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1
Q

What are the safety concerns with moxifloxacin

A

Increased risk of life-threatening liver reactions
Cardiac reactions
Skin reactions

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2
Q

features of optiate intoxication

A 
euphoria
sedation
miosis = excessive constriction of the pupil of the eye.
decreased concentration
hypotension
bradycardia
respiratory depression 
impaired consciousness
death
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3
Q

features of opiate withdrawal

A 
anxiety / aggitation 
anorexia + weight loss
myalgia
muscle weakness
tremor
nausea + vomiting
diarrhoea + abdominal cramps
yawning
lacrimation / rhinorrhoea / sweating
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4
Q

features of alcohol withdrawal

A 
anxiety
irritability
insomnia
headaches
malaise
weakness
nausea + vomiting
hyperension 
tachycardia
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5
Q

What is the PPV?

A

The likelihood that patients with an initial positive test have the infection

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6
Q

What happens to the PPV as the provenance of the infection drops

A

PPVs become lower as prevalence drops

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7
Q

What is the NPV?

A

The likelihood that patients with an initial negative test result do not have the infection

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8
Q

Define sensitivity

A

sensitivity = ability of the test to correctly identify those patients with the disease

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9
Q

Define specificity

A

Specificity = ability of the test to correctly identify those patients without the disease

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10
Q

Arterial supply of the vagina

A

Vaginal artery

and anastomoses with the uterine artery superiorly

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11
Q

Dermatome supply of anterior upper arm

A

C5

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12
Q

Dermatome supply of level of the nipple

A

T5

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13
Q

Dermatome supply of level of umbilicus

A

T10

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14
Q

Dermatome supply of medial ante-cubital fossa

A

T1

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15
Q

Dermatome supply of the acromio-clavicular joint

A

C4

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16
Q

Dermatome supply of the axilla

A

T2

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17
Q

Dermatome supply of the little finger

A

C8

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18
Q

Dermatome supply of the mid anterior thigh

A

L2

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19
Q

Dermatome supply of the middle finger

A

C7

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20
Q

Dermatome supply of the perianal area

A

S5

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21
Q

Dermatome supply of the thumb

A

C6

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22
Q

Duration for spermatogenesis

A

70-75 days

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23
Q

Length of the inguinal canal in adults

A

4cm

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24
Q

Length of vagina

A

6 - 7.5cm anteriorly

9cm posteriorly

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25
Q

Lymph drainage of base of cervix

A

Internal iliac lymph nodes

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26
Q

Lymphatic drainage of the bladder

A

External Iliac nodes
Fundus to internal iliac nodes
Some to common Iliac and sacral

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27
Q

Lymphatic drainage of the distal rectum

A

Internal iliac nodes

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28
Q

Nerve root control of knee-jerk

A

L3/4

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29
Q

Nerve root of the femoral nerve

A

L2-4

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30
Q

Nerve root of the sciatic nerve

A

L4-5, S1-3

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31
Q

To what lymph group does the cervix drain to

A

Internal iliac

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32
Q

To what lymph group does the distal rectum drain to

A

Internal iliac

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33
Q

To what lymph group does the majority of the breast drain to

A

Pectoral group of

the axillary lymph nodes

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34
Q

To which lymph nodes does lymph from the scrotum and penis first pass?

A

Superficial inguinal lymph nodes

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35
Q

Venous drainage of the bladder

A

Internal iliac veins

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36
Q

Venous drainage of the right ovary

A

Direct into inferior Vena cava

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37
Q

Venus drainage of the left ovary

A

Left renal vein

into inferior Vena cava

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38
Q

Venous drainage of the vagina

A

Vaginal plexus

With vaginal vein to internal iliac vein or uterine vein

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39
Q

What are the 3 sites of constriction of the ureters

A

Crossing the Pelvic brim
Pelvo-ureteric junction
vesico-uretreic junction

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40
Q

What is the nerve root supply for the muscle group of the ankle reflex

A

S1-2

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41
Q

What is the nerve root supply for the muscle group of the biceps reflex

A

C5 - 6

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42
Q

What is the nerve root supply for the muscle group of the knee reflex

A

L3 - 4

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43
Q

What lymph group does the vulva drain to

A

Superficial inguinal lymph nodes

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44
Q

What muscle is mainly responsible for knee extension

A

quadriceps

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45
Q

What muscles does the median nerve innervate

A

LOAF muscles
Flexor carpi radialis
Pronator teres

46
Q

What muscles does the radial nerve supply

A

Triceps,
brachioradialis,
supinator,
abductor pollicis longus

47
Q

What nerve roots mediates the anal reflex

A

S3-4

48
Q

What roots supply the pudendal nerve

A

Anterior rami of S2-4

49
Q

What structures prevent prolapse of the uterus and vagina

A

Uterosacral ligaments
Cardinal ligaments
Levator ani muscles

50
Q

Where does lymph from the Fallopian tube drain to?

A

Para-aortic nodes

51
Q

In what patients should ciprofloxacin be avoided

fluroquinolones or quinolones

A 
ciprofloxacin resistant bacteria 
unknown susceptibility
previous SE from fluroquinolones / quinolones
caution in >60yo
or on corticosteroids
or kidney disease 
or organ transplant
52
Q

What serious side effects can occur from

fluroquinolones or quinolones

A

Muscle / tendon rupture
pain
peripheral neuropathy
CNS effects - hallucinations / depression

53
Q

What is Chemsex

A

the use of drugs in a sexual context

  • methamphetamine (crystal, meth, Tina)
  • mephedrone (meph/drone, miaow miaow, m-cat)
  • GHB/GBL (G, Gina)
54
Q

What is slamming

A

Injecting the drugs used for chemsex

55
Q

What factors contribute to the high burden of HIV among trans-women

A 
high levels of discrimination
structural barriers to healthcare
violence - physical and sexual
poverty
high unemployment
housing instability
56
Q

What does Chemsex do?

A 
Better sex / increased pleasure
Increased stamina / longer sex / multiple partners
Increase confidence 
Disinhibition 
Mild anaesthetic
57
Q

What % of HIV +ve MSM report chemsex

A

7% HIV positive MSM report recreational drug use in past 3 months

29% engaged in chemsex in last year

10% in slamsex

58
Q

What % of HIV -ve MSM report chemsex

A

5% during last time sex

54% engaged in chemsex in last 3 months

59
Q

Risks associated with Chemsex

A 
High risk sexual behaviour - increased number of partners / less condom use / aero-sorting
Increased STI risk
Delayed obtaining PEPSE
Decreased adherence to ARVs for PEPSE / PrEP or HIV tx
Mental health issues
Physical health
financial issues
crime
60
Q

Which patients are likely to benefit from safer sex advice?

A

adolescents
people from, or who have visited countries with high rates of HIV and/or other STIs
MSM

history of:
frequent partner change  
multiple concurrent partners 
early onset sexual activity
previous bacterial STI
attendance as a contact of STI
alcohol or substance abuse
61
Q

What impacts condom effectiveness

A 
late application
early removal 
Condom slippage and errors 
condom associated erection loss 
Use of oil based lubricant -

Lubricant use reduces condom breakage for anal but not vaginal sex

The risk of condom slippage may be doubled with the use of lubricant for vaginal sex

62
Q

Safer sex advice for Oral Sex

A

Advise of risks of transmission of STIs from oral sex
Advise condom use / dental dams for oral sex
Avoiding oral sex with ejaculation - reduces risk of HIV and possibly other infections
Insertive fellatio is lower risk than receptive
Avoid brushing teeth or flossing before oral sex reduces risk of HIV and possibly other infections
Avoiding oral sex if oral cuts / sores a or a sore throat

63
Q

What STIs are transmissible through Oral Sex

A 
Herpes simplex virus (HSV)
human papilloma virus (HPV)
gonorrhoea
Chlamydia
syphilis
HIV
Hepatitis B 
possibly Hepatitis C
64
Q

Which drugs are commonly used in chemsex

A

GHB/GBL
Mephedrone
Crystal Methamphetamine

others - MDMA, Cocaine, Poppers, Speed, ketamine, viagra

65
Q

Harm reduction advice for people using GHB / GBL

A

GBL is a depressant
Advise against mixing it with alcohol or ketamine due to the sedative effect
Start with small volumes (0.5ml)
Avoid re-dosing too soon (aim for 3 hours min)
Advise against using others’ G as the strength is not known
Measure using a syringe or pipette
G can become physically addictive after a short time

66
Q

Signs of dependence to GHB / GBL

A

sweats
shaking
insomnia
anxiety

67
Q

Harm reduction advice for people using Crystal Meth

A

Avoid injecting if possible - carries the additional risk of sharing needles, damage to veins and abscesses

Can lower inhibitions leading to more risky injecting and sexual practices. Sharing needles and equipment leads to increased risk of blood borne virus (BBV) transmission.

Can lead to hallucinations / feelings of depressions/low mood

Individuals at risk of forgetting to take ARVS / PrEP or missing window for PEPSE

68
Q

Harm reduction advice for people using mephedrone

A

No safe way to take it
Least risk from ‘bombing it’ = swallow wrapped in paper
Causes irritation when snorted - nose bleeds
Causes a sore throat when swallowed

Try to avoid injecting - due to added risk.
Advise re local needle exchanges and drug services

69
Q

contraindications to Azithromycin

A

Severe hepatic impairment
drugs which prolong the QT interval
hypokalaemia (risk of QT prolongation)
history of prolonged QT interval

70
Q

mechanism of action of Azithromycin

A

bacteriostatic
Inhibits some gram -ve, some gram +ve and many aytipicals

Azalide = type of macrolide

71
Q

Side effects of Azithromycin

A

<1% stop azithromycin due to SE

Nausea / vomiting
diarrhoea
abdo discomfort
pseudomembranous colitis (c. diff) 
anaphylaxis
hepatotoxicity +/- jaundice
72
Q

drug interactions with Azithromycin

A

warfarin - may increase INR
statins - increased risk of rhabdomyolysis
Ciclosporin - affects clearance of cyclosporin
any drugs which prolong the QT interval (amiodarone, sotalol, amisulpride, terfenadine)
Any drugs which cause hypokalaemia (risk long QT)

73
Q

What type of drug is doxycycline

+ MOA

A 
Tetracycline class
broad spectrum 
bacteriostatic
74
Q

Contraindications to doxycycline

A 
Pregnancy 
breastfeeding
liver disease
SLE
Myasthenia
Porphyria
75
Q

Side effects of doxycycline

A

Nausea / vomiting
diarrhoea
photosensitivity
benign intracranial hypertension (rare)

76
Q

Drug interactions with doxycycline

A

accelerated metabolism of doxycycline is caused by - pentobarbital / carbemazebine / phenytoin / primidone
Decreased levels of doxycycline caused by - Rifampicin
Decreased absorption of doxycycline - Sucralfate / antacids

77
Q

What impact does doxycycline use in pregnancy have on the infant

A

Affects feral tooth and bone development

FDA category D

78
Q

History to determine risk for MSM

A

frequency and number of condomless anal sex partners
serosorting
seropositioning
negotiated safety
understanding of ARVs as HIV treatment-as-prevention
Knowledge / use of PrEP and PEPSE
Sexual activities conferring risk for enteric infections and Hepatitis C or hepatitis A = oro-anal sex (rimming) / fisting;

Discuss ways of meeting partners - use of internet/ apps
sex-on- premises or cruising venues

alcohol intake
use of recreational drugs during sex
problems with sexual dysfunction

79
Q

What is negotiated safety

A

Partners begin the relationship exclusive and stay monogamous
Both partners test for HIV and repeat this after the window period and share their results
Both partners use condoms until both partners know they’re HIV-negative
Both partners develop a clear spoken / written agreement about their sex practices within and outside of the relationship
e.g. not having other sexual partners / not having anal sex outside the relationship / only having oral sex outside the relationship / always using condoms for sex outside the relationship.

Agreement kept by both partners.
If the agreement is broken it’s discussed right away.
And condoms are used until both partners test HIV negative after the window period

80
Q

In men with rectal symptoms, the presence of tenesmus and constipation is significantly associated with which infection

A

lymphogranuloma venereum

LGV

81
Q

Why should GUM clinics routinely ask about drug and alcohol use

A

Excessive alcohol use is associated with STI diagnosis
Alcohol use is more common among adult and adolescent MSM
Binge drinking, use of inhaled nitrites and methamphetamine are markers of increased STI risk in MSM
Ask re injected drug use and equipment sharing +/- offer Hep B / C tests

82
Q

Asymptomatic screening offered to MSM

A 
CT and GC NAAT 
from all sites = urethra, pharynx and rectum - irrespective of HIV status or sexual history
HIV and STS serology 
\+/- Hep B - unless immunity known
\+/- Hep C 
\+/- Hep A
83
Q

Risk factors for LGV

A 
MSM
HIV-positive 
practicing higher risk sex.
Hepatitis C infection
Chemsex (specifically the use of GHB)
condomless anal sex 
fisting
84
Q

When is routine LGV typing recommended

A

In HIV positive MSM with symptomatic or asymptomatic CT

But NOT in HIV-negative MSM with CT (unless symptomatic proctitis)

85
Q

A bidirectional transmission synergy exists between HIV infection and which type of HSV

A

HSV-2

86
Q

3 monthly STI screening including HIV should be offered to which MSM

A
  • Unprotected anal intercourse with partner(s) of unknown or serodiscordant HIV status over last 12 months
  • > 10 sexual partners in last 12 months
  • Drug use (methamphetamine, inhaled nitrites) during sex over last 6 months (Or GBL, ketamine, other NPSs - evidence less robust)
  • Multiple or anonymous partners since last tested
  • Any unprotected sexual contact (oral, genital or
    anal) with a new partner since last tested
87
Q

Causes of sexually transmitted enteric infections

A 
Shigella spp. 
VTEC
Campylobacter spp. 
Salmonella spp. 
Entamoeba histolytica 
Cryptosporidium spp.
Cytomegalo virus
Giardia duodenalis 
Microsporidium spp
Hepatitis A
88
Q

Infectious causes of gastrointestinal infections in MSM

A
  • Viruses - Hepatitis A / norovirus
  • Bacteria: Campylobacter spp., E. coli, Salmonella spp., Shigella spp., Yersinia enterocolitica
  • Parasites: Cryptosporidium spp., Entamoeba histolytica, Giardia lamblia/intestinalis, Blastocystis spp., Dientamoeba fragilis, Isospora spp., Microsporidium spp.
89
Q

Symptoms of proctitis

A

rectal pain
rectal discharge
rectal bleeding
+/- tenesmus

aetiology is usually classic STI pathogens

90
Q

Symptoms of enteric infections

A

diarrhoea and/or dysentery
abdominal pain

usually have colitis or enterocolitis that is caused by enteric pathogens

91
Q

Investigations for proctitis

A

full sexual health screen

Microscopy of a Gram-stained rectal smear - >5 or >10 polymorphonuclear cells/high power field = proctitis
culture for NG from all sites prior to treatment
swabs for HSV PCR and T. pallidum PCR

92
Q

Empirical therapy in symptomatic men with proctitis

A

Cover CT, LGV and GC
(treatment for LGV also covers STS)

Doxycycline 100 mg twice daily orally for 21 days
+ Ceftriaxone 1g IM STAT

93
Q

Risk factors for AIN

A 
HPV
Receptive anal intercourse
immunosupression (including HIV)
smoking
increased age
94
Q

Anal cancer is usually what type

A

SCC

usually preceded by AIN

95
Q

Symptoms of AIN

A 
pruritus
anal discharge
suspicious skin lesions (white / erythematous / scaly / pigmented) 
fissures
eczematous changes
96
Q

Diagnosis of AIN

A

biopsy

97
Q

Management of AIN

A

Observation - may spontaneously regress - FU every 6-12months
local excision if <1/3 of anal circumference
imiquimod 5%

98
Q

Symptoms of anal cancer

A 
Anal pain
bleeding
discharge
pruritus
ulceration

if anal sphincter infiltrated –> faecal incontinence and tenesmus

99
Q

Characteristics of enteric infections

A

sudden onset diarrhoea
with or without vomiting
usually transient
due to enteric infection with viruses, bacteria or protozoa,

typically affect large bowel (the colon)
less commonly - small bowel

Other symptoms =

  • blood and/or mucous in the faeces (dysentery)
  • fever
  • malaise
100
Q

History required for a MSM presenting with acute diarrhoea

A 
Question re severity of illness
medication hx - incl recent abx
exposure to untreated water
animals
occupational risk of transmission 
risk factors - including travel abroad / food history

Sexual risks in 2 weeks preceding onset

  • receptive oro-anal (both direct and indirect, i.e. performing oral sex after anal penetration)
  • multiple sexual partners
  • group sex
  • chemos sex
  • sexual activities involving faeces (e.g. scat play).
101
Q

Investigations for acute onset diarrhoea in MSM

A

Full sexual health screen
Microbiology examination of stool
- for ova, cysts + parasites
- culture + antibiotic susceptibility testing

102
Q

Management of patients with STEI

A

conservative management
Oral rehydration
+/- use oral rehydration salts after each loose stool passed for up to 48 h

AVOID Antidiarrhoeal drugs e.g. loperamide = contraindicated in infectious diarrhoea

AVOID empirical antibiotic therapy,

Consider empirical therapy guided by microbiology advice when:
• patient pyrexial (temperature >38C)
• stools are bloody
• Diarrhoea lasts > 7 days
• Co-morbidities (frailty, IBD, immunocompromised)

103
Q

Advice on sexual practices for preventing spread of enteric infections

A
  • Wash hands, genitals and perianal skin before and after sexual activities - including intercourse / rimming / fingering / handling used condoms or sex toys.
  • Use condoms for anal sex
  • Use latex gloves for digital penetration or fisting
  • Dental dams or a condom cut into a square as a barrier for rimming
  • Avoid sharing sex toys or douching equipment.
  • Avoid sexual contact until 7 days after the last episode of diarrhoea
104
Q

Ovarian blood supply

A

Right + left ovarian arteries - arise from descending abdominal aorta
Right + left ovarian veins

Rt ovarian vein drains to IVC
Lt ovarian vein drains to Lt renal vein then IVC

105
Q

which ligament do the ovarian arteries and veins travel in

A

infundibula-pelvic ligament

106
Q

blood supply to the fallopian tubes

A

Uterine artery and ovarian artery

Ovarian veins + uterine veins

107
Q

arterial supply to the penis

A

3 arteries - arise from internal pudendal artery

= dorsal artery of penis
+ deep cavernosal artery
+ bulbo-urethral artery

108
Q

venous drainage of penis

A

superficial dorsal vein of penis

deep dorsal vein of penis

109
Q

lymphatic drainage of penis

A

skin + prepuce drain to superficial inguinal lymph nodes

glans drains to

  • superficial inguinal lymph nodes
  • or directly into deep inguinal nodes
  • or into external iliac nodes
110
Q

Treatment of acute bacterial prostatitis

A

4 weeks of antibiotics
e.g. trimethoprim
check sensitivities

111
Q

Common organisms causing acute bacterial prostatitis

A

60% = E.coli / proteus / klebsiella
enterococci
anaerobes
urethral GC

112
Q

Chronic bacterial prostatitis symtoms and treatment

A

recurrent UTI
persistent focus of infection in prostate

treatment = 4 weeks of ciprofloxacin 500mg BD
or 4 weeks Ofloxacin 200-400mg BD

Dip GUM (27 decks)

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