Question 297 1D Title The most effective measure for prevention of trachoma CO Flag as important Font Size: A A A Which one of the following measures is of most importance in reducing the prevalence of trachoma infection in a susceptible community such as indigenous Australians? A Childhood vaccination. % © | Prophylactic use of tetracycline. % Oc _| Avoidance of community bathing. # (© | Regular hand and face washing. Eradication of mosquitoes.Option D is correct To reduce the prevalence of trachoma infection, the strategy defined and implemented by the World Health Organization (WHO) should be followed. This strategy is called SAFE that stands for surgery, antibiotics, facial hygiene (cleanliness) and environmental factors. © Surgery is used to correct the entropion before it leads to permanent damage to the cornea. © Azithromycin is the antibiotic of choice in this strategy and is given, in oral form, to family members with active trachoma. © Facial hygiene is achieved through regular hand and face washing. © Environmental factors should be addressed by improving water supply, better community hygiene and dust and fly control. Among the following measures surgery and antibiotics are used for treatment not prevention; hence they have no effect on prevalence. The most important measure, which with proper education will significantly reduce the prevalence of the disease, is regular hand and face washing. (Option A) There is no effective vaccine against Chlamydia trachomatis. (Optipn B) Tetracycline is not used for prophylaxis or treatment of Chlamydia. Azithromycin is the drug of choice for such purposes. (Option C) Chlamydia trachomatis is spread via direct contact e.g. from mother to the child. Avoidance of community bathing does not seem to have a significant impact on the prevalence. (Option E) Tra ———oteaee f\ies NOtlial © alata celal = alae ace lace ceri aa Lael noes la eel a°: used for treatment not prevention; hence trey have no effect on prevalence. The most important measure, which with proper education will significantly reduce the prevalence of the disease, is regular hand and face washing (Option A) There is no effective vaccine against Chlamydia trachomatis. (Optipn B) Tetracycline is not used for prophylaxis or treatment of Chlamydia. Azithromycin is the drug of choice for such purposes (Option C) Chlamydia trachomatis is spread via direct contact e.g, from mother to the child. Avoidance of community bathing does not seem to have a significant impact on the prevalence. (Option E) Trachoma is transmitted by flies not mosquitoes; therefore, eradication of mosquitoes would not be an effective measure Reference(s) + AMC Handbook of Multiple Choice Quest ions - page 623 +624 cc EuE Nour MEY CaeQuestion 143 ID Title The choice of polio vaccine booster for a 4- year-old boy CO Flag as important Font Size: A A A You are working in a rural area. A 4-year-old Somali boy is presented to you by his mother for polio vaccine. He has received 3 doses of oral polio vaccine (OPV) at 2, 4 and 6 months of age back at his country with the last dose being given approximately 3 years ago. You only have injectable polio vaccine available in your office. Which one of the following would be the best appropriate management? Oa Check his immune status. OB No further vaccination is needed. @c Refer him to another clinic. Op Give the injectable polio vaccine. OE Try to find oral polio vaccine for him.bead Somali boy is presented to you by his mother f polio vaccine. He has received 3 doses of oral polio vaccine (OPV) at 2, 4 and 6 months of age back at his country with the last dose being given approximately 3 years ago. You only have injectable polio vaccine available in your office. Which one of the following would be the best appropriate management? x A Check his immune status. % © _ | No further vaccination is needed % ©c__ Refer him to another clinic. ¥ Op | Give the injectable polio vaccine. x — | Try to find oral polio vaccine for him. Cer eae EVs aaa eeOption D is correct Injectable Inactivated polio vaccine (IPV) is the polio vaccine currently in use in Australia, and is given intramuscularly. Oral polio vaccine (OPV) is no longer in use in Australia. OPV and IPV are interchangeable Children, who have been started on OPV should complete their polio vaccination schedule using IPV (IPOL®) or IPV-containing vaccines. IPV (IPOL) or IPV-containing vaccines are recommended for infants at 2, 4 and 6 months of age. The 1st dose of an IPV-containing vaccine can be given as early as 6 weeks of age. If the 15¢ dose is given at 6 weeks of age, the next scheduled doses should still be given at 4 months and 6 months of age.A booster dose of IPV (IPOL®) or IPV-containing vaccine is recommended at 4 years of age. This is commonly provided as DTPa-IPV, which can be given as early as 3.5 years, but if DTPa-IVP is not available, IPV alone is used. The only absolute contraindications to IPV (IPOL®) or IPV-containing vaccines are: © Anaphylaxis following a previous dose of any IPV-containing vaccine © Anaphylaxis following any vaccine component Reference(s) _« http://www.health.gov.au/internet/im munise/publishQuestion ID 110 Title Cholesterol content of foods CO Flag as important Font Siz: A A A You are counselling a patient who is concerned about the cholesterol content of foods. Which one of the following foods contains the most cholesterol content? @a Yoghurt. OB Avocado. Oc Coconut oil. Op Peanut butter. OE Canola.Question ID 110 Title Cholesterol content of foods CO Flag as important Font Size A A A You are counselling a patient who is concerned about the cholesterol content of foods. Which one of the following foods contains the most cholesterol content? ¥ OA — Yoghurt. x B Avocado. * ()c Coconut oil. % © )D_— Peanut butter. x E Canola.% © )D Peanut butter. * OE Canola. Option A is correct Cholesterol is only found in animal products such as meat, poultry, fish, dairy products and egg. Although vegetable products have different levels of fat, they do not contain cholesterol. Of the given options, only yoghurt (a dairy product) contains cholesterol Reference(s) http://www.betterhealth.vic.gov.au/bhe v2/bhcarticl PCRs TeraQuestion 109 1D Title Counselling about cholesterol content of cooking oils © Flag as important Font Size: A A A Sarah, whose husband has a plasma cholesterol of 6.4 mmol/L (normal <5.5mmol/l), wants to know which cooking oil she should use when she cooks. Which one of the following would you advise? A There is not much difference between cooking oils. B Any margarine is suitable. G An oil rich in saturated fat rather than those rich in unsaturated fats. D She should use either canola or sunflower oil. E None of the above.C frag 25 important Font Size: A A A Sarah, whose husband has a plasma cholesterol of 6.4 mmol/L (normal <5.5mmol/I), wants to know which cooking oil she should use when she cooks. Which one of the following would you advise? % (A __ There is not much difference between cooking oils. x B Any margarine is suitable. x c_ Anoilrich in saturated fat rather than those rich in unsaturated fats. v Db She should use either canola or sunflower oil. % (Ee None of the above. err EeeOption D is correct Epidemiological studies have shown reduced mortality from cardiovascular causes if diets containing increased levels of mono- and polyunsaturated fatty acids are used. Canola oil and olive oil have a high concentration of monounsaturated fatty acids, while sunflower oil is rich in polyunsaturated fatty acids. Both canola and sunflower oil are appropriate dietary oils for Sarah's husband. For lowering the plasma cholesterol levels, the National Heart Foundation of Australia recommends that saturated fat in the diet be replaced with a combination of mono- and polyunsaturated fats. Cholesterol content of foods does increases LDL cholesterol. LDL cholesterol is directly related to the amount of saturated and trans fat contents of dietary intake. Ret ae jon.org.au/he c een cuted janationsOption D is correct Epidemiological studies have shown reduced mortality from cardiovascular causes if diets containing increased levels of mono- and polyunsaturated fatty acids are used. Canola oil and olive oil have a high concentration of monounsaturated fatty acids, while sunflower oil is rich in polyunsaturated fatty acids. Both canola and sunflower oil are appropriate dietary oils for Sarah's husband. For lowering the plasma cholesterol levels, the National Heart Foundation of Australia recommends that saturated fat in the diet be replaced with a combination of mono- and polyunsaturated fats. Cholesterol content of foods does increases LDL cholesterol. LDL cholesterol is directly related to the amount of saturated and trans fat contents of dietary intake. Reference(s) + http://www.heartfoundation.org.au/he althy-eating/f janation:+O Infectious Diseases cED + Clinical Pharmacology O Clinical Oncology O Clinical immunology +O Critical Care / Emergency Medicine & General Practice / Public Heal WS) G Fitness to drive & Smoking, alcohol and substance abuse G Heath issues in Aboriginal Australians G Epidemiology and biostatisites + Preventive medicine O Professionalism / Ethics / Medicolegal Issues Items No. of Important Unread per page selected MCQs MCQs MCQs only only 10Question 1696 ID Title Vaccination of an 18-month-old child with history of febrile seizures CO Flag as important Font Size: A A A Tom, 18 months of age is brought to your general practice for vaccination. Today, he has a runny nose and fever of 38.1°C but otherwise is doing well and healthy. He had an episode of febrile seizure 7 months ago when he had an upper respiratory tract infection. Which one of the following vaccine is best to not be given to him today? A Pneumococcal vaccine. B Polio vaccine. c DTPa vaccine. D MMR vaccine. E Influenza vaccine.ee eee ee CO Flag as important Font Size: A A A Tom, 18 months of age is brought to your general practice for vaccination. Today, he has a runny nose and fever of 38.1°C but otherwise is doing well and healthy. He had an episode of febrile seizure 7 months ago when he had an upper respiratory tract infection. Which one of the following vaccine is best to not be given to him today? % (A Pneumococcal vaccine. * © )B__ Polio vaccine. * ()c _— DTPa vaccine. v D MMR vaccine. % ()eE — Influenza vaccine. Ree enc aSOption D is correct Infants and young children are most at risk for febrile seizures. Up to 5% of young children will have a febrile seizure at some time in their life. Febrile seizures happen in children between the ages of 6 months and 5 years, with a peak prevalence between 14 and 18 months of age. About one third of children with one episode of febrile seizure will have at least one more later during childhood. Fevers can be caused by common childhood illnesses like colds, ear infection, roseola, or any other febrile conditions. Although most vaccines can cause a mild fever as an adverse effect, febrile seizures are uncommon after vaccination. However, caution should be exercised about MMR (measles, mumps, and rubella) and MMRV (measles, mumps, rubella, and varicella) vaccines because studies suggest a small increased risk of febrile seizures during the 5 to 12 days after the vaccine. Studies have not shown an increased risk for febrile seizures after the separate varicella (chickenpox) vaccine. For this child with a current mild fever (38.1°C) and history of febrile seizures, it is best to postpone the MMR vaccine to a later date when he is out of his current illness and there is least chance of febrile seizure following vaccination. NOTE — while children with mild illnesses and fever less than 38.5°C can be safely vaccinated, itis still best to avoid the MMR vaccine as precautionary measure in this child. Children with fevers of 38.5°C or higher should receive their vaccines when they have iMpr0VC——s cluld with a current mild fever (38.1°C) ans history of febrile seizures, it is best to postpone the MMR vaccine to a later date when he is out of his current illness and there is least chance of febrile seizure following vaccination. NOTE — while children with mild illnesses and fever less than 38.5°C can be safely vaccinated, itis still best to avoid the MMR vaccine as precautionary measure in this child. Children with fevers of 38.5°C or higher should receive their vaccines when they have improved. One specific formulation of trivalent influenza vaccine (TIV) had a link with febrile seizures in the past, especially if co-administered with pneumococcal vaccine, but current TIV formulations (option E) do not cause febrile seizures, nor does the pneumococcal vaccine (option A). Currently, there is no evidence to link Polio vaccine (option B) or DTPa vaccine (option C) to febrile seizures. NOTE - febrile convulsion following vaccination is not a contraindication to vaccination. Reference(s) RACGP - AJGP - Seizures following vacci nation in children: Risks, outcomes and management of subsequent revaccinati onQuestion 1640 1D Title The health topic to cover for 13-year-old children at school (Flag as important Font Size: A A A You, as a GP, are assigned to give a lecture in a girls’ high school. At school, you are told that girls you will be talking to today are 13 years old, and that sex education topic has already been covered by another doctor. Which one of the following topics is the most important one you would consider to cover at this session? A Sunscreening. B Regular cancer screening. c Bullying. D Cervical screening. E AlcoholCO tlag as important Font Size: A A A You, as a GP, are assigned to give a lecture in a girls’ high school. At school, you are told that girls you will be talking to today are 13 years old, and that sex education topic has already been covered by another doctor. Which one of the following topics is the most important one you would consider to cover at this session? ¥ OA. Sunscreening. x B Regular cancer screening. x c Bullying. *% (© )D_— Cervical screening. * Oe Alcohol Cora Ee aOption A is correct According to the RACGP guidelines for age-related health checks in children and young people, promotion of sunscreen use to prevent screen damage and skin cancers in future is the only option that should be covered for this age group. The following are the assessment and preventive measures recommended by the RACGP for children aged 6-13 years Assessment: © Measure growth and BMI routinely * Promote oral health Promote healthy eating and drinking ‘Lift the lip’ dental check. Encourage regular dental reviews Promote healthy physical exercise and reduction of sedentary behaviour Enquire about progress at school as an index of wellbeing © When behaviour is a concern, explore possible contributing factors within the family and the wider social environment Preventive counselling and advice © Injury prevention * Promote social and emotional wellbeing * Promote sun protection (Options B and D) Regular cancer screening programs currently in place in Australia are colorectal cancer screening starting at 50 years, breast cancer screening at starting at 50 years, and cervical cancer screening starting at 25 years. No cancer screening topic is recommended to be covered for children 6-19 years.© Promote healthy physical exercise and reduction ci sedentary behaviour Enquire about progress at school as an index of wellbeing © When behaviour is a concern, explore possible contributing factors within the family and the wider social environment Preventive counselling and advice © Injury prevention * Promote social and emotional wellbeing * Promote sun protection (Options B and D) Regular cancer screening programs currently in place in Australia are colorectal cancer screening starting at 50 years, breast cancer screening at starting at 50 years, and cervical cancer screening starting at 25 years. No cancer screening topic is recommended to be covered for children 6-19 years. (Option C) Assessment of progress at school as part of wellbeing is part of preventive programme for children aged 6-19 years; however, bullying by itself is not one of the quoted factors that has to be questioned and covered. (Option E) Alcohol is covered for children aged 14-19 years under the topic ‘healthy eating and drinking’ as is. asking about smoking and provision of a strong anti- smoking message. Reference(s) + RACGP - The Red Book - Preventive act ivities in children and young people Tamer srteyQuessin 1634 1D Title Management of a 7-year-old boy with family history of familial hypercholesterolemia CO Flag as important Font Size: A A A Amother has brought her 7-year-old son for evaluation because her husband has been recently diagnosed with familial hypercholesterolemia and low-density lipoprotein receptor (L.DLR) gene mutation after evaluation for established diagnosis of acute coronary syndrome. She insists that her son undergo genetic testing for the condition. Which one of the following will be the most appropriate next step in management? A Refer the son for LDLR gene mutation testing. B Pre-test counselling. c Send the whole family for LDLR gene mutation testing. D Refer the son to a specialist dietitian. E Refer the mother for LDLR gene mutation testing.Font Size: A A A Amother has brought her 7-year-old son for evaluation because her husband has been recently diagnosed with familial hypercholesterolemia and low-density lipoprotein receptor (LDLR) gene mutation after evaluation for established diagnosis of acute coronary syndrome. She insists that her son undergo genetic testing for the condition. Which one of the following will be the most appropriate next step in management? x A Refer the son for LDLR gene mutation testing. vB | Pre-test counselling. * (© )c Send the whole family for LDLR gene mutation testing. % (© )D __ Refer the son to a specialist dietitian. x — Refer the mother for LDLR gene mutation testing. aoOption B is correct Familial hypercholesterolaemia (FH) is a dominantly inherited condition due to a genetic defect in one of several genes that affect receptor-mediated uptake of low-density lipoprotein (LDL). Affected individuals have metabolic and clinical features including impaired uptake of plasma LDL cholesterol, resulting in high cholesterol levels and increased risk of premature cardiovascular disease. Untreated, men have a 50% chance of coronary heart disease (CHD) before the age of 50 years and women a 30% risk by the age of 60 years. Atherosclerosis caused by FH starts in childhood and adolescence, highlighting the need to identify cases early and commencement of preventive measures. Offspring of FH patients will inherit either the normal gene or the defective gene; therefore, they have a 50% chance of being affected. This leads to quite a high prevalence in the general population. Estimates range between 1:200 and 1:500, but some groups exhibit a “founder gene effect” that enriches the prevalence of the disorder. It is more common in Mediterranean countries, Christian Lebanese, French Canadians and Afrikaner South Africans. In these populations the prevalence may exceed 1:100. The prevalence of homozygous FH is around 1:1 million in the general population. Index cases of FH present with one or more of the following features: © Severe hypercholesterolaemia that is not explained by secondary causes - relative hypercholesterolaemia is present from birth, but levels rise with age * Astrong personal or family history of premature atherosclerotic cardiovascular diseaseeee eRe eter ree EERE rere: EEE SE a’ount! 1:4 million in the general population. Index cases of FH present with one or more of the following features: * Severe hypercholesterolaemia that is not explained by secondary causes - relative hypercholesterolaemia is present from birth, but levels rise with age * Astrong personal or family history of premature atherosclerotic cardiovascular disease * Tendon Xanthomas Although the clinical picture of FH will be clear-cut in many cases, the diagnostic criteria suggest that genetic testing can provide certainty of diagnosis in some cases where confounding factors such as borderline cholesterol levels, inconclusive family histories or tendon injuries have resulted in a diagnostic dilemma. The major value in making a molecular diagnosis is its use in predictive testing of other family members for FH. This is useful in early detection of cases that need intervention to prevent CVD and in re-assuring family members who may not have the condition. Individuals in whom predictive genetic tests are required should be offered pre-test genetic counselling prior to consenting to sample collection for genetic analysis because the genetic testing is expensive and time consuming, and sometimes no mutation can be detected with current methods. These facts should be shared with the patients in full details and informed consent is obtained before proceeding to genetic testing. Since the father is an established case of, there is a 50% chance that the son has the condition as well. The best option after pre-test counselling and informed consent would be referring the son for genetic testing. Reference(s) + Guidelines for the Diagnosis and Manag ement of Familial Hypercholesterolaemia ioehypercholesterolaemia is present from birth, but levels rise with age * Astrong personal or family history of premature atherosclerotic cardiovascular disease Tendon Xanthomas Although the clinical picture of FH will be clear-cut in many cases, the diagnostic criteria suggest that genetic testing can provide certainty of diagnosis in some cases where confounding factors such as borderline cholesterol levels, inconclusive family histories or tendon injuries have resulted in a diagnostic dilemma. The major value in making a molecular diagnosis is its use in predictive testing of other family members for FH. This is useful in early detection of cases that need intervention to prevent CVD and in re-assuring family members who may not have the condition. Individuals in whom predictive genetic tests are required should be offered pre-test genetic counselling prior to consenting to sample collection for genetic analysis because the genetic testing is expensive and time consuming, and sometimes no mutation can be detected with current methods. These facts should be shared with the patients in full details and informed consent is obtained before proceeding to genetic testing Since the father is an established case of, there is a 50% chance that the son has the condition as well. The best option after pre-test counselling and informed consent would be referring the son for genetic testing. Reference(s) + Guidelines for the Diagnosis and Manag ement of Familial Hypercholesterolaemia + RACGP - AFP - Detecting hypercholest erolaemia in general practiceQue: ID Title Management of a 47-year-old man presenting for cholesterol check CO Flag as important Font Size: A A A A 47-year-old man presents for cholesterol check. On examination, he has a blood pressure of 140/90 mmHg. His laboratory studies show a cholesterol level of 6 mmol/L and fasting blood sugar of 5.4 mmol/L. He smokes 20 cigarettes per day and drinks alcohol on weekends and social occasions. Which one of the following would be the most appropriate management of this patient? A Advise that he should start smoking cessation program. B Order an oral glucose tolerance test (OGTT). c Start him on antihypertensive medications. D Start him on statins. E Start him on aspirin.G Fag es unportant Font Size: A A A A 47-year-old man presents for cholesterol check. On examination, he has a blood pressure of 140/90 mmbg. His laboratory studies show a cholesterol level of 6 mmol/L and fasting blood sugar of 5.4 mmol/L. He smokes 20 cigarettes per day and drinks alcohol on weekends and social occasions. Which one of the following would be the most appropriate management of this patient? v (©)A | Advise that he should start smoking cessation program. x B Order an oral glucose tolerance test (OGTT). % © )c__ Start him on antihypertensive medications. % (©)D__ Start him on statins. % (Ee Start him on aspirin.Option A is correct The remarkable findings in this scenario are an upper limit normal for blood pressure both systolic and diastolic (SBP>140mmHg, DBP>90 mmHg), smoking history, and a cholesterol level of 6 mmol/L (normal <5.5 mmol/L) are significant risk factors for cardiovascular diseases. Of the given options, advice that she should start smoking cessation program is the most appropriate one. ‘Smoking is associated with significantly increased risk of cardiovascular disease such as myocardial infarction, stroke, and limb ischemia, as well as other harms to health such as increased risk of various malignancies just to name one. Every smoker should be briefly consulted about benefits of quitting at each visit. This patient has a normal blood glucose and does not any specific interventions for now except; however, based on current Australian guidelines, he should have his blood glucose monitored every 3 years using fasting blood sugar (FBS) or HbA1C. OGGT (option B) is not required now or used as test to monitor this patient for diabetes in the future. He also has slightly elevated cholesterol level for which regular exercise and a healthy diet for 6 months should be advised before decision as to commencement of anti-lipid therapy using statins is made. Therefore, starting him in statins (option D) is not appropriate for now. This patient has systolic and diastolic blood pressures right at the upper limit of normal blood pressure. He can be consider pre-hypertensive and advised for life style modification such as regular exercise, healthy diet (including low salt intake), weight reduction (if overweight or obese), and smoking cessation. At this stage he does not need to be started on hypertensive medications (option C). Genaiallispaasmanatbasopyefor hypertensionmade Therefore, starting him in statins (option D} is not appropriate for now. This patient has systolic and diastolic blood pressures right at the upper limit of normal blood pressure. He can be consider pre-hypertensive and advised for life style modification such as regular exercise, healthy diet (including low salt intake), weight reduction (if overweight or obese), and smoking cessation. At this stage he does not need to be started on hypertensive medications (option C). Generally, pharmacotherapy for hypertension is not considered as long as the blood pressure is less than 160 mmHg (systolic) or 10 mmHg (diastolic). In general, aspirin (option E) is not recommended for primary prevention of cardiovascular diseases in patients with low and moderate cardiovascular risk bases on absolute CVD risk assessment (see the topic review). TOPIC REVIEW Absolute CVD risk assessment In non-aboriginal patients over the age of 45 without cardiovascular disease and aboriginal and Torres Strait Islander patients over the age of 35 without cardiovascular absolute cardiovascular disease (CVD) assessment should be performed. Absolute CVD tisk assessment combines risk factors to calculate the probability of development of cardiovascular event or vascular event within a specified time frame (usually 5 years). Based on calculations, patients fall into either low-risk, medium tisk, or high-risk for CVD. Absolute CVD tisk assessment should be conducted at least every two years. This calculation requires information on the patient's age, sex, smoking status, total and high-density lipoprotein-cholesterol (HDL-C), systolic blood pressure (SBP), and whether the patient is known to have diabetes or left ventricular hypertrophy (LVH). In adults atmaiinainaoiatenteididatials blood test(usually 5 vears). Based on calculations, patients fall into either low-risk, medium risk, or high-risk for CVD. Absolute CVD risk assessment should be conducted at least every two years. This calculation requires information on the patient's age, sex, smoking status, total and high-density lipoprotein-cholesterol (HDL-C), systolic blood pressure (SBP), and whether the patient is known to have diabetes or left ventricular hypertrophy (LVH). In adults at low absolute CVD risk, blood test results within 5 years may be used for review of absolute CVD risk unless there are reasons to the contrary. Adults >74 years of age may have their absolute CVD risk assessed with age entered as 74 years. This is likely to underestimate five-year risk but will give an estimate of minimum risk. Patients with a family history of premature CVD (ina first-degree relative - men aged <55 years, women aged <65 years) or obesity (body mass index [BMI] above 30 kg/m? or more) may be at greater risk. Similarly, patients with depression and atrial fibrillation (AF) may also be at increased risk. Adults with any of the following DO NOTE require absolute CVD risk assessment using the absolute risk calculator, because they are already known to be at clinically determined high risk of CVD: * Diabetes and >60 years of age © Diabetes with microalbuminuria (>20 yg/min or urine albumin-to-creatinine ratio (UACR) >2.5 mg/mmol for males, >3.5 mg/mmol for females) Moderate or severe chronic kidney disease (CKD; persistent proteinuria or estimated glomerular filtration rate [@GFR] <45 mL/min/1.73 m2) Previous diagnosis of familial hypercholesterolemia (FH) Systolic blood pressure (SBP) 2180 mmHg or diastolic blood pressure (DBP) 2110 mmHg Serum total cholesterol >7.5 mmol/L Aboriginal or Torres Strait Islander peoples aged >74 years oS SaFld Neneh tettet alll eetine Me ie! Sibel |e teal armenia Sisnilariy, patients with depression and atrial fibril (AF) may also be at increased risk. Adults with any of the following DO NOTE require absolute CVD risk assessment using the absolute risk calculator, because they are already known to be at clinically determined high risk of CVD: * Diabetes and >60 years of age © Diabetes with microalbuminurta (>20 g/min or 7 viol urine albumin-to-creatinine ratio (UACR) >2.5 ylabebln me mg/mmol for males, >3.5 mg/mmol for females) _ EB Meio claws ™ * Moderate or severe chronic kidney disease (CKD; persistent proteinuria or estimated glomerular filtration rate [@GFR] <45 mL/min/1.73 m2) * Previous diagnosis of familial hypercholesterolemia (FH) * Systolic blood pressure (SBP) 2180 mmHg or diastolic blood pressure (DBP) 2110 mmHg * Serum total cholesterol >7.5 mmol/L * Aboriginal or Torres Strait Islander peoples aged >74 years (Practice Point) According to the RACGP guideline, aspirin is not recommended for low-risk and moderate-risk patients. Also blood pressure lowering and/or lipid-lowering agents should be considered in addition to lifestyle advice if 3-6 + months of lifestyle intervention does not reduce the risk or: * Blood pressure is persistently 160/100 mmHg © There is a family history of premature CVD * Specific population where the absolute CVD risk assessment underestimates the risk such as in Aboriginal and Torres Strait Islander, South Asian, Maori, Pacific Islander and Middle Eastern peoples Lifestyle modification includes: © Smoking cessation (if smoker) © Following a diet rich in vegetables and fruit, low in salt and Sataaciecussdnisgintntiammonths of lifestyle intervention does not reduce the risk oF. * Blood pressure is persistently 2160/100 mmHg © There is a family history of premature CVD © Specific population where the absolute CVD risk assessment underestimates the risk such as in Aboriginal and Torres Strait Islander, South Asian, Maori, Pacific Islander and Middle Eastern peoples Lifestyle modification includes: © Smoking cessation (if smoker) © Following a diet rich in vegetables and fruit, low in ‘salt and saturated and trans fats At least|30 minutes)of_physical activity on most or preferably every day of the week © Limit alcohol intake Reference(s) diovascular disease risk ma nage! mbesessment of TPA aan aRO Ten eaQuestion ID 1582 Title Indications for prescribing PrEP (Flag as important Font Size: A A A As a general practitioner, you are trying to follow the current Australian guidelines to reduce the incidence of HIV infection in your community by administration of Pre-exposure prophylaxis (PrEP) to those who are at risk. Which one of the following is in need for PrEP? A Commercial sex workers. B Intravenous drug users. cE Men who have sex with men. D Female partner of an HIV-positive man with undetectable viral load. E HIV-positive male partner of a female.Font Size: A A A As a general practitioner, you are trying to follow the current Australian guidelines to reduce the incidence of HIV infection in your community by administration of Pre-exposure prophylaxis (PrEP) to those who are at risk. Which one of the following is in need for PrEP? % (A Commercial sex workers. % ()B Intravenous drug users. v c Men who have sex with men. x D Female partner of an HIV-positive man with undetectable viral load. *% ()eE — HIV-positive male partner of a female. ee Reo Uo!Option C is correct PrP is used to significantly reduce the risk of HIV transmission in the community using antiretroviral drugs, Usually tenofovir! emisicitabine, in people who are HIV negative but at a significantly increased risk of HIV infection, ‘One important point to consider is that PrEP is used in those who are currently HIV negative as means of prophylaxis; therefore, those who are already HIV positive do not require PrEP and should be referred for HIV prescription. The following groups are considered to be at “high risk’ if they had these risks in the previous 3 months, or if they foresee these risks in the upcoming 3 months. For such patients, PrEP is recommended: Receptive CLI with any casual male partner ‘* Rectal gonorrhea, rectal chlamydia or infectious syphi Methamphetamine use CLI with a regular HIV-positPEMMEMOTSTOTTERMEMeEMM has a detectable viral load(eer ‘* Receptive CLI with any casual male partner '* Rectal gonorrhea, rectal chlamydia or infectious syphilis ‘* Methamphetamine use CLI with a regular HIV-positive partner who is not on treatment andior has a detectable viral load Deer Receptive CLI with any casual male partner Rectal or vaginal gonorrhea, chlamydia or infectious syphilis, Methamphetamine use CLI with a regular HIV+ partner who is not on treatment andior has a detectable viral load, Receptive CL with any casual MSM partner ‘A woman in a serodiscordant heterosexual relationship, who is planning natural conception in the next 3 months CLI with a regular HIV+ partner who is not on treatment and/or has a detectable viral load‘© Shared injecting equipment with an HIV+ individual or with MSM of unknown HIV status CLE: condomiess intercourse (Of the options, only men who have sex with men (MSM) are high-risk for HIV Infection and require PrEP. (Option A) Commercial sex worker are usually on routine STI follow-up programs and do not require PrEP ‘merely for their carrier. However, once they have any of the high-risk conditions as outlined in the above table, they will require PrEP. (Option B) Unless the intravenous drug user is not sharing needles with an HIV-positive individual or with MSM of unknown HIV status, PrEP is not indicated (Option D) As long as a man has undetectable viral load and take precautionary measures such as use of male condoms, PréP for his female partner is not indicated as the risk of transmission is extremely low. (Option E) Prophylaxis aims to prevent the infection. Once a person is HIV infected, prophylaxis has no point, and treatment with antiretroviral regimens should be started.Question ID 1556 Title Risks of chronic marijuana use (CO Flag as important Font Size: A A A Which one of the following is correct regarding chronic use of marijuana? DA It is associated with decreased incidence of COPD. )B It masks psychosis. oc It reduces anxiety. Dp It impairs the ability to drive. OE It is associated with improves job performance. cone eeeQuestion ID 1556 Title Risks of chronic marijuana use (CO Flag as important FontSize: A A A Which one of the following is correct regarding chronic use of marijuana? % (JA __ Itis associated with decreased incidence of COPD. % ()B__ Itmasks psychosis. *% ()c_ Itreduces anxiety. ¥v ©)p | Itimpairs the ability to drive. *% ()E _ Itis associated with improves job performance. rica Cams} Roa iriOption D is correct - us pi Marijuana is the second most commonly smoked 7 mu) substance worldwide after tobacco. The constituents of marijuana smoke are qualitatively and, to a large extent, quantitatively similar to those of tobacco smoke, with the exceptions of 9-tetrahydrocannabinol (THC), found only in marijuana, and nicotine, found only in tobacco. Given these similarities, there is concern that the health risks of regular marijuana smoking may be similar to those of habitual tobacco smoking. Chronic obstructive pulmonary disease (COPD), which is associated with high morbidity and mortality, is among those risks. Firm conclusions cannot be drawn about the association between use of marijuana and COPD based on the limited and inconsistent data available. The conducted studies are limited by their small numbers of participants and by the uncertain accuracy of self-reported use of marijuana, particularly in view of its illegality and the difficulty of accurately recalling amounts previously used. Some of these studies are also limited by their cross- sectional design, and most are limited by the young age (40 years or younger) of participants. Nevertheless, the consistency of some aspects of the available data allows us to more firmly conclude that smoking marijuana by itself can lead to respiratory symptoms because of injurious effects of the smoke on larger airways. Given the consistently reported absence of an association between use of marijuana and abnormal diffusing capacity, and signs of macroscopic emphysema, it can be close to concluding that smoking marijuana by itself does not lead to COPD. Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use,capacity, and signs of macroscopic emphysema, It can be close tw concluding that smoking marijuana by ase. does not lead to COPD. Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use, the greater the risk. Cannabis use does not mask the psychosis (option B); rather results in it or worsens it. However, in individuals with schizophrenia and other psychoses, a history of cannabis use may be linked to better performance on learning and memory tasks. Cannabis use does not appear to increase the likelihood of developing depression, anxiety, and posttraumatic stress disorder in general; however, evidence suggest that regular cannabis use is likely to increase the risk for developing social anxiety disorder. — In patients diagnosed with bipolar disorders, near daily cannabis use may be linked to greater symptoms of bipolar disorder than for nonusers. Moreover, heavy cannabis users are more likely to report thoughts of suicide than are nonusers. Although there has been no strong link between regular cannabis use and increased incidence of anxiety disorders in general, it has not shown to reduce anxiety (option C) either. Because cannabis use acutely impairs cognitive there is a concern that chronic cannabis use nay Cause chronic cognitive impairment. Such a chronic effect is not necessarily permanent but it can persist even after the elimination of cannabinoids from the body, and therefore would be the result of secondary changes induced by cumulative exposure to cannabinoids. Such chronic effects could produce relatively enduring behavioural deficits which presumably reflect changes in brain function. Given these, cannabis is could potentially decrease the work performance and is not associated with increased work performance (option E)Peete (ciotien C} either. Because cannabis use acutely impairs cognitive processes, there is a concern that chronic cannabis use may cause chronic cognitive impairment. Such a chronic effect is not necessarily permanent but it can persist even after the elimination of cannabinoids from the body, and therefore would be the result of secondary changes induced by cumulative exposure to cannabinoids. Such chronic effects could produce relatively enduring behavioural deficits which presumably reflect changes in brain function. Given these, cannabis is could potentially decrease the work performance and is not associated with increased work performance (option E). Marijuana significantly impairs judgment, motor coordination, and reaction time, and studies have found a direct relationship between blood THC concentration and impaired driving ability. Reference(s) + The Health Effects of Cannabis and Can nabinoids: The Current State of Evidence and Recommendations for Research. + NIH ~ Does marijuana use affects drivi ng? + CMAJ - Does smoking marijuana increa se the risk of chronic obstructive pulmo nary dis-ease? + Australian Government DoH - The heal th and psychological consequences of ca nnabis use - chapter 7Question 1534 1D Title Response to request of a fitness-to-drive certificate from an unfit patient (© Flag as important Font Size: A A A Steven is {en \ear-old patient of yours, who has presented a year and a half ago for a health review before enewal of his driver's license. Your examination revealed 6/24 vision for his both eyes; therefore, you advised that he should not drive anymore and encouraged him to self-report to licensing authorities and is referred for assessment by an ophthalmologist. Today, he has presented again and asks if you could change your mind and give him a letter than he can drive. You examine him again and realize he still has poor eye sight and is unfit to drive. When you tell him so, he becomes irritated and says that last year he saw another doctor who give him a letter and he has been driving since then, and why you cannot just go on and give him a similar letter as well. Which one of the following is the most appropriate action now that you are aware of him driving despite his unfitness to drive? A Call the police. B Call the doctor who issued the letter and -,steven Is a O/-year-old patient of yours, WNO NaS presert=d a year and a half ago for a hezIth rsview before renewal of his driver's license. Your examination revealed 6/24 vision for his both eyes; therefore, you advised that he should not drive anymore and encouraged him to self-report to licensing authorities and is referred for assessment by an ophthalmologist. Today, he has presented again and asks if you could change your mind and give him a letter than he can drive. You examine him again and realize he still has poor eye sight and is unfit to drive. When you tell him so, he becomes irritated and says that last year he saw another doctor who give him a letter and he has been driving since then, and why you cannot just go on and give him a similar letter as well. Which one of the following is the most appropriate action now that you are aware of him driving despite his unfitness to drive? A Call the police. B Call the doctor who issued the letter and ask him why he has done so. c Report the patient to the relevant Road and Traffic department. D Ask him to drive only if there is someone else in the car to supervise him. E It is not your duty to report him to anyone. Just tell him again that he is unfit to drive and has to submit his license to authorities.is the most appropriate action now that you are aware of him driving despite his unfitness to drive? x A Call the police. % (©)B Call the doctor who issued the letter and ask him why he has done so. *% © )c Report the patient to the relevant Road and Traffic department. x Dp Ask him to drive only if there is someone else in the car to supervise him. ¥ (©)E | Itis not your duty to report him to anyone. Just tell him again that he is unfit to drive and has to submit his license to authorities. EVR edOption E is correct According to Australian Road Safety (Austroads), a person is not fit to hold a driver licence if: © The corrected visual acuity (with glasses or contact lenses) is less than 6/12 for the better eye for private vehicle drivers. © The corrected visual acuity is less than 6/18 for the worse eye and less than 6/9 for the better eye. This patient has a visual acuity of 6/24 both eyes which is less than the minimum standard; so, he is not fit to drive for now and should be referred to ophthalmologist or optometrist for clinical assessment with regards to the driving task. Assessment of fitness to drive is one of the most challenging situations in medical practice. On one side is the patient's important issues such as independence, and probably financial issues especially for commercial vehicles drivers, and on the other side is the health and safety of the public. A medical practitioner should be able to balance between their duty to the patient and the duty to act in public's interest. When a patient is likely to pose risk to health and wellbeing of others, it should become ient that driving under their medical condition is dangerous both for him/her and the public. Many patients are likely to choose not to drive when the condition is explained to them in an empathetic and reasonable manner. The patient should also become aware of his/her civil responsibilty to self-report the medical condition to the driver licensing authorities. This discussion and the given advice should be documented in the patient's notes. However, it is important to note that the relationshipmedical condition to the driver licensing authorities. This discussion and the given advice should be documented in the patient's notes. However, it is important to note that the relationship between a patient and the treating doctor is confidential; therefore, doctors will not normally communicate directly with the Driver Licensing Authority and will provide the patient with advice about the ability to drive safely as well as a letter or report to take to the authority. It is not the doctor's duty to report the patient to the police (option A) or driving licensing authority (option C) directly. What they must do though is refusing to sign the ‘fitness to drive’ form and encourage the patient to self-report himself. In terms of the duty to the public, if a doctor believes that patient is not heeding advice to cease driving, he/she may report directly to the Driver Licensing Authority; however, except in South Australia (SA) and Northern Territory (NT) this reporting is not mandatory. In this case, Steven should be clearly made aware of all the risks involved, his responsibility to self-report and not driving. If you form a belief that he will not follow the instructions and is likely to place the public at risk, you may choose to report or must report to authorities depending on the state you are practicing in. (Option C) It is not a doctor's responsibility to investigate other doctors as to their decision and actions. Calling the doctor who allegedly has given the patient a certificate of fitness to drive is beyond a doctor's limits of practice. (Option D) The presence of a supervisor does not make an unfit person fit to drive. Reference(s) + Austroads - A ing Fitness to DriveQuestion 1524 1D Title Management of a 31-year-old woman with established gonorrhea infection CO Flag as important Font Size: A A A A31-year-old woman, sex worker by profession, presents to your practice for a regular check up. Testing for sexually transmissible infections (STIs) shows she has gonorrhea infection. In addition to treating her for gonorrhea, which one of the following would be the next best action? A Trace her sexual contacts in the past 12 months and treat them. B Trace her sexual contacts in the past 6 months and treat them. . Ask her to avoid sex. D Inform the Health Department. E Tell that she should tell her clients to use male condoms.(Flag as important Font Size: A A A A31-year-old woman, sex worker by profession, presents to your practice for a regular check up. Testing for sexually transmissible infections (STIs) shows she has gonorrhea infection. In addition to treating her for gonorrhea, which one of the following would be the next best action? % (A __ Trace her sexual contacts in the past 12 months and treat them. x B Trace her sexual contacts in the past 6 months and treat them. * ©)c__ Ask her to avoid sex. v D___ Inform the Health Department. % ()e _ Tell that she should tell her clients to use male condoms. orOption D is correct Gonorrhea infection is a notifiable disease and confirmed cases should be reported to the relevant health authorities (health department). A confirmed case requires laboratory definitive evidence only. Confirmation may be through isolation of Neisseria gonorrhea, or detection of Neisseria gonorrhoeae by nucleic acid testing, or detection of typical Gram-negative intracellular diplococci in a smear from a genital tract specimen. This woman has confirmed gonorrhea infection and informing the health department is the most appropriate of the options. (Options A and B) Contact tracing of this woman's sexual contacts in the past two months is another important step. The patient can decide to inform their own contacts (patient referral) or organize for someone else to inform them (provider referral). Often, a sex worker is reluctant to disclose the name of his/her clients and provider referral is the method of choice to consider. However, tracing her contacts for the past 6 or 12 months is unnecessary and inappropriate. (Option C) Sex workers should not practice sex until their current STI is adequately treated. In case of HIV infection, they cannot work as a sex worker anymore. Gonorrhea is a curable disease. She should avoid sex as. long as she is infected and undergoing treatment but asking to avoid sex forever is not appropriate. (Option E) Advising male condoms is important but not a priority because protected sex is almost practiced universally in sex industry. Re-emphasizing is a good idea; however, as long as this woman is under treatment for her current infection and within exclusion period, no sex of any kind mushbe practiced because althoughe's to inform them (provider referral). Often, a sc worker is reluctant to disclose the name of his/her clients and provider referral is the method of choice to consider. However, tracing her contacts for the past 6 or 12 months is unnecessary and inappropriate. (Option C) Sex workers should not practice sex until their current STI is adequately treated. In case of HIV infection, they cannot work as a sex worker anymore. Gonorrhea is a curable disease. She should avoid sex as long as she is infected and undergoing treatment but asking to avoid sex forever is not appropriate. (Option E) Advising male condoms is important but not a priority because protected sex is almost practiced universally in sex industry. Re-emphasizing is a good idea; however, as long as this woman is under treatment for her current infection and within exclusion period, no sex of any kind must be practiced because although male condoms reduce the risk of infection transmission to or re-infection from male partners, it does not eliminate the risk. Reference(s) + The Department of Health - Australian national notifiable diseases and case def initions + Health VIC - Notifications procedures f or infectious diseases + MSHC - Screening of sex workers for ST Is and BBV; Policy Procedure + STI Management Guideline - Gonorrho eaQuestion 1522 1D Title Priorities in management of a 25-year-old woman with Chlamydia infection CO Flag as important Font Size: A A A A 25-year-old woman presents with a history of greenish-yellow vaginal discharge. Testing for sexually transmissible infections (STIs) is positive for chlamydia infection. The woman has had multiple sex partners in the past six months. Which one of the following would be the most appropriate advice for her in terms of priority? A Trace all her sexual contacts in the past six months and treat them. B Ask her to bring her most recent sexual contacts for testing and treatment. C Ask her to practice safe sex. D Advise that she should not use intrauterine contraception devices until there is no infection. E Tell that she should report her infection topartners in the past six months. Which one of the follcwirig would be the most appropriate advice fur her in terms of priority? ¥ A | Trace all her sexual contacts in the past six months and treat them. x B Ask her to bring her most recent sexual contacts for testing and treatment. x c__ Ask her to practice safe sex. x D__ Advise that she should not use intrauterine contraception devices until there is no infection. x E Tell that she should report her infection to the relevant health authorities. EVR edOption A is correct Chlamydia infection is a communicable disease and contact tracing is mandatory. For Chlamydia infection, it is recommended that sexual contacts of the index case in the past six months be traced and treated if infected. Initiation of contact tracing is the responsibility of the diagnosing physician. Contact tracing starts with a conversation with the patient about informing their partners. The patient can decide to inform their own contacts (patient referral) or organize for someone else to inform them (provider referral). Patient referral is the most common type of contact tracing used in general practice. For this type of contact tracing to be successful, itis important that the diagnosing doctor informs the patient about who needs to be informed and what information needs to be given. If the patient decides to use provider referral, the diagnosing doctor can collect the contacts’ details and either notify the contacts directly or pass the details to a practice nurse or a sexual health clinic who can undertake this. NOTE - Currently in Victoria, reporting Chlamydia infection is the responsibilty of the testing laboratories, not the doctor. (Option B) This patient's sexual contacts in the past six months must be traced. Only testing and treating her most recent contacts is inadequate and inappropriate. (Option C) Asking the patient to practice safe sex is an essential part of consultation but not the most appropriate option here. This woman should avoid sex until the infection is treated. Her current partner(s) should also be treated to reduce the risk of re-infection. (Option D) Intrauterine devices are contraindicated in the presence of pelviguinfection.This.natient should beNY TE: ee ee ee ke eee ipfevstan is the responsibilty of the testing laboratories, not the doctor. (Opti mont! most (Opti jon B) This patient's sexual contacts in the past six hs must be traced. Only testing and treating her recent contacts is inadequate and inappropriate. jon C) Asking the patient to practice safe sex is an essential part of consultation but not the most appropriate option here. This woman should avoid sex until the infection is treated. Her current partner(s) should also be treated to reduce the risk of re-infection. (Opti ion D) Intrauterine devices are contraindicated in the presence of pelvic infection. This patient should be advised not to use intrauterine devices while she has the infection but contact tracing should take precedence in priority. (Opti ion E) Chlamydia infection is a notifiable disease, and notifying such diseases is the diagnosing physician’s responsibility not that of the patient Reference(s) « STI Management Guidelines eo + RACGP - AFP - Contact tracing for STIs Rute ieee eae AMEDEX PTY LTD. All Rights RQuestion 1476 1D Title Aiding a 72-year-old depressed patient to quit smoking (© Flag as important Font Size: A A A John is 72 years old and a regular patient of yours in your GP clinic. He has depression and has been treated for that a few times. He also smokes 15-20 cigarettes a day and drinks alcohol in moderation. He is in the clinic today and wants to quit smoking. Which one of the following would be the most important option to consider for him to assist his quitting? A Cognitive behavioral therapy (CBT). B Nicotine replacement therapy (NRT). C Varenicline (Champix®). D Bupropion. E Coping skills and lifestyle counselling.(CO Flag as important FontSiz: A A A John is 72 years old and a regular patient of yours in your GP clinic. He has depression and has been treated for that a few times. He also smokes 15-20 cigarettes a day and drinks alcohol in moderation. He is in the clinic today and wants to quit smoking. Which one of the following would be the most important option to consider for him to assist his quitting? % (A Cognitive behavioral therapy (CBT). ¥v ©)B __ Nicotine replacement therapy (NRT). * ()c__ Varenicline (Champix®). x D Bupropion. % © )E Coping skills and lifestyle counselling.Option B is correct There is a strong association between smoking and depression. Patients with current or past history of depression are approximately twice as likely to be current smokers and smoke more cigarettes per day than those who are not depressed. Quitting is a health priority for smokers with depression because they are at higher risks of smoking related diseases than the general population of smokers. Compared to the general population of smokers, the chances for successful quitting are lower and relapse rates are higher in depressed smokers. Depressed smokers are more nicotine dependent and usually experience more severe withdrawal symptoms. First-line pharmacological treatments for quitting smoking are NRT, bupropion, and varenicline. All these treatments can be used for depressed smokers as well with about the same efficacy. Varenicline (option C) is more effective than bupropion (option D) for quitting, but the additional antidepressant action of bupropion may be beneficial in some cases. However, NRT would be the mainstay of treatment for John because of its safety profile and the fact that depressed smokers are more nicotine dependent. On the other hand, nicotine has some antidepressant effects as well. Varenicline or bupropion, if given along with NRT can provide additional benefits. The combination of a nicotine patch with a quick acting form of nicotine such as gum or lozenge and precessation use of nicotine patches are likely to increase success rates further. CBT (option A) is a good option to address the depression and has been shown to be of a small positive effect on quitting. The effect is greater for patients with recurrent episode of depression. CBT can be consideredSe ee ere eer ree eee rere eee ee some antiepressant effects as well. Varenicline bupropion, if given along with NRT can provide additional benefits. The combination of a nicotine patch with a quick acting form of nicotine such as gum or lozenge and precessation use of nicotine patches are likely to increase success rates further. CBT (option A) is a good option to address the depression and has been shown to be of a small positive effect on quitting. The effect is greater for patients with recurrent episode of depression. CBT can be considered along with NRT for John but is not the most important arm of treatment for him. Coping skills and lifestyle counselling (e.g. exercise, diet, sleep, pleasurable activities) (option E) as well as other psychological strategies such as problem solving, stress management, mindfulness, distraction have been applied and tested for their efficacy but with mixed results and uncertain efficacy. Such measures can be recommended for their overall benefits but not for a definite result for smoking cessation. Reference(s) RACGP - AFP: Smoking and depression ieee eae ee neo)Title Advice on STI screening in a 28-year-old sex worker C Flag as important Font Size: A A A Patricia is a 28-year-old sex worker, working in a licensed brothel. She is in your office for sexual health assessment and receiving a sexual health certificate. In consulting her, which one of the following is the correct advice? A She needs to perform vaginal and anal swabs every 12 months. B She should be screened for chlamydia and gonorrhea using a mid-stream urine every 3 months. Cc She should be screened for hepatitis C infection every 12 months. D She should be screened for chlamydia and gonorrhea using high vaginal swabs every 3 months. E She should be screened for syphilis every 12 months.Font Siz: A A A Patricia is a 28-year-old sex worker, working in a licensed brothel. She is in your office for sexual health assessment and receiving a sexual health certificate. In consulting her, which one of the following is the correct advice? % (© )A_ She needs to perform vaginal and anal swabs every 12 months. x B She should be screened for chlamydia and gonorrhea using a mid-stream urine every 3 months. x Cc She should be screened for hepatitis C infection every 12 months. ¥ © )p__ She should be screened for chlamydia and gonorrhea using high vaginal swabs every 3 months. x — She should be screened for syphilis every 12 months. DsOption D is correct ‘This question asks about requirements by law in order to renew a license for sex work practice, Requirements for such issue is different from current guidelines by the RACGP and STI guidelines in Australia. Based on clinical guidelines, its recommended that high risk individuals for STIs (such as sex. ‘workers) undergo screening every 12 months; however, these guidelines advise that state legislations should be followed regarding the intervals of such tests for legal matters such as issuance or renewal of a sexual health certificate for sex workers. Based on current legislations in Australia, sex workers require to be screened for STIs quarterly (every 3 months) to have their licenses renewed. Lgislations for STI screening are in accordance with the Public Health and Wellbeing Act 2008. Based on this act, sex workers are required to undergo the following tests and measures every 3 months: Blood tests: ‘© Syphilis Antibody ‘© HIV Antigen/Antibody © Hanatitis R enre antinody and SSS SOM CRT a PPTBlood tests: ‘© Syphilis Antibody ‘* HIV Antigen/Antibody '* Hepatitis B core antibody and surface antibody (HBcAb and HBsAb) ‘* Hepatitis A antibody (where appropriate) ‘Swabs (Women): © Chlamydia (High Vaginal Swab) '* Gonorrhea (High Vaginal Swab) '* Trichomoniasis (High Vaginal Swab) (only at first presentation or if the woman is a contact of infection) © Cervical Screening when required as per policy © Gonorrhea (pharyngeal) © Chlamydia (pharyngeal) Genital Examination (Women): ‘© Vulval examination is performed at each visit to exclude visible lesions of genital wart or genital herpes '* Aspeculum examination is not routinely performed on asymptomatic women unless they require a cervical screening ——Genital Examination (Women): ‘© Vulval examination is performed at each visit to exclude visible lesions of genital wart or genital herpes. ‘© Aspeculum examination is not routinely performed on asymptomatic women unless they require a cervical screening ‘© Aspeculum examination should be considered ifthe woman is symplomatic, has experienced 2 ‘condom breakislip, or they have a retained sponge/tampon/condom. Gonorrhea and chlamydia testing for Male Sex Workers: '* As per the policy - Screening of Asymptomatic Men for Sexually Transmitted Infections by Sexual Health Nurses. '* Men must also undergo a genital examination to exclude visible lesions of genital warts and genital herpes, Provision of vaccinations: vaccinations should be advised, when appropriate against: + Hepatitis B © Hepatitis AProvision of vaccinations: vaccinations should be advised, when appropriate against: © Hepatitis B ‘* Hepatitis A Based on current legislation, the only correct option would be high vaginal swabs for chlamydia and ‘gonorrhea testing using Nucleic acid amplification test (NAAT) every 3 months, (Option A) Vaginal swabs should be performed every 3 months for renewal of sex work certificate. Anal swabs are required only i there has been anal sex. (Option 8) If instead of high vaginal swabs, a urine sample is considered, the specimen used should be a first catch urine, not midstream urine. (Option C) Screening for hepatitis C is nat routinely required unless there is high risk for such infection, 2.9, injection drug users. (Option E) Although testing for syphilis is required in sex workers, the interval proposed by law is 3 months, not 12 months.TOPIC REVIEW ‘The following is the recommendation by the RACGP regarding STI screening: Risk assessment of Seen What should be done? Po Low-average risk: Urine, cervical or genital ‘swab polymerase chain reaction (PCR; or self- collected) for chlamydia COpportunisticaly if indicated (evidence is unclear on testing interval) Heterosexual asymptomatic, Up to 29 years of age requesting sexually transmissible infection (STI) check up Consider other infections ‘based on risk assessment Medium-high risk: ‘above ‘Opportunistically if indicated (evidence is unclear on + <20 years of age testing interval) © Rural and remote: Consider other infections, particularly gonorrhea andaren up Medium-high risk: © «20 years of age ‘© Rural and remote, [As above Consider other infections, particularly gonorrhea and syphilis, based on risk assessment ‘Opportunistically if indicated (evidence is unclear on testing interval) Higher risk: '* Aboriginal or Torres Strait Islander peoples, ‘Testing for chlamycia, ‘gonorrhea, syphilis ‘Serology for human immunodeficiency virus (HIV), syphilis and, ifthe person is not vaccinated or immune, hepatitis Aand B Offer hepatitis A and B vaccination Every 12 months (evidence is Unclear on testing interval) Other higher risk: “Testing for chlamycia, Every 12 months (evidence is(Other higher risk: '* People who inject drugs © Sox workers “Testing for chlamydia, gonorrhea, syphilis; Serology for HIV, syphilis; if the person is not vaccinated or immune, hepatitis A and B Offer hepatitis A and B vaccination Hepatitis C testing i the patient injects drugs Every 12 months (evidence is Unclear on testing interval) Highest risk: ‘* Asymptomatic men who have| sex with men Highest risk in those who: ‘© have unprotected anal Urine, throat and rectal swab {or chlamydia PCR ‘Throat and rectal swab for ‘gonorrhea PCR ‘Serology for HIV, syphilis, and, ifthe person is not — + Every 12 months; every 3-6 ‘months in higher risk menHighest risk: Urine, throat and rectal swab | Every 12 months; every 3-6 for chlamydia PCR ths in higher risk men, * Asymptomatic men who have rchlamysia Per eee sex with men Throat and rectal swab for gonorthea PCR Highest risk in those who: ‘Serology for HIV, syphilis. ‘and, ifthe person is not vaccinated or immune, ‘© have unprotected anal sex ‘+ had >10 partners in tits A and B past six months sired © participate in group Offer hepatitis A and B sex or use recreational vaccinations ‘drugs during sex. Reference(s) + Melbourne Sexual Health Centre (MSHC) - Screening of sex workers for STIs and BBV: P lew DrvrechiraQuestion 1461 ID Title Indications for commencement of nicotine replacement therapy © Flag as important Font Size: A A A Ted, 63 years old, is a regular smoker patient of your clinic. Last year, he was diagnosed with chronic obstructive pulmonary disease (COPD) and was advised to give up smoking. On every visit, you have briefly advised him about smoking cessation as the best step thing he can do for his COPD and his health in general, but he did not seem interested. Today he says he has decided to quit and asks for help. He confides in you that he has tried three times before but to no avail because every time he tried to quit, he had severe craving and agitation, so he had to smoke again. He is frustrated and believes there is no way for him to get rid of it. After consulting him regarding his good decision and that there are ways you can help him, you decide to start him on nicotine replacement therapy. Which one of the following is the most important factor in the history supporting such decision? A His failed previous attempts. B Withdrawal symptoms.Font Size: A A A Ted, 63 years old, is a regular smoker patient of your clinic. Last year, he was diagnosed with chronic obstructive pulmonary disease (COPD) and was, advised to give up smoking. On every visit, you have briefly advised him about smoking cessation as the best step thing he can do for his COPD and his health in general, but he did not seem interested. Today he says he has decided to quit and asks for help. He confides in you that he has tried three times before but to no avail because every time he tried to quit, he had severe craving and agitation, so he had to smoke again. He is frustrated and believes there is no way for him to get rid of it. After consulting him regarding his good decision and that there are ways you can help him, you decide to start him on nicotine replacement therapy. Which one of the following is the most important factor in the history supporting such decision? A His failed previous attempts. B Withdrawal symptoms. c His COPD. D His frustration with his failed attempts. E Nicotine replacement therapy is recommended for all patients attempting to quit smoking.best step thing ne Can Go for AlS VU and Ns: heath in general, but he did not seem in‘2resied. Today he says he has decided to quit and asks for help. He confides in you that he has tried three times before but to no avail because every time he tried to quit, he had severe craving and agitation, so he had to smoke again. He is frustrated and believes there is no way for him to get rid of it. After consulting him regarding his good decision and that there are ways you can help him, you decide to start him on nicotine replacement therapy. Which one of the following is the most important factor in the history supporting such decision? x A __ His failed previous attempts. ¥ ©)B Withdrawal symptoms. * ()c — His COPD. *% ©)D__ His frustration with his failed attempts. x E Nicotine replacement therapy is recommended for all patients attempting to quit smoking. En TennOption B is correct The five important steps in consulting every patient with drug, alcohol or smoking problems are known as the 5 ‘A's (ask, assess, advice, assist and arrange). One important part is assessing the degree of dependence to that drug. For smokers trying to quit, assessment of dependence is a key step in management because it determines whether pharmacotherapy (nicotine, bupropion, or varenicline [Champix®]) or a combination of these is required assist the patient in quitting smoking. While patients who are not nicotine dependent are managed non-pharmacologically by counselling, cognitive and behavioral coping strategies, written information (e.g. Quit Pack), those with dependence need pharmacotherapy to increase the chances of successful quit attempt. In assessment of dependence, the following questions should be asked: ¢ How many minutes after waking to you smoke your first cigarette? * How many cigarettes do you smoke a day? * Have you had cravings or withdrawal symptoms in previous quit attempts? The following strongly indicate nicotine dependence and the need for pharmacotherapy: © Smoking with 30 minutes of waking Smoking more than 10 cigarettes a day. * Craving or withdrawal symptoms in previous attempt. Based on the above, Ted requires pharmacotherapy because he has sedassoningunaduagitesion (a symptom ofThe following strongly indicate nicotine dependence and the need for pharmacotherapy: © Smoking with 30 minutes of waking. * Smoking more than 10 cigarettes a day. * Craving or withdrawal symptoms in previous attempt. Based on the above, Ted requires pharmacotherapy because he has had craving and agitation (a symptom of nicotine withdrawal) in previous attempts, indicating nicotine dependence. Other options are bupropion or varenicline that could be added to nicotine based on his condition and preferences. (Option A) failed previous attempts alone do not justify use of pharmacotherapy for Ted. Such failure may have been caused by social and psychological factors, and not necessarily nicotine dependence. Unless there is nicotine dependence, one can still make another attempt to quit without pharmacotherapy. A medical condition (COPD) (option C) does not justify the use of pharmacological therapy for a patient if there is no nicotine dependence, neither does frustration with previous failed attempts (option D) unless withdrawal symptoms have caused such failure. (Option E) Nicotine replacement therapy is only indicated for patients with nicotine dependence. Not all smokers are nicotine dependent. Reference(s)» RACGP - Supporting smoking cessation : A guide for health professionals exes}Question 1457 1D Title Advice regarding screening for a 33-year-old man with famiy history of colorectal cancer © Flag as important Font Siz: A A A Peter, 33 years of age, is concerned about colon cancer because his father had it at the age of 49 and his elder brother at the age of 46 years. He denies any symptoms such as rectal bleeding, altered bowel habits or those related to anemia. Which one of the following would be the most appropriate advice for him regarding colon cancer screening? A Screening with FOBT 2-yearly from the age of 50 years. B Screening with FOBT 2-yearly from the age 40 years. c Screening with yearly FOBT starting from now. D Screening with colonoscopy 5-yearly from the age of 50 years. E Screening with colonoscopy 5-yearly starting from now.FontSize: A A A Peter, 33 years of age, is concerned about colon cancer because his father had it at the age of 49 and his elder brother at the age of 46 years. He denies any symptoms such as rectal bleeding, altered bowel habits or those related to anemia. Which one of the following would be the most appropriate advice for him regarding colon cancer screening? % (A Screening with FOBT 2-yearly from the age of 50 years. ¥ ©)B Screening with FOBT 2-yearly from the age 40 years. x c_ Screening with yearly FOBT starting from now. x D Screening with colonoscopy 5-yearly from the age of 50 years. % ()E — Screening with colonoscopy 5-yearly starting from now.Option B is correct Recommendations for colorectal cancer screening is based on individual risk. The risk categories, criteria, ‘and recommended screening program for colorectal cancer currently in use in Australia (recently updated) is ‘outined in the following table: — average or slightly increased risk: (Relative risk: 1-2); 95-08% of population Asymptomatic people with: '* no personal history of bowel Fecal occult blood test (FOBT) every 2 years beginning from the cancer, colorectal adenomas,| age of 50 years. inflammatory bowel disease ‘or family history of colorectal oRaverage or slightly increased risk: (Relative risk: 1-2); 95-98% of population symptomatic people with: '* no personal history of bowel Fecal occult biood test (FOBT) every 2 years beginning from the cancer, colorectal adenomas,| age of 50 years. inflammatory bowel disease ‘or family history of colorectal cancer oR '* one first-degree or one second-degree relative with ‘colorectal cancer diagnosed ‘aged 255 years NOTE - fore those with a family history of colorectal cancer, as ‘mentioned for this category, itis recommended that 2-yearly, FOBT starts from the age of 45 years, re ee te erentee eter 5 Srey Asymptomatic people with: ' one first-degree relative with colorectal cancer diagnosed ‘aged <55 years oR FOBT every 2 years from 40 to 49 years of age. two first-degree relatives with| ine : me colorectal cancer diagnosed AND at any age Colonoscopy every 5 years from 50 to 74 years of age. oR one first-degree relative AND | at least two second-degree relatives diagnosed with colorectal cancer at any age re neon p ryrae ar hAsymptomatic people with ‘© atleast three first-degree or FOBT every two years from 36 to 44 years of age second-degree relatives ce diagnosed with colorectal cancer at aby age, Colonoscopy every five years from 45 to 74 years of age Peter has two first-degree relatives diagnosed with colorectal cancer. With this in history, he falls in category 2, and requires FOBT testing 2-yearly from the age of 45 years until 49, and colonoscopy every 5 year from the age of 50 years. Reference(s) + Australian Journal of General Practice (AJGP) ~ Colorectal cancer screening in Australia An updateQuestion 1453 ID Title Management of unfitness to drive in a 52- year-old man (Flag as important Font Size: A A A Daniel, 52 years old, is in your office with complaint of excessive daytime sleepiness for the past six months. He says he has never felt his night sleeps refreshing enough, and he takes every opportunity to take a nap during the day. On further questioning, he admits to snoring and that some nights his wife leaves the bedroom to sleep on the couch in the living room because his snoring does not let her sleep, and in fact, she has made him to see you for this problem. He denies smoking or any other significant medical condition. On examination, his blood pressure is 150/88 mmHg, pulse rate of 80 bpm and respiratory rate of 17 breaths per minute. He has a BMI of 37 and waist circumference of 135 cm. The rest of the examination is inconclusive. You suspect $leep apneavas the diagnosis, and arrange —) for him to see a sleep specialist. You advise him not ) drive until a full assessment is undertaken by the — specialist, including sleep studies. He becomes upset and says he cannot stop driving as this is his job. Which one of the following would be the most appropriate next step to take in this situation? A Explain to him about the serious risks he op) | nc if honot let her sleep, and in fact, she has made him to see you for this problem. He denies smoking ur any other significant medical condition. On examination, his blood pressure is 150/88 mmHg, pulse rate of 80 bpm and respiratory rate of 17 breaths per minute. He has a BMI of 37 and waist circumference of 135 cm. The rest of the examination is inconclusive. You suspect sleep apnea as the diagnosis, and arrange for him to see a sleep specialist. You advise him not to drive until a full assessment is undertaken by the specialist, including sleep studies. He becomes upset and says he cannot stop driving as this is his job. Which one of the following would be the most appropriate next step to take in this situation? A Explain to him about the serious risks he could pose to himself and others if he keeps driving while he is untreated. B Ask him to report his condition to the relevant driver licensing authority. € Inform the driver licensing authority (DLA). D Ask him to submit his driver's license to you now. E Advise weight reduction to alleviate the condition and decrease the risk of accidents.ETT. PERS POSE OE BIS CACHTIAUUEL 1S HIGUIGIMOIVG. TOM suspect sizep apnea as the diagnosis, aril ar-anje for him to see a sleep specialist. You advise him not to drive until a full assessment is undertaken by the specialist, including sleep studies. He becomes upset and says he cannot stop driving as this is his job. Which one of the following would be the most appropriate next step to take in this situation? YOR Explain to him about the serious risks he could pose to himself and others if he keeps driving while he is untreated. x B Ask him to report his condition to the relevant driver licensing authority. x c Inform the driver licensing authority (DLA). *% (pd Ask him to submit his driver's license to you now. x — Advise weight reduction to alleviate the condition and decrease the risk of accidents.Option A is correct Assessment of fitness to drive is one of the most challenging situations in medical practice. On one side is the patient's important issues such as independence, _and in this case financial problems Daniel will fa prevented from driving as a commercial driver, and on the other side, lies health and safety of the public. A medical practitioner should be able to balance between their duty to the patient and the duty to act in public's interest. In case a patient is likely to pose risk to health and wellbeing of others, the following measures should be taken: STEP 1 - most importantly, it should become clear to the patient that driving under their medical condition is dangerous both for him/her and the public. Many patients are likely to choose not to drive when the condition is explained to them in an empathetic and reasonable manner. STEP 2- the patient should become aware of his/her civil responsibility to self-report the medical condition to the driver licensing authorities. This discussion and the given advice should be documented in the patient's notes. STEP 3- reporting to the licensing authorities if the patient: - © jis unable to understand the impact of their condition; OR * is unable to take notice of the health professional's recommendations due to cognitive impairment; OR * continues driving despite appropriate advice and is likely to Crederqentressetsteme L Elune a fuoromerysexplained to them in an empathetic and reasonable mainer. STEP 2- the patient should become aware of his/her civil responsibilty to self-report the medical condition to the driver licensing authorities. This discussion and the given advice should be documented in the patient's notes. STEP 3 - reporting to the licensing authorities if the patie * is unable to understand the impact of their condition; OR is unable to take notice of the health professional's recommendations due to cognitive impairment; OR continues driving despite appropriate advice and is likely to endanger the public Daniel has the provisional diagnosis of sleep apnea (or other sleep disorders) that has resulted in daytime sleepiness. Driving while drowsy or sleepy poses a significant risk to his or others’ health. This should be explained to him as the first step in management. He should also be asked to self-report to driving licensing authorities (option B). If you find out that Daniel keeps driving despite the advice, you can breach the confidentiality and personally inform the authorities (option C). (Option D) asking a patient to surrender his/her driver's license is not a task of doctors. Doctors are not in a position, legally or morally, to make such a request. (Option E) Weight reduction will benefit Daniel not only for the sleep apnea but also in terms of general health and should be advises; however, it is a long-term management with future results and not likely to resolve his daytime sleepiness in short term. NOTE - The take-home message of this question is that talking to the patient and convincing them to stop driving val inte en odatianesleepiness Driving while drowsy or sleepy poses 4 significant risk to his or others’ health. This should be explained to him as the first step in management. He should also be asked to self-report to driving licensing authorities (option B). If you find out that Daniel keeps driving despite the advice, you can breach the confidentiality and personally inform the authorities (option C). (Option D) asking a patient to surrender his/her driver's license is not a task of doctors. Doctors are not in a position, legally or morally, to make such a request. (Option E) Weight reduction will benefit Daniel not only for the sleep apnea but also in terms of general health and should be advises; however, itis a long-term management with future results and not likely to resolve his daytime sleepiness in short term. NOTE - The take-home message of this question is that talking to the patient and convincing them to stop driving voluntarily and follow your recommendations is always the most important first step to take in cases of unfitness to drive. Reference(s) - Austroads - Assessing Fitness to Drive ieee ae ea EEEQuestion 1449 ID Title Travel advice to an 36-year-old asplenic man (Flag as important Font Size: A A A A 36-year-old man presents to a general practice for advice about vaccination before he goes ona business trip to Cambodia. His past medical history is significant for splenectomy two years ago after he sustained a car accident and had his spleen severely injured. To which one of the following infections would he be most susceptible during this trip? A Dengue fever. B Hepatitis B. C Hepatitis A. D Malaria. E Traveler's diarrhea.Title Travel advice to an 36-year-old asplenic man (Flag as important Font Size: A A A A 36-year-old man presents to a general practice for advice about vaccination before he goes ona business trip to Cambodia. His past medical history is significant for splenectomy two years ago after he sustained a car accident and had his spleen severely injured. To which one of the following infections would he be most susceptible during this trip? % (A __ Dengue fever. * ()B Hepatitis B. *% © )c Hepatitis A. vd Malaria. % (Ee — Traveler's diarrhea.Risk Option D is correct tvifectiow pst- Spiemee Lo pneu oxaceatients who are asplenic (no spleen) or hyposplenic (for example, decreased function of spleen due to ongoing 2- Hib microinfarcts caused by sickle cell disease) are at snl env \dopreased risk of severe septicemia with Streptococcus pneumoniae (S.pneumoniae), Hemophilus influenza type 4. Capnory " (Hib), Neisseria meningitidis, and Capnocytophaga Cow.mox™ “ canimorsus (acquired by dog or cat bites). Infection with ~ these organisms in asplenic (or hyposplenic) individuals is called overwhelming post-splenectomy infection (OPSI). Risk of OPSI is highest in the first two years of splenectomy. S. pneumoniae accounts for approximately 50% of patients. Therefore, itis recommended that all patients receive pneumococcal 23 valent polysaccharide vaccine PPV23 (Pneumovax 23). Itis recommended that the vaccine be given at least 2 weeks before elective splenectomy or, in case of emergency splenectomy, after days but not later than 14 days post-splenectomy (or at discharge). A ®goster dose is required at 5 years Itis # also recommended that such patients receive prophylactic antibiotic (e.g. amoxicillin 250mg/day) until two years after splenectomy. ars afer 6p) Other recommended vaccines are Neisseria meningitidis, Hib, and annual influenza vaccine. The reason for recommending influenza vaccine even though it is not among OPSI, is that influenza infection can result in S. pneumoniae being superimposed. Another important issue to consider for such patients is travel advice and prophylaxis. Although all the given options can pose a risk to the patient's health during his visit to Cambodia, malaria is the most serious condition to take care of. People with asplenia or hyposplenia are at increased risk of severe malaria when traveling to endemic areas. Hewhoutsbe-werisedsfer preventionalso recommended that such patients receive prophylactic antibiotic (e.g. amoxicillin 250mg/day) until two years after splenectomy. Other recommended vaccines are Neisseria meningitidis, Hib, and annual influenza vaccine. The reason for recommending influenza vaccine even though it is not among OPSI, is that influenza infection can result in S. pneumoniae being superimposed. Another important issue to consider for such patients is travel advice and prophylaxis. Although all the given options can pose a risk to the patient's health during his visit to Cambodia, malaria is the most serious condition to take care of. People with asplenia or hyposplenia are at increased risk of severe malaria when traveling to endemic areas. He should be advised for prevention when travelling to a malaria endemic region such as Cambodia. This advice includes vector avoidance (using protective measures such as wearing long sleeved clothing, sleeping in closed and protected areas, and insect repellent), antimalarial medications, and seeking immediate medical advice if there is any symptom. Dengue fever (option A) is endemic in Cambodia and the patient should be advised regarding it; however, health risks caused by this viral infection is almost the same as patients with intact spleen. This is true about hepatitis A (option C), hepatitis B (option B) and traveler's diarrhea (option E). Reference(s) - RACGP - Post-splenectomy infectionQuestion 1314 ID Title The best health predictor in a 55-year-old woman C Flag as important FontSize: A A A Marian, 55 years old, is in your office for consultation. She is obese and has a BMI of 33, waist circumference of 125 and hip circumference of 110cm. Laboratory studies you ordered before show an LDL of 3mmol/L (normal <0.2 mmol/L) and HDL of 0.7 (normal:0.9-1.93 mmol/L). Which one of her physical or biochemical markers is the most important predictor of her health risk? A BMI. B Waist-to-hip ratio. C Waist circumference. D High LDL. E Low HDL.(© Flag as important Font Size: A A A Marian, 55 years old, is in your office for consultation. She is obese and has a BMI of 33, waist circumference of 125 and hip circumference of 110cm. Laboratory studies you ordered before show an LDL of 3mmol/L (normal <0.2 mmol/L) and HDL of 0.7 (normal:0.9-1.93 mmol/L). Which one of her physical or biochemical markers is the most important predictor of her health risk? x Oa BML. ¥ ©)B_ Waist-to-hip ratio. x ic Waist circumference. % © High LDL. x E Low HDL.Option B is correct Waist-to-hip ratio (WHR) has been suggested as the preferred measure of obesity for predicting cardiovascular disease, with more universal application in individuals and population groups of different body builds. This parameter reflects abdominal (central) fat which is strongly associated with ischemic heart disease, hypertension and type II diabetes mellitus. In terms of predicting obesity-related mortality, WHR is more reliable than BMI and waist circumference together. Waist circumference alone comes next and BMI alone last. (Option A) BMI is advocated by World Health Organization (WHO) as the epidemiological measure of obesity; nevertheless, BMI is a crude index that does not take into account the distribution of body fat, resulting in variability in different individuals and populations. For example, individuals with the same BMI may have different ratios of body fat to lean mass. A muscular athlete may have the same BMI of a less muscular person. Women have more body fat than men at equal BMIs and people lose lean tissue with age so an older person will have more body fat than a younger one with same BMI. (Option C) Waist circumference has been recommended as a simple and practical measure for identifying overweight and obese patients, but it does not take into account body size and height. High LDL (option D) and low HDL (option E) are associated with increased cardiovascular disease risk, but these two are not strong predictors per se. For example they are not strong predictors for development of hypertension or insulin resistance. NOTE — for each 1 cm increase in waist circumference, there is an incre risk (RR) foraperson will have more body fat than a younger one with sane BMi. (Option C) Waist circumference has been recommended as a simple and practical measure for identifying overweight and obese patients, but it does not take into account body size and height. High LDL (option D) and low HDL (option E) are associated with increased cardiovascular disease risk, but these two are not strong predictors per se. For example they are not strong predictors for development of hypertension or insulin resistance. NOTE — for each 1 cm increase in waist circumference, there is an increase of 2% in the relative risk (RR) fora cardiovascular event. For a 0.01 unit increase in waist-to- hip ratio, this relative risk is 5%. Reference(s)» hitps://v publicati v.nhmrc.gov.au/_files_nhmrc/ ons/att /n57_obesity_gui delines_140630.pdf chme| + https://academic.oup.com/eurheartj/ar ticle/28/7/850/2887789 Hide the correct option ie ees area 1 AMEDEX PTY LTD. Alll Rights Reserved1299 Title Calculation of relative risk (RR) © Flag as important Font Size: A A A In a randomized controlled trial (RCT) conducted to study the effect of aspirin on prevention of coronary artery events among diabetic smokers, the results in the two arms of the study are as follows: ASA group Placebo group | event No coronary 99 98 event Which one of the following is the relative risk of not using ASA? Coronary 1 2 | A 1%. B 2%. c 100%. D 200%. E 50%.artery events among diabetic smokers, the results in the two arms of the study are as follows: ASAgroup Placebo group | event No coronary 99 98 event Which one of the following is the relative risk of not using ASA? Coronary 1 2 | KOA 1%, x B | 2%. x Oc 100%. vd 200%. ROE 50%. ee enueOption D is correct In statistics and epidemiology, relative risk or risk ratio (RR is the ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a non-exposed, comparison group. Of 100 diabetic smokers who are on aspirin, 1 person has developed a coronary event. So the incidence of coronary event in this group is 1% [1/(1+99)x100], while the incidence of coronary events in the group taking placebo instead of aspirin is 2% [2/(2+98)x100] In this scenario the exposure is taking aspirin. Exposed group has a 1% chance of developing a coronary event versus 2% in those who do not take aspirin. The RR is then calculated by dividing the odds of the condition in the exposed group (1%) by that of the non- exposed group: RR= P(exposed) / P(non-exposed) : RR=1% / 2%=0.5 Here, the RR indicates that the odds of developing a coronary event in those diabetic smokers who are on aspirin is half compared to those on placebo. In other words, those who are on aspirin has a 50% risk reduction. Inversely, those who are not taking aspirin are twice as likely to develop a coronary event compared to those who are taking it. So the RR. This means that not taking aspirin is associated with a 200% increase in incidence of coronary events. Reference(s) + http://www.wikihow.com/Calculate-Rel ative-RiskQuestion 1295 ID Title The screening test associated with significant decline in mortality CO Flag as important Font Size: A A A Which one the following test is a mass population screening test which has been demonstrated to reduce cancer mortality significantly? A Annual fecal occult blood testing in people over the age of 50 years. B Annual colposcopy in sexually active women. ic Annual plasma CA125 in post menopausal women. D Annual colonoscopy in siblings of patients with colon cancer. E 2-yearly mammography in women aged 35-45 years.Flag as important Font Size: A A A Which one the following test is a mass population screening test which has been demonstrated to reduce cancer mortality significantly? vA. Annual fecal occult blood testing in people over the age of 50 years. x B Annual colposcopy in sexually active women. x c Annual plasma CA125 in post menopausal women. x Dp Annual colonoscopy in siblings of patients with colon cancer. x E 2-yearly mammography in women aged 35-45 years. exes}