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AKT 5 Flashcards

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1
Q

What does the Civil Aviation Authority (CAA) provide guidelines on?

A

Air travel for people with medical conditions

Please see the link provided.

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2
Q

Patients with unstable angina should _______.

A

not fly

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3
Q

After how many days may a patient fly following an uncomplicated myocardial infarction?

A

7-10 days

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4
Q

What is the recommended waiting period to fly after a complicated myocardial infarction?

A

4-6 weeks

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5
Q

When can a patient fly after coronary artery bypass graft surgery?

A

10-14 days

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6
Q

How soon after percutaneous coronary intervention can a patient fly?

A

3 days

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7
Q

How long should a patient wait to fly after experiencing a stroke?

A

10 days

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8
Q

Under what condition can a stable stroke patient fly within 3 days of the event?

A

If stable

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9
Q

What is the guideline for air travel following pneumonia?

A

Should be clinically improved with no residual infection

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10
Q

What is the absolute contraindication for air travel?

A

Pneumothorax

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11
Q

When can a patient travel after successful drainage of pneumothorax?

A

2 weeks after successful drainage if no residual air

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12
Q

What did the British Thoracic Society previously recommend for air travel after pneumothorax?

A

6 weeks post drainage

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13
Q

What is the maximum gestation period for which most airlines allow travel for a single pregnancy?

A

36 weeks

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14
Q

After how many weeks do most airlines require a certificate confirming normal pregnancy progression?

A

28 weeks

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15
Q

How long should patients avoid travel following abdominal surgery?

A

10 days

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16
Q

How soon can a patient fly after laparoscopic surgery?

A

24 hours

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17
Q

What is the guideline for flying after colonoscopy?

A

24 hours

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18
Q

What is the travel restriction after the application of a plaster cast?

A

24 hours for flights less than 2 hours or 48 hours for longer flights

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19
Q

What is the minimum haemoglobin level for patients to travel without problems?

A

Greater than 8 g/dl

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20
Q

What should be considered alongside haemoglobin levels for travel eligibility?

A

Coexisting condition such as cardiovascular or respiratory disease

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21
Q

What is the recommended treatment for exacerbations of chronic bronchitis?

A

Amoxicillin or tetracycline or clarithromycin

These guidelines are based on current BNF recommendations.

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22
Q

What antibiotic is used for uncomplicated community-acquired pneumonia in patients allergic to penicillin?

A

Doxycycline or clarithromycin

Amoxicillin is the first choice for those not allergic.

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23
Q

Which antibiotic should be added if staphylococci are suspected in pneumonia cases?

A

Flucloxacillin

This applies specifically in cases of influenza.

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24
Q

What is the recommended treatment for pneumonia possibly caused by atypical pathogens?

A

Clarithromycin

This antibiotic targets atypical organisms.

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25
What is the treatment for hospital-acquired pneumonia within 5 days of admission?
Co-amoxiclav or cefuroxime ## Footnote These treatments are for early-onset hospital-acquired infections.
26
What should be administered for hospital-acquired pneumonia more than 5 days after admission?
Piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g., ceftazidime) OR a quinolone (e.g., ciprofloxacin) ## Footnote These options are for late-onset hospital-acquired infections.
27
What is the first-line treatment for lower urinary tract infections?
Trimethoprim or nitrofurantoin ## Footnote Alternatives include amoxicillin or cephalosporin.
28
What antibiotic is recommended for acute pyelonephritis?
Broad-spectrum cephalosporin or quinolone ## Footnote These are used to treat severe urinary tract infections.
29
What is the treatment for acute prostatitis?
Quinolone or trimethoprim ## Footnote These are effective against bacterial prostatitis.
30
What is the recommended treatment for impetigo?
Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread ## Footnote This is based on the extent of the infection.
31
What antibiotic is used for cellulitis in penicillin-allergic patients?
Clarithromycin, erythromycin, or doxycycline ## Footnote Flucloxacillin is the first choice for non-allergic patients.
32
What is the recommended treatment for cellulitis near the eyes or nose?
Co-amoxiclav ## Footnote Alternatives for penicillin-allergic patients include clarithromycin + metronidazole.
33
What antibiotic is used for erysipelas?
Flucloxacillin ## Footnote Alternatives include clarithromycin, erythromycin, or doxycycline for penicillin-allergic patients.
34
What is the treatment for animal or human bites?
Co-amoxiclav ## Footnote Doxycycline + metronidazole is used for penicillin-allergic patients.
35
What is the recommended treatment for mastitis during breastfeeding?
Flucloxacillin ## Footnote This is the first-line treatment for this condition.
36
What antibiotic is recommended for throat infections in penicillin-allergic patients?
Erythromycin alone ## Footnote Phenoxymethylpenicillin is the first choice for non-allergic patients.
37
What is the treatment for sinusitis?
Phenoxymethylpenicillin ## Footnote This antibiotic is effective against sinus infections.
38
What is the first-line treatment for otitis media?
Amoxicillin ## Footnote Erythromycin is used for penicillin-allergic patients.
39
What is the recommended treatment for otitis externa?
Flucloxacillin ## Footnote Erythromycin is the alternative for penicillin-allergic patients.
40
What antibiotic is used for periapical or periodontal abscess?
Amoxicillin ## Footnote This is the first-line treatment for dental abscesses.
41
What is the treatment for acute necrotising ulcerative gingivitis?
Metronidazole ## Footnote This antibiotic targets anaerobic bacteria involved in this condition.
42
What is the treatment for gonorrhoea?
Intramuscular ceftriaxone ## Footnote This is a standard treatment for gonococcal infections.
43
What antibiotic is used for chlamydia?
Doxycycline or azithromycin ## Footnote Both are effective against chlamydial infections.
44
What is the recommended treatment for pelvic inflammatory disease?
Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole ## Footnote This combination addresses polymicrobial infections.
45
What is the treatment for syphilis?
Benzathine benzylpenicillin or doxycycline or erythromycin ## Footnote Benzathine benzylpenicillin is the first-line treatment.
46
What is the recommended treatment for bacterial vaginosis?
Oral or topical metronidazole or topical clindamycin ## Footnote These options are effective in treating bacterial vaginosis.
47
What is the first-line treatment for the first episode of Clostridioides difficile infection?
Oral vancomycin ## Footnote This is the standard treatment for initial episodes.
48
What is the recommended treatment for subsequent episodes of Clostridioides difficile infection?
Oral fidaxomicin ## Footnote This is reserved for recurrent infections.
49
What antibiotic is used for Campylobacter enteritis?
Clarithromycin ## Footnote This antibiotic is effective against Campylobacter jejuni.
50
What is the treatment for non-typhoid Salmonella infections?
Ciprofloxacin ## Footnote This antibiotic is used for severe cases.
51
What is the recommended treatment for Shigellosis?
Ciprofloxacin ## Footnote This antibiotic targets Shigella species effectively.
52
What is Universal Credit?
A general payment designed to help with living costs, replacing multiple existing benefits. ## Footnote Universal Credit is part of an overhaul of the benefits system in the UK.
53
List the benefits that Universal Credit is replacing.
* Child Tax Credit * Housing Benefit * Income Support * income-based Jobseeker's Allowance (JSA) * income-related Employment and Support Allowance (ESA) * Working Tax Credit ## Footnote These benefits are being consolidated into Universal Credit.
54
How must all claims for Universal Credit be made?
Online ## Footnote This requirement reflects the digitalization of the benefits application process.
55
How often is Universal Credit paid?
Monthly or twice a month for some people in Scotland ## Footnote Payment frequency may vary based on location.
56
What are the eligibility criteria for Income Support?
Aged 16-59 years, on low income, working less than 16 hours per week, and not receiving Job Seekers Allowance. ## Footnote Income Support is designed for those with limited working hours.
57
What age range is applicable for Job Seekers Allowance?
From 18 years old to state pension age. ## Footnote Claimants must be capable of working and actively seeking work.
58
What did the Personal Independence Payment (PIP) replace?
Disability Living Allowance (DLA) for adults. ## Footnote PIP is a tax-free benefit for those needing help with personal care or mobility.
59
Who is eligible for Statutory Sick Pay?
Employees unable to work due to illness for more than 4 days in a row. ## Footnote SSP is limited to a maximum of 28 weeks of payment.
60
What replaced Incapacity Benefit for new claimants?
Employment and Support Allowance (ESA). ## Footnote ESA is available for those not entitled to Statutory Sick Pay, including self-employed individuals.
61
At what age can one claim the state pension?
From 66 years, increasing to 67 between 2026 and 2028. ## Footnote State pensions are taxable and can be claimed regardless of other employment.
62
What is the Bereavement Support Payment?
A lump sum followed by 18 monthly payments, replacing 'Bereavement payment' and 'Bereavement allowance'. ## Footnote Eligibility depends on national insurance contributions and the age of the spouse at the time of death.
63
When must a claim for Bereavement Support Payment be made to receive the full amount?
Within 3 months of your partner's death. ## Footnote Claims can be made up to 21 months after death but result in fewer monthly payments.
64
What is a funeral payment?
One-off payment to the partner or parent of the deceased if they are on benefits to help pay for a funeral ## Footnote This payment is designed to assist with funeral costs.
65
What is the Bereavement Support Payment?
Lump sum and then up to 18 monthly payments if they are under the state pension age when their partner died ## Footnote Eligibility depends on national insurance contributions and Child Benefit status.
66
What factors determine the rates of Bereavement Support Payment?
Depends on national insurance contributions and whether the claimant gets Child Benefit ## Footnote Different rates are paid based on these criteria.
67
Who is eligible for the Widowed Parent's Allowance?
Payable to a parent whose husband or wife has died, if they are bringing up a child < 19 years of age and receiving child benefit ## Footnote The deceased partner must have made adequate national insurance contributions.
68
What are the eligibility criteria for the Widowed Parent's Allowance?
Surviving partner is bringing up a child < 19 years of age and receiving child benefit; deceased partner had made adequate national insurance contributions; woman was expecting her late husband's baby ## Footnote Divorcees and those who remarry are not eligible to claim.
69
True or False: A surviving partner can claim Widowed Parent's Allowance if they remarry.
False ## Footnote Remarriage disqualifies an individual from claiming this allowance.
70
What benefits can patients with a chronic illness or cancer claim?
Personal Independence Payment and Attendance Allowance ## Footnote Patients entitled to these benefits must have a disability severe enough to need help with self-care.
71
What is the age requirement for claiming Personal Independence Payment (PIP)?
Under 65 years ## Footnote PIP is specifically for patients under the age of 65.
72
What is Personal Independence Payment (PIP) replacing?
Disability Living Allowance ## Footnote PIP is designed to assist patients with long-term health conditions or disabilities.
73
What are the eligibility requirements for Personal Independence Payment (PIP)?
Long-term health condition or disability, difficulties with daily living or mobility for 3 months, expected to last 9 months ## Footnote Terminally ill patients are exempt from these rules.
74
Is Personal Independence Payment (PIP) means tested?
No ## Footnote PIP is tax-free and not based on income.
75
What are the two components of Personal Independence Payment (PIP)?
* Daily living component * Mobility component
76
What is Attendance Allowance (AA)?
A tax-free allowance for people aged 65 or over needing help with personal care ## Footnote AA is not means tested.
77
How long must a patient have needed help with care to claim Attendance Allowance (AA)?
6 months ## Footnote This requirement is in place to establish the need for assistance.
78
What defines a terminal illness for benefit purposes?
An expectation that the patient will not live for more than 12 months ## Footnote This classification allows for expedited benefit claims.
79
What is the SR1 form used for?
To provide evidence of a terminal illness for benefits claims under the Special Rules ## Footnote It replaced the previous DS1500 form.
80
Who must complete the SR1 form?
A healthcare professional registered with the GMC or NMC ## Footnote This ensures the validity of the medical report.
81
What information is required on the SR1 form?
* Patient's diagnosis * Prognosis * Clinical features * Treatment received or planned
82
What is the time frame for completing and submitting the SR1 form?
Completed within 28 days and submitted to DWP within 28 days of completion ## Footnote If unable to complete in time, a written explanation must be provided.
83
What happens if the SR1 form meets the criteria for the Special Rules?
The patient can claim benefits sooner than usual ## Footnote This is designed to assist terminally ill patients in accessing necessary support.
84
What is universal credit?
A benefit designed to help people meet the cost of living and simplify the welfare system.
85
What benefits are combined into universal credit?
* Child Tax Credit * Housing Benefit * Income Support * Income-based Jobseeker's Allowance (JSA) * Income-related Employment and Support Allowance (ESA) * Working Tax Credit
86
How is universal credit usually received?
Monthly or twice a month in Scotland.
87
Can you apply for the old benefits system?
No, you can no longer apply for the old benefits system.
88
Who is eligible for universal credit?
* Live in the UK * Aged 18 or over with low income or out of work * Have less than £16,000 in savings * Below the age of receiving the state pension * In rare cases, 16 and 17-year-olds can claim
89
What are some circumstances under which 16 and 17-year-olds can claim universal credit?
* They are a carer * Estranged from their parents * Have a child * Unable to work
90
What determines the monthly standard allowance for universal credit?
Age and relationship status: single vs couple.
91
What extra payments can be awarded under universal credit?
* For up to 2 children * For having a disability or caring for a severely disabled person * To help with housing costs
92
How does earning money affect universal credit payments?
Payments reduce as people earn money.
93
What is the work allowance in universal credit?
The amount people can earn before their payment is decreased.
94
Who has a higher work allowance?
* People responsible for children/young people * People with disabilities limiting work
95
What is a supposed benefit of universal credit?
Encourages people to work instead of relying solely on benefits.
96
How does universal credit help people budget?
Monthly payments are designed to help people learn to budget their money.
97
How can people apply for universal credit?
Online.
98
What is a controversial aspect of universal credit regarding payment timing?
People have to wait 5 weeks to receive their first payment.
99
What is a controversial issue related to childcare under universal credit?
Childcare must be paid by parents upfront and is then refunded.
100
How do many disabled people and households fare under universal credit compared to the old system?
They receive less than they did with the old benefits system.
101
What payment policy does universal credit have for children born after April 2017?
It only pays for the first 2 children.
102
What challenge do private tenants face under universal credit?
They find it harder to rent.
103
What did NICE publish in 2012 regarding palliative care?
Guidelines on the use of opioids in palliative care ## Footnote Selected points are listed below. Please see the link for more details.
104
What is the recommended starting treatment for patients with advanced and progressive disease?
Regular oral modified-release (MR) or oral immediate-release morphine ## Footnote Depending on patient preference, with oral immediate-release morphine for breakthrough pain.
105
What is the initial dosage of modified-release morphine for patients without comorbidities?
20-30mg of MR a day with 5mg of oral morphine for breakthrough pain ## Footnote For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required.
106
What should be prescribed to all patients initiating strong opioids?
Laxatives ## Footnote This is to prevent constipation, a common side effect of opioids.
107
What is the recommendation regarding nausea in patients starting strong opioids?
Patients should be advised that nausea is often transient ## Footnote If it persists, then an antiemetic should be offered.
108
What should be considered if drowsiness does not settle in patients on opioids?
Adjustment of the dose should be considered.
109
What year did SIGN issue guidance on the control of pain in adults with cancer?
2008
110
What is the breakthrough dose of morphine according to SIGN guidelines?
One-sixth the daily dose of morphine
111
What should all patients receiving opioids be prescribed according to SIGN?
A laxative
112
Which opioid is preferred for palliative patients with mild-moderate renal impairment?
Oxycodone
113
What opioids are preferred for patients with severe renal impairment?
Alfentanil, buprenorphine, and fentanyl
114
What are the treatment options for metastatic bone pain?
Strong opioids, bisphosphonates, or radiotherapy ## Footnote NSAIDs are not supported by studies for effectiveness in metastatic bone pain.
115
What should be considered for all patients with metastatic bone pain?
Referral to a clinical oncologist for consideration of further treatments such as radiotherapy
116
By what percentage should the next opioid dose be increased?
30-50%
117
In addition to strong opioids, which treatments may be used for metastatic bone pain?
Bisphosphonates and denosumab
118
What are the usually transient side effects of opioids?
Nausea, drowsiness
119
What are the usually persistent side effects of opioids?
Constipation
120
What is the conversion factor from oral codeine to oral morphine?
Divide by 10
121
What is the conversion factor from oral tramadol to oral morphine?
Divide by 10
122
What is the conversion factor from oral morphine to oral oxycodone?
Divide by 1.5-2
123
What does a transdermal fentanyl 12 microgram patch equate to in oral morphine dosage?
Approximately 30 mg oral morphine daily
124
What does a transdermal buprenorphine 10 microgram patch equate to in oral morphine dosage?
Approximately 24 mg oral morphine daily
125
What is the conversion factor from oral morphine to subcutaneous morphine?
Divide by 2
126
What is the conversion factor from oral morphine to subcutaneous diamorphine?
Divide by 3
127
What is the conversion factor from oral oxycodone to subcutaneous diamorphine?
Divide by 1.5
128
What is the primary importance of identifying the cause of nausea and vomiting in palliative care?
To guide choice of anti-emetic therapy.
129
Name the six broad nausea and vomiting syndromes identified in palliative care.
* Reduced gastric motility * Chemically mediated * Visceral/serosal * Raised intra-cranial pressure * Vestibular * Cortical
130
What receptors are related to reduced gastric motility?
* Serotonin (5HT4) * Dopamine (D2)
131
Which syndrome is most frequently opioid-related in palliative care?
Vestibular syndrome.
132
What are the two approaches to choosing drug therapy for nausea and vomiting?
* Empirical * Mechanistic
133
Which first-line medications are recommended for reduced gastric motility?
* Metoclopramide * Domperidone
134
What should be avoided when using metoclopramide?
In cases of complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery.
135
What medications are suggested for chemically mediated nausea and vomiting due to opioid medications?
* Ondansetron * Haloperidol * Levomepromazine
136
What are the first-line treatments for visceral/serosal causes of nausea and vomiting?
* Cyclizine * Levomepromazine
137
What is the first-line treatment for nausea and vomiting due to raised intra-cranial pressure?
Cyclizine.
138
Which medication can be used for raised intra-cranial pressure apart from cyclizine?
Dexamethasone.
139
What is recommended for vestibular-related nausea and vomiting?
Cyclizine as a first-line treatment.
140
What alternative treatments are suggested for refractory vestibular causes?
* Metoclopramide * Prochlorperazine * Atypical antipsychotics (e.g., olanzapine, risperidone)
141
Which medication is useful for anticipatory nausea?
Lorazepam.
142
What is the preferred route of administration for anti-emetics?
Oral.
143
In what situations should the parenteral route of administration be used?
If the patient is vomiting, has issues with malabsorption, or has severe gastric stasis.
144
What can be used if intravenous access is already established?
Intravenous route for anti-emetics.
145
What underlying causes of confusion should be looked for and treated?
* Hypercalcaemia * Infection * Urinary retention * Medication ## Footnote These conditions need to be identified and managed appropriately to address confusion.
146
What is the first choice medication for treating agitation and confusion?
Haloperidol ## Footnote Haloperidol is recommended as the first-line treatment.
147
Name two other options for treating agitation and confusion besides haloperidol.
* Chlorpromazine * Levomepromazine ## Footnote These medications can be considered if haloperidol is not effective.
148
What is the best treatment for agitation or restlessness in the terminal phase of illness?
Midazolam ## Footnote Midazolam is preferred for managing symptoms in the terminal phase.
149
What is chlorpromazine used for?
Licensed for the treatment of intractable hiccups ## Footnote Chlorpromazine is an antipsychotic medication that can be effective in treating severe hiccups.
150
Name two other medications used for hiccups besides chlorpromazine.
* Haloperidol * Gabapentin ## Footnote Haloperidol is an antipsychotic, and gabapentin is typically used for neuropathic pain but has been found useful for hiccups.
151
What role does dexamethasone play in hiccup management?
Used particularly if there are hepatic lesions ## Footnote Dexamethasone is a corticosteroid that can help reduce inflammation and may be used in specific cases of hiccups.
152
True or False: Haloperidol is not used for treating hiccups.
False ## Footnote Haloperidol is one of the medications utilized for managing hiccups.
153
Fill in the blank: _______ is licensed for the treatment of intractable hiccups.
Chlorpromazine ## Footnote Chlorpromazine is specifically noted for its effectiveness in severe cases of hiccups.
154
When should a syringe driver be considered in palliative care?
When a patient is unable to take oral medication due to: * nausea * dysphagia * intestinal obstruction * weakness * coma ## Footnote A syringe driver is a medical device used to deliver medication continuously over a specified period.
155
What are the two main types of syringe drivers used in the UK?
1. Graseby MS16A (blue) - delivery rate in mm per hour 2. Graseby MS26 (green) - delivery rate in mm per 24 hours ## Footnote These syringe drivers are specifically designed for palliative care settings.
156
Which solution is recommended for mixing with certain drugs in syringe drivers?
Sodium chloride 0.9% is recommended for: * granisetron * ketamine * ketorolac * octreotide * ondansetron ## Footnote Water for injection is compatible with the majority of drugs.
157
List commonly used drugs for nausea and vomiting in palliative care.
* cyclizine * levomepromazine * haloperidol * metoclopramide ## Footnote These medications are effective for managing nausea and vomiting symptoms.
158
Which drugs are commonly used for respiratory secretions and bowel colic?
* hyoscine hydrobromide * hyoscine butylbromide * glycopyrronium bromide ## Footnote These drugs help manage secretions and colic pain in palliative patients.
159
What medications are used to address agitation and restlessness?
* midazolam * haloperidol * levomepromazine ## Footnote These drugs are commonly prescribed for managing agitation in palliative care.
160
What is the preferred opioid for pain management in palliative care?
Diamorphine ## Footnote Diamorphine is favored for its efficacy in managing severe pain.
161
Which drugs is diamorphine compatible with?
* dexamethasone * haloperidol * hyoscine butylbromide * hyoscine hydrobromide * levomepromazine * metoclopramide * midazolam ## Footnote This compatibility allows for a more effective pain management regimen.
162
What complication can arise when mixing cyclizine with diamorphine?
Cyclizine may precipitate with diamorphine when given at higher doses ## Footnote This highlights the importance of monitoring drug combinations in palliative care.
163
Which drugs are incompatible with cyclizine?
* clonidine * dexamethasone * hyoscine butylbromide (occasional) * ketamine * ketorolac * metoclopramide * midazolam * octreotide * sodium chloride 0.9% ## Footnote Awareness of these incompatibilities is crucial in medication management.
164
What are common features of Patau syndrome (trisomy 13)?
Microcephalic, small eyes, cleft lip/palate, polydactyly, scalp lesions ## Footnote Patau syndrome is associated with severe developmental issues and multiple congenital anomalies.
165
What are the key features of Edward's syndrome (trisomy 18)?
Micrognathia, low-set ears, rocker bottom feet, overlapping of fingers ## Footnote Edward's syndrome often leads to significant developmental delays and health complications.
166
What are the characteristics of Fragile X syndrome?
Learning difficulties, macrocephaly, long face, large ears, macro-orchidism ## Footnote Fragile X syndrome is the most common inherited cause of intellectual disability.
167
Identify common features of Noonan syndrome.
Webbed neck, pectus excavatum, short stature, pulmonary stenosis ## Footnote Noonan syndrome can affect multiple systems in the body and may have variable expressivity.
168
What features are associated with Pierre-Robin syndrome?
Micrognathia, posterior displacement of the tongue, cleft palate ## Footnote Pierre-Robin syndrome can lead to upper airway obstruction due to the positioning of the tongue.
169
List the common features of Prader-Willi syndrome.
Hypotonia, hypogonadism, obesity ## Footnote Prader-Willi syndrome is characterized by insatiable hunger leading to obesity.
170
What are the key characteristics of William's syndrome?
Short stature, learning difficulties, friendly extrovert personality, transient neonatal hypercalcaemia, supravalvular aortic stenosis ## Footnote William's syndrome is associated with distinctive facial features and cardiovascular issues.
171
What are the features of Cri du chat syndrome?
Characteristic cry, feeding difficulties, learning difficulties, microcephaly, micrognathism, hypertelorism ## Footnote Cri du chat syndrome results from a deletion on chromosome 5 and is named for the distinctive cry of affected infants.
172
True or False: Treacher-Collins syndrome is autosomal recessive.
False ## Footnote Treacher-Collins syndrome is autosomal dominant, often with a family history.
173
What is the traditional hierarchy of evidence in medicine?
Systematic reviews or randomized control trials at the top and case-series/report at the bottom
174
What is a limitation of traditional hierarchies in evidence-based medicine?
They are overly simplistic and do not account for certain research questions that cannot be answered using RCTs
175
What did the Oxford Centre for Evidence-Based Medicine introduce in 2011?
Levels of Evidence system that separates study questions and provides a hierarchy for each
176
What is the highest level of evidence according to the Oxford CEBM Levels of Evidence?
1a - Systematic reviews (with homogeneity) of randomized controlled trials
177
What is the second level of evidence for cohort studies?
2a - Systematic reviews (with homogeneity) of cohort studies
178
What does the GRADE system evaluate?
The quality of evidence in systematic reviews and guidelines
179
What are the four classifications of evidence quality in the GRADE system?
* High * Moderate * Low * Very low
180
What does a 'High' grade in the GRADE system indicate?
Further research is very unlikely to change our confidence in the estimate of effect
181
What does a 'Moderate' grade in the GRADE system indicate?
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
182
What is a 'Low' grade in the GRADE system indicative of?
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
183
What does a 'Very low' grade in the GRADE system signify?
Any estimate of effect is very uncertain
184
What is the first step in the GRADE process?
Formulating a study question and identifying specific outcomes
185
What types of evidence are classified as high in the GRADE system?
Randomised trial
186
What type of study is classified as low quality in the GRADE system?
Observational study
187
What is the classification for any other type of evidence in the GRADE system?
Very low
188
What is one reason to decrease the grade of evidence?
Serious limitation to study quality (- 1) or very serious limitation (- 2)
189
What is one criterion for increasing the grade of evidence?
Strong evidence of association with a significant relative risk of > 2 based on consistent evidence from two or more observational studies (+1)
190
Fill in the blank: The GRADE system is used in the development of _______ clinical guidelines.
NICE
191
What type of evidence is considered high quality?
Randomised trial ## Footnote Randomised trials are designed to minimize bias and establish causation.
192
What type of evidence is considered low quality?
Observational study ## Footnote Observational studies can show associations but cannot establish causation due to potential confounders.
193
What type of evidence is considered very low quality?
Any other evidence ## Footnote This includes anecdotal evidence or expert opinions which lack rigorous methodology.
194
What is the impact on grading if there is a serious limitation to study quality?
Decrease grade by -1 ## Footnote Serious limitations indicate significant concerns regarding the reliability of the study.
195
What is the impact on grading for very serious limitations to study quality?
Decrease grade by -2 ## Footnote Very serious limitations suggest fundamental flaws in the study's design or execution.
196
What is the impact on grading for important inconsistency?
Decrease grade by -1 ## Footnote Inconsistencies in study results can undermine confidence in the findings.
197
What is the impact on grading for some uncertainty about directness?
Decrease grade by -1 ## Footnote Uncertainty about directness indicates that the evidence may not directly apply to the target population or outcome.
198
What is the impact on grading for major uncertainty about directness?
Decrease grade by -2 ## Footnote Major uncertainty about directness can severely limit the applicability of study results.
199
What is the impact on grading for imprecise or sparse data?
Decrease grade by -1 ## Footnote Imprecise data can lead to unreliable conclusions and recommendations.
200
What is the impact on grading for a high probability of reporting bias?
Decrease grade by -1 ## Footnote Reporting bias can distort the reported outcomes and mislead interpretations of the evidence.
201
What increases the grade by +1?
Strong evidence of association with significant relative risk of > 2 based on consistent evidence from two or more observational studies, with no plausible confounders ## Footnote This indicates a potentially strong causal link between exposure and outcome.
202
What increases the grade by +2?
Very strong evidence of association with significant relative risk of > 5 based on direct evidence with no major threats to validity ## Footnote Such evidence strongly supports a causal relationship.
203
What piece of evidence increases the grade by +1?
Evidence of a dose-response gradient ## Footnote A dose-response gradient suggests that as exposure increases, the effect also increases, supporting causation.
204
What increases the grade by +1 regarding confounders?
All plausible confounders would have reduced the effect ## Footnote This indicates that the observed effect is likely a true association rather than an artifact of confounding variables.
205
What is the highest level of research hierarchy?
Systematic reviews (with homogeneity) of randomized controlled trials ## Footnote This level indicates a comprehensive synthesis of multiple high-quality studies.
206
What type of studies fall under level 1b of the research hierarchy?
Individual randomized controlled trials (with narrow confidence interval) ## Footnote These trials provide direct evidence but are limited to their specific conditions.
207
What is an example of a study type in level 2a?
Systematic reviews (with homogeneity) of cohort studies ## Footnote These reviews synthesize findings from multiple cohort studies that demonstrate consistency.
208
What is the difference between level 2b and level 2c?
Level 2b refers to individual cohort studies or low quality randomized controlled trials, while level 2c refers to 'Outcomes' Research; ecological studies ## Footnote Level 2b studies may have methodological weaknesses, whereas level 2c focuses on broader population outcomes.
209
What type of studies are classified under level 3a?
Systematic review (with homogeneity) of case-control studies ## Footnote This level summarizes findings from multiple case-control studies with consistent results.
210
What is included in level 4 of the research hierarchy?
Case series (and poor quality cohort and case-control studies) ## Footnote These studies typically lack rigorous design and may not provide strong evidence.
211
What characterizes level 5 research?
Expert opinion without explicit critical appraisal, or based on physiology, bench research or 'first principles' ## Footnote This level reflects subjective insights rather than empirical evidence.
212
Fill in the blank: Systematic reviews (with homogeneity) of __________ are found at level 1a.
randomized controlled trials ## Footnote These systematic reviews are considered the gold standard in evidence-based research.
213
True or False: Level 3b includes systematic reviews of case-control studies.
False ## Footnote Level 3b refers specifically to individual case-control studies, not systematic reviews.
214
What defines the quality of studies in level 2b?
Low quality randomized controlled trials (e.g. <80% follow-up) ## Footnote These studies may compromise the reliability of their findings due to inadequate participant retention.
215
Fill in the blank: Level __________ encompasses expert opinion without explicit critical appraisal.
5 ## Footnote This level does not rely on systematic evidence, making it less reliable for decision-making.
216
What does validity refer to?
The extent to which something measures what it claims to measure.
217
What is the major distinction in validity?
Internal validity and external validity.
218
How is reliability different from validity?
Reliability is the extent to which an experiment, test, or any measuring procedure yields the same result on repeated trials.
219
What is internal validity?
The confidence that we can place in the cause and effect relationship in a study.
220
What does internal validity assess?
Whether the change in the independent variable caused the observed change in the dependent variable.
221
What is a threat to internal validity related to measurement instruments?
Reliability of measurement instruments.
222
What does regression towards the mean refer to?
Subjects selected based on extreme scores will tend to regress spontaneously towards the mean on subsequent tests.
223
What is experimental mortality?
Loss of participants over time may result in unequal characteristics in two groups.
224
What is instrument obtrusiveness?
The instrument should not affect the data collection, e.g., poorly designed questionnaires.
225
What is manipulation effectiveness?
The independent variable must be manipulated enough so that the effect can be seen.
226
What does history refer to as a threat to internal validity?
Potential for various other influences to get introduced when measurements of the dependent variable occur over time.
227
What is maturation in the context of internal validity?
People mature over time, which may explain the change in a dependent variable.
228
What is measurement sensitisation?
The instrument may affect the way the subject sees the world and may bias future measures.
229
What is measurement instrument learning?
People may get used to the measurement instrument, affecting performance on repeated use.
230
What is external validity?
The degree to which the conclusions in a study would hold for other persons in other places and at other times.
231
What is a threat to external validity related to sample selection?
Representativeness of the sample.
232
What are reactive effects of setting?
Whether the research setting is artificial.
233
What does the effect of testing refer to?
If a pre-test was used that will not be used in the real world, this may affect outcomes.
234
What is multiple treatment inference?
Study's in which subjects receive more than one treatment, and the effects may interact.
235
What is face validity?
The general impression of a test; it appears to test what it is meant to.
236
What is content validity?
The extent to which a test assesses the full content of a subject or area.
237
What does criterion validity involve?
The comparison of tests to see if a new test works as well as an old, accepted method.
238
What is concurrent criterion validity?
The predictor and criterion data are collected at or about the same time.
239
What is predictive criterion validity?
The predictor scores are collected first, followed by criterion data at a later point.
240
What does construct validity measure?
The extent to which a test measures the construct it aims to.
241
What is convergent validity?
A test has convergent validity if it has a high correlation with another test that measures the same construct.
242
What is divergent validity?
A test's divergent validity is demonstrated through a low correlation with a test that measures a different construct.
243
What does reliability imply in statistics?
Consistency of a measure ## Footnote Reliability refers to the degree to which an assessment tool produces stable and consistent results.
244
How is validity determined?
By whether a test accurately measures what it is supposed to measure ## Footnote Validity assesses the extent to which a concept is accurately measured or defined.
245
Are reliability and validity dependent or independent of each other?
Independent of each other ## Footnote A measurement can be valid but not reliable, or reliable but not valid.
246
Can a measurement be valid but not reliable? True or False?
True ## Footnote This means that a test can provide accurate results inconsistently.
247
Provide an example of a measurement that is reliable but not valid.
A pulse oximeter that records oxygen saturations 5% below the true value every time ## Footnote In this case, the device consistently gives the same incorrect reading, making it reliable, but the reading is not valid.
248
What is an example of a reliable measurement?
A pulse oximeter consistently giving a reading 5% below the true value ## Footnote This shows that while the readings are consistent, they do not reflect the actual oxygen saturation levels.
249
What does it mean if a test is not valid?
The reported results do not accurately reflect the true values ## Footnote This indicates that the test fails to measure what it claims to measure.
250
What is the first stage in the Calgary-Cambridge observation guide?
initiating the session ## Footnote This model outlines key stages in a medical consultation.
251
List the stages in the Calgary-Cambridge observation guide
* initiating the session * gathering information * building the relationship * giving information, explaining and planning * closing the session ## Footnote These stages help guide the consultation process.
252
What are the key components of Stewart's patient-centred clinical method?
* exploring both the disease and the illness experience * understanding the whole person * finding common ground * incorporating prevention and health promotion * enhancing the doctor-patient relationship * being realistic (with time and resources) ## Footnote This method emphasizes a holistic approach to patient care.
253
What does Pendleton's consultation approach emphasize regarding the patient's attendance?
define the reason for the patient's attendance (ideas, concerns and expectations) ## Footnote This approach focuses on understanding the patient's perspective.
254
Fill in the blank: Pendleton's approach involves achieving a shared understanding of the problems with the _______.
patient ## Footnote Collaboration with the patient is crucial in this model.
255
What are the areas of competence identified by Fraser?
* interviewing and history-taking * physical examination * diagnosis and problem-solving * patient management * relating to patients * anticipatory care * record keeping ## Footnote These competencies are essential for effective clinical practice.
256
What are the five checkpoints in Neighbour's Inner Consultation model?
* connecting * summarising * handing over * safety netting * housekeeping ## Footnote These checkpoints help ensure a thorough consultation process.
257
What is the main idea of Tuckett's meeting of two experts concept?
the consultation is a meeting between two experts ## Footnote This concept highlights the collaborative nature of the doctor-patient relationship.
258
True or False: According to Tuckett, patients are considered experts in their own illnesses.
True ## Footnote This perspective encourages doctors to value patient input.
259
What is the focus of Stott and Davis's research on consultations?
* management of presenting problems * management of continuing problems * modification of help-seeking behaviour * opportunistic health promotion ## Footnote Their work highlights the broader potential of consultations beyond immediate care.
260
What should the development of a urinary tract infection (UTI) in childhood prompt consideration of?
Possible underlying causes and damage to the kidneys (renal scarring) ## Footnote This is in contrast to adults where such considerations may not be as critical.
261
What does NICE recommend for infants under 6 months with a first UTI that responds to treatment?
An ultrasound within 6 weeks ## Footnote This imaging is critical to rule out underlying issues.
262
Do children over 6 months require imaging for a first UTI that responds to treatment?
No, unless there are features suggestive of an atypical infection or recurrent infection ## Footnote Atypical infections may warrant further investigation.
263
What are features suggestive of an atypical infection in children?
* Seriously ill * Poor urine flow * Abdominal or bladder mass * Raised creatinine * Septicaemia * Failure to respond to treatment within 48 hours * Infection with non-E. coli organisms ## Footnote These features indicate a need for further investigation.
264
What is the purpose of sending urine for microscopy and culture in children with UTI?
To confirm diagnosis, as only 50% of children with a UTI have pyuria ## Footnote Microscopy or dipstick of the urine alone is inadequate for diagnosis.
265
When should a static radioisotope scan (e.g. DMSA) be performed?
4-6 months after initial infection in children with recurrent UTI (usually above 6monthd old) ## Footnote This scan helps to identify renal scars.
266
What does micturating cystourethrography (MCUG) identify?
Vesicoureteric reflux ## Footnote Recommended only for infants younger than 6 months presenting with atypical or recurrent infections.
267
Fill in the blank: Urine should be sent for culture because only _______ of children with a UTI have pyuria.
50% ## Footnote This highlights the importance of culture in accurate diagnosis.
268
True or False: Children over 6 months with a first UTI always require imaging.
False ## Footnote Imaging is only required if there are atypical features.
269
270
What virus most often causes genital herpes?
Herpes simplex virus (HSV) type 2 ## Footnote Cold sores are usually due to HSV type 1.
271
What are the characteristics of primary attacks of genital herpes?
Often severe and associated with fever ## Footnote Subsequent attacks are generally less severe and localized to one site.
272
What are the typical symptoms of genital herpes?
Multiple painful ulcers
273
What bacterium causes syphilis?
Treponema pallidum
274
What are the stages of syphilis infection?
Primary, secondary, and tertiary stages
275
What is a characteristic feature of the primary stage of syphilis?
Painless ulcer (chancre)
276
What is the incubation period for syphilis?
9-90 days
277
What disease is caused by Haemophilus ducreyi?
Chancroid
278
What are the symptoms of chancroid?
Painful genital ulcers and unilateral, painful inguinal lymph node enlargement
279
Describe the characteristics of ulcers caused by chancroid.
Sharply defined, ragged, undermined border
280
What causes lymphogranuloma venereum (LGV)?
Chlamydia trachomatis
281
What are the stages of lymphogranuloma venereum (LGV)?
Stage 1: small painless pustule which later forms an ulcer Stage 2: painful inguinal lymphadenopathy Stage 3: proctocolitis
282
What is the treatment for lymphogranuloma venereum (LGV)?
Doxycycline
283
Name other causes of genital ulcers.
* Behcet's disease * Carcinoma * Granuloma inguinale: Klebsiella granulomatis
284
Granuloma inguinale was previously called what?
Calymmatobacterium granulomatis
285
What is the age range for women offered the NHS Breast Screening Programme?
50-70 years ## Footnote The program offers mammograms every 3 years.
286
How often are women in the NHS Breast Screening Programme offered mammograms?
Every 3 years ## Footnote Women over 70 are encouraged to make their own appointments.
287
How many lives per year is the NHS Breast Screening Programme thought to save?
Around 1,400 lives ## Footnote The effectiveness of the program is regularly debated.
288
What year did NICE publish guidelines on the management of familial breast cancer?
2013 ## Footnote These guidelines detail who needs referral.
289
If a person has only one first-degree or second-degree relative diagnosed with breast cancer, do they need to be referred?
No, unless specific family history factors are present ## Footnote These factors include age of diagnosis < 40 years, bilateral breast cancer, and others.
290
What are the criteria that require referral for familial breast cancer?
* Age of diagnosis < 40 years * Bilateral breast cancer * Male breast cancer * Ovarian cancer * Jewish ancestry * Sarcoma in a relative younger than age 45 years * Glioma or childhood adrenal cortical carcinomas * Complicated patterns of multiple cancers at a young age * Paternal history of breast cancer (two or more relatives on father's side)
291
Who may be offered screening from a younger age due to family history?
Women at increased risk of breast cancer ## Footnote Referral to the breast clinic may be necessary.
292
What is one criterion for referral to the breast clinic related to a first-degree female relative?
Diagnosed with breast cancer at younger than age 40 years ## Footnote This applies to one first-degree male relative diagnosed at any age as well.
293
What is the significance of bilateral breast cancer in familial breast cancer referrals?
One first-degree relative with bilateral breast cancer diagnosed at younger than age 50 years requires referral ## Footnote This indicates a higher risk.
294
What combination of relatives diagnosed with breast cancer requires referral?
* Two first-degree relatives * One first-degree and one second-degree relative * One first-degree or second-degree relative diagnosed with breast cancer and one with ovarian cancer
295
What is the referral requirement if there are three first-degree or second-degree relatives diagnosed with breast cancer?
Referral is required ## Footnote This indicates a significant familial risk.
296
What is the significance of family history in breast cancer screening?
Women with a family history may be offered screening from a younger age.
297
Who should be referred to the breast clinic for further assessment?
Patients with any of the following: * one first-degree female relative diagnosed with breast cancer at younger than age 40 * one first-degree male relative diagnosed with breast cancer at any age * one first-degree relative with bilateral breast cancer diagnosed at younger than age 50 * two first-degree relatives or one first-degree and one second-degree relative diagnosed with breast cancer at any age * one first-degree or second-degree relative diagnosed with breast cancer and one first-degree or second-degree relative diagnosed with ovarian cancer (one should be a first-degree relative) * three first-degree or second-degree relatives diagnosed with breast cancer at any age.
298
Fill in the blank: Women with a family history of breast cancer may begin screening at a _______ age.
younger
299
True or False: A first-degree male relative diagnosed with breast cancer at any age does not warrant referral to the breast clinic.
False
300
What is one criterion for referral involving bilateral breast cancer?
One first-degree relative with bilateral breast cancer diagnosed at younger than age 50.
301
What constitutes a family history of breast cancer that requires referral?
Any of the following: * one first-degree female relative diagnosed at <40 years * one first-degree male relative diagnosed at any age * one first-degree relative with bilateral breast cancer diagnosed at <50 years * two first-degree relatives or one first-degree and one second-degree relative diagnosed at any age * one first-degree or second-degree relative with breast cancer and one with ovarian cancer (one must be first-degree) * three first-degree or second-degree relatives diagnosed at any age.
302
What is an ACE inhibitor?
A medication prescribed for specific conditions related to chronic kidney disease.
303
In which patients are ACE inhibitors prescribed?
Patients with chronic kidney disease and specific albumin:creatinine ratios.
304
What ACR is required for ACE inhibitor prescription in patients with co-existent diabetes?
More than 3 mg/mmol.
305
What ACR is required for ACE inhibitor prescription in patients with co-existent hypertension?
Greater than 30 mg/mmol.
306
What is the ACR threshold for ACE inhibitor prescription in patients without additional conditions?
Greater than 70 mg/mmol.
307
What is proteinuria?
An important marker of chronic kidney disease, especially for diabetic nephropathy ## Footnote Proteinuria indicates the presence of excess protein in urine, which can be a sign of kidney damage.
308
What ratio does NICE recommend for identifying patients with proteinuria?
Albumin:creatinine ratio (ACR) ## Footnote ACR is preferred over protein:creatinine ratio (PCR) due to its greater sensitivity.
309
What is the alternative method for quantifying and monitoring proteinuria?
Protein:creatinine ratio (PCR) ## Footnote While PCR can be used, ACR is specifically recommended for diabetic patients.
310
When should urine reagent strips be used?
They are not recommended unless they express the result as an ACR ## Footnote Reagent strips may not provide accurate quantification of proteinuria.
311
What type of urine sample is recommended for collecting an ACR sample?
A first-pass morning urine specimen ## Footnote Collecting a spot sample avoids the need for a 24-hour urine collection.
312
What is the initial ACR threshold that should be confirmed by a subsequent sample?
Between 3 mg/mmol and 70 mg/mmol ## Footnote If the initial ACR is 70 mg/mmol or more, no repeat sample is needed.
313
What does NICE state about a confirmed ACR of 3 mg/mmol or more?
It is regarded as clinically important proteinuria ## Footnote This threshold indicates a significant health concern.
314
What ACR value warrants referral to a nephrologist unless known to be caused by diabetes?
70 mg/mmol or more ## Footnote Patients already treated for diabetes may not require referral at this level.
315
What combination of ACR and haematuria suggests referral to a nephrologist?
ACR of 30 mg/mmol or more with persistent haematuria ## Footnote Haematuria is indicated by two out of three dipstick tests showing 1+ or more of blood.
316
What should be considered for referral if ACR is between 3-29 mg/mmol?
Persistent haematuria and other risk factors ## Footnote Risk factors include declining eGFR or cardiovascular disease.
317
What are the ACR categories for proteinuria?
* A1 (< 3): Normal to mildly increased * A2 (3-30): Moderately increased * A3 (> 30): Severely increased ## Footnote These categories help classify the severity of proteinuria.
318
What is the frequency of eGFR monitoring for G1A1?
< 1 time per year ## Footnote This indicates the least frequent monitoring for patients in this category.
319
What is the frequency of eGFR monitoring for G4 A3?
3 times per year ## Footnote More frequent monitoring is required as kidney function declines.
320
What class of medications is key in managing proteinuria?
ACE inhibitors or angiotensin II receptor blockers ## Footnote These medications help reduce proteinuria and manage blood pressure.
321
When should ACE inhibitors be used in patients with CKD?
If the ACR is > 30 mg/mmol and in patients with coexistent hypertension ## Footnote These medications are first-line treatments for managing proteinuria.
322
What is the role of SGLT-2 inhibitors in managing proteinuric CKD?
They block reabsorption of glucose and reduce sodium reabsorption ## Footnote This leads to glycosuria, natriuresis, and reduced intraglomerular pressure.
323
Fill in the blank: NICE recommends using the _______ in preference to the protein:creatinine ratio.
albumin:creatinine ratio (ACR) ## Footnote ACR is preferred for its greater sensitivity in detecting proteinuria.
324
What is the eGFR category for normal to mildly increased ACR?
A1 (< 3) ## Footnote ACR refers to Albumin-to-Creatinine Ratio.
325
What is the eGFR category for moderately increased ACR?
A2 (3-30) ## Footnote ACR refers to Albumin-to-Creatinine Ratio.
326
What is the eGFR category for severely increased ACR?
A3 (> 30) ## Footnote ACR refers to Albumin-to-Creatinine Ratio.
327
What is the frequency of monitoring eGFR for a patient with G1A1?
< 1 ## Footnote G1A1 indicates stage 1 CKD with normal to mildly increased ACR.
328
What is the frequency of monitoring eGFR for a patient with G1A2?
1 ## Footnote G1A2 indicates stage 1 CKD with moderately increased ACR.
329
What is the frequency of monitoring eGFR for a patient with G1A3?
> 1 ## Footnote G1A3 indicates stage 1 CKD with severely increased ACR.
330
What is the frequency of monitoring eGFR for a patient with G2A1?
< 1 ## Footnote G2A1 indicates stage 2 CKD with normal to mildly increased ACR.
331
What is the frequency of monitoring eGFR for a patient with G2A2?
1 ## Footnote G2A2 indicates stage 2 CKD with moderately increased ACR.
332
What is the frequency of monitoring eGFR for a patient with G2A3?
>= 1 ## Footnote G2A3 indicates stage 2 CKD with severely increased ACR.
333
What is the frequency of monitoring eGFR for a patient with G3a A1?
1 ## Footnote G3a A1 indicates stage 3a CKD with normal to mildly increased ACR.
334
What is the frequency of monitoring eGFR for a patient with G3a A2?
1 ## Footnote G3a A2 indicates stage 3a CKD with moderately increased ACR.
335
What is the frequency of monitoring eGFR for a patient with G3a A3?
2 ## Footnote G3a A3 indicates stage 3a CKD with severely increased ACR.
336
What is the frequency of monitoring eGFR for a patient with G3b A1?
<= 2 ## Footnote G3b A1 indicates stage 3b CKD with normal to mildly increased ACR.
337
What is the frequency of monitoring eGFR for a patient with G3b A2?
2 ## Footnote G3b A2 indicates stage 3b CKD with moderately increased ACR.
338
What is the frequency of monitoring eGFR for a patient with G3b A3?
>= 2 ## Footnote G3b A3 indicates stage 3b CKD with severely increased ACR.
339
What is the frequency of monitoring eGFR for a patient with G4 A1?
2 ## Footnote G4 A1 indicates stage 4 CKD with normal to mildly increased ACR.
340
What is the frequency of monitoring eGFR for a patient with G4 A2?
2 ## Footnote G4 A2 indicates stage 4 CKD with moderately increased ACR.
341
What is the frequency of monitoring eGFR for a patient with G4 A3?
3 ## Footnote G4 A3 indicates stage 4 CKD with severely increased ACR.
342
What is the frequency of monitoring eGFR for a patient with G5 A1?
< 4 ## Footnote G5 A1 indicates stage 5 CKD with normal to mildly increased ACR.
343
What is the frequency of monitoring eGFR for a patient with G5 A2?
>= 4 ## Footnote G5 A2 indicates stage 5 CKD with moderately increased ACR.
344
What is the frequency of monitoring eGFR for a patient with G5 A3?
>= 4 ## Footnote G5 A3 indicates stage 5 CKD with severely increased ACR.
345
What is chronic kidney disease often diagnosed by?
Abnormal urea and electrolyte results ## Footnote Chronic kidney disease is usually asymptomatic until diagnosed through lab tests.
346
What are common symptoms of late-stage chronic kidney disease?
Possible features include: * Oedema (e.g. ankle swelling, weight gain) * Polyuria * Lethargy * Pruritus (secondary to uraemia) * Anorexia (which may result in weight loss) * Insomnia * Nausea and vomiting * Hypertension ## Footnote Symptoms may develop in patients with undetected late-stage disease.
347
Fill in the blank: Chronic kidney disease is usually _______.
asymptomatic
348
True or False: All patients with chronic kidney disease experience symptoms.
False
349
What is a common feature of chronic kidney disease related to appetite?
Anorexia ## Footnote Anorexia may result in weight loss.
350
What symptom of chronic kidney disease could cause swelling in the ankles?
Oedema
351
List two gastrointestinal symptoms of chronic kidney disease.
Nausea and vomiting ## Footnote These symptoms can significantly affect patient quality of life.
352
What term describes excessive urination as a symptom of chronic kidney disease?
Polyuria
353
Fill in the blank: A common symptom of chronic kidney disease is ________ due to uraemia.
pruritus
354
What is a potential effect of chronic kidney disease on sleep?
Insomnia
355
What cardiovascular symptom may be present in chronic kidney disease?
Hypertension
356
What is the most significant factor causing anaemia in chronic kidney disease (CKD)?
Reduced erythropoietin levels ## Footnote Erythropoietin is a hormone produced by the kidneys that stimulates erythropoiesis in the bone marrow.
357
What type of anaemia is typically observed in patients with CKD?
Normochromic normocytic anaemia ## Footnote This type of anaemia becomes apparent when the GFR is less than 35 ml/min.
358
When does anaemia in CKD become apparent?
When the GFR is less than 35 ml/min ## Footnote Other causes of anaemia should be considered if the GFR is > 60 ml/min.
359
What is the relationship between anaemia in CKD and left ventricular hypertrophy?
Anaemia predisposes to the development of left ventricular hypertrophy ## Footnote This condition is associated with a three-fold increase in mortality in renal patients.
360
What effect do elevated hepcidin levels have in CKD?
Lead to decreased iron absorption and impaired release of stored iron ## Footnote Hepcidin is an acute-phase reactant that increases due to inflammation and reduced renal clearance.
361
What condition can inhibit the conversion of ferric iron to ferrous iron in CKD?
Metabolic acidosis ## Footnote This condition is common in CKD and can reduce iron absorption.
362
What are some causes of anaemia in renal failure?
* Reduced erythropoietin levels * Reduced absorption of iron * Toxic effects of uraemia on bone marrow * Anorexia/nausea due to uraemia * Reduced red cell survival * Blood loss due to capillary fragility * Stress ulceration leading to chronic blood loss
363
What is the target haemoglobin level suggested by the 2011 NICE guidelines for patients with CKD?
10 - 12 g/dl ## Footnote This target is set for managing anaemia in CKD.
364
What should be determined and optimized prior to administering erythropoiesis-stimulating agents (ESA)?
Iron status ## Footnote This step is crucial for effective management of anaemia in CKD.
365
What type of iron supplementation should be offered to patients not on ESAs or haemodialysis?
Oral iron ## Footnote If target Hb levels are not reached within 3 months, patients should switch to IV iron.
366
What is recommended for patients on ESAs or haemodialysis regarding iron supplementation?
Generally require IV iron ## Footnote This is essential for managing iron levels effectively.
367
Which erythropoiesis-stimulating agents (ESA) are mentioned for use in CKD patients?
* Erythropoietin * Darbepoetin ## Footnote These should be used in patients likely to benefit in terms of quality of life and physical function.
368
What is the typical treatment requirement for hypertension in patients with chronic kidney disease (CKD)?
More than two drugs are usually required to treat hypertension in CKD patients.
369
Which class of drugs is considered first-line treatment for hypertension in CKD?
ACE inhibitors
370
In what type of renal disease are ACE inhibitors particularly helpful?
Proteinuric renal disease (e.g. diabetic nephropathy)
371
What effect do ACE inhibitors have on glomerular filtration pressure (GFR)?
They tend to reduce filtration pressure.
372
What is the expected change in GFR and creatinine when using ACE inhibitors?
A small fall in GFR and a rise in creatinine.
373
What does NICE suggest is an acceptable decrease in eGFR when using ACE inhibitors?
Up to 25%
374
What rise in creatinine is considered acceptable according to NICE?
Up to 30%
375
What should be done if a patient's creatinine rises greater than 30%?
Careful monitoring and exclusion of other causes (e.g. NSAIDs).
376
What may indicate underlying renovascular disease in CKD patients?
A rise in creatinine greater than 30%.
377
What is the role of Furosemide in the treatment of hypertension in CKD?
It is useful as an anti-hypertensive, particularly when GFR falls below 45 ml/min.
378
What additional benefit does Furosemide provide for CKD patients?
It lowers serum potassium.
379
What is typically required when administering Furosemide to CKD patients?
High doses are usually required.
380
What should be considered if a CKD patient on Furosemide becomes at risk of dehydration?
Temporarily stopping the drug.
381
Fill in the blank: ACE inhibitors are particularly helpful in _______.
proteinuric renal disease
382
What is the recommended blood pressure management level for adults with type 1 diabetes without albuminuria or metabolic syndrome features?
135/85 mmHg ## Footnote This level applies unless there are specific complications such as albuminuria or metabolic syndrome.
383
What is the recommended blood pressure management level for adults with type 1 diabetes who have albuminuria or 2 or more features of metabolic syndrome?
130/80 mmHg ## Footnote This lower level is recommended to manage increased cardiovascular risks.
384
What is the recommended blood pressure management level for adults with type 1 diabetes without albuminuria or metabolic syndrome features?
135/85 mmHg ## Footnote This level applies unless there are specific complications such as albuminuria or metabolic syndrome.
385
What is the recommended blood pressure management level for adults with type 1 diabetes who have albuminuria or 2 or more features of metabolic syndrome?
130/80 mmHg ## Footnote This lower level is recommended to manage increased cardiovascular risks.
386
What is IgA nephropathy also known as?
Berger's disease
387
What is the commonest cause of glomerulonephritis worldwide?
IgA nephropathy
388
What classically presents as macroscopic haematuria in young people following an upper respiratory tract infection?
IgA nephropathy
389
List three associated conditions of IgA nephropathy.
* alcoholic cirrhosis * coeliac disease/dermatitis herpetiformis * Henoch-Schonlein purpura
390
What is thought to cause IgA nephropathy?
Mesangial deposition of IgA immune complexes
391
What is one significant pathological overlap with IgA nephropathy?
Henoch-Schonlein purpura (HSP)
392
What histological findings are associated with IgA nephropathy?
* mesangial hypercellularity * positive immunofluorescence for IgA & C3
393
What is a typical presentation of a patient with IgA nephropathy?
Young male, recurrent episodes of macroscopic haematuria
394
Is nephrotic range proteinuria common in IgA nephropathy?
No, it is rare
395
Is renal failure common in IgA nephropathy?
No, it is unusual and seen in a minority of patients
396
What differentiates IgA nephropathy from post-streptococcal glomerulonephritis regarding complement levels?
Post-streptococcal glomerulonephritis is associated with low complement levels
397
What is the main symptom in post-streptococcal glomerulonephritis?
Proteinuria (although haematuria can occur)
398
What is typically observed between upper respiratory tract infection (URTI) and the onset of renal problems in post-streptococcal glomerulonephritis?
An interval
399
What is the management for isolated hematuria with minimal proteinuria and a normal GFR in IgA nephropathy?
No treatment needed, only follow-up to check renal function
400
What is the initial treatment for persistent proteinuria above 500 to 1000 mg/day with a normal or slightly reduced GFR?
ACE inhibitors
401
What treatment is indicated for active disease or failure to respond to ACE inhibitors in IgA nephropathy?
Immunosuppression with corticosteroids
402
What percentage of patients with IgA nephropathy develop end-stage renal failure (ESRF)?
25%
403
What is a marker of good prognosis in IgA nephropathy?
Frank haematuria
404
What is the primary presentation of minimal change disease?
Nephrotic syndrome ## Footnote Minimal change disease accounts for 75% of cases in children and 25% in adults.
405
What percentage of minimal change disease cases are idiopathic?
Majority ## Footnote In 10-20% of cases, a cause is identified.
406
List three potential causes of minimal change disease.
* Drugs: NSAIDs, rifampicin * Hodgkin's lymphoma, thymoma * Infectious mononucleosis
407
Describe the pathophysiology of minimal change disease.
T-cell and cytokine-mediated damage to the glomerular basement membrane → polyanion loss ## Footnote This leads to a reduction of electrostatic charge and increased glomerular permeability to serum albumin.
408
What are the key features of minimal change disease?
* Nephrotic syndrome * Normotension * Highly selective proteinuria * Normal glomeruli on light microscopy * Electron microscopy shows fusion of podocytes
409
What is the typical blood pressure finding in minimal change disease?
Normotension ## Footnote Hypertension is rare.
410
What type of proteins leak through the glomerulus in minimal change disease?
Intermediate-sized proteins such as albumin and transferrin
411
What is the first line of management for minimal change disease?
Oral corticosteroids ## Footnote Majority of cases (80%) are steroid-responsive.
412
What is the next step in management for steroid-resistant minimal change disease?
Cyclophosphamide
413
What is the overall prognosis for minimal change disease?
Good ## Footnote Although relapse is common.
414
Approximately what proportion of patients with minimal change disease have frequent relapses that stop before adulthood?
1/3
415
Fill in the blank: In minimal change disease, about 1/3 of patients have _______.
just one episode
416
What findings are observed on renal biopsy for minimal change disease?
Normal glomeruli on light microscopy
417
What does electron microscopy reveal in minimal change disease?
Fusion of podocytes and effacement of foot processes
418
What accounts for around 80% of nephrotic syndrome cases?
Primary glomerulonephritis
419
What type of glomerulonephritis causes 80% of nephrotic syndrome in children?
Minimal change glomerulonephritis
420
What percentage of nephrotic syndrome cases in adults is caused by minimal change glomerulonephritis?
30%
421
List two other types of glomerulonephritis that can cause nephrotic syndrome.
* Membranous glomerulonephritis * Focal segmental glomerulosclerosis
422
What systemic diseases account for about 20% of nephrotic syndrome cases?
* Diabetes mellitus * Systemic lupus erythematosus * Amyloidosis
423
Name two drugs that can cause nephrotic syndrome.
* Gold (sodium aurothiomalate) * Penicillamine
424
What are some other causes of nephrotic syndrome?
* Congenital * Neoplasia: carcinoma, lymphoma, leukaemia, myeloma * Infection: bacterial endocarditis, hepatitis B, malaria
425
Which types of glomerulonephritis cause both nephritis syndrome and nephrotic syndrome?
* Diffuse proliferation GN * Membranoproliferative GN * Post streptococcal GN
426
What are the key symptoms of nephritis syndrome?
* Haematuria * Hypertension
427
What are the key symptoms of nephrotic syndrome?
* Proteinuria * Oedema
428
What is Alport's syndrome usually inherited as?
X-linked dominant pattern ## Footnote Alport's syndrome is primarily passed down through this inheritance pattern.
429
What defect causes Alport's syndrome?
Defect in the gene coding for type IV collagen ## Footnote This defect leads to an abnormal glomerular-basement membrane.
430
In which gender is Alport's syndrome more severe?
Males ## Footnote Females rarely develop renal failure associated with the syndrome.
431
What can cause renal transplant failure in an Alport's patient?
Presence of anti-GBM antibodies ## Footnote This can lead to a Goodpasture's syndrome like picture.
432
At what age does Alport's syndrome usually present?
Childhood
433
List some common features of Alport's syndrome.
* Microscopic haematuria * Progressive renal failure * Bilateral sensorineural deafness * Lenticonus * Retinitis pigmentosa ## Footnote Lenticonus refers to the protrusion of the lens surface into the anterior chamber.
434
What is a characteristic finding on renal biopsy for Alport's syndrome?
Splitting of lamina densa seen on electron microscopy
435
What are the methods used for diagnosing Alport's syndrome?
* Molecular genetic testing * Renal biopsy * Electron microscopy ## Footnote Electron microscopy shows the longitudinal splitting of the lamina densa of the glomerular basement membrane.
436
What is the characteristic appearance of the glomerular basement membrane in Alport's syndrome?
'Basket-weave' appearance
437
What percentage of Alport's syndrome cases are inherited in an autosomal recessive fashion?
10-15% ## Footnote Rare autosomal dominant variants also exist.
438
What is the preferred term for Wegener's granulomatosis?
Granulomatosis with polyangiitis ## Footnote This term reflects updated nomenclature in the medical field.
439
What type of condition is granulomatosis with polyangiitis?
An autoimmune condition ## Footnote It is associated with necrotizing granulomatous vasculitis.
440
Which organs are primarily affected by granulomatosis with polyangiitis?
Upper and lower respiratory tract, kidneys ## Footnote This condition leads to significant complications in these areas.
441
List three features of upper respiratory tract involvement in granulomatosis with polyangiitis.
* Epistaxis * Sinusitis * Nasal crusting
442
List two features of lower respiratory tract involvement in granulomatosis with polyangiitis.
* Dyspnoea * Haemoptysis
443
What is a common renal manifestation in granulomatosis with polyangiitis?
Rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients) ## Footnote This type of glomerulonephritis is characterized by a rapid decline in kidney function.
444
What physical deformity is associated with granulomatosis with polyangiitis?
Saddle-shape nose deformity ## Footnote This deformity results from destruction of nasal cartilage.
445
Name two additional features of granulomatosis with polyangiitis.
* Vasculitic rash * Eye involvement (e.g. proptosis)
446
What percentage of patients with granulomatosis with polyangiitis test positive for cANCA?
> 90% ## Footnote cANCA positivity is a key diagnostic marker.
447
What percentage of patients with granulomatosis with polyangiitis test positive for pANCA?
25% ## Footnote pANCA positivity is less common than cANCA.
448
What imaging study can show a wide variety of presentations in granulomatosis with polyangiitis?
Chest x-ray ## Footnote It may reveal cavitating lesions among other findings.
449
What finding is characteristic of renal biopsy in granulomatosis with polyangiitis?
Epithelial crescents in Bowman's capsule ## Footnote This finding is indicative of severe glomerular damage.
450
What is the primary management for granulomatosis with polyangiitis?
Steroids ## Footnote Steroids are a cornerstone of treatment.
451
What medication has a 90% response rate in treating granulomatosis with polyangiitis?
Cyclophosphamide ## Footnote This immunosuppressive drug is often used in severe cases.
452
What treatment option is used for severe cases of granulomatosis with polyangiitis?
Plasma exchange ## Footnote This procedure may be indicated in life-threatening situations.
453
What is the median survival for patients with granulomatosis with polyangiitis?
8-9 years ## Footnote Survival rates can vary based on treatment and disease severity.
454
What is the preferred term for Churg-Strauss syndrome?
Eosinophilic granulomatosis with polyangiitis (EGPA) ## Footnote EGPA is an ANCA associated small-medium vessel vasculitis.
455
What type of vasculitis is Eosinophilic granulomatosis with polyangiitis (EGPA)?
ANCA associated small-medium vessel vasculitis ## Footnote ANCA stands for anti-neutrophil cytoplasmic antibodies.
456
List three key features of Eosinophilic granulomatosis with polyangiitis (EGPA).
* Asthma * Blood eosinophilia (e.g. > 10%) * Paranasal sinusitis
457
What is the occurrence rate of renal involvement in Eosinophilic granulomatosis with polyangiitis (EGPA)?
Around 20% ## Footnote Renal involvement is one of the features of EGPA.
458
What percentage of patients with Eosinophilic granulomatosis with polyangiitis (EGPA) are pANCA positive?
60% ## Footnote pANCA refers to perinuclear anti-neutrophil cytoplasmic antibodies.
459
True or False: Leukotriene receptor antagonists may precipitate Eosinophilic granulomatosis with polyangiitis (EGPA).
True
460
What is mononeuritis multiplex in the context of Eosinophilic granulomatosis with polyangiitis (EGPA)?
A neurological feature associated with EGPA ## Footnote Mononeuritis multiplex refers to the simultaneous involvement of multiple peripheral nerves.
461
What are Anti-neutrophil cytoplasmic antibodies (ANCA) associated with?
A number of small-vessel vasculitides, including: * granulomatosis with polyangiitis * eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) * microscopic polyangiitis ## Footnote ANCA are critical in diagnosing these conditions.
462
How does the prevalence of ANCA associated vasculitis change with age?
It is more common with increasing age ## Footnote This suggests a potential age-related risk factor for developing the disease.
463
What are common findings in ANCA associated vasculitis?
Common findings include: * renal impairment * respiratory symptoms * systemic symptoms * ear, nose and throat symptoms ## Footnote Each condition has its distinct features but shares these common findings.
464
What causes renal impairment in ANCA associated vasculitis?
Immune complex glomerulonephritis ## Footnote This leads to raised creatinine, haematuria, and proteinuria.
465
List some respiratory symptoms associated with ANCA associated vasculitis.
* dyspnoea * haemoptysis ## Footnote These symptoms reflect lung involvement in the disease.
466
What systemic symptoms are commonly seen in ANCA associated vasculitis?
* fatigue * weight loss * fever ## Footnote These symptoms indicate a systemic inflammatory response.
467
What is a vasculitic rash?
A type of rash that is present only in a minority of patients ## Footnote It is not a common finding in all cases of ANCA associated vasculitis.
468
What ear, nose, and throat symptom is associated with ANCA associated vasculitis?
Sinusitis ## Footnote This reflects the involvement of upper respiratory tract structures.
469
What is the general approach to first-line investigations for ANCA associated vasculitis?
The investigations include: * urinalysis for haematuria and proteinuria * blood tests (urea and creatinine, full blood count, CRP) * ANCA testing * chest x-ray ## Footnote These tests help assess the extent of the disease and organ involvement.
470
What blood tests are typically performed to assess renal impairment in ANCA associated vasculitis?
* urea * creatinine * full blood count * CRP ## Footnote These tests help identify kidney function and any inflammatory response.
471
What are the two main types of ANCA?
* cytoplasmic (cANCA) * perinuclear (pANCA) ## Footnote These types are used to differentiate between various forms of vasculitis.
472
Which condition is primarily associated with cANCA?
Granulomatosis with polyangiitis ## Footnote cANCA is typically seen in this condition.
473
What conditions are associated with pANCA?
* eosinophilic granulomatosis with polyangiitis * ulcerative colitis * primary sclerosing cholangitis * anti-GBM disease * Crohn's disease ## Footnote pANCA is associated with a range of conditions, listed in order of sensitivity.
474
Goodpastures syndrome features
Haemoptysis Systemically unwell: fever, nausea Glomerulonephritis
475
What is primary sclerosing cholangitis?
A biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts.
476
What are the associations of primary sclerosing cholangitis?
* Ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC. * Crohn's disease (much less common association than UC). * HIV.
477
What are the main features of primary sclerosing cholangitis?
* Cholestasis. * Jaundice. * Pruritus. * Raised bilirubin + ALP. * Right upper quadrant pain. * Fatigue.
478
What are the standard diagnostic investigations for primary sclerosing cholangitis?
* Endoscopic retrograde cholangiopancreatography (ERCP). * Magnetic resonance cholangiopancreatography (MRCP).
479
What do ERCP or MRCP show in cases of primary sclerosing cholangitis?
Multiple biliary strictures giving a 'beaded' appearance.
480
What laboratory marker may be positive in primary sclerosing cholangitis?
p-ANCA.
481
What does a liver biopsy show in primary sclerosing cholangitis?
Fibrous, obliterative cholangitis often described as 'onion skin'.
482
What is a major complication of primary sclerosing cholangitis?
Cholangiocarcinoma (in 10%).
483
What is the increased risk associated with primary sclerosing cholangitis?
Increased risk of colorectal cancer.
484
What is primary biliary cholangitis previously referred to as?
Primary biliary cirrhosis ## Footnote This term is now considered outdated.
485
What is the female to male ratio in primary biliary cholangitis?
9:1 ## Footnote Indicates a higher prevalence in females.
486
What is thought to be the aetiology of primary biliary cholangitis?
Autoimmune condition ## Footnote The exact cause is not fully understood.
487
What is the classic presentation of primary biliary cholangitis?
Itching in a middle-aged woman ## Footnote This symptom is often one of the first noticed.
488
List some associations with primary biliary cholangitis.
* Sjogren's syndrome * Rheumatoid arthritis * Systemic sclerosis * Thyroid disease ## Footnote Sjogren's syndrome is seen in up to 80% of patients.
489
What are some early clinical features of primary biliary cholangitis?
* May be asymptomatic * Fatigue * Pruritus ## Footnote Raised ALP on routine LFTs may be the only finding.
490
What are some late clinical features of primary biliary cholangitis?
Liver failure ## Footnote This can occur as the disease progresses.
491
What imaging is required before diagnosing primary biliary cholangitis?
Right upper quadrant ultrasound or MRCP ## Footnote This is to exclude extrahepatic biliary obstruction.
492
What is the first-line management for primary biliary cholangitis?
Ursodeoxycholic acid ## Footnote This treatment slows disease progression and improves symptoms.
493
What medication is used to manage pruritus in primary biliary cholangitis?
Cholestyramine ## Footnote This helps alleviate itching.
494
What is a significant complication associated with primary biliary cholangitis?
Increased risk of hepatocellular carcinoma ## Footnote There is a 20-fold increased risk in affected patients.
495
What percentage of patients with primary biliary cholangitis have anti-mitochondrial antibodies (AMA) M2 subtype?
98% ## Footnote These antibodies are highly specific for the disease.
496
What are some complications of cirrhosis in primary biliary cholangitis?
* Portal hypertension * Ascites * Variceal hemorrhage ## Footnote These complications arise from liver damage.
497
Fill in the blank: The presence of _______ is seen in 30% of patients with primary biliary cholangitis.
Smooth muscle antibodies ## Footnote This can aid in diagnosis.
498
What is the role of liver transplantation in primary biliary cholangitis?
Indicated if bilirubin > 100 ## Footnote PBC is a major indication for liver transplantation.
499
What is a potential issue after liver transplantation for primary biliary cholangitis?
Recurrence in graft ## Footnote This can occur but is usually not a significant problem.
500
What are some clinical features of cholestatic jaundice in primary biliary cholangitis?
* Hyperpigmentation * Xanthelasmas * Xanthomata * Clubbing * Hepatosplenomegaly ## Footnote These features can develop as the disease progresses.

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