweights is skewed
C     About 50% of birthweights are above 3000g
D     About 2.5% of birthweights are below 2000g
E     About 95% of birthweights are between 2500g and 3500g

3.      Theme: Summary statistics
         A     mean                                               E          interquartile range
         B     standard deviation                           F          percentage
         C     range                                               G          mode
         D     median                                            H          standard error
        
         For each type of data description given below choose the SINGLE most appropriate summary statistic. Each option may be used once, more than once, or not at all.   

1.     The variability of length of hospital stay for 230 mothers following a caesarean, where length of stay is Normally distributed.
2.     The extremes of length of hospital stay for 230 mothers following a caesarean, where length of stay is Normally distributed
3.     The elective caesarean section rate in a hospital for 2011



4.      To assess the effectiveness of a new antenatal screening test, 100 pregnant women over 45 years of age, were screened.  25 women subsequently had babies with mild congenital problems. 20 of these 25 women had a positive screening test result. 65 of those with normal babies had a negative test result. (Answer yes/no to each statement).

A     The predictive value of a positive test result  as a marker for congenital problems is 20/35
B     The sensitivity of the test will not depend upon the prevalence of congenital problems in the cohort of women to which it is applied
C     The sensitivity of the screening test is 20/100
D     The specificity of the screening test is 65/75
E     Specificity=1-sensitivity

5.      In a study looking at the relationship between blood pressure during pregnancy and fetal growth, 130 women had their 24-hour blood pressure readings taken in mid-pregnancy. The size of the baby was recorded at birth. The Pearson correlation between blood pressure and birthweight was found to equal -0.70 with an associated p-value of  p<0.001.
         (Answer yes/no to each statement):

A     Blood pressure  explains 70% of the variability in birthweight
B     We can conclude that increasing blood pressure is a cause of low birthweight
C     A correlation of zero is interpreted as showing no association between two variables
D     The correlation between blood pressure and birthweight can be different from the correlation between birthweight and blood pressure
E     There is a significant negative linear  relationship between blood pressure and birthweight

6.      In a study of 75 infants with median gestational age 30 weeks (range 25 to 42 weeks), lung area was calculated from chest radiographs and lung volume from measurements of FRC. The aim of the study was to see whether lung area would predict lung volume in neonates.  (choose just one).

A     Chi-square test
B     Correlation coefficient
C     Mann-Whitney U-test
D     Regression analysis
         E     Two-sample t-test


 7.      A cohort of women experiencing nausea and vomiting in pregnancy were given acid-reducing medication. The Pregnancy-Unique Quantification of Emesis and nausea (PUQUE) score was recorded before and after treatment. The clinical effect of the medication could be evaluated using: (Answer yes or no to each statement):

A     The Student paired t-test
B     The Spearman correlation coefficient
C     The Wilcoxon matched-pairs test
D     The Sign test
E     The Mann-Whitney U-test

8.      Theme: Statistical significance tests
         A     Chi-square test                                F          Spearman correlation
         B     Two-sample t-test                            G          Mann-Whitney U-test
         C     Pearson correlation                         H          Wilcoxon test
         D     Fisher’s Exact test                           I           Paired t-test
         E     Linear regression                            J          ANOVA

         For each of the studies described below choose the SINGLE most appropriate statistical test. Each option may be used once, more than once, or not at all.   

1.      A comparison of two audits (2011 vs 2006) of smoking habits of pregnant women looking at the percentage of current smokers.
2.     In a cohort of 500 pregnant women, maternal cotinine levels (an indicator of exposure to cigarette smoke) were measured. The aim of the study was to see whether high maternal cotinine levels were related to subsequent birthweight. It was assumed that cotinine levels would have a highly skewed distribution.
3.     Adrenaline concentrations were measured in 30 mechanically-ventilated babies at 1 hour and 24 hours to assess whether there had been a significant change. The adrenaline concentrations cannot be assumed to follow a Normal distribution.

9.      In a study of diet and epithelial ovarian cancer, 128 women with cancer and 251 women without cancer were asked about their consumption of dairy products. 50% of cancer patients and 10% of controls reported consuming yoghurt regularly: (Answer yes or no to each statement):

A     This is a cohort study
B     The odds ratio is 9
C     The odds ratio is 5
D     The relative risk can be estimated by an odds ratio if the disease is rare and the cases and controls are random samples from the same population.
E     An odds ratio of 0 indicates no difference between cancer patients and controls in the consumption of yoghurt.

10.     In a study of the effect of a new antibiotic therapy for bacterial vaginosis in pregnancy, the infection response rate for women on the new antibiotics was 0.4, whereas it was 0.2  in the control group (p=0.03). (Answer yes or no to each statement):

 A     The infection response rate was significantly lower in the control group.

B     The NNT is the difference in the number of infection-free women in the treated group compared to the control group
C     The NNT=5
D     The NNT=2
E     The NNT is the number of women needed to receive the intervention to see one additional occurrence of the outcome in the treatment group


 We then discussed two essays.

1. With regard to female genital mutilation (FGM).

1.   what are the key aspects of the law in the UK relating to FGM.                        2 marks.
2.   what are the responsibilities of the doctor who suspects that a child may be subjected to FGM?
                                                                                                                             2 marks.
3.   how is FGM graded?                                                                                       3 marks.
4.  outline the management of woman found at booking to have had FGM.   13 marks.

  
 
A 30-year-old woman para 1+1 presents at 34 weeks gestation with right loin pain, frequency of micturition, dysuria and pyrexia.
1. Justify the history you will take.                                                                6 marks.

2. Justify the investigations you will arrange.                                                  6 marks.

3. Justify your management, assuming the diagnosis to be pyelonephritis.     12 marks.

Thursday 23 January 2014

Tutorial 23 January 2014


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15
COC. Missed pills. Starting the Pill.
62
A 35 year-old woman books at 6 weeks. She has noted a left breast mass. Breast cancer is suspected.
1. What is the life-time risk of female breast cancer.         1 mark.
2. How does pregnancy affect the risks of breast cancer. 4 marks.
3. Outline the investigation.                                                    5 marks.
4. Critically evaluate the management.                               10 marks.
63
With regard to epidural anaesthesia:
1.  Outline the main differences between it and spinal anaesthesia. 4 marks.
2.  Outline the main techniques and drugs used.                                   6 marks.
2.  Evaluate the main contraindications.                                                  4 marks.
3.  Discuss the main uses.                                                                            6 marks.
64
A healthy 30-year-old woman with blood group Rh negative is found to have rhesus D antibodies at booking at 8 weeks.
Critically evaluate the management.
65
You have been asked to write guidance for the unit in relation to labour and delivery in water.
1. Outline how you will go about the task.                            8 marks.
2. Discuss the key issues to be included in the guidance. 12 marks
66
A 20 year-old woman with a known history of drug abuse attends the hospital antenatal booking clinic in her first pregnancy.
a. outline the factors determining her level of risk  4 marks.
b. outline the risks to the mother                                 6 marks.
c. outline the risks to the fetus                                      4 marks.
d. outline the risks to the neonate & infant              4 marks.
e. outline the risk to others                                             2 marks.

COC Missed pills. Starting the Pill..
Lead-in.
The following scenarios relate to the combined oral contraceptive (COC) and missed pills.
For each, select the option that best fits the scenario.
Each option can be used once, more than once or not at all.
Abbreviations.
UPSI:     unprotected sexual intercourse.

Option list.
A.        pill that is ≥ 12 hours late.
B.        pill that is > 12 hours late.
C.        pill that is ≥ 24 hours late.
D.        pill that is > 24 hours late.
E.         two missed pills at any time in a single cycle.
F.         the first pill taken in one’s first love affair, now recalled with fond nostalgia for its effectiveness in preventing pregnancy, the Prince having been truly a loathsome toad.
G.       no additional contraception required.
H.        additional contraception required for 7 days.
I.          emergency contraception should be considered.
J.          emergency contraception should be recommended.
K.        take the missed pill immediately, but not if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
L.         take the missed pill immediately, even if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
M.      take the missed pill immediately, even if it means 2 pills in one day; additional contraception for 7 days; pill-free interval as usual.
N.       take one of the missed pills immediately, discard the other missed pills, use extra contraception for 7 days and discuss emergency contraception with your doctor.
O.       take the missed pills immediately, use extra contraception for 7 days and discuss emergency contraception with your doctor.
P.        continuous combined preparation.
Q.       bi-phasic preparation.
R.        quadriphasic preparation.
S.         cannot be answered from the data given.
T.         none of the above.


Scenario 1.
What is the definition of a missed pill?
Scenario 2.
What is the definition of two missed pills?
Scenario 3.
A COC is begun on day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 4.
A COC is begun 5 days after day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 5.
A COC is begun for the first time on day 1 of menstruation. The fifth pill is missed. What advice should be given?
Scenario 6.
A pill is missed on day 14 of a 21-day pack. What advice should be given?
Scenario 7
A pill is missed on day 21 of a 21-day pack. What advice should be given?
Scenario 8
Two pills are missed in the first week of a 21-day pack. What advice should be given?
Answer:
Scenario 9
Two pills are missed in the second week of a 21-day pack. What advice should be given?
Scenario 10
Two pills are missed in the third week of a 21-day pack. What advice should be given?
Scenario 11
What kind of preparation is Qlaira?