Friday, April 12, 2013

A model for the clinical round examination

Station ( 1 )

Obstetrics: case (1)

Take the Obstetric history from the patient (3 marks)

Fundal level =………..weeks gestation(2marks)

Station ( 2 )

Obstetrics: Q (1) :

MENTION :

THREE complications of DM on the mother (3)

Two complications of DM on the fetus

UStation ( 3 )

Obstetrics: Case (2)

Estimate :

Expected date of delivery (EDD) (1)

The gestational age (GA) today (1)

Mention 3 prerequisites for trial of cesarean scar (3)

Station ( 4 )

Obstetrics : ( Q 2 )

Classification of hypertensive disorder with pregnancy (PIH) (3)

Mention 2 complications of accidental hemorrhage (2)

Station (5)

Obstetrics : case (3) :

Identify :

Fetal lie (1)

Fetal presentation (2)

Fetal position (2)

Station (6)

Obstetrics : (Q4)

Mention 5 causes of uterus larger than period of amenorrhea (5)

Station (7)

Gynecology (1)

Mention the complaint of the patient (1 mark)

Take the menstrual history (2 marks)

Mention 2 indications of recto-vaginalexaminaion (2 marks)

Station (8)

Gynecology (Q4):

Differential diagnosis of mass in Douglas' pouch

Station (9)

Gynecology :

Remark the clinical type of genital bleeding (1 )

Enumerate 2 important investigations that help in the diagnosis of such case (2)

What is the most serious cause of postmenopausal bleeding (1)

What is the most common cause of postmenopausal bleeding (1)

Empty Station

Station (10)

Gynecology :

Mention 5 characters of normal uterus (5)

Station ( 11 )

Gynecology :

Type & duration of infertility (2)

List 3 basic investigation for infertile couples (3)

Station ( 12 )

gynecology :

MENTION 3 DIFFERENCES BETWEEN UTERINE & OVARIAN SWELLING

Station ( 13 )

SKILL LAB.

Type of operation (1)

Two indications (2)

Two complications (3)

Station ( 14 )

Jar (1)

Identify the pathology (1mark)

Mention two symptoms (2marks)

Mention two surgical methods of treatment ( 2 marks)

Station (15)

JARS (2)

Identify the pathology (1)

Three methods of early detection (3)

Most common pre-disposing factor (1)

Station ( 16 )

Instruments:

Identify the instrument.

Mention 2 indications

Mention 2 complication

Station (17)

Instrument :

1- Identify the instrument (1)

2- List 2 types of vaginal specula (2)

3- two indications (2) Station (18)

Instrument

IDENTIFY THE INSTRUMENT (1)

MAXIMUM NEGATIVE PRESSUREIS……… (1)

THE VALUE OF THE KNOB IS …………….(1)

MENTION 2 COMPLICATIONS…………….(2)

Diabetic women are at greater risk than diabetic men!!

CVD Affects Women With Diabetes More Than Men

Fran Lowry

Apr 12, 2013

Editors' Recommendations

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Drug & Reference Information

Women with diabetes have a greater risk for death than men with diabetes, especially if the disease goes undiagnosed for a long time, according to new research published online April 5 inDiabetes Care.

"Cardiovascular disease [CVD] in particular has a greater impact on females with diabetes than males, especially when the disease is diagnosed late, as is often the case," coauthor Madonna M. Roche, MSC, from the research and evaluation department, Newfoundland and Labrador Centre for Health Information, St. John's, told Medscape Medical News.

"Clinicians could consider glucose control in addition to CVD risk factors when designing treatment strategies for patients, recognizing that female patients may be at higher risk than males for adverse outcomes," Ms. Roche suggested.

In Canada, as elsewhere, the incidence and prevalence of diabetes have been increasing in recent years. All too often, type 2 diabetes is diagnosed late, sometimes as long as 9 to 12 years after the disease develops, and as a result, complications are often present at the time of diagnosis, she said.

Madonna M. Roche

"Newfoundland and Labrador have the highest age-standardized prevalence of diabetes in Canada, and the age-standardized mortality and hospitalization rates for CVD, acute myocardial infarction [AMI], and stroke are some of the highest in the country," she noted.

The current study aimed to compare the risk for all-cause, CVD, AMI, and stroke mortality and hospitalizations for men and women with and without diabetes, as well those with early and late diagnoses of diabetes.

Tamoxifen more is better

Tamoxifen: More Is Better

Lidia Schapira, MD

Disclosures

Apr 03, 2013

Editors' Recommendations

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Add Breast Cancer to My Topic Alert

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Long-term Effects of Continuing Adjuvant Tamoxifen to 10 Years Versus Stopping at 5 Years After Diagnosis of Estrogen Receptor-positive Breast Cancer: ATLAS, a Randomized Trial

Davies C, Pan H, Godwin J, et al

Lancet. 2013;381:805-816

Study Summary

For women with estrogen-receptor-positive (ER+) early-stage breast cancer, treatment with tamoxifen for 5 years has been conclusively shown to reduce relapse risk and mortality throughout the first 15 years after diagnosis. The ATLAS study aimed to assess the effect of continuing treatment with tamoxifen to 10 years instead of stopping at 5 years.

The global ATLAS study enrolled 12,894 women with early-stage breast cancer who had completed 5 years of adjuvant tamoxifen, and randomly assigned them to continue for another 5 years or stop. Allocation was 1:1. The investigators report on outcomes for the 6846 women with ER+ disease included in the analysis of main effects on recurrence and breast cancer mortality.

Women in the treatment group had a reduced risk for recurrence and mortality from breast cancer that was apparent with longer follow-up. Breast cancer mortality appeared similar for both groups between years 5 and 9 but was significantly reduced in years 10-14. The cumulative risk for recurrence during years 5-14 was 12.2% for women in the treatment arm and 15.0% for those in the control arm. Treatment effect was only noticeable for women with ER+ disease. Among all women entered into the study, mortality without recurrence from causes other than breast cancer was hardly affected. Rates of occurrence of known side effects were similar to those reported in other studies: RR for pulmonary embolism 1.87, ischemic heart disease 0.76, endometrial cancer 1.7. The cumulative risk of endometrial cancer during years 5-14 was 3.1% (mortality 0.4%).

For women with ER+ early-stage breast cancer, continuing tamoxifen to 10 years rather than stopping at 5 years produces a further reduction in recurrence and mortality after year 10, suggesting a significant benefit for longer duration of treatment.

Viewpoint

ATLAS recruited patients from 36 countries during 1996-2005. When the study began, 2 years and 5 years of tamoxifen were both standard options, and aromatase inhibitors were not routinely available for adjuvant therapy. This report tracks women who had completed a median of 5 years and were then randomly assigned to continue or stop. Only 53% of the total sample had confirmed ER+ tumors. Women randomly assigned longer duration of treatment had fewer recurrences and death from breast cancer, which became apparent only with longer follow-up. The curves shown in the study (and presented at the 2012 San Antonio Breast Cancer Symposium) really begin to separate after 10 years, indicating that benefit of a longer duration of treatment is manifested only between years 10 and 14 and not spread evenly between years 5-14. The study authors posit that there is a known carryover effect of tamoxifen, and this likely explains the lack of difference in years 5-9.

The study authors provide a comprehensive discussion and analysis of the benefits of prolonged tamoxifen in the second decade after diagnosis. They also reassure us that risks are manageable and predictable given what we know of the mechanism of action on tissues other than the breast. In conclusion, for women who remain premenopausal at the end of 5 years of adjuvant endocrine therapy, consideration of prolonged use of tamoxifen is now recommended.

Thromboembolic Risk Raised in stillbirths and preterm births

Thrombotic Risk Raised in Stillbirths and Preterm Births

Yael Waknine

Apr 09, 2013

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Stillbirth and preterm birth can increase a woman's risk for de novo postpartum venous thromboembolism (VTE), according to the results of a large epidemiologic study published online April 2 in Blood.

After adjusting for maternal age, body mass index, smoking status, and number of prior births, Alyshah Abdul Sultan, from the Division of Epidemiology and Public Health at the University of Nottingham in the United Kingdom, and colleagues found that stillbirth was linked to a 6-fold increased risk for VTE (vs live birth; incidence rate ratio [IRR], 6.24 [95% confidence interval (CI), 2.77 - 14.1]; absolute risk/100,000 person-years [AR], 2444 [95% CI, 109 - 5440]). Compared with full-term birth, preterm birth of 37 weeks or less was linked to a near tripling of risk (IRR, 2.69 [95% CI, 1.99 - 3.65]; AR, 854 [95% CI, 649 - 1124]).

"We believe the strong association between stillbirths and premature births, and VTE in particular, is a finding of real importance which has received only limited attention to date," senior author Matthew Grainge, PhD, also from the Division of Epidemiology and Public Health at the University of Nottingham, commented in a university news release, adding, "They are not currently incorporated in the guidelines for risk assessment for VTE and, if they were, then many cases associated with those risk factors could potentially be prevented."

376,000 Pregnancies

For the study, the researchers analyzed electronic medical records for 376,154 women aged 15 to 44 years whose pregnancies ended in live birth or stillbirth during a 14-year period from 1995 to 2009. Although the overall incidence of VTE was low, postpartum rates were higher than those in pregnancy (338 vs 84 per 100,000 person-years).

Additional pregnancy-related factors linked to an increased risk for postpartum VTE included cesarean delivery (IRR, 1.99 [95% CI, 1.52 - 2.58]; AR, 637 [95% CI, 513 - 790]), having 3 or more prior births (IRR, 2.07 [95% CI, 1.34 - 3.20; AR, 904 [95% CI, 611 - 608]), pregnancy bleeding (IRR, 2.89 [95% CI, 1.53 - 5.43]; AR, 963 [95% CI, 518 - 1791]), and urinary tract infections (IRR, 1.88 [95% CI, 1.28 - 2.77]; AR, 145 [95% CI, 102 - 206]).

Although gestational diabetes was linked to an increased risk for VTE, hypertension was not (gestational diabetes: IRR, 1.71 [95% CI, 0.54 - 5.41]; AR, 165 [95% CI, 53 - 514]; hypertension: IRR, 1.01 [95% CI, 0.37 - 2.76]; AR, 95 [95% CI, 35 - 254]).

Obesity (body mass index ≥ 30 kg/m²) was linked to an almost quadrupled risk for VTE (IRR, 3.75 [95% CI, 2.76 - 5.08]; AR, 926 [95% CI, 742 - 1554]), whereas other maternal characteristics had a more moderate effect, including advanced maternal age (≥35 years: IRR, 1.51 [95% CI, 1.15 - 1.98]; AR, 497 [95% CI, 399 - 618]) and smoking status (IRR, 1.31 [95% CI, 1.01 - 1.71]; AR, 403 [95% CI, 324 - 504]).

Certain medical comorbidities also showed a strong association with VTE, including systemic lupus erythematosus (IRR, 6.69 [95% CI, 0.95 - 47.0]; AR, 2374 [95% CI, 344 - 16,856]), cardiac disease (IRR, 6.58 [95% CI, 1.63 - 26.5]; AR, 2258 [95% CI, 646 - 10,335]), varicose veins (IRR, 3.83 [95% CI, 2.51 - 5.82]; AR, 1330 [95% CI, 899 - 1969]), and inflammatory bowel disease (IRR, 4.56 [95% CI, 1.88 - 11.0]; AR, 1514 [95% CI, 630 - 3638]).

Nothing New, Experts Say

According to Nancy Chescheir, MD, clinical professor of maternal-fetal medicine in the Department of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill School of Medicine, the IRR analysis neglected to account for some important confounders.

"Both premature birth and stillbirth are often associated with infection, which might also increase risk for VTE. Also, some thrombophilias increase risk for stillbirth and, of course, risk for VTE," Dr. Chescheir toldMedscape Medical News, noting that women with known risk factors for premature birth also may have been on bed rest for some time, which would increase VTE risk as well.

Jeffrey C. King, MD, professor and director of maternal-fetal medicine at the University of Louisville in Kentucky, concurs.

"Patients who have a preterm delivery may have been hospitalized and managed either as an inpatient or outpatient with varying periods of time with bedrest or modified bedrest, which would increase their risk for VTE," Dr. King told Medscape Medical News, noting that some of the conditions (or their treatments) underlying stillbirth are also known to increase the risk for VTE.

"I'm not sure that they discovered anything really new regarding the issues surrounding VTE and pregnancy," Dr. King added. "Multiparity, women of advanced age, patients undergoing cesarean delivery, obese patients, patients having operative delivery, and those suffering from obstetric-related injury or hemorrhage are well known to be at increased risk for VTE events."

One of the study coauthors has reported receiving honoraria for giving lectures from Leo Pharma and sanofi-aventis (makers of thromboprophylactic drugs) and has received funds from Leo Pharma for development of an electronic slide kit about obstetric thromboprophylaxis. The other authors, Dr. Chescheir, and Dr. King have disclosed no relevant financial relationships.

Blood. Published online April 2, 2013. Abstract

Immunotherapy what's new?

AACR: Immunotherapy Antibody Has Activity in Range of Solid Tumors

By Anna Azvolinsky, PhD¹ | April 10, 2013

¹Freelance Science Writer and Cancer Network Contributor. Follow Her on Twitter

Washington, DC—The immunotherapy anti-programmed death-ligand 1 (anti-PD-L1) antibody MPDL3280A is effective for several different cancers and was well tolerated. Responses were seen in several different tumor types including lung, kidney, colon, and stomach cancer patients. All patients who responded are continuing to respond to the treatment.

Michael S. Gordon, MD

These results of the first phase I clinical trial with MPDL3280A were presented at the American Association for Cancer Research (AACR) annual conference, held April 6–10 in Washington, DC, by Michael S. Gordon, MD, research director at Pinnacle Oncology Hematology in Scottsdale, Arizona. MPDL3280A is a human monoclonal antibody being developed by Genentech.

Results from 30 patients enrolled in the initial dose escalation portion of the trial were presented. Patients were treated with various doses of the antibody from 0.01 mg/kg to 20 mg/kg at either 2-week or 3-week intervals. Patients had previously received a median of two prior therapies and received a median of 5.5 doses of the antibody.

Thus far, no dose-limiting toxicities attributed to MPDL3280A of grade 4 or greater have been reported at any dose. A single grade 3 toxicity, in the form of rash was reported and no pneumonitis has been observed in this cohort.

Based on the pharmacokinetics, the optimal dosing schedule is likely to be every 3 weeks and in the range of 15 to 20 mg/kg, Gordon told Cancer Network in an email correspondence.

The international phase I advanced solid tumor trial is still enrolling and is expected to accrue approximately 344 patients of different tumor types.

MPDL3280A is an engineered antibody against PD-L1, a protein expressed on the surface of different cancer types. The corresponding receptor that recognizes the PD-L1 ligand on these tumor cells is found on the surface of T cells. The binding of PD-1 on the immune cells to PD-L1 on tumor cells results in a signal that blocks the ability of the immune cells to recognize and facilitate the destruction of the tumor cells.

Several immunotherapy antibodies that target the family of immune checkpoint signaling molecules are currently in various stages of development. Another anti-PD-L1 antibody, BMS-936559 is currently being tested in a phase I trial for advanced solid tumors. Other checkpoint inhibitors in development target the PD-1 protein, including CT-011, MK-3475, and nivolumab. Nivolumab is currently in several phase III trials for melanoma, non–small-cell lung cancer, and renal cell carcinoma. These anti-PD-1 antibodies block the interaction of PD-1 with its two ligands—PD-L1 and PD-L2.

“The PD-L1 antibody differs most significantly [from anti-PD-1 antibodies] in that it binds PD-L1, the tumor-expressed ligand for PD-1, as opposed to the PD-1 receptor itself,” said Gordon. “One key difference is that the anti-PD-L1 antibody does not affect the interaction between the PD-L2 protein expressed in lung tissue and the PD-1 receptor. This may provide an additional safety benefit by reducing the risk of pneumonitis and pulmonary toxicity.” Results from a phase I trial with the antibody against PD-1 have shown pneumonitis as a very rare, but serious toxicity. The target of the anti-PD-L1 antibody is on the tumor itself rather than on the T cell, which could also result in more specific tumor targeting and less off-target effects, according to Gordon.

Further research and clinical trial data will continue to add to our knowledge of how this class of antibodies targets various tumor types and their efficacy and safety. There is so far limited data for all of the immune checkpoint modulator antibodies.

“In terms of antitumor activity, all of [these immune checkpoint targeting] agents seem to have exciting activity in patients with metastatic solid tumors,” said Gordon. The remaining question is whether some of these outstanding responses will be long lasting.”

The anti-PD-L1 antibody is likely to be active against any tumor type as long as the tumor expresses the PD-L1 protein on its cell surface and that PD-L/PD-L1 signaling is important for the tumor’s growth. Gordon emphasized that expression of PD-L1 is likely to be an efficient biomarker to identify patients who are eligible for anti-PD-L1 therapy.

MPDL3280A is also being explored as part of a combination therapy with the BRAF inhibitor vemurafenib (Zelboraf) in a phase I trial for metastatic melanoma. Vemurafenib is an approved therapy for BRAF-positive metastatic melanoma. Another MPDL3280A phase I trial is testing the antibody in combination with the antiangiogenesis antibody bevacizumab

(Drug information on bevacizumab)

in patients with advanced cancer. A phase II non–small-cell lung cancer trial with MPDL3280A will be started soon.

Unnecessary cervical cancer screening ( we can do less)

Unnecessary testing for cervical cancer in women younger than 21 years and in those who have had a hysterectomy is costing about $850 million annually in the United States. It also poses clear risks without documented benefit.

So conclude Nancy Morioka-Douglas, MD, MPH, and Paula Adams Hillard, MD, both from Stanford University in California, in a viewpoint published online April 8 in JAMA Internal Medicine.

"Cervical cancer screening is a prime example of where we can do less without compromising the health of our patients," writes Michael LeFevre, MD, MSPH, from the University of Missouri in Columbia, in an accompanying invited commentary.

The extent of this unnecessary testing was highlighted earlier this year in a report from the Centers for Disease Control and Prevention, as reported at the time by Medscape Medical News.

Drs. Morioka-Douglas and Hillard and Dr. LeFevre explore in some detail the use of the Papanicolaou (Pap) test in 2 populations: women younger than 21 years and women who have had a hysterectomy. They point out that the guidelines of numerous professional organizations, as well as the US Preventive Services Task Force, recommend against such testing.

Testing Against Guidelines

Drs. Morioka-Douglas and Hillard explain that screening women younger than 21 years is not recommended for several reasons. Cervical cancer is rare in adolescents, and abnormal cervical cytologic findings related to human papillomavirus (HPV) infection are common in this group, they note. Screening these women leads to unnecessary testing and treatments for lesions that would spontaneously regress, and treatments are associated with risks, they add.

Nevertheless, it is being carried out. They estimate that 4.7 million women younger than 21 years have an annual Pap test in the United States. They calculate that this unnecessary testing costs approximately $500 million per year (using a laboratory fee of $103 per Pap test, based on 2011 Medicare fee schedules). This does not include the cost of additional testing to investigate positive screening results.

Guidelines also recommend against Pap testing in women who have had a hysterectomy for a benign condition. However, such testing is being carried out in about 3 million women per year (about 1 million of whom are older than 65 years), Drs. Morioka-Douglas and Hillard note. They estimate that this costs approximately $350 million per year, not including the cost of additional investigations.

"Swimming Upstream"

Even when the cost issue is left out of the debate, Pap testing in these 2 populations can result in more harm than good, writes Dr. LeFevre.

He acknowledges that it is hard to get physicians to do less testing and patients to accept less testing. It is like "swimming upstream," he adds.

The forces to do more are powerful, and with screening, so often the mantra is "if we can save even 1 life, it is worth it," he notes.

There are also liability concerns; the failure to diagnose a problem that later causes significant morbidity or mortality is a leading cause of litigation, he points out. "Are there comparable lawsuits for overuse of medical testing?" he asks rhetorically.

Testing More Frequent Than Recommended

Even in women who meet the recommended criteria for cervical cancer screening, there is evidence that more testing than is recommended is being carried out.

Results from a survey of 2087 primary care physicians, published online April 8 as a research letter, show that most would recommend testing earlier than the 3-year interval that is now recommended for women 30 years and older with a negative test result for oncogenic HPV and a concurrent normal result on Pap testing.

"Primary care providers consistently reported that they would recommend Pap testing sooner than recommended by guidelines, especially after normal cotesting results," the research letter concludes.

OM2WARDA

Friday, April 12, 2013

A model for the clinical round examination

Diabetic women are at greater risk than diabetic men!!

CVD Affects Women With Diabetes More Than Men

Tamoxifen more is better

Tamoxifen: More Is Better

Long-term Effects of Continuing Adjuvant Tamoxifen to 10 Years Versus Stopping at 5 Years After Diagnosis of Estrogen Receptor-positive Breast Cancer: ATLAS, a Randomized Trial

Study Summary

Viewpoint

Thromboembolic Risk Raised in stillbirths and preterm births

Thrombotic Risk Raised in Stillbirths and Preterm Births

Immunotherapy what's new?

AACR: Immunotherapy Antibody Has Activity in Range of Solid Tumors

Unnecessary cervical cancer screening ( we can do less)

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