General Practice/Public Health Flashcards

Question

A 30-year-old woman is concerned about breast cancer because her mother was diagnosed with breast cancer at the age of 48 years. Clinical examination of the breast is normal. Which one of the following would be the most appropriate advice for her? A. Mammography yealy from the age of 40 years. B. Mammography every 2 years from 50 to 74 years. C. Refer to a surgeon. D. Refer for genetic studies. E. Reassure her that she is not at increased risk of breast cancer

Answer 1

**A. Mammography yealy from the age of 40 years.** With a first-degree relative affected by breast cancer diagnosed before the age of 50, this woman is considered as having **moderate risk for breast cancer**. For such patients yearly screening mammography starting from the age of 40 is the best advice to give. (Option B) Mammography every 2 years is the most appropriate recommendation for general population and those with just slightly increased risk above average for breast cancer. (Option C) Referral to a surgeon would have been indicated if a diagnosis of breast cancer was established. (Option D) Referral for genetic testing is an acceptable step for those women who are likely to have a predisposition for familial forms of breast/ovarian cancer. Referral for genetic testing should be considered once screening tools raise suspicion against strong risks of such cancers. (Option E) Although this woman is not in high-risk category and is categorized as having moderate risk, reassuring is not appropriate because she needs a more extensive surveillance program for breast cancer than general population

Answer 2

**C. Vaccination will reduce her risk of infection regardless of her previous exposure.** Varicella-zoster virus (VZV) is a DNA virus and a member of the herpes virus family. Primary infection with VZV is known as varicella or ‘chickenpox’. Herpes zoster (HZ), or ‘shingles’, is caused by reactivation of latent VZV, which typically resides dormant in the dorsal root or trigeminal nerve ganglia following primary infection. Cranial nerves most commonly involved are 5th cranial nerve (CN V) and 7th cranial nerve (CN VII) resulting in herpes ophthalmicus and Ramsay-Hunt syndrome, respectively. Reactivation of VZV causing HZ is thought to be particularly due to a decline in cellular immunity to the virus, and presents clinically as a unilateral vesicular rash in a dermatomal distribution in most cases. A prodromal phase occurs 48 to 72 hours prior to the appearance of the lesions in 80% of patients. Prodromal symptoms may include headache, photophobia, malaise, and an itching, tingling or severe pain in the affected dermatome. In most patients, HZ is an acute and self-limiting disease, with the rash lasting 10 to 15 days. However, complications can occur, especially in older adults. Post-herpetic neuralgia (PHN), the most frequently faced and debilitating complication of HZ, is a neuropathic pain syndrome that persists or develops after the dermatomal rash has resolved. By definition, PHN is established when pain persists for longer than 3 months after the onset of the rash. Other complications may occur, depending on the site of reactivation. These include ophthalmic disease (such as keratitis and chorioretinitis), neurological complications (e.g. meningoencephalitis and myelitis), secondary bacterial skin infection, scarring and pneumonia. Rarely, disseminated HZ may develop, with widespread vesicular rash, and visceral, central nervous system and pulmonary involvement. Disseminated disease is more common in people who are immunocompromised. Dermatomal pain without the appearance of rash is also documented (zoster siné herpéte). Zostavax® is a live attenuated vaccine formulated from the same VZV vaccine strain (Oka/Merck) as the registered varicella (chickenpox) vaccine Varivax®, but is much more potent (on average, at least 14 times). This higher potency is owed to higher viral titer in Zostavax, and is required to elicit a boost in immune response of adults who usually remain seropositive to VZV following primary infection, but have declining cellular immunity with increasing age. **Zostavax® is used for the prevention of HZ in people>50 years of age.** It is important to note that the registered varicella vaccines are not indicated for use in preventing HZ in older people and Zostavax is not indicated for use in younger people who have not been previously immunized or infected with VZV. Zostavax® is used **solely for prophylaxis in a potentially-exposed asymptomatic patient**. It has no therapeutic effect on established HZ infection or PHN; therefore, not indicated once infection develops. However, if given prophylactically, it can reduces the risk of HZ and PHN. (Option A) A single dose of Zostavax® is recommended for adults ≥60 years of age who have not previously received a dose of it regardless of their childhood VZ vaccination status. Routine serological testing prior to vaccination is not indicated. (Option D) Zostavax® is given regardless of a history of previous varicella (chickenpox) infection; therefore, inquiring about previous chicken pox infection is not required. Routine population-based use of zoster vaccine in persons aged 50–59 years is not recommended. Although the incidence of HZ in persons 50–59 years of age is higher than in younger age groups, and zoster vaccine seems effective in those 50–59 years of age, the likelihood of developing PHN and other complications of HZ is lower in this age group than in those ≥60 years of age. People aged 50–59 years who wish to protect themselves against HZ can be vaccinated; however, the duration of efficacy, and need for a booster dose at a later age, is not yet determined. The routine use of vaccine is not recommended for those younger than 50 years.

Answer 3

**A. Nicotine replacement therapy.** Smoking in pregnancy is the most important preventable cause of a wide range of adverse pregnancy outcomes. Smoking causes obstetric and fetal complications. Furthermore, there is growing evidence that harms can extend into childhood and even adulthood. Unfortunately, most smokers who become pregnant continue to smoke, and most of those who quite relapse after delivery. Pregnancy is a window of opportunity for health professionals to help smokers quit. Women are motivated to protect their baby’s health, and quitting smoking during pregnancy reduces the risk of complications. Interventions during pregnancy are modestly effective and assist 6 in every 100 smokers to quit. Many light smokers quit without assistance when they find out they are pregnant. The remaining smokers may need more intensive treatment. **The Australian Smoking Cessation guidelines recommend that pregnant smokers first try to quit with behavioral counselling and support as the first-line treatment.** Smoking should be addressed at every GP visit during pregnancy in view of its serious health impact. Counselling in pregnancy produces a 4%-6% increase in the quit rate, compared with no counselling. **Nicotine Replacement Therapy (NRT) should then be considered if the patient is unable to succeed without it.** NRT should be used under the supervision of a qualified health professional. Intermittent, short-acting forms of NRT such as the lozenge or mouth spray are recommended to deliver a lower total daily nicotine dose. However, this may result in under-dosing and reduced effectiveness. The guidelines also advise that if patches are used they should be removed at bedtime. Although guidelines recommend the smallest effective dose of nicotine, larger doses or even combination therapy may be required. Adequate doses to relieve cravings and withdrawal symptoms, and a full course of at least 8 weeks treatment are supported. The risks and benefits of NRT during pregnancy should be explained without making the patient unduly concerned. There is no evidence of increased rates of miscarriage, stillbirth, admission to neonatal intensive care unit (NICU) or neonatal death between NRT and control groups. There is currently insufficient evidence to determine whether NRT is safe in pregnancy, but available data and expert opinion suggest it is less harmful than continuing to smoke. This patient should be started on counselling and support (not an option). NRT should be considered if the patient requires it. Australian Smoking Cessation Guidelines recommend against the two prescription medicines for smoking cessation, varenicline and bupropion during pregnancy and breastfeeding. `NOTE - Quitting smoking before conception or in the first trimester results in similar rates of adverse pregnancy outcomes compared with non-smokers; however, quitting at any time during produces health benefits. Quitting before pregnancy also allows the use of full range of pharmacotherapies`

Answer 4

**D. 25-29%.** Assessment of cardiovascular disease (CVD) risk on the basis of the combined effect of multiple risk factors (absolute CVD risk) is more accurate than the use of individual risk factors because the cumulative effects of multiple risk factors may be additive or synergistic. In Australia, 64% of the adult population have 3 or more modifiable risk factors. Since CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy. Absolute risk is the numerical probability of a CVD event occurring within 5 years expressed as a percentage. For example, if one patient’s risk is 15%, he/she could be told he/she has a 15% chance of having a CVD event within the next 5 years. In Australia, the following charts are used for calculation of absolute CVD risk in any given patient. The risk percentages are extracted from Framingham Risk Equation (FRE). It takes into account the following variables for calculation of absolute CVD risk: * Age * Gender * Smoking * Systolic blood pressure * Total cholesterol to HDL ratio `NOTE - Different rules apply to diabetic versus nondiabetic individuals and Aboriginal and Torres Strait Islanders.` These charts are used as follows: Identify the chart relating to the person’s sex, diabetes status, smoking history and age. The charts should be used for all adults aged 45 years or over (and all Aboriginal and Torres Strait Islander adults aged 35 - 74 years) without known history of CVD, and not already known to be at clinically determined high risk. On the chart, choose the cell nearest to the person’s age, systolic blood pressure (SBP) and total cholesterol (TC):HDL ratio. The color of the cell that can be the person falls into provides their 5 year absolute cardiovascular risk level. People who fall exactly on a threshold between cells are placed in the cell indicating higher risk. For those older than 74 years, calculate as if they are 74. This patient is male, non-smoker and 72 years. The part of the chart that should be used for risk calculation is shown in the following picture:

Answer 5

**D. Ischemic stroke.** Although hypertension is a risk factor for all of the given to some extent, it **remains the most important modifiable risk factor for stroke and intracerebral hemorrhage (ICH)**. The risk of stroke increases progressively with increasing blood pressure, independent of other factors. Hypertension is the cause of stroke in >50% cases worldwide. Most estimates for hypertension indicate a relative risk of approximately 4 when hypertension is defined as systolic blood pressure ≥160mmHg and/or diastolic blood pressure ≥95mmHg. Hypertension and hypertensive heart disease results in development of left ventricular hypertrophy and diastolic dysfunction that are important risk factors for atrial fibrillation accounting for 20% of cases. Hypertension is also a major risk factor for coronary artery disease (CAD), and treatment of hypertension reduces the risk of a coronary artery disease by one-third; *however, the most important reversible risk factor for CAD is hypercholesterolemia and cigarette smoking*. Cessation of cigarette smoking is the single most important preventive measure for coronary artery disease. Moreover, smoking has the highest association with peripheral arterial disease.

Answer 6

**E. Hypertension.** All of the given options can be potential risk factors for ischemic stroke; however, hypertension is associated with the highest risk. Hypertension is the cause of stroke in >50% cases worldwide. Most estimates for hypertension indicate a relative risk of approximately 4 when hypertension is defined as systolic blood pressure ≥160mmHg and/or diastolic blood pressure ≥95mmHg. The following table compares the relative risk of different preventable risk factors for stroke: - See table below. `NOTE - Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. Stroke incidence rates are 1.25 times greater in men, but because women tend to live longer than men, more women than men die of stroke each year. Obesity is associated with elevated vascular risk in population studies. Furthermore, it has been associated with glucose intolerance, insulin resistance, hypertension, physical inactivity and dyslipidaemia.` (Option A) Hypercholesterolemia seems to act in a complex fashion and does not directly act as a risk factor; however, it is an important modifiable risk factor for coronary artery disease. (Options B and C) Smoking and obesity are associated with relative risks of 1.5 and 1.5-2.0 respectively. (Option D) Diabetes mellitus is associated with a relative risk of 1.8-3.0.

Answer 7

**E. Cigarette smoking** Major traditional risk factors for cardiovascular diseases are: ****Hypercholesterolemia (high LDL) ****Smoking ****Hypertension ****Diabetes mellitus Other traditional risk factors include: ****Family history of premature coronary artery disease in a first-degree relative (female<65 years; male<55 years) ****Low physical activity ****Obesity Of the options, smoking is a major risk factor for coronary artery disease (CAD). People who smoke more than 20 cigarettes a day have a 2- to 3-fold increase in total incidence of heart disease. Continued smoking is a major risk factor for recurrent heart attack. **Cessation of cigarette smoking is the single most important preventive measure for CAD.** Although family history of premature heart disease (male< 55 years and female< 65 years), low level of physical activity, and obesity are considered risk factors for CAD, these factors work through major risk factors to a large extent. Age, by itself, is not a risk factor unless other major risk factors are present. The incidence of CAD increases after the age of 45 years in men and 55 in women.

Answer 8

**A. Smoking cessation.** By far, the most common cause of coronary artery disease (CAD) is atherosclerotic changes of coronary arteries. The most common underlying cause is hypercholestrolemia (high LDL). Smoking is also strongly associated with increased risk of cardiovascular diseases, and its cessation is considered the most effective lifestyle modification to prevent cardiovascular events (more than lipid modification). In a patient with coronary artery disease, quitting smoking is associated with a 36% reduction in mortality. Although family history of premature heart disease (male < 65 and female < 55), low level of physical activity and obesity are considered risk factors for coronary artery disease, these factors exert their effects in the presence of major risk factors. (Option B) This patient should also be advised to reduce alcohol consumption to a maximum of 2 standard drinks (one for women) with 2 alcohol-free days every week. This measure is beneficial for general health but does not have a specific effect on cardiovascular status as does smoking cessation. (Option C) Wearing a properly-adjusted seatbelt reduces the risk of mortality by 50%; however this reduction is related to trauma and severe injuries, not to cardiovascular diseases. (Option D) Blood pressure and body weight are directly related. For every 1kg reduction in weight, the systolic blood pressure will drop by 1mmHg. Weight reduction is particularly beneficial if the patient has insulin resistance and/or hyperlipidemia. Weight reduction, however, is not as effective as smoking cessation in improving cardiovascular risk. (Option E) Regular exercise increases high-density lipoprotein cholesterol and reduces body weight, and contribute to improved cardiovascular status, but not as smoking cessation does. **TOPIC REVIEW** Major traditional risk factors for coronary artery disease (CAD) are as follow: ****Hypercholesterolemia (high LDL) ****Smoking (especially smoking cigarettes) ****Hypertension ****Diabetes mellitus Other traditional risk factors include: ****Family history of heart disease (premature) ****Low level of physical activity ****Obesity

Answer 9

**A. Inform him that he is already in high risk group for cardiovascular disease and do not need risk calculation.** Assessment of cardiovascular disease risk on the basis of the combined effect of multiple risk factors (absolute CVD risk) is more accurate than the use of individual risk factors, because the cumulative effects of multiple risk factors may be additive or synergistic. In Australia, 64% of the adult population have 3 or more modifiable risk factors. As CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy. Absolute cardiovascular risk assessment should be conducted at least every 2 years in all adults aged 45 years or older who are not known to have CVD or to be at clinically-determined high risk. Calculation of the absolute risk requires information on the patient’s age, sex, smoking status, total and HDL cholesterol, systolic blood pressure and if the patient is known to have diabetes or left ventricular hypertrophy. Absolute risk calculation is not indicated if: The patient has current or history of cardiovascular disease e.g. stroke, transient ischemic attack (TIA), ischemic heart disease (IHD), or peripheral arterial disease (PAD). The patient is already clinically-determined high risk: * Diabetes and age >60 years * Diabetes with microalbuminuria (>20 µg/min or urine albumin:creatinine ratio (UACR) >2.5 mg/mmol for males, >3.5 mg/mmol for females) * Moderate or severe CKD (persistent proteinuria or estimated glomerular filtration rate (eGFR< 45mL/min/1.73 m2) * Previous diagnosis of familial hypercholesterolaemia (FH) * SBP ≥180 mmHg or diastolic blood pressure (DBP) ≥110 mmHg * Serum total cholesterol >7.5 mmol/L * Aboriginal or Torres Strait Islander peoples aged over 74 years **With diabetes and age of 62 (>60) on one hand and an albumin/creatinine ratio of 5mg/mmol (>2.5mg/mmol), this patient has 2 conditions that categorizes him as clinically-determined high risk; therefore, risk calculation is not required.** (Option B) He does not need absolute cardiovascular risk assessment now or any other time because he is already clinically-determined high risk. (Option C) Reassurance of a patient who high-risk for CVD is not wise. (Options D and E) There are no pointers in the scenario towards inadequacy of diabetes treatment; hence, increasing the dose of the current medications or commencement of insulin appears irrelevant.

Answer 10

**C. He should be involved in a smoking cessation program.** By far,** smoking is the single most modifiable risk factor for coronary artery diseases (CAD)**. Smoking is associated with a 2- to 3-fold increase in CAD. Smoking cessation alone reduces the risk of CAD by 32%; therefore, advice against smoking and encouraging the patient to actively participate in a smoking cessation program will be the most appropriate step. Adopting a healthy lifestyle including regular exercise and diet is also important for reduction in CAD risk but smoking remains the most important factor. The patient’s blood pressure is at the cut-off point for hypertension. Presently, antihypertensive medications are not indicated. `The target cholesterol level is < 4mmol/L.` **With a cholesterol level of 5.5 mmol/L, this patient should initially be advised to start regular exercise and a healthy diet. Statins as first-line medications for hypercholesterolaemia are indicated if diet and exercise fail to lower the cholesterol levels in 3-6 months.**

Answer 11

**D. Regular hand and face washing.** 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. * **S**urgery is used to correct the entropion before it leads to permanent damage to the cornea. * **A**zithromycin is the antibiotic of choice in this strategy and is given, in oral form, to family members with active trachoma. * **F**acial hygiene is achieved through regular hand and face washing. * **E**nvironmental 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) Trachoma is transmitted by flies not mosquitoes; therefore, eradication of mosquitoes would not be an effective measure

Answer 12

**D. He should use yellow fever vaccine.** Yellow fever is caused by a flavivirus. **The virus is transmitted to humans from the bite of insect mosquito vectors such as Aedes Egypti.** The reservoir for the virus is the monkey population of tropical rainforests of South and Central America and West and South Africa. Travellers to these areas are prone to the disease. Yellow fever presents with rigors and fever, jaundice, petechiae, hematemesis and circulatory failure. Treatment is almost supportive and symptomatic. Stamaril ® is the live, attenuated yellow fever virus (17D-204 strain) freeze-dried vaccine available in Australia. It is given as a single intramuscular or subcutaneous injection of 0.5mL of reconstituted vaccine. Stamaril ® is almost 100% effective against yellow fever and should be advised as the most important preventive means for those travelling to endemic areas. Protective immunity occurs within 1–2 weeks in 90–95% of people, and a single dose lasts at least 10 years. Under international health regulations, revaccination is required every 10 years. `NOTE - Stamaril ® is contraindicated in patients with history of egg allergy or previous anaphylaxis to the vaccine. It is also contraindicated in pregnancy. Pregnant woman should be advised against travelling to endemic areas; however, if the travel is inevitable, the benefits of vaccination outweigh the risks.` Other protective measures include staying indoors or under mosquito nets to avoid contributing to the transmission cycle. Advice should be given regarding avoidance of epidemics and minimization of high risk behavior (e.g. jungle visits). Personal protective measures are an important part of any travel medicine consultation where the traveller is heading to any region of mosquito-borne disease. Mosquito avoidance includes the use of treated mosquito nets and screening of living and work areas

Answer 13

**B. A pneumococcal serotype that the vaccine did not protect against.** Streptococcus pneumoniae (Pneumococcus) is a Gram-positive coccus. Capsule polysaccharide is the most important virulence factor of pneumococci. **Over 90 capsular antigen types (serotypes) have been recognized**, each of which elicits type-specific immunity in the host. The natural reservoir of pneumococci is the mucosal surface of the upper respiratory tract of humans. Different pneumococcal serotypes vary in their propensity to cause nasopharyngeal colonization or the disease. Worldwide, **only a limited number of serotypes are responsible for most cases of invasive pneumococcal disease (IPD)**, but the predominant serotypes vary by age group and geographic area. The introduction of **7-valent pneumococcal conjugate vaccine (7vPCV) in Australia** has led to a dramatic reduction in the overall incident of IPD. However, since the implementation of the universal 7vPCV program, increased rates of IPD caused by serotypes not contained in 7vPCV (replacement disease) have been observed in Australia and several other countries. This is **particularly so common among non-Indigenous children aged < 2 years, and is the most likely cause to IPD in immunized children.** This child has been diagnosed with meningitis as an IPD despite a full course of vaccination against pneumococci; therefore, the most likely explanation is infection with a specific serotype which has not been covered by 7vPCV. (Option A) An underlying immune deficiency is also a possible explanation; however, this is unlikely in a previously healthy child. (Option C) Failure of the vaccine to elicit an immune response in a healthy patient with intact immune system is a very remote possibility. (Option D) A cardiac defect with right-to-left shunt does not explain the event. (Option E) Sample contimantion would have caused growth of different types of organisms on culture. With growth of streptococcus in isolation, such an event is not likely

Answer 14

**A. A full course of vaccination should be started now.** A physician should take every opportunity to review one’s vaccination history and administer the appropriate vaccine(s). For those, who do not have a documented receipt of vaccines scheduled in the National Immunisation Program (NIP) appropriate for their age, a catch-up schedule should be planned, documented and discussed with the person or their caretakers/parents. The number of doses to give and the intervals may differ according to the age at which the catch-up is planned. The objective of catch-up vaccination is to complete a course of vaccination and provide optimal protection as quickly as possible. The assessment of vaccination status should be based on the schedule for the state or territory where the person to be vaccinated is residing. (Option B) Commencement of vaccination with vaccines appropriate for the child’s current age while previous doses have been missed will not be appropriate because adequate protection may not be achieved. (Option C) Postponing vaccination is not appropriate because this child should receive his vaccines right now. (Option D) The decision regarding vaccination of children completely lies within parents hands. They can refuse vaccination of their chidlren as their legal right, and reporting the family to child protection services not appropriate. (Option E) Receiving both initial and catch-up doses at the same time is not appropriate. This child shoud receive initial doses at this visit followed by catch-up doses according to the vaccination guidelines

Answer 15

**C. Mumps.** **Hepatitis B specific immunoglobulin (HBIG)** is used for neonates born to mothers with hepatitis B infection and non-immune persons who are exposed through occupational exposure to the blood of unidentified persons, or to persons who are chronically infected with hepatitis B or whose hepatitis status cannot be established in time. **Hepatitis A vaccination** is recommended in preference to NHIG for post-exposure hepatitis A prophylaxis in persons ≥12 months of age who are immunocompetent. **NHIG can be used when hepatitis A vaccine administration is contraindicated such as in infants < 12 months of age, or in persons who are immunocompromised and who might not mount a sufficient response following vaccination.** NHIG contains sufficiently high levels of antibody against hepatitis A to prevent or ameliorate infection in susceptible persons, if administered within 2 weeks of exposure. Specific **zoster immunoglobulin (ZIG)** is highly efficacious. Normal high-titer zoster immunoglobulin is available from the Australian Red Cross Blood Service on a restricted basis for the prevention of varicella in high-risk subjects who report a significant exposure to varicella or herpes zoster. ZIG has no proven use in the treatment of established varicella or zoster infection. ZIG must be given early in the incubation period (within 96 hours of exposure), but may have some efficacy if administered as late as 10 days post exposure. ZIG is able to prevent or ameliorate varicella in infants < 1 month of age, in children who are being treated with immunosuppressive therapy, and in pregnant women. Administration of **NHIG for rubella infection** is not recommended and does not prevent infection in non-immune contacts; however it **may prolong incubation period and marginally reduce fetal risk and maternal clinical symptoms**. Its use may be considered in rare situations (within 72 hours of exposure), or in outbreaks as a pre-exposure prophylactic for non-immune pregnant women in high risk occupations. Serological follow-up is required for up to 2 months. `NIHG has not proven effective in prevention or treatment of mumps.` **TOPIC REVIEW** Immunoglobulin preparations are used to provide passive immunization, that is, the direct administration of antibodies to a non-immune person to provide immediate protection against infection or disease. There are two types of immunoglobulin: 1. Normal human immunoglobulin (NHIG) - NHIG is derived from the pooled plasma of blood donors. It contains antibody to microbial agents that are prevalent in the general population. 2. Specific immunoglobulins - Specific immunoglobulin preparations are obtained from pooled blood donations from patients convalescing from the relevant infection, donors recently vaccinated with the relevant vaccine, or those who, on screening, have been found to have sufficiently high antibody concentrations. These blood-derived specific immunoglobulins contain concentrations of antibody to an individual organism or toxin at a higher titer than would be present in NHIG. *Specific immunoglobulins* available in Australia include: * Hepatitis B specific immunoglobulin * Rabies specific immunoglobulin * Varicella zoster specific immunoglobulin * Botulism antitoxin * Tetanus immunoglobulin * Respiratory syncytial virus monoclonal antibodies * Cytomegalovirus immunoglobulin For infections or disease other than above, NHIG is used if indicated and there is proven efficacy. NHIG use for passive prophylaxis has proven effective for measles and hepatitis A if vaccination is contraindicated; however, in selected cases, NHIG is used for poliomyelitis and rubella as well with less efficacy.

Answer 16

**C. Organize a full course of hepatitis B immunization.** If the index case is HBsAg negative and unlikely to be within the window period, no post-exposure prophylaxis for the nurse was required if she had been immunized. **There is no risk for the nurse to contract hepatatis B from this exposure; however, she should receive a full course of hepatitis B vaccine. This ideally should be started within 24 hours.** Another appropriate approach (not an option) is **to check for HBV antibody titer of the nurse**. If the titre was **equal or greater than 10mIU/ml, no vaccination is required either**. (Option A) Although the nurse is not likely to become infected from this exposure, she should have follow-up for immunization due to uncertain immunization status. (Option B) Since the index case is HBsAg negative and unlikely to be in window period, post-exposure prophylaxis is not required. (Option D) It is important that the incident is reported to a *team manager or supervisor*, but reporting to an infectious disease specialist in not necessary. (Option E) Checking for the nurse’s HBsAg status was indicated if the index case was HBsAg positive. `TOPIC REVIEW` Recommendations regarding post-occupational exposure prophylaxis: Hepatitis B * If the source is HBsAg-negative, and unlikely to be in the window period, no further follow-up testing is required for source or healthcare worker. The healthcare worker should have full HBV immunization if it has not been already performed. It should be commenced as soon as possible, and preferably within 24 hours of exposure. * If hepatitis B immunoglobulin (HBIG) is indicated, it should be given as soon as possible and preferably within 24 hours exposure. Efficacy of HBIG beyond 7 days of exposure is unknown. Hepatitis C * If the source is HCV antibody negative, and unlikely to be in the window period, no further follow-up testing is required for the source or healthcare worker. * Follow-up testing of the healthcare worker should be done in all other circumstances, and should include HCV RNA testing at 4 to 6 weeks, and HCV antibody and ALT at 4 to 6 months. * There is no effective or active immunoprophylaxis. Early therapy if seroconversion occurs should be considered. HIV * If the source is HIV antibody negative, and unlikely to be in the window period, no further follow-up testing is required for the source or healthcare worker. * In all other circumstances, the healthcare worker should have follow-up antibody testing at 6 weeks and 3 months, and up to 6 months, along with tests for other blood-borne viruses as above. * If post-occupational exposure prophylaxis (PEP) for HIV is indicated, it should be commenced as soon as possible after exposure. It is substantially less effective in animal studies when started more than 24-36 hours after exposure, but the interval after which no benefit is gained is unknown. * Recommendation for PEP include a basic regimen of 2 nucleoside/nucleotide reverse transcriptase inhibitors for most HIV exposures, and an expanded regimen with the addition of a third drug when the exposure poses an increased risk for transmission. * Expert advice from an HIV physician or adherence to local agreed guideline is essential before PEP for HIV infection is initiated.

Answer 17

**A. Vaccinate him with MMR vaccine now.** **MMR-containing vaccines are not routinely recommended for infants younger than 12 months of age because maternal antibodies to measles** (if the mother has immunity) are known to persist in many infants until approximately 11 months of age and may interfere with active immunization if performed before 12 months of age. However, there is some evidence that the first dose if given at ≥11 months (but prior to 12 months) is sufficiently immunologic. **Rubella infection provides life-long immunity in an immunocompetent person**, but not against measles and mumps. This child is still in risk of catching measles and mumps, and MMR vaccine is still indicated regardless of immune status for rubella. **He is 11 months of age; therefore, the first dose of MMR vaccine can be administrated now.** (Options B) The results of anti-rubella serology will not affect further plans regarding MMR vaccination; therefore, serologic studies for rubella is inappropriate. (Option C) Although the child will be immune against rubella after the infection, he is still in need for MMR for measles and mumps. A monovalent vaccine for rubella does not exist. (Option D) Although the recommended time for first dose of MMR is at 12 months of age, for the sake of convenience, this child can receive his first dose of MMR vaccine in this visit and at the age of 11 months. MMR vaccine can also be administered **as early as 9 months of age if the infant is high risk** for measles, mumps, or rubella, e.g. travel to endemic area, outbreaks, etc. (Option E) The first dose of MMR vaccine should be given at 12 months of age (≥11 months). Deferring the first dose untill 15 months is not appropriate `TOPIC REVIEW` `Update on MMR vaccination` Two doses of measles-containing vaccine are recommended for all children. The first dose should be given **at 12 months of age as MMR vaccine**. MMRV (measles, mumps, rubella, varicella) vaccines are NOT recommended for use as the 1st dose of MMR-containing vaccine in children < 4 years of age, due to a small but increased risk of fever and febrile seizures when given as the 1st MMR-containing vaccine dose in this age group. The second dose of measles-containing vaccine is recommended to be given routinely **at 18 months of age as MMRV vaccine**. The recommended age for administration of the second dose of measles-containing vaccine has been **moved down from 4 years of age, to provide earlier 2-dose protection against measles, mumps and rubella, and to improve vaccine uptake**. Catch-up vaccination of children who did not receive the second dose of MMR-containing vaccine at 18 months of age can occur at the 4-year-old schedule point. **Use of MMRV vaccine at the 4-year-old schedule point is preferred when varicella vaccination is also indicated.** Children >12 months of age who have received 1 dose of MMR vaccine can be offered their **second dose of MMR-containing vaccine early (if at least 4 weeks after the 1st dose has elapsed) if they are considered at risk of coming in contact with measles.** If MMRV vaccine is inadvertently administered as dose 1 of MMR-containing vaccine, the dose does not need to be repeated (providing it was given at ≥12 months of age). However, parents/carers should be advised regarding the small but increased risk of fever and febrile seizures (compared with the expected risk following MMR vaccine)

Answer 18

**B. She should receive MMR vaccine now.** Measles is highly infectious. The main route of transmission is by respiratory airborne droplets; however, it can rarely be passed on to others by means of particles soiled with respiratory droplets. The infectivity of a person with measles begins 2 days before the onset of the symptoms until 4 days after eruption of the rash. This woman has been in contact with her friend 2 days before the rash; therefore, within the infectivity period, and is at risk of contracting measles if not already immune. Any non-immunocompromised individual with a definite positive history of measles disease, documented evidence of having received 2 doses of a measles-containing vaccine (MMR) administered at least 4 weeks apart and with both doses administered ≥ 12 months of age, or positive measles antibody test is considered to be immune. This woman does not remember if she has been immunized or contracted measles. In such situations, **where the immunity status is unknown, it is recommended that all immunocompetent, non-pregnant patient receive MMR of vaccine within 72 hours of exposure**. A second dose should then follow at least 4 weeks later. (Option A) Measles serology was the correct answer if the woman was *pregnant or immunocompromised* and considered for prophylaxis with natural human immunoglobulin (NHIG). In such cases, if time allows, serology testing is recommended, as a positive IgG against measles will indicate immunity and no need for prophylaxis. (Option C) NHIG is used if the patient is in need for prophylaxis but there is a contraindication to MMR vaccination such as pregnancy or immunodeficiency. (Option D) This woman is uncertain about her immune status. She does not remember contracting measles or if she had been vaccinated. She cannot be considered immune and post-exposure prophylaxis should be considered. (Option E) While post-exposure is indicated in this patient in an attempt to decrease the risk of measles infection, telling the patient to wait until she develops active infection is not appropriate. `TOPIC REVIEW` Measles (rubeola) virus is a single-stranded RNA virus of the family Paramyxoviridae. Humans and monkeys are the only known hosts. There are no carrier states. Measles has an incubation period of 10-14 days. Initially, the illness presents with the following: * Fever * Malaise * Cough * Coryza (inflammation of the mucous membranes of the nose) * Conjunctivitis * Koplik’s spots (white spots, each surrounded by a red ring, found on the buccal mucosa) Two to 4 days after the initial symptoms, a maculopapular rash develops. The rash typically starts from face and upper neck and later spreads to involve the whole body. The infectivity periods starts 2 days before the onset of rash untill 4 days after the rash develops. Measles is often a severe disease. Complication may occur, and include otitis media in 7% and bronchopneumonia in 6% of immunocompetent patients. Acute encephalitis is a rare complication occurring in between 2 and 10 per 10,000 reported cases with measles in the general population, with an associated mortality rate of 10 -15 %. Around 15 - 40 % of survivors of measles encephalitis will have permanent brain damage. Measles can be more sever in the following groups: * Immunocompromised people, especially those with T-cell deficiencies such as certain leukemias, lymphomas and acquired immunodeficiency syndrome (AIDS), in whom measles can be severe, atypical (e.g. without rash) and prolonged, with virus shedding for several weeks after the acute illness * Malnourished children, particularly those with vitamin A deficiency * Children younger than 5 years and adults 20 years of age and older, in whom complications of measles are more common * Pregnant women in whom infection is associated with increased risk of premature labor, spontaneous abortion, and low birth weight. Birth defects have not conclusively been associated with measles virus infection. Management of contacts Neonates or infants less than 12 months of age * This group is at high risk of developing complications from measles infection if they have not acquired maternal antibodies from a measles-immune mother; therefore, *NHIG should be administered to infants of non-immune mothers as early as possible*, and at the latest within 6 days (144 hours) of potential exposure. * NHIG should be administered to pre-term neonates (< 37 weeks) or immune-suppressed infants regardless of maternal history or antibody status. * Infants 6-8 months of age exposed within 144 hours should receive NHIG (irrespective of mother's immune status) * If exposure has occured within 72 hours, immune competent infants 9-11 months should receive MMR now then second dose at 12 months or 4 weeks later (whichever is later). * If exposure within 73-144 hours, give NHIG Non-immunosuppressed non-vaccinated people over 1 year of age * Consider MMR vaccination within 72 hours of exposure for all non-immune contacts. Individuals in whom protection is desirable, but live vaccination is contraindicated * Pregnant women and immunocompromised children (or adults) should not be given live vaccine. NHIG should be administered as early as possible and up to 6 days (144 hours) of exposure

Answer 19

**A. Vaccinate him now.** Pertussis vaccine is available in Australia only in combination with diphtheria, tetanus and other antigens. The acronym **DTPa**, using capital letters, signifies **child formulations** of diphtheria, tetanus and acellular pertussis-containing vaccines. The acronym dTpa is used for formulations that contain substantially lesser amounts of diphtheria toxoid and pertussis antigens than child (DTPa-containing) formulations; dTpa vaccines are usually used in adolescents and adults. Pertussis-containing vaccine is recommended in a 3-dose primary schedule for infants at **2, 4 and 6 months of age**. Due to the high morbidity and occasional mortality associated with pertussis in the first few months of life, the first dose can be given as early as 6 weeks of age. Giving a first dose at 6 weeks of age rather than 2 months of age is estimated to prevent an additional 8% of infant pertussis cases. The next scheduled doses should still be given at 4 months and 6 months of age. Extensive limb swelling, defined as swelling and/or redness involving at least half the circumference of the limb and the joints both above and below the injection site is a recognized adverse event that occurs rarely following booster doses of DTPa. Such reaction begins within 48 hours of vaccination, last for 1 to 7 days and resolve completely without sequelae. History of such event is not a contraindication to the vaccine use. No change in the formulation is required or recommended either. `NOTE – The only absolute contraindications to pertussis containing vaccines are:` * Anaphylaxis following a previous dose of any acellular pertussis-containing vaccine * Anaphylaxis following any vaccine component **Children with mild disease and fever < 38.5°C can be safely vaccinated.** However, if the fever is ≥38.5°C, or the child has serious systemic illness, vaccination should be deferred until the child improves. The rationale behind such recommendations is to avoid adverse events in an already unwell child, or to avoid attributing symptoms to vaccination. Conditions such as mild diarrhea or URTI without systemic symptoms are safe for vaccination. **This child had an adverse reaction to the DTPa vaccine that is known to be benign and self-limiting, and is not a contraindication to vaccination with pertussis containing vaccines. Although febrile, his fever is less than 38.5°C associate with a mild disease; therefore, he can be safely vaccinated with DTPa now.** Other facts about pertussis-containing vaccines * Febrile convulsions are very infrequently reported following DTPa-containing vaccines within 48 hours of vaccination. The risk is even lower in infants who complete their primary course at 6 months of age, as febrile convulsions are uncommon in children < 6 months of age. Children who experience a febrile convulsion after a dose of DTPa-containing vaccine have a slightly greater risk of a further febrile convulsion following a subsequent dose of a DTPa containing vaccine. This risk can be minimized by appropriate measures to prevent fever, so vaccination still recommended. * Pertussis-containing vaccines do not cause infantile spasms or epilepsy. Infants and children known to have active or progressive neurological disease can be safely vaccinated with DTPa-containing vaccines. * Sudden infant death syndrome (SIDS) is not associated with either DTPa or any pertussis-containing vaccine. Some studies suggest a decreased risk of SIDS in children who have been vaccinated. * Brachial neuritis (inflammation of a nerve in the arm, causing weakness or numbness) has been described following the administration of tetanus toxoid-containing vaccines, with an estimated excess risk of approximately 0.5–1 in 100,000 doses in adults.

Answer 20

**D. Postpone the vaccination untill after recovery from her current illness.** Children with mild disease and fever < 38.5°C can be safely vaccinated. However, **if the fever is ≥38.5°C, or the child has serious systemic illness, vaccination should be deferred until the child improves**. The rationale behind such recommendations is to avoid adverse events in an already unwell child, and to avoid attributing symptoms to vaccination. Conditions such as mild diarrhea or URTI without systemic symptoms and fever < 38.5°C are safe for vaccination. This child has a fever of 38.7°C; therefore, vaccination is recommended to be deferred until she is out of the disease and the fever subsides. The only vaccines available in Australia is MMR (measles, mumps, rubella) and MMRV (measles, mumps, rubella, varicella). Separate monovalent vaccines against rubella, measles or mumps do not exist. Current guidelines recommend two doses of MMR vaccine at 12 months and 18 months of age. Postponing MMR vaccine until the age of 4 years is against recommendations and not appropriate.

Answer 21

**C. He should be started on lipid lowering agents.** With a previous MI, this man is already high risk (absolute risk >15%), and absolute cardiovascular risk calculation should not be performed for him. This patient is following strict lifestyle modification. He quit smoking which is the single most modifiable risk factor for cardiovascular diseases. He takes exercise on a regular basis, and follows a healthy diet. **Statins should be started in all patients with coronary heart disease (CHD) regardless of they current lipid profile status as it is associated with decreased mortality.** His lipid profile then should be checked evey 3-6 months. Target values for patients with CHD are: * Low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L * High-density lipoprotein cholesterol (HDL-C) > 1.0 mmol/L * Triglyceride (TG) < 2.0 mmol/L * Non–high-density lipoprotein cholesterol (NHDL-C) < 2.5 mmol/L Although the target blood pressure in patients with CHD is ≤130/85mmHg, his blood pressure of 137/85mmHg is not of significant concern compared to importance of commencement of lipid-lowering agents. He should also be advised to keep on diet and regular exercise.

Answer 22

**A. Trichiasis.** **Blindness from Chlamydia trachomatis** is a major cause of blindness where the socioeconomic status is poor and people disadvantaged. Many Aboriginal Australian communities exemplify such situation. Recurrent infections with Chlamydia trachomatis cause **chronic keratoconjunctivitis**. This is then followed by scarring of the tarsal conjunctiva. A the condition progresses, tarsal plates become distorted eyelids and eyelashes turn inwards (entropion) as do eyelashes. Inwardly-turned eyelashes will irritate the cornea (trichiasis). Chronic irritation leads to abrasions, corneal opacification and eventually blindness. Although all other options can potentially lead to blindness, infection with Chlamydia trachomatis remains the major risk and concern in Aboriginal communities

Answer 23

**D. Cross sectional study.** The objective of the study is determining the prevalence of vitamin D deficiency in Australia. When **prevalence** of a specific condition in a population is the aim, **cross sectional studies** are used as the **most appropriate method**. `Cross sectional studies are also called prevalence studies`, because one of the main measures available is the 'population prevalence'. These studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. Cross sectional studies can also describe the odd ratio, absolute risk and relative risk. These parameters cannot be elicited from case-control studies. Cross-sectional are also able to support (not establish) the interference of cause and effect. Cross-sectional studies are different from case-control studies in that they aim to provide data on the entire population under study, whereas case-control studies typically include only individuals with a specific characteristic. (Option A) In cohort studies, the *population group is identified*. Subjects who have been exposed to a certain risk factor are *followed over time and compared with a group not exposed to the risk factor*. Cohort studies are prospective (forward-looking), and subjects are tracked forward in time. It can determine incidence and causal relationship; however, the population must be followed long enough for the incidence to appear. (Option B) Case-control studies are *observational studies* that *compare subjects who have a disease or outcome (cases) with subjects who do not have the disease or outcome (controls)*, and *look back retrospectively* to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. (Option C) Randomized controlled trials (RCTs) are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention. (Option E) Case series is objective report of a clinical characteristic or outcome from a group of clinical subjects (n>1). For example, patient at a local hospital with hospital acquired pneumonia. `NOTE - Cross sectional studies are the method of choice for determining prevalence in a population.`

Answer 24

**B. Cross sectional study.** For determining the prevalence of a disease or a condition in a population, cross sectional studies are used as the method of choice. Cross sectional studies are also called prevalence studies because one of the main purposes and measures available is determining the ‘prevalence’ of a condition (e.g. disease). These studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. (Option A) Double blind studies are gold-standard for interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention. (Option C) The main objective in cohort studies is to see if there is an established link between one variable and the disease. In cohort studies, the population group is identified. Subjects who have been exposed to a certain risk factor are followed over time and compared with a group not exposed to the risk factor. The outcome is the disease incidence in each group, as well as the linkage between the cause (risk factor) and the effect (disease). Cohort studies are prospective (forward-looking), and subjects are tracked forward in time. A cohort study can determine incidence and causal relationship (such as hypercholesterolemia and myocardial infarction); however, the population must be followed long enough for the incidence to appear. (Option D) Case-control studies (also known as retrospective studies and case-referent studies) are observational studies that compares subjects who have a disease or outcome (cases) with subjects who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. ``` NOTE – The main differences between cohort study and case control study are: In case control study the subjects in the study population have the disease, while in cohort subjects are not diseased. Cohort study is prospective (forward-looking), while case control study is retrospective (back-looking) ``` (Option E) Similar to randomized double blind studies, RCTs are also interventional studies.

Answer 25

**B. Cohort study.** Cohort studies are the option of choice when a **causal relationship between a variable (e.g. a risk factor) and a disease or condition** is the objective of the study. In fact they are **best for identification of risk factors, as well as the incidence**. Cohort studies are usually **prospective (forward-looking)**. They are planned in advance and carried out over a future period of time. In a prospective cohort study, a research question is raised first, forming a hypothesis about potential causes of a disease. The researcher then observe a group of people (the cohort) over a period of time (often several years), collecting data that may be relevant to the disease. This allows the researchers to detect any changes in health in relation to the potential risk factors they have indentified. To establish a relationship between the number of nevi (risk factor) and melanoma (the disease), cohort study is the study of choice. (Option A) Cross sectional studies are the studies of choice whenever determination of the prevalence of particular condition of disease is desired. (Option C) Case-control studies (also known as retrospective studies and case-referent studies) are observational studies that compares subjects who have a disease or outcome (cases) with subjects who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. (Option D) Comparative analysis is the item-by-item comparison of two or more comparable alternatives, processes, products, qualifications, set of data, etc. It can be used, for example, for comparing two treatments for one condition, but generally it is not a distinct research entity, nor can it establish or exclude a relationship between a risk factor and a condition. (Option E) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story. Case reports are considered the lowest level of evidence, but they are also the first line of evidence, because they are where new issues and ideas emerge. Case series report (study) is similar to case report (study) with the only difference being the number of cases compared to case report (n=1 versus n>1)

Answer 26

**A. Cohort study.** To see if there is a relationship between hypertension as a risk factor and myocardial infarction as the outcome, cohort studies are the most appropriate option. Cohort studies are the option of choice when a **casual relationship between a variable (e.g. a risk factor) and a disease or condition is investigated**. They are best for **identification of risk factors, as well as the incidence**. Cohort studies are usually **prospective (forward-looking)**. They are planned in advance and carried out over a future period of time. In a prospective cohort study, a research question is raised first, forming a hypothesis about **potential causes** of a disease. The researcher then observe a group of people (the cohort) over a period of time (often several years), collecting data that may be relevant to the disease. This allows the researchers to detect any changes in health in relation to the potential risk factors they have indentified. (Option B) Cross sectional studies are also called prevalence studies because one of the main purposes and measures available is population prevalence. These studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. (Option C) Case-control studies (also known as retrospective studies and case-referent studies) are observational studies that compare subjects who have a disease or outcome (cases) with subjects who do not have the disease or outcome (controls), and look back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. (Option D) Randomization is a sampling method used for unbiased sample definition and selection for research studies which is a necessary element for a study to be valid and trustable. It is not a study. (Option E) Double blinded studies are gold-standard for interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention.

Answer 27

**A. Randomized controlled trial.** Randomized controlled trials (RCTs) are the **gold-standard study for assessment of safety and effectiveness of an intervention such as a vaccine, drug, or method of treatment.** Cohort study, cross-sectional study, case-control study and case series report are all observational, and not interventional studies. Observational studies are used for assessment and examining the etiology and potential risk factors of a disease

Answer 28

**C. Case control study.** When evaluation of a causal relationship between a variable such as a risk factor and a disease or condition is desired, either a case control or a cohort study should be considered and designed. The decision as to whether which one should be used depends on several factors. Cohort study is a study designed when one or more samples (called cohorts) are followed prospectively (forward-looking) to see if there is a linkage between a variable, such as a risk factor, and an outcome of interest. Cohort studies are used to investigate the cause of disease, and establishing links between risk factors and health outcomes. Cohort studies are usually prospective (forward-looking). They are planned in advance and carried out over a future period of time. Case control studies **compare patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcomes (controls)**, and **looks back (retrospective)** to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. Case control studies are observational because no intervention is attempted and no attempt is made to alter the course of the disease. **The goal is to retrospectively determine the exposure to the risk factor of interest from each of the two groups of individuals: cases and controls.** These studies are designed to estimate odds. Case control studies are also known as "retrospective studies" and "case-referent studies”. This scientist wants to compare a group of neonates with jaundice (disease present) with a group of neonates without jaundice, by looking back at the history to see how exposure to hypothesized parameters could have resulted in jaundice. Therefore, he should use a case control study as the most appropriate method. (Option A) Cohort study is a forward-looking study for assessment of the relationship between a variable (risk factor) and a condition e.g. the relationship between hypertension and ischemic heart disease. The relation can also be determined by case-control studies; however, cohort study has many advantages over the latter, making it the preferred study. (Option B) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story. (Option D) Prospective study is the term sometimes used for a cohort study. (Option E) RCTs are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention.

Answer 29

**A. Case control study.** This study is intended to assess if there is a causal linkage between a risk factor (exposure to smoke and the severity) and an outcome of interest (asthma) in a group, who **already have** the condition (asthmatic patients). For such an approach, case control study should be conducted. Case control studies compare patients who have a disease or outcome of interest (cases) with patients who do not have the disease or the outcomes (controls), and looks back (retrospective) to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. Case control studies are observational because no intervention is attempted and no attempt is made to alter the course of the disease. The goal is to retrospectively determine the exposure to the risk factor of interest from each of the two groups of individuals: cases and controls. These studies are designed to estimate odds. (Option B) Cross sectional studies are also called prevalence studies because one of the main purposes and measures available is population prevalence. These studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. (Option C) Cohort study is another method to see if a relationship between cause and effect exist, in a retrospective (forward-looking) manner. It consists of observing the development of the condition of interest (e.g. asthma) in case who do not have asthma at the beginning of the study and seeing whether the case develops the condition in the future, and if so, how relevant it can be to the cause (smoke in this question). Unlike case control study, cohort is usually prospective, and the **population studied has not the condition** in the outset. (Option D) Observational study is a term used for studies in which no intervention is attempted during the study. Cohort, case control, cross sectional, case report, and case series report are all observational studies. (Option E) RCTs are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention.

Answer 30

**C. Case control study.** The objective of this study is to see if there in a causal relationship between a risk factor (alcohol) and a condition of interest (dementia). When establishment of such association or linkage is the purpose, two studies can be used: Case control studies - Compare patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcomes (controls), and looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. These studies are designed to estimate odds. Cohort studies - Cohort study is another method to investigate a relationship between cause and effect, but it is prospective (forward-looking), and observes the development of the condition of the interest (e.g. dementia) in cases who do not have the disease at the beginning of the study and sees if they develop the condition in the future, and if so how relevant it can be to the cause (amalgam in this question). Unlike case control study, cohort is usually prospective and the population studied has not the condition in the beginning of the study. **This doctor is using a sample of people who already have dementia and wants to look back at their history of alcohol intake to see if he can find a relationship. These features are characteristics of a case control study.** (Option A) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story. Case series report (study) is similar to case repot (study) with the only difference being the number of cases compared to case report (n=1 versus n>1). (Option B) In cohort study, the target group **has not the disease yet**. In the study conducted by this doctor, dementia (the disease) has already established in the study group. (Option D) Cross sectional studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. They are used mostly to see how prevalent a condition is in a population. (Option E) RCTs are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention.

Answer 31

**B. Cohort study.** When evaluation of a causal relationship between a variable such as a risk factor and a disease of condition is desired, either a case-control or a cohort study should be considered and designed. The decision as to whether which one should be used depends on several factors. Cohort studies are used to investigate the cause of disease, and establishing links between risk factors and health outcomes. Cohort studies are usually prospective (forward-looking). They are planned in advance and carried out over a future period of time. In a prospective cohort study, a research question is raised first, forming a hypothesis about potential causes of a disease. The researcher then observe a group of people (the cohort), over a period of time (often several years), collecting data that may be relevant to the disease. This allows the researchers to detect any changes in health in relation to the potential risk factors they have indentified. For example, scientists may ask participants to record specific lifestyle details over the course of a study, before going on to analyze any possible correlations between lifestyle factors and disease. In contrast, case control studies are retrospective, looking back at data that already exist and, through this, try to indentify risk factors for particular conditions. The drawback to this study is the fact that the researchers are limited in their interpretations because they cannot retrospectively retrieve missing data. Here, being born to a diabetic mother has been considered a risk factor, and the intended future outcomes related to this risk factor is the objective of this study. For this purpose, a cohort study serves best. (Option A) Cross sectional studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study group. They are used mostly to see how prevalent a condition is in a population. (Option C) Case control study was the choice if the aim of the study was to find out how a current problem in the babies could be related to the maternal obesity (retrospective approach). (Option D) RCTs are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention. (Option E) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story.

Answer 32

**C. Case control study.** The objective of this study is to see if there in a **causal relationship between a risk factor (amalgam) and dementia**. When investigating such association or linkage is the purpose, two studies can be used: Case control studies - Compare patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcomes (controls), and looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. These studies are designed to estimate odds. Cohort studies - Cohort study is another method to investigate a relationship between cause and effect, but it is prospective (forward-looking), and observes the development of the condition of the interest (e.g. dementia) in cases who do not have the disease at the beginning of the study and sees if they develop the condition in the future, and if so how relevant it can be to the cause (amalgam in this question). Unlike case control study, cohort is usually prospective and the population studied has not the condition in the beginning of the study. **Of the two of your samples, one consists of the cases who already have dementia, and you want to look back at their history of dental fillings with amalgam to see if there is a meaningful linkage between amalgam as a risk factor and dementia as an outcome. These features are characteristics of a case control study.** (Option A) Cross sectional study has different structure and is mostly used for prevalence studies. (Option B) RCTs are interventional studies conducted for the assessment of effectiveness and safety of a drug, procedure or any other intervention. (Option D) In cohort study, the target group has not the disease yet. In this study, dementia (the disease) has already established in the study group. (Option E) Case report is an article describing and interpreting an individual case, often written in the form of a detailed story. Case series report (study) is similar to case repot with the only difference being the number of cases compared to case report (n=1 versus n>1).

Answer 33

**C. Counselling and follow-up.** This health care worker had a needle stick injury and blood test came back positive for hepatitis B surface antigen meaning that he has hepatitis B infection. This healthcare worker should be **counseled about the result and should have follow-up testing at 3 months and 6 months**. If the blood tests remain positive for hepatitis surface antigen beyond 6 months, the patient should be referred to specialist.

Answer 34

**D. Randomized controlled trial (RCT).** When it comes to assessment of the efficacy or safety of a drug, procedure, or any other interventional treatment of any kind, RCTs or randomized double blind trials are the option of choice. RTCs in humans are used to test the safety and potential benefit of a treatment. While the harms of a treatment sometimes prove to outweigh the benefits, this form of testing is acceptable to the participants because the investigators are aiming to develop a new treatment and usually have a reasonable expectation of safety at least, if not a positive effect of treatment. **RCTs, especially if double blind, are the gold-standard study for medical interventions.** They have become the standard for assessment of efficacy and safety of an experimental drug or method of treatment. (Options A and B) Cohort and case control are observational studies and not used for assessment of an intervention. (Option C) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story. Case series report (study) is similar to case repot (study) with the only difference being the number of cases compared to case report (n=1 versus n>1). Case reports, as the name implies, just report a condition and are not able to define a cause. (Option E) Randomization is a sampling method used for unbiased sample definition and selection for research studies which is a necessary element for a study to be valid and trustable. It is not a study.

Answer 35

**D. Double blind clinical trial.** Logically, when the effect of vitamin C on the efficacy of iron tablets is intended as the objective of this study, an interventional study should be conducted. Two groups are selected randomly from persons who are taking iron tablet in a similar controlled way. The intervention will be the addition of vitamin C to one group only, and to see how effective vitamin can be in treatment outcomes compared to the control group. This is called randomized controlled trial (RCT). A double blind clinical trial is an RTC, in which neither the group populations, nor the researchers are aware of who is being intervened during the trial. No one in trial groups knows if he/she is taking vitamin C, nor does the researcher. This method is the gold standard study in clinical trials, and should be used as first-line study (if possible) for assessment of the efficacy or safety of a drug or therapy. (Options A, B and C) Cohort, case control and case series are all observational studies. Observational are not interventional and inappropriate and irrelevant when efficacy of an intervention is the objective of the study. (Option E) Randomization is a sampling method used for unbiased sample definition and selection for research studies which is a necessary element for a study to be valid and trustable. It is not a study.

Answer 36

**A. Case control.** Case control studies are the most appropriate option **to find the possible cause(s) of the disease in outbreaks**. Case-control studies are useful when epidemiologists investigate an outbreak of a disease, because the study design is powerful enough to identify the cause of the outbreak especially when the sample size is small. Attributable risks may also be calculated. (Option B) Case report (study) is an article describing and interpreting an individual case, often written in the form of a detailed story. Case series report (study) is similar to case repot (study) with the only difference being the number of cases compared to case report (n=1 versus n>1). Case report, as the name implies, just reports a condition, and is not able to define a cause. (Option C) Cross sectional studies consist of assessing a population, as represented by the study sample, at a single point in time. Cross-sectional study investigates the presence or absence of any disease or other condition in each member of the study. They are used mostly to see how prevalent a condition is in a population. (Option D) Randomization is a sampling method used for unbiased sample definition and selection for research studies which is a necessary element for a study to be valid and trustable. It is not a study. (Option E) Cohort studies are used to establish linkage between a cause (e.g. risk factor) and the effect (disease) in a prospective approach. They are also excellent for determining incidence.

Answer 37

**B. What is your part time job?** **Salmonella gastroenteritis** is febrile diarrheal disease presenting with fever, vomiting, bloody diarrhea and abdominal pain. The disease is **food-borne**, and the main rout of spread is food handling. Therefore, of the questions, the most important question to ask is if the patients job has the potentials to spread the infection to others. The risk of disease spread is particularly high in those who handle or prepare food and dishes. If this patient has a job related to food or food handling, or other jobs that might pose risk to others, **it is very important that he is excluded from work until 48 hours after the diarrhea stops. Exclusion from school until 24 hours after resolution of the diarrhea is also important.** Salmonella infection transmission occurs through oral-fecal route. Public transport is NOT a significant route of transmission if general hygienic measures, such as frequent hand washing, are considered. Other questions are not as important as the question asking whether he has a part time job that includes food handling.

Answer 38

**D. Case report.** To answer this question, one should be familiar with the hierarchy of studies used for medical research. Each study provides some evidence. The more qualified evidence a specific type of study provides, the higher it is in the order of hierarchy. The research studies used in medical research, in order of their ability to reliably provide evidence are as follows: 1. Meta-analysis 2. Systematic review 3. Practice guideline 4. Randomized controlled trial 5. Cohort study 6. Case control study 7. Cross sectional study 8. **Case report** 9. Individual opinion papers Of the given options case report is weakest in providing evidence. Meta-analysis provides the strongest evidence

Answer 39

**C. Chickenpox vaccine.** If varicella-containing vaccines are not contraindicated, vaccination can be offered to non-immune, age-eligible children and adults, who have a significant exposure to varicella or herpes zoster, and wish to protect against primary infection with varicella zoster virus (VZV). Post-exposure vaccination is generally successful when given within 3 days (72 hours) and up to 5 days after exposure; the earlier, the better. Live attenuated **varicella vaccine (VV)** is currently available in Australia as a monovalent vaccine. Two quadrivalent combination vaccines containing live attenuated measles, mumps, rubella and varicella viruses (MMRV) are also registered in Australia. MMRV vaccine can be given to children in this setting, particularly if MMR vaccination is also indicated. (Option A) VZIG is indicated for patients in whom prophylaxis is indicated, but vaccination is contraindicated. (Option B) Acyclovir is the treatment of choice and indicated once the child has the clinical symptoms of varicella zoster. (Option D) While post-exposure prophylaxis can reduce the risk of infection, just observation to see if symptoms develop is not an appropriate option. (Option E) Exclusion from school until the blisters are dried out (usually 5 days) is indicated if the child develops chickenpox. The child is not affected yet.

Answer 40

**C. Screening for her is funded by the government.** Despite the fact that a family history of breast and/or ovarian cancer is common in women with breast or ovarian cancer, only less than 10% of all breast cancers and less than 15% of ovarian cancers are associated with inherited genetic mutations. Mutations in **BRAC1 and BRCA2** account for the majority of hereditary breast/ovarian cancers. Less common mutations are **TP53 (Li-Fraumeni syndrome)** and **PTEN (Cowden syndrome)**. Hereditary syndromes associated with BRCA1 and BRCA2 are inherited in an autosomal dominant fashion, meaning that 50% of offspring of a person with such mutations will have the faulty gene. There are national guidelines to use when offering publically funded BRCA gene testing in Australia. It is generally accepted that when offering BRCA testing in a family for the first time, the person who is offered testing must be either affected by a relevant cancer (usually breast or ovarian cancer) and have a more than 10% likelihood of a gene mutation, or if unaffected and have more than a 20% chance of a gene mutation. **This woman is unaffected; however, with a mother with proven BRCA1 mutation, she has a 50% of chance of having a BRCA1 gene mutation; therefore, she is eligible for BRCA gene testing at the expense of government.** BRCA1 and BRCA2 testing is not subsidized by Medicare. These tests are done through the public hospital system, funded by state health department. The following patients are eligibe for BRCA gene testing funded by public health system: * Breast cancer < 30 years; triple negative breast cancer < 40 years****, ovarian cancer (high grade serous, endometrioid or clear cell) < 70 years * Males with breast cancer < 60 year would usually be eligible for testing while older men require additional family history Other (usually eligible): * Ashkenazi Jewish heritage and either a personal or family history of breast or ovarian cancer * An affected woman with a family history of breast and ovarian cancer * Three first- or second-degree relatives with breast cancer, especially if < 50 years * Bilateral breast cancer with the first cancer occurring in the 30’s or 40’s * Affected patients whose family history scores >16 on the Manchester risk score `TOPIC REVIEW` The following screening strategy is recommended by expert groups for women with hereditary breast/ovarian cancer (HBOC) syndrome, who have not undergone risk-reducing surgery (i.e., bilateral mastectomy, oophorectomy): * Monthly breast self-examination beginning at age 18 * Clinical breast examination 2 to 4 times annually beginning at age 25 * Annual mammography and breast magnetic resonance imaging (MRI) screening (commonly alternated every 6 months) beginning at age 25 or individualized based on the earliest age of onset in the family * Twice yearly ovarian cancer screening with transvaginal ultrasound and serum CA-125 levels (preferably drawn on day 1 to 10 of menstrual cycle for premenopausal women) beginning at age 35, or 5 to 10 years earlier than the earliest age of first diagnosis of ovarian cancer in the family `NOTE - The lack of efficacy of ovarian cancer screening has prompted many clinicians to recommend risk-reducing bilateral salpingo-oophorectomy at the completion of childbearing rather than intensified screening for ovarian cancer.` ****Any breast cancer than does not express the genes for estrogen receptor, progesterone receptor (PR) or Her2/neu

Answer 41

**D. A full course of hepatitis B vaccine and HBIG.** Post-exposure prophylaxis for hepatitis B during pregnancy is the same for non-pregnant persons and follows the same general guidelines. After exposure to hepatitis B, serology testing for the person who has had the exposure should be performed urgently. **A negative HBsAg and a HBsAb titer of >10IU/mL indicates sufficient immunity against hepatitis B, and no further action is required.** `With HBsAb titers < 10 (and HBsAg negative), the person has not enough immunity, and should receive both hepatitis B vaccine and HBIG within 72 hours of exposure, ideally within 24 hours.` Vaccine should also be given at 1 and 6 months after the first dose **(0, 1 and 6 months)**. Serology testing should be repeated in 3 months. If the mother is found to be HBsAg positive despite prophylaxis, the baby should receive vaccine and HBIG within 12 hours of birth.

Answer 42

**D. The new drug is not superior to other available drugs.** A P-value is used to interpret output from a statistical test (a clinical trial here). P-value is used to control if the new results are statistically different from previous trials. A standard P-value is set in the beginning of the trial. After the study is concluded, the P-value of the study is computed and compared with the standard P-value: **If the computed P-value from the study is ≤ standard P-value then the results has statistical significance.** **If the computed P-value from the study is > standard P-value then the results has not reached statistical significance.** For this study, a standard P-value of ≤0.02 has been set by the ethical committee, meaning that if the computed P-value from the study is ≤0.02 the new drug has statistical significance and can be claimed to be superior to other available drugs. **With a computed P-value of >2, this new drug cannot be told to be superior to other available drugs.** At the end of the trial, this new drug has a computed P-value of 0.04 that is > 0.02. This means that the new drug has no superiority over the available drugs. (Options A and B) P-value does not indicate adverse effects. It can only determine if a new drug has superiority over others or not. (Option C) With a P-value> standard P-value, this drug cannot be claimed to be superior to other available drugs. (Option E) P-value predicts if a drug can be superior or not superior to other drugs. Inferiority cannot be predicted by P-value.

Answer 43

**A. Annual fecal occult blood testing in people over the age of 50 years.** There have been at least three randomized control trials conducted which show that 1- to 2-yearly fecal occult blood testing (FOBT) in the population over the age of 50 years reduces the mortality from colorectal cancer by approximately 20%. (Option B) Colposcopy is a *diagnostic*, not a screening test. The appropriate screening test for cancer of the cervix in sexually active women is the Papanicolaou (Pap) smear. (Option C) Plasma CA125 levels may be raised in asymptomatic women with ovarian cancer but there is not any current evidence to support it as a mass screening test. (Option D) Colonoscopy for siblings of patients with colorectal cancer may reduce their mortality, but this is a 'selective' screening targeting a high-risk group. It is not a mass screening. (Option E) While mammography in the *50-70 age group* has been shown to reduce mortality from breast cancer by up to 30%, the benefit for women between 40-50 years is small. This benefit is even smaller in younger women `NOTE – Regular pap smear has been shown to reduce the incidence and mortality of cervical cancer by up to 80% and would be the correct answer if it was an option.`

Answer 44

**A. Give antiretroviral drugs for 4 weeks.** In the event of needle stick injury and exposure to an HIV positive person, post-exposure HIV prophylaxis is recommended. Provision of post exposure prophylaxis should not be delayed while establishing the HIV status of the source. **Early initiation** of post-exposure prophylaxis (PEP), **as soon as possible** after exposure, is strongly recommended. PEP should not be delayed more than 72 hours post-exposure. **A 28-day (4-week) course of PEP is recommended.** This health care worker should have **follow-up HIV antibody testing** at baseline, **6 weeks, 3 months, and 6 months**, along with tests for other blood-borne viruses. Recommendations for occupational post-exposure prophylaxis include a basic regimen of two nucleoside/nucleotide reverse transcriptase inhibitors for most HIV exposures, and an expanded regimen with the addition of a third drug when the exposure poses an increased risk for transmission.

Answer 45

**D. 200%.** 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.

Answer 46

**B. Waist-to-hip ratio.** 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 increase of 2% in the relative risk (RR) for a cardiovascular event. For a 0.01 unit increase in waist-to-hip ratio, this relative risk is 5%`

Answer 47

**D. Malaria.** Patients who are **asplenic** (no spleen) or **hyposplenic** (for example, decreased function of spleen due to ongoing microinfarcts caused by sickle cell disease) are at **increased risk of severe septicemia** with Streptococcus pneumoniae (S.pneumoniae), Hemophilus influenza type b (Hib), Neisseria meningitidis, and Capnocytophaga 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, it is recommended that all patients receive pneumococcal 23 valent polysaccharide vaccine PPV23 (**Pneumovax 23**). It is recommended that the vaccine be given at least 2 weeks before elective splenectomy or, in case of emergency splenectomy, after 7 days but not later than 14 days post-splenectomy (or at discharge). A **booster** dose is required at 5 years. It is 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).

Answer 48

**A. Explain to him about the serious risks he could pose to himself and others if he keeps driving while he is untreated.** 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 face if he is 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: * 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.

Answer 49

**B. Screening with FOBT 2-yearly from the age 40 years.** 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 outlined in the following table: - See table below. 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.**

Answer 50

**B. Withdrawal symptoms.** 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 do 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 within 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.

Answer 51

**D. She should be screened for chlamydia and gonorrhea using high vaginal swabs every 3 months.** 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, it is 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.** Legislations 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 * 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 * A speculum examination is not routinely performed on asymptomatic women unless they require a cervical screening * A speculum examination should be considered if the woman is symptomatic, has experienced a condom break/slip, 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 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 if there has been anal sex. (Option B) 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 not routinely required unless there is a high risk for such infection, e.g., 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`

Answer 52

**B. Nicotine replacement therapy (NRT).** 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 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.

Answer 53

**A. Trace all her sexual contacts in the past six months and treat them.** 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, it is 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 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. (Option E) Chlamydia infection is a notifiable disease, and notifying such diseases is the diagnosing physician’s responsibility not that of the patient.

Answer 54

**D. Inform the Health Department.** 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 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.

Answer 55

**B. Hepatitis B vaccine and immunoglobulin.** Post-exposure prophylaxis for hepatitis B (hepatitis B vaccine and immunoglobulin) is recommended in the following situations: * The exposed person has been vaccinated in the past and post-vaccination anti-HBs level is below 10mIU/ml * Unvaccinated exposed individuals * Unknown vaccination status of the exposed person In previously vaccinated individuals, who have been exposed to either an HBsAg-positive source or a source whose hepatitis B status cannot be determined, post-exposure prophylaxis is not necessary if there is a documented protective response (anti-HBs level ≥10 mIU/mL) at any time after vaccination.

Answer 56

**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.** 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 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. The patient should also 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. 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

Answer 57

**D. It impairs the ability to drive.** Marijuana is the second most commonly smoked 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, 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 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.**

Answer 58

**C. Men who have sex with men.** PrEP is used to significantly reduce the risk of HIV transmission in the community using `antiretroviral drugs, usually tenofovir/ emtricitabine`, 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**: - See table below. 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, PrEP 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

Answer 59

**A. Advise that he should start smoking cessation program.** 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**. OGTT (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). 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 based 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 risk 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 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 (in a first-degree relative – men aged < 55 years, women aged < 65 years) or obesity (body mass index [BMI] above 30 kg/m2 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 NOT 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 μg/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 [eGFR] < 45 mL/min/1.73 m2) * Previous diagnosis of familial hypercholesterolemia (FH) * Systolic blood pressure (SBP) ≥180 mmHg or diastolic blood pressure (DBP) ≥110 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 saturated and trans fats * At least 30 minutes of physical activity on most or preferably every day of the week * Limit alcohol intake

Answer 60

**B. Pre-test counselling.** **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 Afrikaaner 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 * A strong 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**.

Answer 61

**A. Sunscreening.** 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. (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.

Answer 62

**D. MMR vaccine.** 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, it is 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.`

Answer 63

**E. Reduce meals to 2x a day with no snacks in between.** Supervised lifestyle interventions are the essential component of all weight loss strategies and are the first line of management for individuals with a BMI of 30-40kg/m2. Options for initial weight loss strategies include a **reduced energy diet (RED) or low energy diet (LED). When these options have failed, a very low-energy diet (VLED) is recommended as the next step. (E is correct)** VLEDs are often recommended for 12 weeks. However, VLEDs can be continued for 6-12 months under careful supervision. Individuals may follow a partial or a complete VLED regimen. The partial regimen is the most common program recommended and is based on 2-meal replacements per day (typically breakfast and lunch) and 1 serving of lean protein, usually for dinner, with vegetables. Milk (other than small quantities in tea or coffee) should be avoided. The complete VLED regimen is based on 3 meal replacements per day, plus vegetables. The choice of the program (partial vs. complete) depends on the target weight and the individual’s ability to tolerate the VLED. Baseline blood tests should be taken and reviewed every 4 to 6 weeks. Contraindications to VLED: * Pregnancy or lactation * Severe psychological disturbance (e.g., unstable anxiety disorders, major depression), alcoholism or drug dependence * Recent myocardial infarction, cerebrovascular event, or unstable angina * Porphyria * Age >65 years (VLED in this age group should be advised with caution) Caution in the following groups: 1. Diabetes on insulin or sulphonylureas * The dose of sulphonylureas or insulin should be reduced by 50% on the commencement of the VLED. It should be stressed that if hypoglycemia occurs, it takes precedence over the diet and must be treated with appropriate carbohydrate ingestion. 2. Chronic kidney disease * Individuals with an estimated glomerular filtration rate (eGFR)< 60 mL/min/1.73m2 need closer supervision and should have electrolytes assessed more frequently. 3. Taking Warfarin * The diet increases vegetable intake and may alter the international normalized ratio (INR). Individuals on Warfarin should be instructed to test INR one week after commencing the VLED to adjust the warfarin dose. Individuals are considered to be responding to the VLED if they lose on average 1.0 to 1.5 kg per week. Once the target weight is reached, individuals are weaned off the VLED, and food is progressively re-introduced over a period of 8 weeks. If no weight is lost or less than 1.0 kg is lost per week over 4 weeks, review the person’s adherence to the VLED or other factors that may be affecting weight loss. Otherwise, pharmacotherapy is the next step. Semaglutide (option A), a glucagon-like peptide-1 (GLP-1) receptor agonist, was recently approved for the treatment of obesity and type 2 diabetes mellitus. It is given as a weekly subcutaneous injection. However, VLED would still be the most appropriate next step. Orlistat (option B) inhibits pancreatic and gastric lipase, and in the long-term results in the deficiency of the fat-soluble vitamins A, D, E, and K, and the development of oxalate kidney stones. It is not recommended as a first-line option for weight loss. Other approved medications for weight loss are phentermine (centrally acting adrenergic agonist) and liraglutide (GLP-1 receptor agonist). Off-label medication includes topiramate. Although considered the most efficacious means of weight reduction, bariatric surgery (option C) which is an invasive procedure is reserved for those who are unresponsive to more conservative means; therefore, not the best initial option. `NOTE - Indications for bariatric surgery:` * BMI >40 kg/m2 * BMI >35 kg/m2 and comorbidities that may improve with weight loss * BMI >30 kg/m2 who have poorly controlled type 2 diabetes and are at increased cardiovascular risk Psychotherapy (option D) would be pertinent to review the underlying factors as to why this patient failed her initial diet plan but not as a weight loss management option per se.

Answer 64

**B. Immunoglobulin and hepatitis B vaccine.** Since the exposed person is not immune to hepatitis B, he should be given a single dose of hepatitis B immunoglobulin (preferably within the first 24 hours post-exposure) and 3 doses of hepatitis B vaccine over 6 months. The status of the source and exposed person should be followed up by requesting full hepatitis B serology. However, if the exposed person has previously been vaccinated for hepatitis B, and has a blood test documenting an adequate response to the vaccine (HBsAB≥10mIU/ml), no prophylaxis is necessary.

General Practice/Public Health Flashcards

(88 cards)