101. 102, 103. Answer is B (National population is always taken as the standard population): Park 23°63 A ‘Standard population’ is defined as one for which the number in each age and sex group are known. The choice of the standard population is arbitrary. National population may be used as the standard population, but itis certainly ‘not the taken as the standard population always. Answer is D>C (‘Ensure the groups are comparable on base line characteristics’ and ‘Reduce selection bias in allocation to treatment’) ~ Park 23"/82 Randomization is an attempt to eliminate bias and allow for comparability. Although Randomization is an attempt to allow for comparability, Randomization does not ‘ensure? that groups are comparable. By the process of randomization we only ‘hope’ that factors which are important yet unrecognized will be distributed equally between the two groups. Although randomization wil give the greatest confidence that groups are comparable; it wil still not ‘ensure? comparability. Both options D & C are correct but since we have to decide on to one, option D is the single best answer. Analysis of options Ensure that groups are comparable on base line characteristics [Reduce selection bias in allocation fo treatment ‘+ Randomization will give the greatest confidence thatthe groups» ‘Randomization ensures that investigator has are comparable so that lke can be compared with like ~Park ‘no control over allocation of participants to + Randomization is essential to allow comparability for those either study or control group thus factors which are important but whose effect is not recognized or ‘climinating what is known as ‘selection cannot be determined -Park bias. (Theoretically itis possible to assure comparability by matching, * Randomization ensues that every individual ‘but when one matches one can only match those factors which gets equal chance of being allocated to either are known to be important. the contro or the trial (treatment) group. + With randomization ‘hopefully ll other unrecognized factors (Randomization definitely reduces selection get distributed equally between the two groups thus making bias) them comparable. (Randomization is an attempt to allow for comparability but does not ensure it) Answer is D (Avoid observer and subject bias): Park 23°83 Double blinding ensures that both the observer and subject are unaware of the group allocation and treatment. It there by eliminates both subject bias and the observer bias. Blinding is a technique to eliminate bias (errors of assessment due to human element) Blinding can be done in three ways: Participant (subject) is not aware Participant (subject) and investigator Participant (subject) doctor (observer) whether he belongs tothe study (observer) are both not aware ofthe group and evaluator are all unaware of the ‘f0up or control group allocation and treatment received ‘group allocation and treatment received + + + Eliminates subject bias Eliminates subject bias and observer bias Eliminates subject bias, observer bias and evaluation bias. "Subject bias Observer bias Evaluation bias Bias on the part of participant Bias on the part of the investigator Bais on the part of the evaluator who who may subjectively feel better (observer) measuring the outcome, who may subconsciously give a favourable ‘orreport improvement ifthey may be influenced if he knows before _report ofthe outcome of the trial knew they were receiving hand the particular procedure or therapy to ‘treatment which the patient has been subjected104. 105. Answer is C (Sample size required depends on the hypothesis): Park 23/83, 851; Methods in biostatistics Mahajan 690 Sample size is an important, independent predictor of the precision of results while confirming or refuting an aetiological hypothesis. A small sample size lacks precision whatever the hypothesis. tis believed that sample size should not be less than 30 (whatever the hypothesis). + Sample size is very vita in a scienti hypothesis. = A sample small in size (irrespective of hypothesis) is biased and should never be depended upon for drawing any conclusion = A larger sample is more reliable (irrespective of hypothesis) for drawing conclusions or refuting a hypothesis. + Normally the cut off is taken at 30. A sample of size greater than 30 is considered large enough for statistical Purpose. ‘+ Baseline characteristics of study and control groups should be similar, Randomization is the statistical procedure in an RCT by which an attempt is made to make the study & control groups comparable. By the process of randomization it is hoped that baseline characteristics as well as unrecognized factors will be distributed equally between the two groups ‘+ Double blind trial minimizes both investigator bias and subject bias (explained earlier) + The dropouts from the trial should be excluded from the analysis or else results of analysis will not be freely Tepresentative. The losses to follow up are known as attrition, Every effort should be made to minimize attrition and at analysis of results, dropouts should not be used. study. Sample size is a statistical parameter and does not depend on the Answer is B (31): Park 23/139 Positive predictive values of diagnostic test for the given set of date is 31.034 Predictive value of a positive test: - Indicates the probability that a patient with a positive test result has in fact the disease in question True positive = Pretictive yale a POO IS rec Fusco « True positives (in question) = 180 (Number of diseased shown by results) + False positives (in question) = 400 (Number of non diseased shown ‘diseased’ by results) + Predictive value of positive test for this set of data = 180100 =31.034 180-400 Remember: ‘Screening test result by diagnosis Positive a rere positive) b ae positive) atb [Negative (False Negative) (True negative) etd ea Total ate btd atbtetd a Evaluation of a screening test : J(a+e) x 100 /(b+d) x 100 + Predictive value of a positive test =a / (a¥b) x 100 + Predictive value of a negative test = d / (cd) x 100 + Percentage of false negatives = c / (ate) x 100 + Percentage of false positive = b / (b+d) x 100107. 108. 109. 110. Answer is C (80): Park 23/139; Repeat The sensitivity of diagnostic test in question is 80. lity ofa test to identify correctly all those who have the disease ie true positives Sensitivity = ‘Truepositive Trucpositive + Falseposi 100 ‘True positives (in question False negatives (in question) = 10 ~ Sensitivity = 100 =! sitivity = Fp *100= 80 Answer is A (Apolipoproteins): Park 23/369 Apolipoprotrein-B (the major LDL protein) is most strongly associated with the risk of coronary heart disease. Lipoproteins and risk of coronary heart disease ‘Conventional lipoprotein measurements ‘Apolipoprotein measurements = LDL cholesterol Is most directly associated with CHD ~Park ‘polipoproteinA-t (the major HDL prot + VLDL cholesterol Is more strongly a disease than with CHD + HDL cholesterol Recent evidence indicates level of plasma and Apolipoprotein-B (the major LDL protein) are better ited with peripheral vascular ‘predictors of CHD than HDL cholesterol or LDL. ‘cholesterol respectively. Therefore measurement of Apolipoproteins may replace lipoprotein cholesterol Is protective against development of CHD. The higher determination in assessing the risk of CHD” — Park the HDL levels, the lower isthe incidence of CHD Answer is A (School teachers): Park 23/439 “Children are first screened by trained teachers” ~ Park 18/341 Children having problems with their eye sight present with difficulty learning at school. They are first screened by trained school teachers. Those suspected to have refractive errors are seen by ophthalmic assistants. Answer is D (Visual acuity < 3/60 in the better eye with best correction): Park 23/401; Parson's 19/583 “WHO defined blindness as a visual acuity of less than 3/60 or inaibilty to count fingers in day light at a distance of 3 meters” ~ Park 18"/319 WHO criteria for definition of blindness isa visual acuity of less than 3/60 in the better eye with best possible refractive corrections. - Parsons 19"/583 1 (Visual impairment) 2 (Severe visual impairment) 3 4 5, 9 616 10 6/8 Normal <6/18 to 6/ 60 Low Vision (Category 1&2). = < 6/60 to 3/60 _ < 3/60 to 1/60 < 1/60 Blindness (category 3, 4 &5) ‘No light perception ‘Unqualified visual loss Answer is B (1.49 %): Parson's 23/402; Khurana 3/583 “The prevalence of blindness Prevalance of blindness jia_is as follows: - Khurana 3°%/42. 1.00% 0.7% India is 1.49% (WHO ~ NPCB 1986-89)” — Khurana 3/500 WHO — NPCB 1986-89 WHO Bulletin vol. 73, 1995 Bie | WHO Regional Health Report, 1996112. 113. Answer is A (Cataract + References mentioned with explanation Uncorrected Refractive errors are the most common cause for ocular morbidity followed by Cataract. The existing definitions are however based on best-corrected visual acuity, which exclude uncorrected refractive error as a cause of visual impairment or ocular morbidity. Cataract therefore is the single best answer of choice. ww n for Low Vision lar Mor! tevision of visual impairment definitions in the International Statistical Classification of Diseases ; BMC Medicine 2006, 4:7 A WHO consultation has suggested : "A person with low vision as one who has impairment of visual functioning even afier ireatment of refractive errors, and has a visual acuity of less than 6/18 10 light perception. This definition of low vision’ thus identifies persons who have poor vision despite correction of refractive errors” Implication: + The definition misses visual impairment caused by uncorrected reftactive error ‘+ Substantial underestimation of the total visual impairment burden ‘Most common causes of Low Vision in India (Journal articles) 1, Uncorrected refractive errors ( most common) 2, Cataract (2 most common cause ) Note that by definition Low Vision due to Uncorrected Refractive Errors is not classified technically as ‘Low vision’ ‘and hence Cataract is the single best answer of choice here. Answer is B (5.2 % of GDP ): References mentioned with text According to World Health Report 2000 India’s total expenditure on health as % of GDP was 5.2 ~ World Health Report 2000 ¢http:/'www.who.int'whr/2000/en/whr00_en,pdf) Selected national health accounts indicators: WHO Statistics for India ‘Measured levels of expenditure on health, 1997-2001 (http://www.who.int whr/2004/annex/country/ind/en/index.html) ‘World Health Report Statistics 1997 1998 ——~«1999~—~=2000~—~—«2001 Total expenditure on health as % of GDP__ 5.3 3 $2 5 5. NOTE :World Health Report 2000, gave satsties for the year 1999 India's health expenditure is 5.2% of ts GDP, while public and private health expenditure is 13% and 87%, respectively, according to World Health Report 2000.- The Economic Times (http://economictimes.indiatimes.com/corppiramalshow/968767.cms) Answer is C (7.8): References as mentioned with text “GDP growth for the previous financial year 2003-04 was at 8.5 per cent’, - The Central Statistical Organisation Statistics (http://www.domain-b com/economy/general/2006/20060202_growth.html) “The cumulative average growth for April-December 2003, thus, works out to 8.2 percent’- The Washington Times (hitp://washingtontimes.com/upi-breaking/20040401-114255-5049r. htm) Statsitcs are usually available in terms of financial years i April to March, The question is deceptive as it does not mention whether statistics are desired for the financial year 2003 ~ 04 or for the year 2003 in isolation . GDP growth for the financial year 2003-04 according to ‘The Central Statistical Organisation Statistics’ has been clearly mentioned as 8.5 percent. Also the GDP growth for the last three quarters of 2003 has been mentioned as 8.2 percent .The GDP growth in the first quarter of 2003 was a bit less than the growth average however exact figures are not available, 7.8 percent matches the figures closest and is the single best answer of exclusion.16. us. 116. ‘Answer is A (1994): Organ Retrieval in Medicolegal Cases ;Journal of the Academy of Hospital Administration Vol 16, No. 2; hup://vww.indialawinfo.com/bareacts/ransplant. hum! “ To prevent commercialization or fraudulent activities in relation to organ transplantation, the Government of India ‘passed the Transplantation of Human Organs Act on 8th July, 194 -Organ Retrieval in Medicolegal Cases wreacts/transplant.ht ://www.indialawinfo. ‘THE TRANSPLANTATION OF HUMAN ORGANS ACT, 1994 [Act No. 42 of 1994 dated 8th July, 1994] This Act may be called the Transplantation of Human Organs Act, 1994. Answer is C (300 K cals): Repeat: Park 23/633 “The energy requirements of women are increased 300 K cal daily throughout pregnancy’ ~Park Energy Allowance for Vulnerable groups Pregnancy Lacatation +300 K cal daily First 6 months? 6-12 months ® throughout pregnancy +350 K cal daily for +400 K cal daily first 6 months during next 6 months. Answer is A (Rs. 1 per day poor and individual to Rs. 2 per day for a family of seven): Ina:/iwww sebahospital orgh-homl The premium of the ‘Community Based Universal Health Insurance Scheme? ranges from Rs.1 per day for an individual to Rs.2 par day for a family of seven. Premium: Fiicnindaeneea iniversal Health Insurance Scheme + Sponsored by Govt of India for economically weaker sections of people + This is an ideal health scheme for panchayats, NGOs engaged in rural development, various unorganised sectors, groups of self employed persons, traders, craftsman, artisans etc + The policy provides medical reimbursement, personal accident cover, and disability cover. + Benefits Medical Reimbursements The policy provides reimbursement of hospitalisation expenses up to Rs.30000/- to an individual/family subject to the following sublimts 1. Stay: Bed including boarding expenses- up to Rs. 150/- per day; in case of ICU Rs.300/- per day 2. Fees of surgeon, anesthetist, consultant, specialist, nursing etc. up to Rs.4500/- per illness/injury 3. Anesthesia, blood, oxygen, operation theatre, x-ray, all laboratory test, dialysis, radiotherapy, chemotherapy, ‘mediciges, pacemaker , artificial limb - up to Rs.4,500/- per illnessinjury 4, Total expenses incurred for any one illness up to Rs. 15000/- I Accident Cover: Rs, 25000/- for earning Head of the family in case of death due to accident. Cover : Rs. 50/- per day of hospitalisation for earning Head of the family up to 15 days but excluding first 3 days in hospital. + Age limit: 3 months t0 65 years + Family: Head, spouse, dependant children up to three and dependant parents, ‘+ Floater facility: The benefit of family will operate on floater basis. Total amount of Rs.30000/- may be spent on individual or collectively by members of the family. + Premium Subsidy For BPL Families: Govt will pay Rs. 100/- for each family towards premium for families living Below Poverty Line Rs.365/- per year Rs.548/- per year Rs.730/- per year/AIPGME EXAMINATION ANSWERS AND EXPLANATIONS- 2006 * 601 MEDICINE - 117. 118. 119, Answer is A (Inadequate dietary intake): Harrison 199/646 Folic acid deficiency most commonly results from either decreased dietary intake or increased metabolic demand. Amongst the options provided decreased dietary intake is the single best answer. ‘Megaloblastic anemia Cobalamine deficiency Folate deficiency ‘Most common cause is Malabsorption Most common cause is either decreased dietary intake “The dietary intake of cobalamine is more than adequate _-9t increased metabolic demand. for body's requirement except in complete vegetarians The dietary intake of folic acid is marginal in many ‘and their breast fed infants. Thus deficiency of arts of the world. Furthermore because the body's cobalamine is almost always due to malabsorption’ ~ stores of folate are low, folic acid deficiency can Harrison 16/603 arise rather suddenly during periods of decreased dietary intake or increased metabolic demand’ ~ Harrison 16"/603 Answer is D (> 50 years) : Harrison 19"V671; API 7/958 Idiopathic MDS is a disease of the elderly. The mean age of onset is 68 years. Myelodysplastic Syndromes (Disease of the elderly with mean onset > 68 years) Heterogenous group of haematological disorder >, TD Characterized by Classified as ~ Peripheral blood eytopenias The French American British Group has classified this - Trilineage dysplastic changes disorder into 5 pathological entities ~ Hypercellular bone marrow ~ Refractory Anemia = Propensity to undergo transformation into ~ Refractory Anemia with ring siderablasts Acute Myeloid Leukaemia®. ~ Refractory Anemia with Excess blasts ~ Refractory Anemia with Excess blasts in transformation = Chronic Myelomonocytic Leukaemia Answer is C (Multiple Myeloma): Harrison 18%/938-940; 17"/ 703, 704 Backache and Recurrent infections in the backdrop of normal alkaline phosphatase levels and a reversed albumin ‘slobulin ratio (A : G ratio) is highly suggestive of the diagnosis of multiple myeloma, Interpretation of information provided in the question Clinical information Laboratory parameters ~ Backache = Bony pains ‘+ Haemoglobin 12- 16gm 73 ‘Anemia + Weakness of + Cord + Serum Ca"* 9.0-10.Smgidl 12.6 Hypercalcemia Jegs & urinary compression + Alkaline phosphatase 30-120U/L 100 Normal retention «+ Ineffective + Albumin 35-55 emidl 30 Normal ‘© Chest infection defence against. Globulin 20-35 em/dl 7.1 Elevated (recurrent) imiection © Urea 20-40 mgidl 178 Elevated All findings are consistent with the diagnosis of multiple myeloma.120. ‘Malignant proliferation of plasma cells im the bone marrow resulls in production of large numberof complete and incomplete ‘immunoglobulins ‘Suporession of nonmal hematopoitic cll in marrow Proliferation of plasma cells in bone and activation of = Anemia (normocyticnormochromic) ‘stencass activation factor + Eye lesions Bone pain Pathological fractures Cord compression = Hypercalcemia ~ Metastatic caleiication (not dystrophic) = Osteoporosis Increased number of abnormal immunoglobulins Precipitation in kidney Inefetive defence Interference with clotting Hyperviscosity (idney damage) against infections? factors t Bence Jones. + Amyloid damage of Neurological? Manifestations Light chain Recurrent Infections® endothelium = Vertigo, Tinnitus Proteinuria + + Headache? Renal faiture® Bleeding tendency® —— Yagual disturbance Ampioidosis may oceur®) Answer is A (Lytic bone lesions ): Wintrobe’s Haematology ; The Changing Treatment Paradigm in Patients With Newly Diagnosed Multiple Myeloma ONCOLOGY ~ VOL 32, NO 6, 2005 Multiple Myeloma is now widely defined in accordance with the Durie and Salmon diagnostic criteria The diagnostic criteria are divided into major and minor criteria. Lytic bone lesions constitute minor criteria in accordance with the classification system. All other options are part of the major criteria that define multiple myeloma. Diagnosis and Staging of Multiple Myeloma (The Durie and Salmon myeloma diagnostic eriteria) +The Durie and Salmon myeloma diagnostic criteria are used widely in the United States and have been validated by large multicenter trials, + The diagnostic criteria are divided into major and minor. The diagnosis of Multiple Myeloma requires a minimum of one major and one minor criterion or three minor criteria as defined in the table below + Once the diagnostic criteria for multiple myeloma are met, Durie-Salmon clinical staging can be used to determine the stage of disease. /- Plasmacytoma on tissue biopsy. 1 2 Bone marrow plasmacytsis wi rsa ells - - 3. Manoclonal stobulin spe protein) on SPEP:1eG> 3. ating dow) 35 gil [gA > 20 wal light-chain excretion on UPEP > | fobin value > 24 her ine absence of amoidsis Name oye me mi is wit 30% plasma cells ww M protein production 5. Monoclonal globulin spike present, but lower Teves than ue defined in tne major enteia, eavalue 23 gal Lyte bone lesions Utne kappa ot lmba <4 g24ar 4 Nomal teM> SOmd, eA > 00mg orlgG> 600 ge 0612 mg/dl Overall data fits in stage I nor stage II (intermediate burden) ‘The diagnosis of myeloma requires a minimum of one major Sige I ee ar and minor erterion although Ia isnot suficien) ortnee, et Nor ofthe following Gigh ni) minor ritria hat must include ab Hemoglobin value 8.3 gil dolent Myeloma Serum cium value > l2mg/l 2s for myeloma with the elowing imitation: More tan ite bore sion 2 Absent or onl limited bone lesions (<3 tic lesion), 0 High M pote pradction compression facurs IgGvale> 7 pl Sable paraproein evel TgG level <700 mg/d. wA<500 je vane> gS mull Utne kappa or lamba No yimptoms or associated disease features: Karofsky Mcomponce! > 12924 br performance satus > 70%, hemoglobin > 0g normal Substentfction Serum calcium, normal serum creatine, o infections. Avereinine value <2.0 mg/l 4. Plasma cell labeling index 305% B-reatinin value 22.0 mg Ig immunoglobulin; SPEP-serum protein clctrophoresis; UPEP- urine protein electrophoresis121. 122, < Saar ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2006. Answer is D (Having a shorter survival): hu //cll acor.org/cllfag/answers/S7 him ; hutp://www.thedoctorsdoctor.com/diseases/leukemia_prolymphocytic.htm; Harrison 16/652 PLL tends to be more aggressive than CLL and is less responsive to therapy. These patients have an aggressive clinical course with an overall poor prognosis and a shorter survival Prolymphocytic leukemia (PLL) Prolymphocytic leukemia (PLL) is a rare variant of B Cell leukemia usually seen in elderly men Iisa related but distinet B-cell disorder and is one of the B-cell malignancies most often confused with CLL. e CLL, + The abnormal Iymphocytes seen in PLL are immature cells (prolymphocytes) which are not normally seen in the peripheral blood. + A patient with PLL will typically have a very large spleen and a very high white blood count but minimal lymphadenopathy. Most patients do not have enlarged Iymph nodes, but may have non-specific symptoms like tiredness and weight loss + PLL tends to be more aggressive shan CLL and is less responsive to therapy. Approximately 10 percent of patients who have chronic lymphocytic leukemia will have their illness transform and take on the appearance of prolymphocytic leukemia. Answer is C (The proliferating cells are NK cells): Harrison 16/1122; ‘Primary Effusion Lymphoma’, Pathology Case Reviews. 11(2):78-84, March/April 2006.; Primary Effusion Lymphoma: www.diseasesdatabase.com Source NCI Thesaurus, 2004_11_17; ‘Lymphoma with effusion in an HIV patient’,Journal of Community Oncology (www.communityoncology.net/journaVarticles/0205429 pap. Also (wwsw.e-immunohistochemistry.info/webjuly05/Primary effusion lymphoma. htm) Primary effusion lymphoma (PEL) is classified as an aggressive B cell lymphoma. The proliferating cells are B cells and not NK cells. Primary Effusion Lymphomas (PEL) — Various Journals texts hat are Primary Effusion Lymphomas re z am eae ae Se ‘These are rare aggressive lymphomas (of Large B cells) that tend to present as serous effusion without detectable tumor masses. (Epidemiology ‘+ Universally asociated with Human Herpes virus 8 (WHY 8Kaposi sarcoma Herpes Virus (KSHV) [HHV-8/KSHV]) + Mostly occur in association with Immunodeficieney = Mast eases have been reported in HIV positive patients. (AIDS related PEL Eesti ae iSeeoeeNTIEIE| «Primarily seen in patients with Tow CD4 count < 100/nL) + More common in older people Homosexuality is a postive risk factor = Has been described in HIV negative patients who are immunosuppressed or elderly. (Pathology Considered a subtype of Large B cell lymphomas (Non Hodgkins B cell lymphoma) (Although often negative for B cell antigens, the presence of immunoglobulin gene rearrangements is evidence that they are Iymphomes of B cell derivation) (Tumor eels donot express surface markers for B cells or T cells - Harrison) ‘WPyesentation/Ctinical features + Present as serous effusions of body eavites without detectable tumor masses. ~ Usually only one body cavity (pleural, pericardial or peritoneal, rarely subarachnoid) is involved ~ Usually there is no Lymphadenopathy nor organomegaly. (However some patents may secondarily develop tumor masses) + May be associated with ~ Kaposi sarcoma = Multcentric eastleman disease [Prognosis These are aggressive tumors with poor prognosis ‘+The median survival is less than six months123. 124, {ATION ANSWERS AND EXPLANATIONS - 2006 Regarding Body cavity lymphomas (synonymous to Primary Effusion Lymphomas) ~ Harrison 16%V1122 “Immunoblastic lymphomas account for ~60% of the cases of lymphoma in patients with AIDS. These are generally high grade and would have been classified as diffuse histocytic Iymphomas in earlier classification schemes. This tumor is more common in older patients increasing in incidence from 0% in HIV-infected individuals < I year old to <3% in those > 50. One variant of immunoblastc lymphoma is body cavity lymphoma. This malignancy presents with Iymphomatous pleural, pericardial, and /or peritoneal effusions in the absence of discrete nodal or extranodal ‘masses. The tumor cells do not express surface markers for B cells or T cells. HHV-8 DNA sequence have been Sound in the genome of the malignant cells.” Answer is D (Neutropenic Colitis) : Harrisons 16"/492 Acute Right sided lower quadrant pain following chemotherapy in an immunocompromised host in characteristic of Neutropenic colitis, ‘Typhilitis : Syn : Neutropeni itis, Necrotizing entero This syndrome is classically seen in neutropenic patients after chemotherapy with cytotoxic drugs More common in children than adults, More common in patients with AML/ALL than among those with other types of cancer. - Fever ~ Right lower quadrant pain and tenderness (Most characteristic) = Associated bloody diarthea (+) = Immunocompromised blood picture Answer is A (Hypokalemiia): Harrison's 198/138e-5: Transfusion Practices by American Collegeof Anaesthetics 3°20, 21 Massive transfusions are associated with risk of hyperkalemia and not hypokalemia. Massive transfusions: Defined as acute replacement of more than one blood volume within several hours. Major Complications of Massive transfusions ‘Coagulopathy Metabolic General Electrolyie e e + Hyperkalemia’ ‘* Fluid over load" ‘+ Hypothermia? + Hypocalcemia® ‘+ Impaired oxygen capacity of ‘+ Hypomagnesemia® haemoglobin? (¥ 2, 3 DPG) + Alkalosis/Acidosis® Hspothermia: ‘Refrigerated (4°C) or frozen (-18°C) blood components can result in hypothermia when rapidly infused’ - Harrison ycalcemia & Hypomagnesemia: Transfusion Practices by American College of Anaesthetics 3%/20, 21 The potential metabolic problems resulting from blood transfusion are hyperkalemia, hypocalcemia and hypomagnesemia’ ~ Transfusion Practice - American society of Anesthesiologists 3"/20, 21 © Hyperkalemia: Potassium increases in the plasma of stored blood as potassium leaves viable erythrocytes. However, hyperkalemia is rarely a problem in adults for two reasons: (© there is very litle plasma in Red Blood Cells and ‘© the potassium that is present leaves the intravascular space of the recipient and rapidly moves intracellularly. ‘Neonates and patients in renal failure are at increased risk of hypokalemia, in anticoagulant preservative sol + Hypomagnesemia: Citrate also has an affinity for the magnesium ion and the occurrence of hypomagnesemia in the setting of massive transfusion has been reported, ‘ons chelates calcium and causes hypocalcemia+ Alkalosis/Acidosis Stored blood is acidic (pH of 6.6 to 6.9) due to citric acid in the antocoagulant and the accumulation of carbondioxide and lactic acid from erythrocyte metabolism, Banked / stored blood is acide because of accumulated red cell metabolites, However the actual acid load tothe patient is ‘minimal, The acid load on massive blood transfusion is quickly countered by the effect of citrate infusion as citrate is normally metabolized to sodium bicarbonate. 11 is therefore more common for massively transfused patients to exhibit ‘metabolic alkalosis rather than metabolic acidosis. Patients with massive transfusion may present with initial metabolic acidosis, however metabolic alkalosis is more frequent once citrate is metabolized in liver to bicarbonate. + Citrate Toxicity: Citrate toxicity occurs when ionized calcium is significantly reduced by citrate present in anticoagulant preservative solutions and thereby inhibits the coagulant cascade. 125. Answer is C (Decreased fibrinogen levels): Harrison 16/1430, 1432; 17°/ 1505 Increased levels of fibrinogen are associated with increased risk of atherosclerosis (and not decreased fibrinogen levels). Fibrinogen Levels “Fibrinogen levels correlate with coronary risk and provide information regarding coronary risk independent of lipoprotein profile. Elevated fibrinogen levels might promote a thrombotic diathesis’. - Harrison 16%/1432 © WAIST HIP RATIO : This refers to a characteristic ‘male’ distribution of adipose tissue ie. excess of fat in the abdomen compared with that in hips. “An elevated waist/hip ratio has been associated with symptomatic cardiovascular disease and cerebrovascular disease in both men and women, - Pubmed (NCBI - website) + Hypethomocysteinemia and low HDL levels are known risk factors for Atherosclerosis (as depicted in the following, ‘+ Hypertension (BP > 140/90mm/kg) or (on Antihypertensive medication) ‘+ Low HDL cholesterol «© Diabetes mellitus «Family history of CHD ‘© Age (Men > 45 years; Women > 55 years) « Life style risk fctors Obeity (BMI> 30 kg/m) Physical inatvity Atherogeni diet Emerging risk factors + Lipoprotein (a) + Homocystine ‘+ Prothrombotic factors (Fibrinogen) ‘Pro inflammatory factors ‘Impaired fasting glucose « Subclinical atherogenesis 126. Answer is C (Prolonged QT interval): Harrison 16/1318; 17°/ 1395 Prolonged QT interval is not a manifestation of hyperkalemia. Prolonged PR interval, prolonged ORS duration and ventricular asystole are all known manifestations of hyperkalemia, Abnormal ip QT interval Prolonged Shortened + Hypercalcemia ~ Digitalis therapy + Vaga stimulation Conditions of the heart? insult thermia Elect, Acute Rheumatic carditis Cerebrovascular Hypocalcemiat Myocarditis accident Acute myocarditis infarction127. 128, Hpokalemia Hyperkalemia + ST depression’ Early + Increased T wave amplitude Peaked T waves + Flattened or inverted T wave® Later (with severe + Prolonged PR interval + Prominent U wave? degrees of + Prolonged QRS duration ‘+ Prolonged P-R interval? Hyperkalemia) + AV conduction delay + Rarely $-A block + Loss of P waves + Sine wave pattern + Ventricular fibrillation or asystole Answer is A (Kussmaul’s sign): Harrison 16/1416; 17"/ 1490, 1491; Repeat Pulsus paradoxus clinically, electrical alternans on ECG and RVDC on Echocardiography are chracteristic features of Cardiac tamponade. Palas Paradoxes Common Usually absent Rare Jugular viens ct nae a = Prominent x descent Present Usually present Present Rare Kussmaul's sign Absent (Rare)? Present Absent Absent ‘Third hart sound Absent ‘Absent Rare May be present Pericardial knock ‘Absent (Often present Absent Absent (| Blectrocardiogram | Low ECG voltage Maybe present Maybe present May be present Absent | Blectrcalalternans May be present Absent Absent Absent Electrocardiography ‘Thickened pericardium ‘Absent Present Absent Absent Pericardium caleification ‘Absent ‘Often present Absent Absent Pericardial effusion Present ‘Absent ‘Absent “Absent RV size Usually small Usually normal Usually normal Enlarged Myocardial thickness ‘Normal ‘Normal Usually ‘Normal Right atrial collapse and RVDC Present Absent increased Absent Increased early filling, * mitral flow velocity Absent Present Absent “May be present Exaggerated respiratory variation inflow Present Absent Present Absent velocity Present vere q ‘Thickened/calific pericardium Absent Present [Absent Absent Cardiac catheterization Equalization of diastole procedures Usually present Usually present Usually absent __Absent or present (Cardiac biopsy helpful? No No Sometime No a Answer is B (Majority of the case present with features of mitral regurgitation): Harrison 16/1395, 2330; CMDT 2006/330, 331 “Majority of patients with MVP are asymptomatic but may present with non specific chest pain, dyspnea, fatigue or palpitation. MVP has distinct auscultatory presentation in the form of mid or late non ejection systolic click. Mitral ‘regurgitation is seen only as a complication of MVP resulting from rupture of chordae tendinae or failure of papillary ‘muscles. Thus although features of mitral regurgitation may be associated in cases of MVP, these are definitely not the presenting features in the majority.” + Valve leaflets show myxomatous degeneration “In most patients with MVP, however myxomatous degeneration is confined to the mitral or less commonly the tricuspid or aortic valves without other clinical or pathologic manifestations of disease’ — Harrison 16%/1395 + Autosomal dominant inheritance There is an increased familial in tosomal dominant form of inheritance Harrison 16%/1385 diovascular abnorm the major source of morbidity and mortality (inpatients with Marfan’s syndrome). Mitral valve prolapse develops early in life and in one quarter of patients progresses to mitral valve regurgitation of increasing severity’ ~ Harrison 16%2330129, ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2006 » 607 | Mitral Valve Prolapse Review: ‘Also known as ‘Barlow's syndrome’? or ‘Billowing mitral valve' ® or ‘Floppy valve syndrome" Tis most common in females ® Inheritance in familial cases is autosomal dominant ®. Patent are = usually asymptomatic = may present with non specific chest pain, dyspnea, fatigue and palpitations. 2 © Auscultatory findings are Caaaicpe ‘and most important ~ Characteristic mid systolic ® or late systolic non ejection © clicks ® which may be multiple ® = Late systolic ejection murmus (Often but not akways) ~ Accentuation of findings by Valsalva ‘and standing. ® = Diminished by squating and isomeric exercises © Diagnosis = Investigation of choice is echocardiography. © © ECG in most cates is normal ‘+ Complications : ~ MRE. ~ Sudden death ® Infecive endocarditis ® = Arrythmias ® = Transient ischemic attack ® Answer is D (Ventricular septal defect): Harrison 16/1619; Other reference Amongest the options provided ventricular septal defect is the least likely diagnosis to result in sudden cardiac death, + Hypertrophic and Dilated Cardiomyopathy: The cardiomyopathies (Hypertrophic and Dilated) are the second most common category of diseases associated with risk of "Sudden cardiac death’.-Harrison 16/1620 + Eisenmenger’s Syndrome “Most patients with the Eisenmenger’s syndrome die of ‘sudden cardiac death’, probably from a ventricular arrythmia.” The Eisenmenger Syndrome in Adults":http"//www.annals. org/cig/content/full/128/9/745 May 1998/Volume 128 Issue 9/Pages 745-755 ‘+ Ventricular septal defect : ‘The occurance of sudden cardiac death in cases of isolated ventricular septal defect has not been emphasized in literature. Sudden death may probably be seen in early childhood but only isolated case reports have been documented. VSD therefore is the least likely diagnosis and hence the answer of exclusion.J Paediatr Child Health. 1994 Oct: 30(5):439-40 | rE (i Structural Causes Functional Contributing Factors re Coronary heart disease 1, Alterations of coronary blood flow ‘Coronary ser shoal ‘A. Transient ischemia Chronic atherosclerotic lesions B. Reperfusion after ischemia 2 Aout active) leon (gue sung plat Lov eae ouput sass, ‘aggregation, acute thrombosis) A. Hear failure 3. Anomalous coronary artery anatomy 1. Chronic B. Myocardial infarction 2, Acute decompensation 1. Healed B. Shock 2. Acute UL. Systemic metabolic abnormalities ‘Myocardial hypertrophy ‘A. Electrolyte imbalance (e., hypokalemia) ‘A. Secondary B. Hypoxemia, acidosis| B. Hypertrophic cardiomyopathy IV. Neurophysiologic disturbances 1. Obstructive ‘A. Autonomic fluctuations: central, neural, humoral 2. Nonobstructive B. Receptor function UL Dilated cardiomyopathy ~ primary muscle disease V. Toxic responses IV. Inflammatory and infiltrative disorders A. Proarthythmic durg effects ‘A. Myocarditis B. Cardiac toxins (c.g. cocaine, digitalis intoxication) B. Noninfectious inflammatory diseases C. Drug interactions . Infiltrative diseases D. Right ventricular dysplasia V. Valvular heart disease VL. Electrophysiologi abnormalities, structural ‘A. Anomalous pathways in Wolff-Parkinson-White syndrome B. Conducting system disease ‘VIL. Inherited disorders of molecular structure associated with electrophysiologic abnormalities (eg, congenital log QT syndromes, Brugada syndrome)* AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 RS Comino AEE FEB ES! RSS aa Alterations of coronary blood flow UL — ‘metabolic abnormalities ‘A. Transient ischemia A Electrolyte imbalance (eg. bypokalemia) B. Reperfusion after ischemia B. Hypoxemia, acidosis TL. Low cardiac output states IV. Neurophysiologie disturbances A. Heart failure ‘A. Autonomic fluctuations: central, neural, humoral 1. Chronic B. Receptor function 2, Acute decomposition V. Toxic responses B. Shock A. Proarthythmie drug effects B. Cardiac toxins (c.g cocaine, digitalis intoxication) . Drug interactions 130. Answer is C (Salmonella Typhi): Harrison 164/732, 820, 830, 891, 899; Ananthnarayanan 74/192, 200, 204, 212, ‘hutp:/www.ncbi.nlm.nih.gov/entrez/query fegi?cmd=Retrieve&db=PubMed&list_uids=1998650&dopt=Abstract Endocarditis has only been mentioned as rare complication of salmonella typhi infection. — Harrison 164/899 The least likely organism to infective endocarditis amongst the options provided is salmonella typhi. Other options ‘Staphylococcus albus ‘Streptococcus fecalis Pseudomonas Aeroginosa (Staph. epidermis) (Enterococe) Gram negative bail (Coagulase Negative staph.) ~ S. epidermis (albus isthe most Common» Streptococci fecal the most ~ Common agent in endocarditis, coagulase negative staphylocasi common cause of enterococcal ‘among infection drug users + Coagulase negative staph (. infective endocarditis ‘+ P.aeruginosa infects the native heat epidermidis/alba) are the most common» These organism account for 10-20% valves of intravenous drug users 28, cause of ‘Prosthetic valve endocarditis’ of cases of bacterial endocarditis well as prosthetic heart valves 131. Answer is D ( Both intravascul infeetion ) = ‘www. neurosurgery.nu.ac.za/seminarweekKIRAT4.him ; http://www.vghipe gov tw/~jema/68/6/265.pdf A mycotic aneurysm is an infected aneurysm resulting from either an extravascular or an intravascular source of infection Karsner classified three forms of "mycotic" aneurysms on the basis of origin of infection : + Intravascular origin + Extravascular origin + Primary or Cryptogenic origin “The frst and most common arises as a result of embolization from bacterial endocarditis and ths is of intravascular ‘origin The second form occurs by extension from a neighbouring form of infection. This extravascular origin of infectious aneurysms may arise from meningitis, carvenous sinus thrombophlebitis, adjacent osteomyelitis of the skull, a sinus infection, or a post - operative infection. The third form of infectious aneurysm is the so-called "primary or cryptogenic aneurysm’” - www.neurosurgery nu.ac za/seminarweekKIRAT4 htm Ten-Year Experience with Surgical Repair of Mycotic Aortic Aneurysms’ : J Chin Med Assoc June 2005 ;Vol 68;No 6 The pathophysiology of mycotic aneurysm can be described in 1 of 3 ways. + Firstly, bacteremia exists, and septic emboli subsequently infect the arterial wall and cause aneurysm formation. + Secondly, in patients with predisposing factors such as hypertension, hyperlipidemia, and diabetes, an aortic aneurysm forms initially, and subsequently, systemic pathogens may lodge in the existing aortic aneurysm. Thirdly, a mycotic aneurysm may result from an extravascular source or adjacent tissue. Before the introduction of Antibiotics in the 1930s (sulfonamides) and their widespread use from the 1940s onwards (penicillin, streptomycin, etc), mycotic aneurysms of intravascular origin (infection from “within” were generally limited to patients with infective endocarditis. 132. Answer is B ( Fungal infection ): Tabers Dictionary ; Reference mentioned with text Mycotic abscess by definition is an abscess caused by fungal infection. “‘Mycotic abscesses,are characterized by a sof, cystic mass without or with a very slight sign of inflammation Both hyaline and demataceous fungi, as well as higher bacteria (Nocardia species), could be the causative organisms. Mycotic abscess has seldom been reported in the literature’. -Deep fungal and higher bacterial skin infections in Thailand: Clinical manifestations and treatment regimens, International Journal of Dermatology Volume 38 Page 279 - April 1999133. Answer is A (Interstitial lung disease): Harrison 16%/1500, 1556; 17"/1 587-1589, 1643; CMDT 06/223 134, 135, ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2006 ‘Presence of long standing scleroderma together with a ‘restrictive pattern’ on pulmonary function tests suggests a diagnosis of interstitial lung disease. interstitial lung diseases produce a restrictive defect. FEV, and FVC are reduced, but the FEV /FVC ratio is usually normal or increased. Note that FEV expressed as a percentage is actually FEV, JFVC. Scleroderma or systemic sclerosis is a known cause for interstitial lung disease. eT ee ‘The Forced Vital Capacity (FVC) represents the total volume of gas exhaled with maximum expiration following maximal inspiration. A reduced FVC suggests pulmonary restriction. (REV,% or FEVFVC | Note that FEV, exprssed as a percentage is actually FEV /FVC. ‘The volume of gas exhaled during the first second while expiration from FVC is FEV,. FEV, is often represented as a ratio of the FV (often referred to as FEV1% rather than FEV /FVC)-CMDT 06, p 223 Normal o increased FEV1% (FEVI/FVO) suggest restrictive lung disease Decreased FEV1% (FEV/FVO) suggests obstructive lung disease. §DLCO : (Diffusion capacity for carbon monoxide) ‘This reflects the ability of lungs to transfer gas across the alveolar - capillary interface. Decreased DL.CO is consistent with a diagnosis of : + Interstitial lang disease + Emphysema + Pulmonary hypertension AIPGMEE 2006 - EXPLANATIONS (Parameter Obstructive tung ase Restrictive hang lsease Total lng capacity Normal Tncrease® Decrease? | Residual volume Increase ® Decrease ® Vital capacity Decrease® Decrease? [FEVevc FEV %) Decrease ¢ Normal to Increase ¢ FEF 25-75% + Normal aaaeeE (Horced expiratory Now rate) capacity was ‘Normal (4 in emphysema) ss Decreased a Answer is D (Bronchiolitis obliterans organizing pneumonia): Harrison 16/1495 Bronchialits obliterans organizing pneumonia has not been mentioned in association with smoking. All other ‘options have been mentioned in relation to smoking in Harison’s text. ‘Even though chronic obstructive lung disease and neoplasia are two most important respiratory complications of smoking, other respiratory disorders (spontaneous pneumothorax, respiratory broncholitis- interstitial lung disease, ‘eosinophilic granuloma of the lung and pulmonary haemorrhage with Good pasture’s syndrome) are also associated with smoking.’ — Harrison 16%/1495 Respiratory disease linked to Smoking L ‘Significant associations ‘Lass significant associations ‘+ Chronic obstructive pulmonary disease * Spontaneous pneumothorax = Emphysema « Interstitial lung diseases = Chronic bronchitis = Respiratory bronchi + Lung cancer (Bronchial carcinoma) = DIP (Desquammative interstitial pneumonia) Best documented associations is with squamous cell - PLCH carcinoma, but may aso be present with other histological subtypes (eg. small cell) (87% of lung carcinoma occur in active smokers those who have recenly stopped smoking) Answer is A (Binge eating): Harrisons 16/430; Harrisons 14/463 Although Binge eating may be associated with Anorexia Nervosa, it is described as an ‘Uncommon’ association in Harrisons text (14" edition/463). Being an uncommon feature itis single best answer here. ‘It may be associated in 25-50 percent of patients with Anorexia Nervosa, but does not constitute a diagnostic feature of anorexia nervosa. Binge eating is an invariant (common) feature of Bulimia nervosa and is required as a defining criteria for the diagnosis of bulimia nervosa.610 136. 137. ‘+ AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 Diagnostic feature of Anorexia Nervosa a * Refusal to maintain body weight ator above a minimally normal weight for age and height. (This includes a failure to achieve ‘weight gain expected during a period of growth leading to an abnormally low body weight) + Intense fear of weight gain or becoming fat. + Distortion of body image (cg. feeling fat despite an objectively low weight or minimizing the seriousness of low weight) + Amenorrhea. (This criterion is met if menstrual periods occur only) ia + Ritualized exercise? Usual? Rare “Amenorrhea® 100% 50% aa * Other endocrine changes Common ‘Uncommon (GF Antisocial behaviour Rare Frequent = + Cardiovascular changes® Common? ‘Uncommon (bradycardia, hypotension) ‘changes (hirsutism, Usual Rare a ‘carotenemia) ® Hypothermia Usual Rare + Edema +h le = ‘* Medical complications _Hypokalemia®, cardiac arrhythmias? Hypokalemia®, cardiac arhythmias®, aspiration of fastric contents, esophageal or gastric rupture Answer is C (Upper gastrointestinal bleeding): Schwartz 7/1420, 1421; www.emedicine.com/ RADIOMtopicS70.htm Most common presenting symptom of extrahepatic portal hypertension is acute gastrointestinal bleeding. Acute gastrointestinal bleeding is the single best answer as explained below. + ‘Hemetemesis resulting from bleeding esophageal varices isthe most common presentation in patients with portal hypertension’- emedicine + Ascites isnot a usual accompaniment of extrahepatic portal venous obstruction, but has been noted occasionally.~ Schwartz + Encephalopathy rarely occurs in patients with obstruction of the extrahepatic portal venous system without hepatocellular dysfunction- Schwartz + Chronic liver failure in the setting of portal hypertension suggests cirrhosis as the underlying cause. It is less likely ‘with non-cirrhotic portal hypertension, Note: The most constant finding in patients with portal hypertension is splenomegaly (present in 80% of patients)-cspr 1140. (Splenomegaly has not been provided amongst the options and hence upper gastrointestinal bleeding is the single best answer beyond any doubt) Answer is A (Juvenile Polyps): Sabiston 17/1451 ~ 1454 Juvenile Polyps is the single best answer of choice. Juvenile polyps (sporadic), in general occur singly and being hamartomatous lesions have no malignant Potential. Robbins Juvenile polyps are benign polyps - Sabiston polyps associated with Autosomal dominant hereditary syndromes have now been established to carry a small ‘malignant potential (Rare) + Juvenile Polyps are benign but Juvenil ‘malignant potential. ‘The juvenile polyps in Juvenile polyposis syndrome are usually hamartomas but they may contain adenomatous elements and may progress to adenomas. This syndrome is associated with increased risk of (9 ~ 25%) of colorectal cancer, Mutation in Tumor supressor gene SMAD4 are believed to cause 50 % of Reported cases. + Sporadic Hamartomatous polyps are benign but Hamartomas in association with Peutc Jaghers Syndrome may carry a small malignant potential. Peutz Jaghers Syndrome is associated with increased risk (2-10%) of cancer in the intestinal tract. (Sabiston) ‘The malignant potential of polyps associated with Peutz Jaghers Syndrome is small ~ CSDT. Polyps in association with Juvenile Polyposis syndrome carry small138. 139, 140. Review of Hereditary gastrointestinal polyposis syndromes Hereditary autosomal dominant ® gastrointestinal polyposis syndromes 4 t High Malignant Potential 2 Rare (small) Malignant Potential ° (histologically adenomas ®) (histologically hamartomas ®) ” me Distribution Associated | [Syndrome Distribution 7 Familial colonte Large intestine None Petz SI>LI>Stomach Mucocutaneous puma Polyposis Sagher's pigmentations Gardner's Lage intestioe > Osteomas rane Samatstio, syndrome ‘small intestine _Lipomas ei 2 Fibromas — Z Epidermal cyst Juvenile L1>S1>Stomach Various congenital «= ‘Ampullary Ca polyposis abnormalities 3 Desmoid syndrome zg ‘Turcot's syndrome _Large intestine _Brain Tumours = 6 Answer is A (Anti-histone antibodies): Robbins 7*/229 2: Antihistone antibodies are positive in more than 95 percent of patients with drug induced lupus, and signify a ‘high — & correlation’ Peer EAH 2. Anti histone antibodies: Drug induced lupus erythematosis 3. Anti Sm antibody? (antibody to core? protein of small nuclear SLE ribonucleoprotein particles/smith antigen®) 4. SSa (Ro) } mtnctetegrtz eit | ert 6. Antibodies of ribonucleoprotein antigen’ containing ULRNP_ Mixed connective tissue disease 7. Anti DNA topoisomerase antibody (Se/ 70) Systemic sclerosis (diffuse) 8. Anti centromeric antibody? Limited Scleroderma (crest) $ ices ili 10. Anti mitochondrial antibody Primary biliary cirrhosis Answer is C (CREST syndrome): Harrison 16%/1986; 17"/2100 Anticentromere antibodies are characteristic of CREST syndrome, Anticentromere antibodies are present in 40 - 80% of patients with limited cutaneous scleroderma or crest syndrome. Anticentromere antibodies are found in only about 2% to 5% of patients with diffuse cutaneous scleroderma, and rarely in other connective tissue disease.- Harrison 16/1986. Systemic sclerosis subsets ° ‘Antipoisomerase- [antibody Atioentromere antibody Anti double stranded DNA and anti smith antibodies are specific for SLE. Answer is B (Crohn’s disease): CMDT 6/623; Harrison 16%/1781 ~ 1782 ‘Antibodies to the yeast ‘Saccharomyces cerevisiae’ (ASCA) are found in 60 - 70% of patients with Crohn’s disease and 10 - 15% of patients with ulcerative colitis.’ - CMDT 64/623 ‘Serological markers for inflammatory bowel disease —__ Perinuclear Antineutrophil Cytoplasmic Antibodies “Antisaccharomyces Cerevisiae Antibodies (ANCA) (ASCA) © Positive in 60 - 70% of UC. patients ‘© Positive in 60 - 70% of CD patients (and 5 - 10% of CD patients) (and 10 - 15% of U.C. patients) * pANCA+ve with ASCA-ve = 97% specificity for UC © _pANCA-+ve with ASCA He = 97% specificity for CD612 141, 142, 143, © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 Answer is D (Polyarteritis nodos farrison 16*/1707, 2007, 2009; CMDT 09/810 References alongside explanation Amongst the options provided renal artery stenosis is least likely 10 be seen in association with Polyarteritis nodosa. + Atherosclerosis and Fibromuscular disease = Renal artery stenosis is produced predominantly by atherosclerotic occl or fibromuscular dysplasia (10-15% of patients).- CMDT'06 p 460 ~The common cause of renal artery stenosis in the middle aged and elderly is an atheromatous plaque at origin of renal artery. - Harrison - In younger women stenosis is due to intrinsic structural abnormalities of the arterial wall caused by a heterogenous group of lesions called “fibromuscular dysplasia’, - Harrison 16*/1707 + PAN or Takayasu arteritis ? Harrison, CMDT and none of the other standard texts mention PAN or Takayasu arteritis as a cause for renal artery stenosis. A number of research publications, however show Takayasu arteritis as a cause for renal artery stenosis. Ti “Arteritis PAN | Renal areiis stenosis was seen in upto 47% of patients with Renal artery stenosis in a Case of PAN has only been described ‘Takayasu arteritis in a study on 32 north American patients as an unusual association and published as @ rare case report Reference : Takayasu arteitis:A study of 32 North American (single case) patients’ Medicine (Baltimore). 1985 Mar,64(2):89-99 Reference : “PAN with renal Artery Stenosis”: Indian Pediatrics ‘Volume 41-Jan.17, 2004. disease (80% to 90% of patients) Remember Although renal involvement is seen in upto 60% of patients with PAN its pathology does not involve renal artery stenosis ‘The pathology involves arteritis without glomerulonephritis and is characterised by aneurysms of small and medium sized arteries. Stenosis of main renal artery is an unusual association’. Research paper, ww. Indian paediatric. net\Jan 2004/86 pf = Renal artery stenosis : Renal Artery Atherosclerosis Fibromuscular dysplasia ‘Takayasu arteritis and giant cell arteritis (Takayasu > Giant cell) Antiphospholipid syndrome ‘Transplant renal artery stenosis aveer’ Answer is D (Systemic Lupus Erythematosus): Harrison 16/1962; 17%/2077 SLE is characterised typically by a non-erosive Arthritis (erosions ate rate). All other option mentioned in the question ‘may have an erosive picture. “arthritis in SLE include ‘Non erosive arthritis involving two or more peripheral Joints characterized by tenderness, swelling or effusion Answer is A (Fluorosis): Harrisons 16°/410, 2271 Fluorosis is associated with ‘Osteosclerosis’ and not with osteoporosis. Hypogonodism, Hyperthyrodism and Hyperparathyrodism are all known causes for osteoporosis. Diseases associated with an increased risk of generalized osteoporosis in adults ‘Hypogonadal States = ‘Nutritional and gastrointestinal disorders 000 ‘Tumer syndrome ‘Malnutrition Klinefelter syndrome Parenteral nutrition ‘Anorexia nervosa “Malabsorption syndromes Hypothalmic amenorshea Gastrectomy ‘Other primary or secondary hypogonadal states Severe liver disease, especially biliary cithossis Pemicious anemia144. ‘(Endocrine Disorders Cushing's syndrome Hyperparathyroiism Thyrotoxicosis Insulin-dependent diabetes mellitus. Acromegaly ‘Adrenal insufficiency (GSatected inherited & Rheumatologic disorders ‘Osteogenesis imperfecta” ‘Marfan syndrome? Hemochromatosis ‘Hypophosphatasia® Glycogen storage disease Homocystinuria® Ehlers-Danlos syndrome? Porphyria Menke's syndrome Epidermoiysisbullosa Rheumatoid arthritis? ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006» ‘Hematologic Disorders/Malignancy Multiple disorders/malignaney ‘Lymphoma and leukemia Malignancy-associated parathyroid hormone related ~ (PTHtP) production Mastocytosis Hemophilia ‘Thalassemia Miscellaneous Immobilization? Chronic obstructive pulmonary disease Pregnancy and lactation Scoliosis Multiple sclerosis Sarcoidosis Amyloidosis Alcoholism 613, g g 3 a 2 Glucocorticoids? Cyclosporine Cytototoxic drugs Antoconvulsanis Excessive alcohol Excessive thyrotoxin ‘Aluminium Gonadotropin-releasing hormone agonists? Heparin Lithium Answer is A (Diarrhea): Harrison 16/2252; 17/2380, 286 (Repeat) Hypercalcemia is associated with constipation (and not diarrhea). 8 3 8 8 rm Hypercalcemia from any cause can result in fatigue, depression, mental own fusion, anorexia, nausea, vomiting, constipation, reversible renal tubular defects, increased urination (polyuria) a short QT interval and in some patients cardiac arrhythmias. - Harrison 16%/ 2252 Manin of Hypereteeta T + Tv T 7 Bones Abdomen Cardiac’) Calcification + Polyuria® & — —» Bone pain ‘+ Abdominal» Short QT Ectopic Nocturia + When cause is pain (peptic interval in calcification + Renal colic from hyperparathyroidism ulceration) © ECG & in & stones + Bone cysts ‘+ Constipation some patients _chondrocale '* Mental confusion + Brown tumors cardiac ‘nosis altered sensorium) arrythmias * Polyuria results from effect of hypercalcemia on renal tubules reducing there concentrating ability a form of nephrogenic diabetes insipidus 145. Answer is B (Basal ganglia): Repeat; Harrison 16/2390; 178/2531, 2532 “The putamen (basal ganglia) isthe most common site of hypertensive haemorrhage’ Harrison 16/2390 146. Answer is C (Aneurysm): Repeat, Harrisons 16/2387; 17/2531, 2532 “The most common cause of subarachnoid haemorrhage is rupture of a saccular aneurysm (excluding head trauma)? — Harrison. ‘Previously asked frequently as follows: (Excluding hand trauma) ‘Most common cause of subarachnoid haemorthage is rupture of @ saccular aneurysm? ‘Most common cause of subarachnoid haemorrhage is rupture of a Berry aneurysm? ‘Most common cause of subarachnoid haemorthage is rupture of ‘Circle of Willis’ aneurysm®, (Saccular aneurysms are synonymous with Berry Aneurysms and most commonly occur in the anterior circulation ‘on the Circle of Willis) 147. Answer is A (Phenylpropanolamine): KDT 5/115614 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 ‘Many reports associating PPA use for weight os with haemorrhagic stroke amongst women appeared in USA, , “KDI 5*/115 None of the other agents has been mentioned to be associated with any risk of haemorrhagic stroke. Phenviprop: ine + Chemically and pharmacologically similar to ephedrine + Used in oral cold/decongesant combination remedies ised as an af suppressant? + Many reports associating PPA use for weight loss with haemorhagic stroke appeared in USA. + Accase control study ‘Haemorthagic Stroke Project” was undertaken, Study showed only a marginally increased risk, but also revealed a strong association when 3 day exposure preceding stroke was considered. + The FDA has concluded that indications for which PPA is used do not warrant the excess risk (though marginal) and has recommended discontinuation of PPA containing products. 148. Answer is A (Astrocytomas): Harrisons 16/2453; Repeat “Tumors with astrocytic cytological features are the most common primary intracranial neoplasms’ — Harrison 149, Answer is D (Parietal lobe) : References along side texts Brain abscess resulting from cyanotic heart diseases result from metastatic haematogenous spread of infective foci. These tend to embolice to the distribution of the middle cerebral artery and hence the parietal and frontal lobes are more commonly involved. The parietal and frontal lobes have been mentioned as the most commonly involved regions with brain abscess in eyanotic heart disease in most studies. ‘Our study identified the parietal lobe as the most common region involved in brain abscess, followed by temporal and frontal lobes’.- ‘Cyanotic Heart Disease and Brain Abscess: A 6 ~ year Review’ Salaya et al PJCVo/.31,No.4 October ‘December2003 ‘Frontal lobe was the commonest site of abscess localization (37.5 percent) followed by parietal lobe (32.5 percent)’ Brain abscess in cyanotic congenital heart disease Indian Heart Journal 1989 May-Jun; 41(3): 190-3 ‘Cyanotic Heart Disease and Brain Abscess : Cyanotic congenital heart disease (CCHD) is identified as an important predisposing factor in the development of brain abscess .The intracardiac right to left shunting in these lesions bypasses the pulmonary filtration system allowing ‘microorganism to have a direct access tothe brain causing cerebral abscess. Site of involvement is influenced by the manner of spread and cause of abscess. _——————— {Cardiogenic or Peripheral Septic embolt + Mostly involve temporal and cerebellar areas» Moly supratentorial + Embolize tothe distribution of the mide cerebral artery + Parietal and froma lobes are most commonly involved (temporal lobe may also be frequently involved) 150, Answer is B (Extraocular muscle involvement): Harrisons 16%/2540; 17"/2696 Involvement of extraocular and facial muscles excludes a diagnosis of Polymyositis. — Harrison ‘Iisa subacute inflammatory myopathy and mimics many other myopathies. + Its diagnosis is essentially established as a disgnosisd of exclusion, + Polymyositis should be considered in adults and rarely in children who DO NOT HAVE any of the following : (DONOT HAVE Rash Involvement of extraocular and facial muscles Family history of a neuromuscular disease History of exposure to myotoxic drugs or toxins Endocrinopathy Neurogenic disease Muscular dystrophy Biochemical muscle disorder (deficiency of a muscle enzyme)151. Answer is C (Hypokalemia): References along with text Generalized muscle weakness following barium carbonate ingestion results from hypokalemia due to a large shift of extracellular potassium into muscle REF: Periodic paralysis and the sodium-potassium pump’, Lavzer RB ;Ann Neurol, 11(6):547-52 1982. Barium carbonate (BaCO4) is rat poison. This works by interfering with the sodium-potassium pump and causing a paralysis of the muscles, including the heart muscles and respiratory muscles, causing death. ‘Analysis of the pathophysiology of hypokalemic paralysis, as it occurs in barium poisoning An increased ratio of muscle sodium permeability o potassium permeability reduces the ionic diffusion potential, while the resting membrane potential is sustained by an increase of Na-K pump electrogenesis. The result is that potassium entry (the sum of active and passive influx) exceeds potassium efflux; this causes a large shift of extracellular Potassium into muscle (hypokalemia) until the Na-K pump turns off, leading to depolarization and paralysis. The primary defect in familial hypokalemic periodic paralysis, as in the example of barium poisoning, may be a marked reduction of muscle permeability 10 potassium. Toxie Myopathies:(www.newro.wustl.edw/neuromuscular/mother/myotox.htmttbarium) Barium myopathy : (Hypokalemic Myopathy ) + Toxicology :Soluble salts; Acetate, Carbonate, Chloride, Hydroxide, Nitrate, Sulfide + Weakness : Mechanism: Shift of extracellular K* into muscle + Laboratory :Hypokalemia: Ofien severe, K" as low as 0.8 mEq/L SURGERY 152, 153. 154. Answer is B (Squamous cell carcinoma) : Repeat; CSDT 11""/1252; Bailey & Love 24/208, 968 “When a squamous cell carcinoma occurs in a burn scar it is called a Marjolin’s ulcer” — CSDT 11"/1252 ARTO ee ‘Squamous cell carcinoma developing in long standing scars/uleers [Most frequently associated with © Chronic venous ulcer ® + Long standing burn scar? Marjolin’s ulcer Bailey & Love + Marjolin’s ulcer is an eponym used to describe carcinomatous change occurring at the edge of a chronic venous ulcer. + Such change can in fact occur atthe edge of any long standing benign ulcer, irespective of its cause and should be considered as a possibility. + This type of tumor is usually a squamous cell carcinoma — (Bailey/968) Answer is C (Extremity): Devita 6/2186 Rhabdomyosarcoma of the extremity are generally associated with alveolar histology and a poor prognosis. “RMS arising in the extremities is more likely to be identified in the second decade of life. Almost one half of these extremity primaries contain alveolar elements that are associated with a more aggressive tumor biology'- Devita (Primary tumor sites with better prognosis: Devita 6/2193)" + Orbit + Genitourinary (paratesticular) + Prostate Answer is D (Aneurysmal Bone Cyst) : Various text books and internet sites ABC is an expanding osteolstic lesion consisting of blood-filled spaces of variable size separated by connective tissue ‘septa containing trabeculae of osteoid tissue and osteoclast giant cells. Fine needle aspiration from an ABC only reveals red blood cells and hence is inconclusive. Diagnosis of ABC is suggested by plain radiography ,CT scan or ‘MRI imaging and confirmed on histological examination of biopsy specimen156. 157. Answer is € (Incision and drainage isthe treatment of choice): Bailey & Love 249/771, Schwarte 7/601 The treatment of thyroglossal cyst involves excision of the whole thyroglossal tract. Incision and drainage is no m and drainage may be required if the cyst presents with an abscess as a temporary management. With the resolution of inflammation resection of the whole thyroglossal tract is required as a definitive procedure.) ibipilonsal pits Schwarte 74/601, 602° EN These represent a persistence of the thyroglossal tract and therefore may be found anywhere in or adjacent to the ‘midline from the tongue base to the isthmus. Presentation al + Classically these cyst present as a midline masses in childhood. + They have been reported to be as much as 2cm from the midline and may present for the first time in adults. ~ Schwartz + Most common site is ator just below the hyoid bone (80%) (May be found anywhere along the embryonic line of descent of the thyroid gland from the foramen caecum to the isthmus) + The swelling moves upward (elevated) on swallowing and on protrusion of the tongue because of its anatomical connection. ‘Treatment (SISTRUNK’S Operation) a ‘Treatment must include the excision of the whole thyroglossal tract which involves resection of the cyst together with removal of the central portion of hyoid bone, following the sinus superiorly upto the foramen caecum and excising it in its entirety. Answer is C (Most common in Parotid gland): Bailey & Love 24/730; CSDT 11/294; Schwartz 7"/657 Mixed tumors (pleomorphic adenoma) are most common in the parotid gland. ‘The mast common benign salivary gland tumor is the benign mixed tumor or pleomorphic adenoma which accounts for 70% of parotid tumors and 50% of all salivary gland tumors.’ - CSDT “The parotid gland is the most common site of salivary tumors. Most common is pleomorphic adenoma’ Bailey 24/730 ‘+ Mixed tumor or pleomorphic adenoma is the most common salivary gland tumor and is most common found in the parotid gland + Pleomorphic adenoma (mixed tumors) are benign and slow growing Although mixed tumors are benign - + they recur after surgery unless they completely removed (nucleation is inadequate) + malignant transformation may occur (although uncommon) + Association with calculi has not been mentioned, Remember: 90% of Minor salivary gland tumors are malignant © Gailey) 80% of Major salivary gland tumors (Parotid) are benign ® (Schwartz) Answer is B (Stage of the tumor at the time of diagnosis): Harrison 16"/520; Robbins 7/1146, 1147 The most important prognostic variables are provided by tumor staging- Harrison 16/520 Staging encompasses more than one major prognostic factors and therefore acts as the strongest predictor of prognosis. Prognostic factors for Breast Carcinoma “Major prognostic factors ‘Minor prognostic factors = + Lymph node metastasis or axillary node status ~ Histological factors ‘most important single prognostic factor for invasive ‘+ Tumor grade carcinoma in absence of distant metastasis - Robbins ) + Estrogen and progesterone receptors + Tumor sizeof the carcinoma ‘+ Her 2/neu over expression (poor prognosis) (Second most important prognostic factor) - Robbins + Proliferative rate ('S" phase faction, ete) + Distant metastasis + DNA content « Invasive carcinoma in situ disease ‘Ancuploid tumors have poor prognosis) + Locally advanced disease + Lymphovascular invasion + Inflammatory carcinoma158, 159, 160. Answer is C (Lobular carcinoma) : Robbins 7/1144 Lobular carcinomas are associated with a greater incidence of bilaterality, than other subtypes. A biopsy of the contralateral breast is therefore best considered for lobular carcinomas. Lobular Carinomas : Robbins + Lobular carcinomas have been reported to have a greater incidence of bilaterality ~ Robbins + They may produce a diffuse pattern of invasion and may produce only a vaguely thickened area of the breast ~ Robbins + They may produce only subtle architectural changed on mammography ~ Robbins A biopsy of the contralateral breast may therefore be considered inthis histological variant of Ca Breast. Answer is D (Angiosarcoma): Robbins 7/1151; European Journal of Dermatology. Volume 11, Number 6, 580-3 Other references as detailed with text. Cutaneous angiosarcoma isa rare, highly malignant soft tissue sarcoma that sometimes occurs in the breast as alate sequel of conserving surgery for breast cancer, Etiology and pathogenesis of angiosarcoma are poorly understood but they are more likely in association with chronic lymphedema, after irradiation or after persistent lymphedema promoted by radiation therapy ~ ‘Cutaneous breast angiosarcoma after conserving treatment of breast cancer’~ European Journal of Dermatology. Volume 11, Number 6, 580-3, Novembre - Décembre 2001, Cas cliniques (Scientific paper October 2003 Department of Pathology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma (htp://moon.ouksc.edu/kfung/JTY1/Com/Com3 10-2-Diss.him)) Angiosarcoma of the breast is a rare and highly lethal neoplasm accounting for less than 0.19% of malignant breast tumors Although these tumors may arise de novo in the breast, there is increased incidence in patients who have had radiation therapy and in patients with chronic lymphedema. Stewart-Treves syndrome refers to the sequence of Iymphangiosarcoma occurring as a late complication of severe lymphedema of the arm after excision of the Iymph nodes, usually in radical mastectomy. Thus, in patients treated for breast carcinoma with radiation therapy and ‘mastectomy, which is often complicated by chronic lymphedema, the incidence of angiosarcoma is estimated to be cas high as 0.3% 10 0.4%. Data from the National Cancer Institute show a relative risk of developing angiosarcoma after lumpectomy, axillary node dissection, and radiation to be 15.9.Clearly, the recognition of the development of angiosarcoma in this population of patients is important for both clinicians and pathologists (Robbins TSI “Angiosarcoma of the breast arise spontaneously or as a complication of radiation therapy. There is 0.3% to 0.4% of risk of angiosarcoma after radiation therapy for breast carcinoma, most cases arising 5 to 10 years after treatment. Most of these tumors arise in the skin of the breast.’ Angiosarcoma may also arise in the skin of a chronically edematous arm after mastectomy (Stewart Treves Syndrome) - Robbins Answer is D (Pelvic Abscess) : Several References. Pelvic abscess is the single best answer of exclusion Inflamed Ovaries may present with pain along the inner side of thigh: Obturator neuralgia is frequent in women suffering with ovarian lesions, the pain extending along the inner side of the thigh as low as the knee. —‘Newralgia' Practice of Medicine by Thomas “May present with referred pain along the cutaneous distribution of obturator nerve ie the inner side of thigh down to the knee.” = Regarding pain from ovarian lesions ‘Accidents to ovarian cysts The Obstetrician & Gynaecologist January 2002 Volume: 4 ;Issue yne in Pelvic ureter me ut with pain along the inner side of thigh: Pain may be referred to the cutaneous areas innervated from the spinal segments which supply the ureter mainly T1I to 2.Pain may be felt from the loin to the groin,and scrotum or the labium majus and may extend to the proximal thigh by projection of the genitofemoral nerve (L.I,L2).The genitofemoral nerve supplies the anteromedial thigh. - Gray's M/1126,1128161. 162, Inflamed Pelvic Aj Abs Both inflamed pelvic appendix and pelvic abscess have not been mentioned as causes for pain along the inner side of thigh. The consensus of opinion amongst most surgery consultants is that an inflamed pelvic appendix may present with pain along the medial side ofthe thigh as a result of iritating the obturator nerve.In their opinion Pelvic appendix is clearly more likely to cause pain along the medial side of thigh than a pelvic abscess. Pelvic abscess is therefore the single best answer of exclusion. Answer is A (Bacteroides): Surgical management of severe secondary peritonitis. British Journal of Surgery. 86(11):1371-1377, November 1999; Acute suppurative bacterial peritonitis is synonymous with Secondary Bacterial Peritonitis and represents an acute infection of the peritoneal cavity resulting from the perforation or anastomotic disruption of the digestive tract or infected necrotizing peritonitis. The most frequently encountered microbiology is a combination of E. coli and Bacteroides fragilis. ‘In secondary bacterial peritonitis, the infection is most commonly polymicrobial with the most frequently encountered combination being E. coli and Bacteroides fragilis’- British Journal of Surgery. 86(11):1371-1377, November 1999. Bacterial Peritonitis 1 Bacterial Peritonitis (Primary) | [Secondary Bacterial Peri re Diffuse Bacterial Infection ofthe Peritonial cavity ‘Acute infection of the Peritoneal cavity usually Resulting occurring without loss of integrity of the digestive tract _from perforation or anastomotic disruption of the digestive tract or infected necrotizing peritonitis. [9 Gsnaliy monomicrobial & aerobic infection A Gaaity potymicrobiat | 1 Classically, seen in young Usually, seen in adults in The most frequently encountered girls without ascitis and the setting of alcoholic combination is that of E.coli and alcoholic cirthosis cithosis and ascitis Bacteroides Fragilis Classically caused by Eccoli (most common) Streptococcus Kleibsella (2™ most Pneumoniae common) Note : ‘+ Spontaneous bacterial Peritonitis is only rarely caused by anaerobic organism or by more than one type of bacteria. +The presence of polymicrobial infection or anaerobic bacteria (bacteroides) should raise suspicion of bacterial peritonitis. Answer is A (Escherichia coli): References elaborated below Microbiology of choledochal bile in patients with choledocholithiasis Journal of Gastroenterology and Hepatology(2003)118,333-336; Guidelines for ‘Infection control in endoscopy’ /p24-25 ; www. health qld gov.aw/endoscopereprocessing/Documents/14062a,pdf Amongst the options provided E.Coli is the single best answer of choice. Kleibsella and Streptococcus faecalis have not been provided as options and Pseudomonas is responsible in a minority of patients where instruments are not meticulously cleaned “The expected pathogens at E.R.C.P. are E. coli, Klebsiella and Streptococcus faecalis. There is a possibility of Pseudomonas if instruments are not meticulously cleaned’ - Guidelines for ‘Infection control in endoscopy’ Microbiology of Cholangitis: (Jownal of Gastroenterology and Hepatology (2003)18,333~-336) E-coli has been reported as the most frequent microbiological agent responsible for cholangitis + E.coli, K. pneumoniae are the most common gram negative agents causing cholangitis (pseudomonas has been reported in a minority of patients (3.4%) ‘+E faecalis and Streptoccocus sp. are the most common gram positive agents causing cholangitis Gram negative cholangitis is more common than Gram positive cholangitis.163. 164. Answer is D (When removed by exploration of the common bile duet, the T-tube can be removed after 3 days). Bailey 24°/1109, 1110; CSDT 11615 Non-Invasive Preoperative Predictors of Choledocholithiasis before Laparoscopic Cholecystectomy, Kuwait Medical Journal 2003, 35 (1): 19-23 ; Management of T Tubes for Common Bile Duct Stones: A New Technique ; Digestive ‘Surgery’ 1998;15:279-282 After exploration of the common bile duct a T-tube is left in place for longer than 3 days to allow the track to mature «and thereby prevent biliary leakage and biliary peritonitis, ‘+ Tubes are left in place anywhere from 7 10 30 days. (CSDT 11°V615,Other Mentioned Ref.) “Current practice entails a wide variation in the duration of leaving T tubes in place, anywhere from 7 t0 30 days, ‘and in the time to postoperative cholangiogram’. -Management of T Tubes for Common Bile Duct Stones: A New Technique ; Digestive Surgery 1998;15:279-282 CCholangiograms are taken a week or so postoperatively, once the bile has become clear and the patient recovered. If any residual stones are found, the tube is eft in place for 4-6 weeks so that the track is mature and these stones can then be extracted through the T-tube tract. + A bile duct diameter of >6mm may suggest the presence of bile duct stones A dilated CBD on US is a noninvasive preoperative predictor of choledocholithiasi. ‘+ Hunt etal using mm as the maximum normal diameter of CBD on US reported a sensitivity of 89%. + Al-Mulhim etal using 6 mm as the maximum normal diameter of CBD on US, reported a sensitivity of 80% Non-Invasive Preoperative Predictors of Choledocholithiasis before Laparoscopic Cholecystectomy Kuwait Medical Journal 2003, 35 (1): 19-23 ‘+ Stones in bile duct may present with the Charcot’s triad (Bailey & Love 24¢h/1109) ‘The consequences of duct stones are either obstruction to ble flow or infection. The presence of infection may result in the Charcot’s triad (cholangitis). | Charcot’s triad ~ Pain ~ Jaundice + Fever + Endoscopic papillotomy is the preferred first technique with a sphincterectomy and removal of the stones using a dormia basket (balloon clearance) Answer is A ( Upper ) : Causes and Prevention of Laparoscopic Bile Duct Injuries: Analysis of 252 Cases From a ‘Human Factors and Cognitive Psychology Perspective. Annals of Surgery. 237(4):460-469, April 2003. ‘Most common dct injuries occur during attempted dissection of the cystic duct when the common bile duct is mistaken ‘or the cystic duct. These injuries involve transaction of the upper part of the CBD and excision of a variable portion ‘of the common bile duct proximal to the first transaction, including the eystic duct-common duct junction. Class TI ic cholecystectomy : (Causes and Prevention of Laparoscopic Bile Duct Injuries: Analysis of 252 Cases from a Human Factors and Cognitive Psychology Perspective Annals of Surgery. 237(4):460-469, April 2003). ‘Stewart Way Classification: Laparoscopic bile duct injuries have been classified according to Stewart Way Classification into four classes.165. 166. 167. All classes of Laparoscopic Bile duet injuries are confined to the upper part of the common bile duet or further proximal. &, % Class I Class 1 Class D1 Class IV TCLASST7%) CLASS IV (10%) Incomplete Incomplete transaction Complete transaction of Complete / Incomplete transaction of the of common Hepatic CBD and excision of a transaction ofthe Right CBD with no loss of duct (Lateral damage) variable portion proximal Hepatic Duct. duct. (ote that injury is to the first transaction (Note that injury is (Note that upper CBD proximal to CBD) (Note that upper CBD is. proximal to CBD) is involved) involved) The incidence of common duct injury during laparoscopic cholecystectomy ranges from zero to 7 percent. This represents a significantly higher incidence of common duct injury than that associated with open cholecystectomy (zero 10 2 percent) Answer is A (Ultrasonic waves): Devita 6°/2691; Harrison 16th Ultrasonic waves are not described as a method of local ablative therapy for liver secondaries. Local Al ‘Techniques for Local Ablation ive therapy for liver seco Freezing Cryotherapy Large zone of necrosis Requires laparotomy Easily followed by Large size probe size ultrasound ie Radiofrequency or cm Percutaneous technique Smal size of necrosis) tive necrosis microwave ablation S Ethanol 3om Simple, inexpensive Inhomogenous ‘Acetic acid distribution ‘Chemotherapy Hot saline Gene transfer Variable Variable Efficacy unknown Intralesional TL 2 Focused ultrasound a Answer is B (Cancer of Stomach) : Endoscopy. 1998 Jun;30(5):484-6 Misra SP, Dwivedi M, Misra V Even in a developing country like India, malignancy is the commonest cause of gastric outlet obstruction. Endoscopy. 1998 Jun; 30(5):484-6 Misra SP, Dwivedi M, Misra V. ‘Malignancy is the most common cause of gastric outlet obstruction even in a developing country’ : Endoscopy. 1998 Jun;30(5):484-6 Misra SP, Dwivedi M, Misra V Dept. of Gastroenterology, M. L. N. Medical College, Allahabad, India ‘Conclusion: Even in a developing country like India, malignancy is the commonest cause of gastric outlet obstruction ‘and endoscopic biopsy specimens should be obtained in all patients with gastric outlet obstruction because the ‘occasional benign lesions can be managed conservatively’ Abstract( Available on Pubmed.) Answer is C (Combined radio and chemotherapy) : Bailey 24/1271 A combination of chemotherapy and radiotherapy, so called chemoradiation (Nigro) has now become the preferred initial therapy for all anal canal tumors.168. 169. (for a period of 1 week) SFU Bieomycin + Cisplatinum Mitomycin Doxorubicin Radiotherapy Given over a period of 3-7 weeks depending on residual tumor mass Abdomini perineal excision Excision of scar Follow up only (if there is obvious tumor remaining) _(ifthere has been a good —_(if no microscopic carcinoma is, response to chemoradiation) present) Answer is C (Chemoradiotherapy): Bailey & Love 24/1271; Repeat ‘A combination of chemotherapy and radiotherapy, so called chemoradiation has now become the preferred initial therapy for all anal canal tumours’ ~ Bailey & Love 24/1271 Answer is C (FK 506): NICE Guidelines ‘Immunosuppression therapy for renal transplantation in adults’ (www. nice.org.uk/pdfTAO8S guidance.pdf) ; KDT Sth/790 The most common regimens include triple therapy with cyclosporine, azathioprine and prednisolone. ‘“Ummunosuppression has customarily constituted triple therapy with : (NICE Guidelines) J. A.aleineurin inhibitor (cyclosporin); 2, An antiproliferative agent (azathioprine); and 3. Acorticosieroid (prednisolone) However, a small number of treatment centers use a policy of intial monotherapy with a calcineurin inhibitor, adding in other agents if necessary. Immunosuppressive therapy for renal transplantation in adults induction therapy ‘+ Is course of intensive immunosuppressive for about 2 weeks immediately post operatively (though often started immediately pre-operatively) with the aim of ‘switching off the immune system after transplantation to reduce the likelihood of accelerated rejection and acute rejection. + Ithas also been used as a means of reducing exposure to calcineurin inhibitors in the early stages after transplantation when the graft may be particularly vulnerable to their nephrotoxic effects. ‘+ The term induction therapy has usually been linked with the use of the following agents: = The polyclonal antibodies antithymocyte immunoglobulin (ATG) - The antilymphocyte immunoglobulin (ALG), and = The monoclonal antibody muromonab-CD3 (OKT3) Initial therapy + Isthe treatment given to all recipients (except where the donor is an identical twin) for 0-3 months after transplantation. ‘+ Initial therapy is usually “triple therapy’, in which a clacineurin inhibitor (traditionally cyclosporine) is used as the ‘primary agent’ in combination with a corticosteroid (prednisolone) and azathioprine. ‘+ Occasionally, dual therapy (cyclosporine plus costicositeroid) is used. ‘Maintenance therapy ‘+ Isthe treatment that patients receive long-term, throughout the duration of allograft survival + Maintenance therapy is often identical to initial therapy (triple therapy) but at a reduced dosage because the transplanted kidney becomes immunologically more stable with increasing time. + However, agents used in maintenance therapy may be altered in response to = Development of acute rejection, severe infections or toxicity. = Poor tolerability leading to non-adherence622 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 170. Answer is B (Bilateral in upto 10% cases) : CSDT 11/1070, Bailey & Love 24thj/1411; other Reference with text. Testicular tumors are bilateral in 15% of familial cases and 5% of sporadic cases Bilateral in 10% of cases is the single best answer of choice. © ‘Bilateral occurrence of the tumor is more frequent in familial than in sporadic cases (15 versus 5%)’. ‘+ About 5% of patients with a unilateral seminoma or nonseminoma have contralateral CIS. (bilateral disease) ‘+ About 15% of patients with a familial unilateral seminoma or nonseminoma have contralateral CIS. (bilateral disease) Ref: Bilateral Testicular Tumors: Atlas of Genetics and Cytogenetics in Oncology and Haematology (http:/www.infobiogen.f/services/chromcancer/Tumors/malegermID5005.html) Note that about 2% of the patients with a seminoma or nonseminoma have an affected family member, indicating a genetic component in the development of this cancer ‘+ Testicular tumors are embryonal cell carcinoma in 20% (Not in 95%) ~ CSDT According to CSDT 11/1070 : Testicular Germ cell tumors ——H—_ ‘Seminomatous Non Seminomatous + Embryonal (20%) + Teratocarcinoma (30%) + Teratoma (5%) + Choriocarcinoma (2%) + Seminomas are more common than teratomas : Bailey & Love 24°/1411 |/Seminomas are the most common testicular tumors Seminomas 40% Teratomas 32% + Testicular tumors are tumors of the young and usually present before the age of 50 Most common age of presentation is 20 — 45 years “Teratoma (younger age group) : 20-35 years ‘Seminomas (older age group): _35~45 years 171. Answer is C (Integrity of palmar arch): Bailey Love 24/518, 886 Alllen’s testis performed to identify patency of the radial and ulnar arteries at the wrist and is indicator of the integrity of the palmar arch, Bailey & Love 24/886 + The patient makes a tight fist while the surgeon compresses both radial and ulnar arteries distally; (this squeezes blood from the hand) + The hand is then released and compression ofthe ulnar artery is released; (the speed of returning colour to hand is assessed). + Ifcolour returns in 5-7 seconds, patency and collateral flow from the ulnar artery is confirmed, 172. Answer is D (Penetrating trauma) : CSDT 11"V845; Bailey & Lover 24°7950 ‘Acquired fistulas result from injuries that produce artificial connections between adjacent arteries and veins and may be the result of trauma or disease. Penetrating injuries are the most common cause®. - CSDT 11"%845 Arteriovenous fistulas (Abnormal communications between an artery and a vein) (Congenital ‘Acquired Congenital fistulas or malformations are offen noted in» Penetrating injuries are the most common cause infancy or childhood. (sometimes seen after blunt trauma) eg + Tatrogenic AV fistulas after arteriography are Osler ~ Weber ~ Rendu disease becoming increasingly common + Surgically created AV fistulas in the arms of patients undergoing renal dialysis.173. 178. 175. Answer is B (Textile Synthetic): Various references Dacron Vascular grafts are Synthetic Vascular grafts based on advanced textile technology and are an example of ‘medical textiles. “Vascular grafts composed of Dacron are made using a variety of processes including fiber extrusion and fabric formation using knitting and weaving techniques Fabrics composed of woven and non-woven yarns are made using ‘standard textile manufacturing processes? - ww. biomed metu.edu.ir/courses/term_papers/BureuUnal htm Sanaa Synthetic L v ‘Most commonly used synthetic grafts: Autografis Allografts + Dacron Grafts from another site in Graft from another + Teflon (ePTFE) the same patient member of same species [Saphenous vein Dacron Prosthesis ePTFE Depending on textile technology (expanded Poly t ene these may be + ePTFE is a non fabric modification of + Knitted type carly woven Teflon prosthesis produced] + Woven type by a heating and mechanical stretching + Velour type process, ~ durable - does not dilate - holds suture - does not undergo biological deterioration Answer is D (Saphenofemoral fistula): Schwartz 7°/420 Saphenofemoral fistulas have not been mentioned as sites for hemodialysis vascular access. Also femoral vessels are not preferred and used only if all upper extremity sites have been used. + The initial site usually is the forearm of the non dominant hand. — Schwartz + The most critical vessels are the cephalic vein in the forearm and upper arm and the veins ofthe antecubital space. Upper limb) ‘* The usual choice for long term dialysis include an Arteriovenous fistula and PTEE graft placement. Fistula PTFE Grafts * Procedure of choice if fistula site and a suitable * Standard procedure (conduit) in patients who do not vein are available have a suitable anatomy for a fistula « Overwhelming choice for longetivity and suitability __» Long term patency is significantly less than for grafts. for dialysis + Classic Brescia — Cimino fistula (Radio cephalic): « Initial site isthe forearm of a non dominant arm Created by anastomosing the cephalic vein and the radial artery atthe wrist side to side or end to side. + Brachiocephalic fistula: created by anastomosing a + Progression to the use of lower extremity femoral large cephalic vein with the brachial artery in the vessels is done if all upper extremity sites have been antecubital space. used. Answer is C (Trans-sphenoidal): Schwart: 8/1636 ‘Most pituitary tumors are approached through the nose by the trans-sphenoid approach’ — Schwartz 8/1636176. Answer is C (Pupil size): Fuller; Bailey Love 24/601 The Glasgow Coma Scale records three parameters namely, ‘Eye opening’, ‘Best motor response’ and ‘Best verbal response’. Pupil size is not part of the GCS System. ‘Spontaneous 4 Oriented & Converses 5 ‘Obeyes command 6 To verbal stimuli | 3 Disoriented/ confused and converses | 4 Localizes pain 5 Topain 2 Inappropriate words 3 ‘Withdraws to pain 4 Nil 1 Incomprehensible words 2 Abnormal flexion 3 No response 1 (ecorticat rigidity) Extension response | 2 Nil 1 Note The maximum scoreis__ 15 The minimum score is__03 177. Answer C (15) : Fuller; Bailey & Love 24/601 Aconscious person has spontaneous eye opening (3), is oriented and converses (5) and obeys commands (6). The total GCS score for a conscious person therefore is 15. Eye opening Spontaneous 4 ‘Verbal Response Oriented / converses 5 Motor Response Obeys commands 6 TOTAL GCS SCORE 15 OBS & GYNAE 178. Answer is C (Luteinizing hormone): Harrison 16/2204, 2205; Shaw 13/353; Dutta 4"/422, 423179, 180. ‘AIPGME EKAMINATION ANSWERS Serum level in PCOS ot _, ‘Androgens ® Estrogens(T) LHWFSH® Insulin” Estrogen excess” LiLlevels are Ted in Ted + Excess production of» Esirogenlevels are «Enhanced estrogen levels. «ed Insuli androgens is seen increased due to exert a resistance from both the ovaries peripheral = positive feedback on LH and adrenal aromatization of, levels (Ted) (Postulated to be due androgens ~ negative feedback on FSH to abnormal regulation + Estrogen® levels are levels (ted) of androgen forming raised LH/FSH Ratio is enzyme) (Estrone > Estradiol) characteristically > 2 Answer is D (Results is potdated pregnancy): Repeat; Novak's Gynecology/876 PCOD is characteristically associated with elevated LH levels, abnormal glucose tolerance and may present with infertility. Postdated pregnancy has not been mentioned as a sequelle to PCOD. PCOD (Novak's Gynaecology) + Hirsuitism 1 + Obesity , ‘= Oligomenorthea or ci SS enocrhoa, + Chronic anovulation % Premenarchial onset of aS + Hyperandrogenemia (in = Hiruitism = interliy —™ absence of any notable cause) = Obesity + Insulin resistance (Abnormal Glucose tolerance) + Elevated LH (LHIFSH Ratio > 2) + Intermittent anovulation associated with hyperandrogenemia (Ted free testosterone, Ted DHEAS) Answer is C (Testicular feminization syndrome): Harrison 16%/2218, Refer previous question, hitp://www.mcg.edv/pediatric/ccivotebook/chapter3/tanner htm Presence of well developed breast (tanner stage 4) with scanty axillary or pubic hair in a phenotypic ‘female’ with primary amenorrhea (? no uterus) suggests the diagnosis of Testicular feminization syndrome. ‘* Resistance to androgens due to mutation inandrogen XY Genotype receptors Resistance to androgens due to mutation in androgen © Genotype is XY receptors ‘= Phenotype is female Female Phenotype and Female psychosexual development + Normal breast (tanner stage 4 or 5) + Short vagina but no uterus (primary amenorrhea) + Seanty pubic and axillary hair ‘Tanner staging: (tip:/‘www.meg edulpediatries/CCNotebook/chapter3¥tanner. him) eee eS oS Stage 1 Early adolescence Preadolescent Preadolescent (10-13 years) [Siage2 ‘Sparse, straight Small mound Stage 3 Middle adolescence Dak, cul Bigger, no contour separation (12-14 years) [Sige Coarse, curly, abundant Secondary mound of areola a Stage 5 (04-17 years) Triangle; medial thigh Nipples projects; areola part of breast| ANSWERS AND EXPLANATIONS - 2006 181, Answer is D (Cortisone): Shaw 13/102, 103 Virilicing hyperplasia of the adrenale leads the Adrenogenital Syndrome. The treatment of this condition consists in the administration of cortisone or hydrocortisone, or the newer synthetic corticosteroids such as prednisolone. Adrenogenital Syndrome (Vitilizing hyperplasia ofthe adrenal cortex) t ‘Congenital Intrauterine adrenogenital syndrome Postnatal adrenogenifal Syndrome * Primary defect is enzyme failure of 21 hydroxylase. + This ean be due to excessive output of ACTH from « This results ina block in the conversion of 17 hydroxy __a basophil adenoma of the anterior pituitary progesterone into hydrocortisone @ (Cushing’s syndrome) which gives rise to adrenal + The main androgenic activity is due to androgenic cortical hyperplasia. nature of 17 hydroxyprogesterone ® and its conversion _« This can also be due to a benign or malignant into other orthodox androgens, adrenal tumor. Treatment to avoid undesirable virilizing effects or hydrocortisone or newer synthetic corticosteroids involves administration of cortisol. such as prednisolone 182, Answer is A (Ca yoma Cervix): Shaws 13/401; ‘Staging of Ca Fallopian tubes’; Other References Carcinoma cervix is associated with minimum risk of metastasis to the ovary amongst the options provided. + Risk of ovarian metastasis from carcinoma cervix: Risk of metastasis o ovary from Ca cervix is low (< 1%) ‘Cervical metastasis tend to bypass the ovarian lymphatics and travel by way of the hypogastric and aortic glands? = Shaw 138401 Cervical cancer is a rare source of metastasis to the ovary.~ Am J obs. Gynt 166:50-53,1992,Cancer 71:407-418,1993 «Risk of ovarian metastasis from uterine body (corpus): The ovarian lymphatics drain the corpus directly and hence carcinomas/sarcomas of the corpus have a higher tendency to metastasis to ovary. “Carcinoma of corpus is 10 times more likely to metastasizes to the ovary than cervix' — Shaws 13/401 + Risk of ovarian metastasis from fallopian tubes: Risk of metastasis to ovary from fallopian tube is high because of the propensity of involvement from direct spread and lymphatics both. Ovaries are involved in early stages of carcinoma of fallopian tubes. Stage II (A); Extension and/or Metastasis to the uterus and/or ovaries 183. Answer is B (Fractional Curettage) : Dutta Gynaecology 4/331; Oxford Handbook of Surgical Specialities 6"/10 ‘A case of postmenopausal bleeding is considered to be due to endometrial carcinoma unless proved otherwise. ~ Dutta /OHCS Fractional curettage is the definitive method of diagnosis of endometrial carcinoma and hence the single best answer of choice here. A ease of postmenopausal bleeding is considered to be due to endometrial carcinoma unless proved otherwise = Dutta /OHCS) Diagnosis of Endometrial Carcinoma and options provided Fractional curettage ‘PAP Smear aS i ‘Transvaginal Ultrasound + Tis the most definitive method of © Itisnota reliable Ircan demonstrate features diagnosis of endometrial carcinoma diagnostic test for suggestive of endometrial Dutta $7331 endometrial carcinoma carcinoma, however it can not + [tallow determination of exact site ~ Dutta 4/331 replace definitive biopsy. of malignancy and also detects the ~ Dutta #°/331 extent of spread of tumor. cate[AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 © 627 CA-125 (Harrisons 164/439) : CA 125 is not a marker for endometrial carcinoma, «© Menstruation * Some Lymphomas «© Peritonitis. «Pregnancy 184, Answer is None: References along with text: National Guidelines (U.S.) (Staging and follow up of ovarian cancer) http://www guidelines. gow/summary/summary.aspx?doc_id=8611 Imaging studies in a case of suspected ovarian cancer will give information regarding all ofthe options mentioned in the question, Imagin, ing of ovarian c Although an exploratory staging laparotomy is required to determine the stage of the disease. Staging is done by combining information from imaging tests with the results of a surgical examination and the histopathology/cytology report from the samples obtained during laparotomy. ‘Standard radiographic techniques such as chest radiograph, barium enema, and excretory urography have been replaced in many countries including the United States by cross sectional imaging, esp ecially CT, for ovarian cancer staging. CT is the imaging modality of choice in the preoperative evaluation of ovarian cancer and has been validated ‘as an accurate method to predict sucessful surgical cytoreduction. CT has been useful for detecting local tumor involvement of the pelvic ureter and uterine serosa, as well as metastases to the peritoneum, omentum, mesentery, liver, Spleen and lymph nodes. CT has a reported accuracy for ovarian cancer staging of up to 94%, — National guidelines cer Imaging studies and characterization of ovarian cancer The role of diagnostic imaging has been ovarian mass characterization, determination of preoperative disease extent, and prediction of tumor respectability.- National Guidelines Transvaginal ultrasound (US) has a role in ovarian cancer screening and characterization of ovarian masses as benign or malignant National Guidelines “The detection of ovarian cancers and their characterization can be improved even more through enhancements in pre-processing (i.e. using sono CT) and post-processing (i.e. using X-rays software designed to bring out subtle ‘patterns obtained from soft tissue structures) detection of microvascularity; development of sonographic parameters ‘which reflect tumor response; contrast enhancement in distinguishing benign from malignant lesions; 3-D representation of vessel networks to detect abnormal branching in tumor neovascularity; and detection and evaluation ‘of normal vs. abnormal contrast kinetics.'- The Use of Ultrasound in Diagnosing Ovarian Cancer: Can We Improve on Current Practice? (http://www. cde. gov/cancer/ovarian/pdfiultrasound_workshop_summary pdf) Imaging studies and resectability of ovarian cancer: For predicting non resectability of ovarian cancer, cross sectional imaging (CT or MRI) plays a critically important role in finding such lesions (greater than 2 cm) at the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatic, intersegmental fissure of the liver, diaphragm, liver dome, lymphadenopathy at or above the celiac axis, presacral extraperitoneal disease, and pelvic sidewall invasion. Unresectable disease can be managed by needle or laparoscopic biopsy, chemotherapy, and possibly a later attempt at optimal debulking, resulting in improved survival by virtue of optimal response to chemotherapy — National Guidelines Imaging studi ecti US can be used to determine the site of origin of a pelvic mass and to characterize the lesion. A combination of morphology and Doppler waveform analysis may provide the most accurate risk assessment for an adnexal lesion by US.- National Guidelines. 185, Answer is C (Wertheim’s hysterectomy): Shaw's Gynaecology 13/181, 180; Dutta Gynecology 4/391, 392 Although ureteric injury may be associated with all the listed surgical procedures the highest incidence is likely with Wertheim’s hysterectomy. ‘Hysterectomy is the gynecological surgery reported to be responsible for the highest incidence of ureteric injury. Abdominal hysterectomy is more commonly associated with ureteral injury than vaginal hysterectomy. Incidence is highest with a radical form of abdominal hysterectomy ~ ‘Ureteral trauma’ ~ www.emedicine.com/MEDytopic2855.htm Wertheim’s hysterectomy being a radical abdominal hysterectomy is the answer of choice.28 186, 187. ‘+ AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 Ureteric injury ss Ureterie injury and 77 Why Werthcim’s hiystereetomy is likely to have __gynecological surgery highest incidence + Because of close anatomical + Risk of ureteric injury is more when pelvic anatomy is disturbed due to association between ureter and previous pelvic pathology ~ Dutta genital organs, ureteric injury isnot «Risk of ureter injury is also mote likely, ifthe gynaecological surgery ‘uncommon during gynaecological performed is more radical surgery- Dutta. Wertheim’s hysterectomy is a radical surgery, performed for cancer cervix + The ureter is vulnerable to injury (malignancy) and involves wide resection of periureteral tissues. during pan hysterectomy, Wertheim’s Its thus likely to have higher incidence of ureteric injury than other options radical abdominal operation for provided. concer cervix, during total abdominal Shaw's 13%/181- Iysierectomy and vaginal + Ureteric fistulae results from direct injury or devascularization of pelvic ‘ysterectomy ~ Shaw. ureters during gynaecological surgery as during Wertheim's operation for carcinoma of the cervc' Answer is C (Abundance of polymorphs): Shaw 13/29; Harrison 16/766 Bacterial vaginosis is associated with a decreased number of polymorphs and not with their abundance. (2 a ‘+ Polymicrobial infection with both aerobic and anaerobic bacteria Gram variable bacilli are seen (both gram positive and gram negative) ‘Common microbes include Hemophilus vaginosis (gram negative), Gardnella vaginalis (gram negative) and Mobiclonus (gram positive) Considerable decrease in number of lactobacilli? Reduced number of leucocytes (Polymorphs)® Presence of Clue-cells? Fishy odour when mixed with 10% KOH (due to aminometabolites from various organisms) pH of discharge of more than 4.5 ‘White milky non viscous discharge (Microscopy in bacterial vaginosis according to Harrison's text - Harrison 167767, © Clue cells + Few leucocytes + No lactobacili or only a few outnumbered by profuse mixed flora including G.vaginalis plus anaerobes species on Grams sain. Answer is C (Tuberculosis): Before Evaluation For Infertility, Take Azithromycin ;Gabe Mirkin, M.D. ; www.drmirkin.com/women/W128.htm; Indian Journal for the Practising DoctorVol. 2, No. 5 (2005-11 - 2005- 12)'Infections and Infertility, www.indmedica.com/journals.php?jounalid=3&issueid=65 &articleid~839caction article; hup:/www-kjivf-com/infertility.asp(non-journal lnk) Genital tuberculosis is extremely common in India. The commonest site of affection of genital tuberculosis is the {fallopian tubes and the pathological process leads o blockage of tubes. Although even an extensive search through Indian journals does not mention genital tuberculosis as the commonest cause of tubal blockage directly, most papers do mention tuberculosis as a fairly ‘common’ cause of tubal blockage in India, A number of non journal publications however mention tuberculosis as the most common cause of tubal Blockage in India. In view of the fact that Tuberculosis is more widespread in India than either Chlamydia or Gonorrhea and because the question specifically asks about the most common cause of tubal blockage in India , Tuberculosis isthe single best answer of exclusion here. Fallopian Tube Blockage Leading To Infertility [Most common cause in India Geveloping nations) | __ Most common eause in developed nations) Tubereulosis Chlamydia ‘Most common causes of ubal damage is tuberculosis in “Infection with chlamydia ts the most common cause of India’ blocked Fallopian tubes that cause infertliy Indian chp: Kin com/nfer. asp Journal for the Practising DocorVol. 2, No.5 2005-11 - (non journal lin) 2005-12) Infections and Infertility: Before Evaluation For Infertility, Take Azithromycin :Gabe Mirkin, M.D _188, Answer is D (Interference with placental functioning): KDT 5"/287, 288 189, Oral contraceptive pills do not act by interference with placental functioning. Mechanism of action of OCPs ibition of ovulation® Inhibition of fertilization® Interference with Implantation® + Progestin reduces frequency + Thick cervical mucus, hostile to.» Endometrium is either rendered of LH secretory pulses, sperms may inhibit fertilization hyperproliferative, ‘while estrogen primarily + “Uterine and tubal contractions hypersecretory or atrophic and reduces FSH secretion. ‘may be modified to disfavour ‘out of phase with fertilization + Both synergize to inhibit Sertilization. and not suitable with nidation. mideycle LH surge. (This action is uncertain but Thus, even if ovulation and + Asa result follicles fail to probably contributes to efficacy fertilization occur, implantation develop and rupture and of minipills and postcoital pills) does not occur normally. ovulation does not occur. Answer is A (There is increased incidence of menorrhagia) : A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia. Am J Obstet Gynecol 1991; 164: 879-83.; Intrauterine release of levonorgestrel - a contraceptive and therapeutical system Kerstin Andersson Department of Obstetrics and Gynaecology, Sahlgrenska University HospitallEast, S-416 85 Gothenburg, Sweden(www.medforum.nl/gynfolleading8.htm) The levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) is used therapeutically for treatment of ‘menorrhagia. It is associated with a decreased incidence and not an increased incidence of menorrhagia, ‘A reduction of objectively measured menstrual blood lass of more than 95% after 6-12 months use of the LNG-IUS has ‘been demonstrated. The LNG-IUS has been described as one of the most effective reversible long-term treatments for ‘menorrhagia to date’.-. A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine ‘contraceptive device in the treatment of idiopathic menorrhagia. Am J Obstet Gynecol 1991; 164: 879-83. ‘The levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena): + Consists of a plain Nova T device and a Silastic rod, impregnated with $2 mg levonorgestrel + The release rate of levonorgestrel is 20 yg/24 h and the effective life span is at least 5 years F on Health benefits ~ Therapeutic u Ttisa highly effective, long acting Potential + Treatment of menorrhagia ‘and rapidly reversible method of reduced risk of LNG-IUS use leads to cessation of regular contraception upper genital menstrual bleeding and blood loss. The LNG- fret infection TUS has been deseribed as one of the most ANLNGIUS affecthe «SCS emerged as a effective reversible long-term treatments f will LNG-IUS affect the 3 for iods promising non ‘menorthagia to date. contraceptive Good counselling is extremely Saat een + Hormone Replacement Therapy (HRT) ‘important prior to insertion, during Low release levonorgestrel (5 or 10 g/24 h) which women should be informed = —— thas been shown to provide endometrial that blood loss will decrease but that protection in both perimenopausal hormone Efrequent irregular bleeding or replacement therapy (HRT) and postmenopausal spotting is common during the first HRT 2-3 months. With prolonged use, + Treatment of endometrial hyperplasia ‘menstrual blood loss is dramatically reduced. Some women will stop bleeding altogether whilst others will experience extremely scanty regular bleeding LNG-IUS has a strong suppressive effect on the endometrium... Because of this endometrial effect it can be used for the treatment of endometrial hyperplasia. The LNG-IUS has been described as an alternative to hysterectomy and endometrial resectionAnswer is B (Decreased ovulation) : ‘The Contraception Report’ March 2002 Vol. 13 No.1 (www.contraceptiononline.org/contrareport/article0I/efin?art=206) All options other than decreased ovulation have been directly mentioned as mechanisms that might account for the ‘reduced risk of upper-genital-tract infection in users of progestin releasing IUDs. is questi “The Contrat : 002. yw mentioned text hi directly quoted from the report and clearly explains the answer. Several mechanisms might account for a potential reduced risk of upper-genital-tract infection in users of progestin releasing IUDs. + First, the local effect of progestin on cervical mucus should make it thick and relatively impenetrable to bacteria. + Since uterine bleeding is eventually greatly decreased in users of the LNG-IUS (progestin releasing IUD), any retrograde menstruation (which might seed the fallopian tubes with bacteria) should be reduced as well. + In addition, decidual changes in the endometrium may make it less susceptible to infection, Stated alternatively, progestin-releasing IUDs may mimic the protective effect of combined oral contraceptives and depot medroxyprogesterone acetate against upper-gential-tract infection. If this potential benefit of the LNG-IUS is corroborated by further studies, this will likely broaden the range of appropriate candidates for intrauterine contraception, Reduction in a woman's risk of salpingitis may emerge as yet another noncontraceptive health benefit of the LNG-IUS. 191, Answer is D (Interrupting an early pregnancy): Dutta Gynaecology 4/452; Shaw 13/233 Emergency contraception is defined as a method used to prevent pregnancy after an unprotected intercourse. Interrupting on early pregnancy is technically ‘abortion’ and not contraception. “Agents like Mifepristone (RH486) can be used both as emergency contraceptives and for termination of early pregnancy. Use of Mifepristone within 72 hours of intercourse interferes with implantation and its use then is termed ‘as emergency contraception. When used after 72 hours Mifepristone acts by interrupting an early pregnancy and its use is then termed as Termination of pregnancy or abortion.~ KDT 5°/284 Emergency Contraception Hormonal contraceptive “Antiprogesterone ‘pills? Miferpristone (RU 486) ‘+ Combined hormonal agents (Yuzpe method) Prevents Implantation Prevents implantation + Moming after pill Introduction of IUD within a “By blocking the action ‘+ Progesterone only pill maximum period of § days can ‘of progesterone on prevent conception. This prevents endometrium, it causes Possible modes of action : Dutta Gynae #7452 implantation ~ Dutta 4/452 sloughing and shedding + Prevention off Delay of ovulation of decidua and prevents + Interfering with Fertilization (thickening of implantation - Shaw cervical mucus) + Implantation is prevented as endometrium is rendered unfavourable Note: Miferpristone also causes interruption of early pregnancy. This agent can be used for termination of pregnancy upto 7 weeks. This use is however not termed as emergency contraception. 192, Answer is D (Fetal blood): Dutta 6/108; www.americanpregnancy.org/prenatal testing ‘Cordocentesis is performed under local anaesthetic usually after 18 weeks of gestation’ -Dutta 6/108 Cordocentesis is a procedure that takes a blood sample from one of the blood vessels in the baby’s umbilical cord, to directly test the baby's blood. Cordocentesis can only be done later in the pregnancy, from about 18-24 weeks, when the umbilical cord has adequately developed bitp:/www.birth.com.au/class.asp?class=66028page http://www.americanpregnancy.org/prenataltesting/cordocentesis htmlés AGM EXAM Prenatal diagnosis >>? ‘Chorionic villus sampling ‘Amniocentesis MSAFP ‘Cordocentesis _{choronic vii) (Amniotic fluid) (Maternal blood) (Fetal blood) 10-12 weeks 14-16 weeks 15-18 weeks 18-20 weeks. 1Oweeks to term (transabdominal) Prenatal diagnosis at 16weeks can therefore be performed using all of the above except fetal blood. 193. Answer is A (Anencephaly): ‘The 1-14-week scan CENTRAL NERVOUS SYSTEM DEFECTS KH Nicolaides, NJ Sebire, RJM Snijders: http://www fetalmedicine.com/1 1-1 4scanbook/Chapter%204/chap04-3.htm Anencephaly can be suspected in scans as early as 9 weeks with an abnormal cephalic pole and demonstrated reliably at an 11 weeks scan (First Trimester Scans) ~ Above reference + Routine Scans to identify fetal abnormalities are performed in the second trimester + In certain high risk patients scans performed in the late first trimester (9 ~ 13 weeks) can reveal evolving signs of anomalies + Anencephaly can be suspected in cans as early as 9 weeks with an abnormal cephalie pole and demonstrated reliably at an 1 weeks scan (First Trimester Scans) Ultrasound reports have demonstrated that in the human,there is progression from acrania to exencephaly and finally anencephaly. Observation of acrania and exencephaly are early signs of an evolving anencephaly Case reports onthe prenatal diagnosis of anencephaly at 11-14 weeks of gestation ‘Acrania (demonstrable at 9 weeks) Author Case Gestation (weeks) __ Ultrasound findings oo + Exencephaly (demonstrable Schmide and Kui 1982” = 13 sanencephaly at 10 weeks) Johnson et al, 1985” 2 ut snencephaly + Rottem et al, 19897" 3 9 abnormal cephalic pole Anencephaly (demonstrable sanencephaly at 10-11 weeks) ‘Kennedy ol. 19907 4 10 cexencephaly Bronshtein and Omoy 1991 5 9 normal 1" normal 12 acrania 14 ancncephaly 194. Answer is D (Amniocentesis): Harrison 16"/408; Ghai 5°/479; Williams 21°/98s fer question from AI 2004, 98 The best way of establishing a diagnosis of Trisomy 21 in the second trimester is Amniocentesis. Fo a Diagnostic tests Suggestive but not diagnostic (Invasive tests are diagnostic) (Non-invasive tests are suggestive but not diagnostic) + First trimester ‘Second trimester are enemas ‘+ Ultrasonography (6-40 weeks) Chronic Villus Sampling Amniocentesis + Triple test (15-18 weeks) ‘+ MSAFP (15-18 weeks) 195, Answer is D (Puerperium): Reference along with text The risk of reactivation of inactive pulmonary TB during the post-partum period is possibly higher. Postpartum period or puerperium is the single best answer of choice.632 196, 197. 198. = AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 and Preg trol vention of losis et Providers (2002-2005), Published by Rural and Regional Health and Aged Care Services Division Government Department of Human Services Melbourne (hiqp:/www. health vic.gov.aw/ideas/diseases/tb_mgmt_guide htm) Effect of Pregnancy on Latent TB : Above Reference + The risk of disease developing in a tuberculin-positive pregnant woman with a normal chest x-ray is the same as the risk for a non-pregnant woman. +The risk of reactivation of inactive pulmonary TB during the post-partum period is possibly higher, but this view is disputed. Answer is C (Dermoid cyst): Novak's Gynaecology 13/426 ‘A benign cystic teratoma is the most common neoplasm to undergo torsion’- Novak's Gynaecology 13/426 Different texts (Shaw's, Dutta) give confusing and contradictory statements, making the correct answer debatable. However in view of the clearly outlined text from Novak's as stated above, the single best answer is dermoid. (Benign cystic teratoma is synonymous with dermoid) Answer is A (Glioma) : Williams 22/1203; 1255; CGDT 9"/429 Amongst the options provided, all tumors other than gliomas have been mentioned to grow more rapidly with Pregnancy. Glioma is the single best answer here. ‘Pituitary adenomas (Williams 22"/1203) Enlargement of both microadenomas (210mm) is seen ‘Although brain tumors are not specifically related to during pregnancy gestation, meningiomas, angiomas and neurofibromas ‘are thought to grow more rapidly with pregnancy’ ~ capt 9/429 ‘Lesions of neurofibromatosis may increase in size and in ‘mumber as a result of pregnancy’ ~ Williams 22"/1255 Answer is D (Folie acid): “Epilepsy and pregnancy: maternal and fetal effects of phenytoin — Toxicology’, Critical Care Nurse, April, 2003 by Joyce M. Brewer, Patricia A. Waltman: htp://www findarticles.com/p/articles/ ‘mi_m0NUC/is_2_23/ai_100543072/pg_10; KDT 5%/372; Repeat Phenytoin interferes with metabolism of folate and patients taking phenytoin may become deficient in folic acid, Phenytoin decreases absorption of folic acid and increases its excretion’ - KDT Vitamin deficiencies common in Pregnant women on phenytoin therapy | 7) Phenioin interferes with + Phenyioin therapy may + Phenytoin interferes with ‘metabolism of folate, and increase the metabolism of vitamin K in the formation of patients taking phenytoin may vitamin D, leading to a precursor protein for therefore become deficient in decrease in vitamin D levels coagulation factors Il, VIL, IX, folate, leading to the that can in turn cause and X. development of macrocytic alterations in calcium + This may be associated with anemia and possible homeostasis. hemorrhage Disease ofthe complications during + This may be associated with ‘Newbom?, pregnancy. maternal osteomalacia® and ‘Pregnant women taking + Matemal deficiency in folate is osteoporosis. phenytoin should receive oral associated with neural tube «Pregnant, women taking Phytonadione supplements? defects in the fetus. phenytoin should receive the (LOmg/kg) during the last month + Pregnant, women taking recommended 400 IU/day of of pregnancy or injections of phenytoin should receive folic cholecalciferol® throughout phytonadione early in labor, to ‘acid supplement of at least 0.4 pregnancy to prevent problems reduce bleeding tendencies in mg/day to minimize risk of in vitamin D levels and the newbom neural tube defects calcium absorption