Statistics is something that we learn and forget fairly quickly. In post-graduate exams, we are expected not only to know it, but also to be able to apply it and discuss it with our peers. From this year onwards, in Part 2 FRACGP, a new station called Peer Level Discussion (PLC) is introduced. This may be the reason why so many of us failed this year. At this station, a metaanalysis result is summarised with all the diagrams and figures for you to read and interpret within 3 minutes. After 3 minutes the bell will ring and you walk in to face the 'expert' peer!!!
What do you understand by Relative Risk (RR)?
Well, I know many of us are not so good in statistics, can each of us put in something that you understood from your reading or research. Give examples if possible. By doing so, you are helping each other to understand the topics better. Mind you, the person who teach wholeheartedly is the person that will gain the most. Questions on statistics are also asked in the Single Best Answer of Part 1. Hopefully, among us, there is someone who is an expert in statistics and who is keen to teach us.
What is Odds Ratio (OR)?
What is Hazard Ratio (HR)?
What is Likelihood Ratio?
What is Surrogate Endpoint?
What is Confidence Interval?
What is P value?
What is Type 1 error?
What is Type 2 error?
What is Positive Predictive Value?
What is Negative Predictive Value?
What is Numbers Needed to Treat (NNT)?
Sunday, September 21, 2008
Thursday, September 18, 2008
Confusion/Pain Mx/Immune Response/Vaccine Efficacy
Please look up the answer for Q9/7 to Q9/11 under the comments of the respective post.
Q9/12
Greta is aged 69 and has advanced lung cancer. You are called urgently because she has become acutely confused. You note that she appears dehydrated. You order pathology tests and are not surprised to find:
a) Hypokalemia
b) Hyperkalemia
c) Hypocalcemia
d) Hypercalcemia
Q9/13
Marjory L has locally invasive carcinoma of the cervix, which has infiltrated her right femoral nerve. She is experiencing shooting, lancinating pain. Which of the following statements is TRUE?
a) Opioids are contraindicated for this type of pain
b) Anticonvulsants are an appropriate option in this situation
c) A tricyclic antidepressant is the optimal treatment
d) Antiarrhythmics are the drug of choice for this condition
Q9/14
Which of the following statements are consistent with passive immunity? (Select one or more responses)
a) Pre-formed antibodies are injected, and these give immediate but short-term protection.
b) Normal human immunoglobulin (NHIG) is derived from the pooled plasma of blood donors. It contains antibodies to microbial agents which are prevalent in the general population.
c) The protection from passive immunity is transient as the half-life of antibodies is between 3 and 4 weeks.
d) Passive immunity, through specific immunoglobulins, is available to protect individuals against specific microbial agents such as cytomegalovirus (CMV), respiratory syncytial virus (RSV), hepatitis B, rabies and varicella-zoster viruses, plus tetanus and diphtheria toxins.
Q9/15
Vaccine efficacy is a measure of the level of protection against a disease in people who have been vaccinated compared with the attack rate in people who have not been vaccinated. A vaccine efficacy of 100% indicates perfect protection, 0% indicates no protective effect. There are many controlled trials and field studies to show the efficacy of vaccines.
How effective are most vaccinations at preventing disease?
a) 100%. Everyone is protected from a disease by every immunisation.
b) At least 85 - 95% of people are protected from a disease by most immunisations.
c) Approximately 50% of people are protected from a disease by immunisation.
d) Approximately 15% of people are protected from a disease by immunisation, that is why we need so many injections.
Q9/16
If a vaccine requires a course of doses (e.g. adult hepatitis b), and a patient misses a vaccine dose, do you have to start the schedule again?
a) Yes, vaccines will only work if they are given strictly according to the dose schedule.
b) No, generally the immune response memory is preserved and the course can be continued from where it was interrupted.
Q9/12
Greta is aged 69 and has advanced lung cancer. You are called urgently because she has become acutely confused. You note that she appears dehydrated. You order pathology tests and are not surprised to find:
a) Hypokalemia
b) Hyperkalemia
c) Hypocalcemia
d) Hypercalcemia
Q9/13
Marjory L has locally invasive carcinoma of the cervix, which has infiltrated her right femoral nerve. She is experiencing shooting, lancinating pain. Which of the following statements is TRUE?
a) Opioids are contraindicated for this type of pain
b) Anticonvulsants are an appropriate option in this situation
c) A tricyclic antidepressant is the optimal treatment
d) Antiarrhythmics are the drug of choice for this condition
Q9/14
Which of the following statements are consistent with passive immunity? (Select one or more responses)
a) Pre-formed antibodies are injected, and these give immediate but short-term protection.
b) Normal human immunoglobulin (NHIG) is derived from the pooled plasma of blood donors. It contains antibodies to microbial agents which are prevalent in the general population.
c) The protection from passive immunity is transient as the half-life of antibodies is between 3 and 4 weeks.
d) Passive immunity, through specific immunoglobulins, is available to protect individuals against specific microbial agents such as cytomegalovirus (CMV), respiratory syncytial virus (RSV), hepatitis B, rabies and varicella-zoster viruses, plus tetanus and diphtheria toxins.
Q9/15
Vaccine efficacy is a measure of the level of protection against a disease in people who have been vaccinated compared with the attack rate in people who have not been vaccinated. A vaccine efficacy of 100% indicates perfect protection, 0% indicates no protective effect. There are many controlled trials and field studies to show the efficacy of vaccines.
How effective are most vaccinations at preventing disease?
a) 100%. Everyone is protected from a disease by every immunisation.
b) At least 85 - 95% of people are protected from a disease by most immunisations.
c) Approximately 50% of people are protected from a disease by immunisation.
d) Approximately 15% of people are protected from a disease by immunisation, that is why we need so many injections.
Q9/16
If a vaccine requires a course of doses (e.g. adult hepatitis b), and a patient misses a vaccine dose, do you have to start the schedule again?
a) Yes, vaccines will only work if they are given strictly according to the dose schedule.
b) No, generally the immune response memory is preserved and the course can be continued from where it was interrupted.
Wednesday, September 17, 2008
Elderly/Backache/Retinopathy/Pain at calf/Ovarian Cancer
Q9/7
11 Hiep N is the 68-year-old grandmother of a patient of yours. She is proficient in English. Her daughters have noticed that she has become increasingly confused over the last six months. She can't remember the names of her friends, and more than once has forgotten that she has left the stove on. This has been a steady deterioration. You consider that the most likely cause is Alzheimer’s type dementia. However you need to exclude other causes of this clinical presentation. Which of the following is most likely to give this pattern of cognitive deterioration?
a) Urinary tract infection
b) Multi infarct dementia
c) Space occupying lesion
d) Hyperthyroidism
Q9/8
Olga, aged 74 presents to you complaining of a pain in the mid back which is worse when she tries to sleep. You consider that her pain is indicative of bony pathology. She has no other symptoms. Which part of your physical examination is MOST likely to reveal the underlying pathology?
a) Palpation of the breasts
b) Assessment of the thyroid
c) Digital rectal examination
d) Examination of the urine
Q9/9
Diabetic retinopathy is primarily characterised by:
a) Drusen formation
b) Vascular leakage
c) Retinal ischaemia
d) Detachment of retina from choroid
Q9/10
Jack M, aged 70, complains of pain in his right leg, particularly in his right calf, of recent onset. There are no localised findings on examination. He has been an active man, but a recent injury has severely limited his mobility. He is MOST likely to have:
a) Baker's Cyst
b) Torn gastrocnemius
c) L4 Sciatica
d) Deep venous thrombosis
Q9/11
Try this and see how close you get to the answer (to be posted later).
What are the common symptoms of ovarian cancer?
11 Hiep N is the 68-year-old grandmother of a patient of yours. She is proficient in English. Her daughters have noticed that she has become increasingly confused over the last six months. She can't remember the names of her friends, and more than once has forgotten that she has left the stove on. This has been a steady deterioration. You consider that the most likely cause is Alzheimer’s type dementia. However you need to exclude other causes of this clinical presentation. Which of the following is most likely to give this pattern of cognitive deterioration?
a) Urinary tract infection
b) Multi infarct dementia
c) Space occupying lesion
d) Hyperthyroidism
Q9/8
Olga, aged 74 presents to you complaining of a pain in the mid back which is worse when she tries to sleep. You consider that her pain is indicative of bony pathology. She has no other symptoms. Which part of your physical examination is MOST likely to reveal the underlying pathology?
a) Palpation of the breasts
b) Assessment of the thyroid
c) Digital rectal examination
d) Examination of the urine
Q9/9
Diabetic retinopathy is primarily characterised by:
a) Drusen formation
b) Vascular leakage
c) Retinal ischaemia
d) Detachment of retina from choroid
Q9/10
Jack M, aged 70, complains of pain in his right leg, particularly in his right calf, of recent onset. There are no localised findings on examination. He has been an active man, but a recent injury has severely limited his mobility. He is MOST likely to have:
a) Baker's Cyst
b) Torn gastrocnemius
c) L4 Sciatica
d) Deep venous thrombosis
Q9/11
Try this and see how close you get to the answer (to be posted later).
What are the common symptoms of ovarian cancer?
Answer to Q9/3, Q9/4, Q9/5, Q9/6
Q9/3
The correct answer is (b).
The national policy on cervical screening provides consensus guidelines on which women need screening and how often Pap smears should be taken. It states:
“Pap smears may cease at the age of 70 years for women who have had two normal Pap smears within the last five years.” Women over 70 years who have never had a Pap smear should have 2 consecutive pap smears performed. Women who request a Pap smear should be screened.If older women are finding pap smears uncomfortable, the use of topical oestrogen for 2 weeks prior to taking a pap smear can reduce the discomfort due to atrophy/dryness.
Q9/4
The correct answer is (c). A benign essential tremor is present constantly, but becomes more pronounced when the limb is maintained against gravity. It is lessened by rest and not markedly enhanced during voluntary movement towards a target. An intention tremor is typical of cerebellar disease and a rest tremor is more likely to be caused by Parkinson’s disease or be an exaggerated physiological tremor.
Answer to Q9/5
The correct answers are MMR, VZV and Oral Rotavirus Vaccine.
You should seek further advice if you are considering administering the following vaccines: MMR, VZV, Oral Rotavirus vaccine, as they are all live-attenuated vaccines.
Answer to Q9/6
The correct response is the influenza vaccine. Note that egg allergy is no longer a contraindication to vaccination with MMR, however closer observation post-vaccination may be warranted. For information on egg allergy and MMR vaccine, refer to the 2nd last dot point of Section 3.11: Measles: Precautions on page 207 of the Handbook.
The correct answer is (b).
The national policy on cervical screening provides consensus guidelines on which women need screening and how often Pap smears should be taken. It states:
“Pap smears may cease at the age of 70 years for women who have had two normal Pap smears within the last five years.” Women over 70 years who have never had a Pap smear should have 2 consecutive pap smears performed. Women who request a Pap smear should be screened.If older women are finding pap smears uncomfortable, the use of topical oestrogen for 2 weeks prior to taking a pap smear can reduce the discomfort due to atrophy/dryness.
Q9/4
The correct answer is (c). A benign essential tremor is present constantly, but becomes more pronounced when the limb is maintained against gravity. It is lessened by rest and not markedly enhanced during voluntary movement towards a target. An intention tremor is typical of cerebellar disease and a rest tremor is more likely to be caused by Parkinson’s disease or be an exaggerated physiological tremor.
Answer to Q9/5
The correct answers are MMR, VZV and Oral Rotavirus Vaccine.
You should seek further advice if you are considering administering the following vaccines: MMR, VZV, Oral Rotavirus vaccine, as they are all live-attenuated vaccines.
Answer to Q9/6
The correct response is the influenza vaccine. Note that egg allergy is no longer a contraindication to vaccination with MMR, however closer observation post-vaccination may be warranted. For information on egg allergy and MMR vaccine, refer to the 2nd last dot point of Section 3.11: Measles: Precautions on page 207 of the Handbook.
Friday, September 12, 2008
Vaccines
Q9/5
Which vaccines should be deferred (and then further advice sought from an expert in immunisation) if a patient has an immunosuppressive illness? Select one or more than one.
Oral Rotavirus vaccine
Combination vaccines that include both Inactivated Polio vaccine (IPV) and DTPa
Measles Mumps Rubella (MMR)
Human Papillomavirus vaccine (HPV) (e.g. "Gardasil")
Varicella vaccine (VZV)
Influenza vaccine
Monovalent Hepatitis B vaccine
Polysaccharide Pneumococcal vaccine (23vPPV)
Conjugate Pneumococcal (7vPCV)
Q9/6
Which vaccinations may be contraindicated if the patient is allergic to egg protein?
Select one or more than one.
Oral Rotavirus vaccine
Combination vaccines that include both Inactivated Polio vaccine (IPV) and DTPa
Measles Mumps Rubella (MMR)
Human Papillomavirus vaccine (HPV) (e.g. "Gardasil")
Varicella Vaccine (VZV)
Influenza vaccine
Monovalent Hepatitis B vaccine
Polysaccharide Pneumococcal vaccine (23vPPV)
Conjugate Pneumococcal vaccine (7vPCV)
Which vaccines should be deferred (and then further advice sought from an expert in immunisation) if a patient has an immunosuppressive illness? Select one or more than one.
Oral Rotavirus vaccine
Combination vaccines that include both Inactivated Polio vaccine (IPV) and DTPa
Measles Mumps Rubella (MMR)
Human Papillomavirus vaccine (HPV) (e.g. "Gardasil")
Varicella vaccine (VZV)
Influenza vaccine
Monovalent Hepatitis B vaccine
Polysaccharide Pneumococcal vaccine (23vPPV)
Conjugate Pneumococcal (7vPCV)
Q9/6
Which vaccinations may be contraindicated if the patient is allergic to egg protein?
Select one or more than one.
Oral Rotavirus vaccine
Combination vaccines that include both Inactivated Polio vaccine (IPV) and DTPa
Measles Mumps Rubella (MMR)
Human Papillomavirus vaccine (HPV) (e.g. "Gardasil")
Varicella Vaccine (VZV)
Influenza vaccine
Monovalent Hepatitis B vaccine
Polysaccharide Pneumococcal vaccine (23vPPV)
Conjugate Pneumococcal vaccine (7vPCV)
Thursday, September 11, 2008
PAP Smear / Tremor
Q9/3:
Meg, 66 is now a widow. She asks you when she can stop having pap smears as she finds them quite uncomfortable. When can older women cease having pap smears?
a) When they have had two normal smears after the age of 70
b) At age 70 if there have been two normal smears in the preceding 5 years
c) At menopause if they have no vaginal discharge or bleeding after this time
d) Once they are no longer sexually active if their last smear was normal
Q9/4:
Cyril J, aged 64, presents complaining that he can't hold a cup of tea steadily. You would suspect a benign essential tremor if the tremor is:
a) Increased with voluntary movement towards a target
b) Most significant at rest
c) Maximal when the limb is maintained against gravity
d) Repetitive and flapping in nature
Meg, 66 is now a widow. She asks you when she can stop having pap smears as she finds them quite uncomfortable. When can older women cease having pap smears?
a) When they have had two normal smears after the age of 70
b) At age 70 if there have been two normal smears in the preceding 5 years
c) At menopause if they have no vaginal discharge or bleeding after this time
d) Once they are no longer sexually active if their last smear was normal
Q9/4:
Cyril J, aged 64, presents complaining that he can't hold a cup of tea steadily. You would suspect a benign essential tremor if the tremor is:
a) Increased with voluntary movement towards a target
b) Most significant at rest
c) Maximal when the limb is maintained against gravity
d) Repetitive and flapping in nature
Answer to Q9/1, Q9/2, Q on 4/9/08
Answer to Q9/1: D
Bleeding piles, bleeding diverticulae and carcinoma of the large bowel can all cause sufficient bleeding to result in an iron deficiency anaemia which would give a hypochromic microcytic pattern on microscopic examination of the blood.
Normocytic normochromic anaemia is more likely to be caused by chronic disease such as chronic renal failure. It could also result from marrow suppression due to drugs or myelofibrosis or combined Fe/B12 deficiency.
Answer to Q9/2: A
DVT and pulmonary embolism are associated with an underlying diagnosis of cancer, particularly cancer of visceral organs such as the pancreas. Recurrent DVT is associated even more strongly with metastatic disease. There is no strong association between the other conditions listed and recurrent DVT, although smoking in combination with the oral contraceptive pill is a risk factor for DVT.
Answer for the question posted on sept 4 (consent of immunisation) is B
Consent is legally valid if all of the following have been fulfilled. The:
person giving consent has the legal and intellectual capacity to do so
consent is given voluntarily
consent is given after explanation of the benefits and risks of the relevant vaccine(s)
person giving consent has had suitable opportunity to find out further relevant information
A child's parent or legal guardian usually has the authority to provide vaccination consent. In this instance, a person is a child if they are under 18 years of age in all Australian states or territories except:
New South Wales where a person under 14 years of age is defined as a child
South Australia and the Northern Territory where a person under 16 years of age is defined as a child
Children of particular maturity and age may be able to consent to vaccination. State and territory immunisation service provider guidelines should be consulted for information on consent from children. Children who refuse vaccinations consented to by their parent/legal guardian should have their wishes respected and the parent/guardian informed.
Consent needs to be documented in the person's medical records. When a vaccination program is explained and consented to at a visit and agreed to vaccinations are provided at other visits, explicit verbal consent is required before each vaccination at the subsequent visits irrespective of whether the original consent was verbal or written.
On pneumococcal vaccine,
The correct response is (a).
Provided they are well, babies born preterm should be immunised according to the standard schedule, beginning at birth, and without correction for prematurity. Preterm babies have adequate antibody responses to most vaccines and are at increased risk for vaccine-preventable diseases. So babies still in hospital at 2 months after birth should be given DTPa, hepatitis B, Haemophilus influenzae type b (Hib), IPV, pneumococcal conjugate, and rotavirus vaccines.
Preterm babies may not respond optimally to hepatitis B, Hib and pneumococcal vaccination. Babies born before 28 weeks gestation (and some other babies) require an extra dose of PRP-OMP and pnemococcal vaccines. It is recommended that babies born before 32 weeks gestation (and those weighing less than 2000 g at birth) receive hepatitis B vaccine at 0, 2, 4 and 6 months and then a booster at 12 months. The 12-month booster can be left out if the anti-HBs response is measured at 7 months and found to be 10 mIU/mL or greater.
Preterm babies who continue to experience health issues at 6 months should receive influenza vaccination - especially if the problems are cardiac, neurological or respiratory.
Up to the age of 2 months, babies born before 37 weeks should be vaccinated using the same needle gauges and insertion angles as full-term babies but a 16 mm length needle should be used rather than 25 mm. Routine vaccinations in preterm babies in hospital can cause increased apnoea. Routine vaccinations are not associated with increased apnoea in babies at home and are not associated with increased Sudden Infant Death Syndrome (SIDS) risk.
Bleeding piles, bleeding diverticulae and carcinoma of the large bowel can all cause sufficient bleeding to result in an iron deficiency anaemia which would give a hypochromic microcytic pattern on microscopic examination of the blood.
Normocytic normochromic anaemia is more likely to be caused by chronic disease such as chronic renal failure. It could also result from marrow suppression due to drugs or myelofibrosis or combined Fe/B12 deficiency.
Answer to Q9/2: A
DVT and pulmonary embolism are associated with an underlying diagnosis of cancer, particularly cancer of visceral organs such as the pancreas. Recurrent DVT is associated even more strongly with metastatic disease. There is no strong association between the other conditions listed and recurrent DVT, although smoking in combination with the oral contraceptive pill is a risk factor for DVT.
Answer for the question posted on sept 4 (consent of immunisation) is B
Consent is legally valid if all of the following have been fulfilled. The:
person giving consent has the legal and intellectual capacity to do so
consent is given voluntarily
consent is given after explanation of the benefits and risks of the relevant vaccine(s)
person giving consent has had suitable opportunity to find out further relevant information
A child's parent or legal guardian usually has the authority to provide vaccination consent. In this instance, a person is a child if they are under 18 years of age in all Australian states or territories except:
New South Wales where a person under 14 years of age is defined as a child
South Australia and the Northern Territory where a person under 16 years of age is defined as a child
Children of particular maturity and age may be able to consent to vaccination. State and territory immunisation service provider guidelines should be consulted for information on consent from children. Children who refuse vaccinations consented to by their parent/legal guardian should have their wishes respected and the parent/guardian informed.
Consent needs to be documented in the person's medical records. When a vaccination program is explained and consented to at a visit and agreed to vaccinations are provided at other visits, explicit verbal consent is required before each vaccination at the subsequent visits irrespective of whether the original consent was verbal or written.
On pneumococcal vaccine,
The correct response is (a).
Provided they are well, babies born preterm should be immunised according to the standard schedule, beginning at birth, and without correction for prematurity. Preterm babies have adequate antibody responses to most vaccines and are at increased risk for vaccine-preventable diseases. So babies still in hospital at 2 months after birth should be given DTPa, hepatitis B, Haemophilus influenzae type b (Hib), IPV, pneumococcal conjugate, and rotavirus vaccines.
Preterm babies may not respond optimally to hepatitis B, Hib and pneumococcal vaccination. Babies born before 28 weeks gestation (and some other babies) require an extra dose of PRP-OMP and pnemococcal vaccines. It is recommended that babies born before 32 weeks gestation (and those weighing less than 2000 g at birth) receive hepatitis B vaccine at 0, 2, 4 and 6 months and then a booster at 12 months. The 12-month booster can be left out if the anti-HBs response is measured at 7 months and found to be 10 mIU/mL or greater.
Preterm babies who continue to experience health issues at 6 months should receive influenza vaccination - especially if the problems are cardiac, neurological or respiratory.
Up to the age of 2 months, babies born before 37 weeks should be vaccinated using the same needle gauges and insertion angles as full-term babies but a 16 mm length needle should be used rather than 25 mm. Routine vaccinations in preterm babies in hospital can cause increased apnoea. Routine vaccinations are not associated with increased apnoea in babies at home and are not associated with increased Sudden Infant Death Syndrome (SIDS) risk.
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