How to Pass the FRACP Written Examination. Jonathan Gleadle

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      Fagin J, Wells S. Biologic and Clinical Perspectives on Thyroid Cancer. New England Journal of Medicine. 2016;375(11):1054–1067.

       https://www.nejm.org/doi/10.1056/NEJMra1501993

       29. Answer: C

      Thyroid nodules are common in the general population. They are palpable in 4–7% of the population and have been detected using ultrasound in up to 60% of adults. The majority of nodules are benign but approximately 7–15% of thyroid nodules are thyroid cancer.

      TFTs should be performed in all patients with a thyroid nodule on examination. While most patients will be euthyroid, a suppressed TSH level indicates a hyperfunctioning nodule and the risk of malignancy is extremely low. Serum calcitonin levels should only be requested when a medullary thyroid carcinoma is suspected.

      The ultrasound assessment provides key information regarding the size and sonographic features of the nodules, which form the basis for risk stratification. A decision to proceed to fine‐needle aspiration (FNA) is typically made based on ultrasound appearance. Features taken into consideration include size and shape of the nodule and other features including homogeneity, presence of micro‐calcifications and vascularity. Ultrasound‐guided FNA is the most sensitive and cost‐effective method to assess the nature of thyroid nodules and the need for surgery. The Thyroid Imaging Reporting and Data System (TIRADS) score and size of the nodule are used to guide whether FNA should be performed. Guidelines recommend FNA for nodules ≥1 cm that have a high pattern of suspicion on ultrasound, ≥1.5 cm that have a moderate suspicion pattern on ultrasound, and nodules ≥2.5 cm that have a mildly‐suspicion pattern on ultrasound. If the cytologic findings are interpreted as non‐diagnostic, FNA should be repeated within 3 months to obtain sufficient cells for a more definitive diagnosis.

      Molecular analysis should be performed in patients with atypia of undetermined significance, follicular lesions of undetermined significance (AUS/FLUS), follicular neoplasm or suspicious for a follicular neoplasm in FNA. One molecular approach is to analyse the specimen by means of a gene‐expression classifier to rule out cancer. The other molecular approach is to directly assess the FNA for BRAF and RAS mutations. If the FNA is positive for a BRAF mutation, the chance of cancer is close to 100%, and if the FNA is positive for a RAS mutation, the chance of cancer is 80 to 90%.

      Durante C, Grani G, Lamartina L, Filetti S, Mandel S, Cooper D. The Diagnosis and Management of Thyroid Nodules. JAMA. 2018;319(9):914–924.

       https://jamanetwork.com/journals/jama/article-abstract/2673975

       30. Answer: C

      Transgender (TGD) people are individuals whose gender identity is markedly and persistently incongruent with their sex assigned at birth. About 0.6% of the population identifies as TGD in Western countries. Gender‐affirmation treatment should be multidisciplinary and include diagnostic assessment, psychotherapy, counselling, real‐life experience, hormone therapy, and surgical therapy.

      Hormonal therapy is effective at aligning physical characteristics with gender identity and improving mental health symptoms.

       Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses.

       Feminising hormone therapy options include transdermal or oral estradiol. Additional anti‐androgen therapy with cyproterone acetate or spironolactone is typically required.

      No data exists on gradual versus rapid titration or comparison of formulations in feminising TGD individuals. The value of biochemical monitoring is uncertain; when performed, trough estradiol levels should be used. Target estradiol levels should be between 250–600 pmol/L and total testosterone levels is < 2 nmol/L. Despite anecdotal reports that progestins increase breast growth, no data supports their use. Furthermore, progestins can increase risk of coronary artery disease, thrombosis, and weight gain. Cyproterone acetate, a commonly used anti‐androgen agent, has progestogenic effects. Anti‐androgens are often required in addition to estradiol therapy to lower endogenous testosterone levels or inhibit testosterone effects. Spironolactone (100–200 mg daily) or cyproterone acetate (12.5–25 mg daily) are both effective. Gonadotrophin‐releasing hormone analogues are used as puberty blockers in adolescents only.

      Hormonal therapy can impair fertility and patients should receive counselling for this prior to commencing gender affirming treatment. Sperm cryopreservation should be discussed before estradiol therapy due to expected changes in spermatogenesis. Oocyte storage can be considered; however, ovulation typically resumes on cessation of testosterone therapy.

      Cheung A, Wynne K, Erasmus J, Murray S, Zajac J. Position statement on the hormonal management of adult transgender and gender diverse individuals. Medical Journal of Australia. 2019;211(3):127–133.

       https://www.mja.com.au/journal/2019/211/3/position-statement-hormonal-management-adult-transgender-and-gender-diverse

       31. Answer: E

       32. Answer: F

       33. Answer: D

       34. Answer: H

      Obesity is a complex, multifactorial disorder that has genetic, biological, and environmental origins. Traditional treatments consist of counseling, restrict calories intake, and lifestyle changes such as eating a nutrient‐dense diet, participating in regular physical activity, and other behaviour modifications. Medications commonly used in the treatment of obesity include orlistat, phentermine, topiramate, naltrexone, and liraglutide. Many patients with severe obesity (BMI≥40) are unable to lose and maintain significant weight loss. Bariatric surgery is an effective treatment morbid obesity because it leads to sustained weight loss, reduction of obesity‐related comorbidities and mortality, and improvement of quality of life.

      There are three types of bariatric surgery:

      1 Restrictive: Laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric banding (LAGB, a restrictive procedure to induce early satiety through reduction of gastric capacity).

      2 Malabsorptive: Biliopancreatic diversion (BPD) with or without duodenal switch comprises this category of bariatric surgery. Each has only a minimal restrictive component that involves the creation of a sleeve like stomach.

      3 Restrictive Malabsorptive: Proximal Roux‐en‐Y gastric bypass (RYGB) is a restrictive‐malabsorptive technique. Gastric capacity is reduced by 90%. The section of the gastrointestinal tract bypassed is called the biliopancreatic limb, which includes the majority of the stomach, the duodenum, and part of the jejunum. This limb drains bile, digestive enzymes, and gastric СКАЧАТЬ