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Yeah. Ok. Hey guys. Um Can you hear me? Could you just um message in the chat to see if um just to check my mic's working? I? Ok, great. Um We'll just give it another minute until six o'clock, see if anyone else joins and then we'll get cracking. Ok. Um So my name is David. Um Welcome to another session of the 6 p.m. series. Um So this is part of your psa exam preparation and today this is the second session out of three and today we're gonna be talking about drug monitoring and data interpretation. Um So just a little bit of information about myself. I'm David. I'm one of the er CT ones. I'm doing a ccs anesthetics. I'm currently on my acute medical er rotation um up in Newcastle and for the last two years, I've been working in Australia and before that I did F one and F two in Pool and Dorset. Um So I'm just gonna check, can you see this next slide? Um Could you just message again just to check the slides are working? Great. Thanks, Gemma. Thank you. Um OK. So, yeah, today we're gonna be talking about um two separate topics. Um, but they are quite closely interlinked for the PSA exam. Um So we're gonna be talking about drug monitoring and data interpretation. Um So there's some key learning outcomes that are kind of general for both. Um But we wanna be able to demonstrate understanding of how to plan appropriate monitoring for either a beneficial effect from a drug or a potential harmful effect. You always wanna take into account that clinical history exam and investigations. Um the major factor will be the timing of those measurements and knowing um how to decide which me measurement is likely to lead to the most appropriate assessment. And then in a similar vein, data interpretation is your ability to um essentially you wanna be able to explain the importance of being able to interpret data um provided by monitoring the effects of the medicine as your role as a prescriber. Um So, um both, like I say, both of them are very closely interlinked. Um But I thought it would be useful just to talk a little bit about the structure of the overall exam. Um Some of you will be very familiar with it, but I think it's important to familiarize yourself with the overall layout of the exam, to have an appreciation of how much time you're lending to specific areas, how much focus you should put into a particular part. And these are all parts of um getting good exam technique which some of you will have nailed down but other people might struggle with a little bit. Um So obviously there's eight separate sections to the exam, there's prescribing prescription review, planning management, providing info calculation skills, some drug adverse reactions and then the final two parts are drug monitoring and data interpretation. Um And we're gonna be talking about those last two. So generally when you look at the breakdown for the overall psa um as I'm sure you're well aware with a week to go. Um the majority or the bulk of the marks come from prescribing and prescription review. Um um out of a possible 200 marks, um 100 and 12 of those come from those two sections. Um So the majority of your time and effort will be focused on these areas in nailing that down. Um But drug monitoring and data interpretation er constitute a total set of marks of 28. Um So which is essentially you can all do math, but essentially it's 14% of the paper. Um but they're easy marks to pick up and easy marks to lose. So, it's important to have these two sections nailed down as they're quite time limited and you come into the end of the exam by the time you're attacking these things usually. Um So generally the PSA blueprint um identifies seven settings of clinical activity into which the eight different item styles are set. But um the main thing is that the majority of your questions. So, um they're gonna be focused around medicine, Gerry and GP stuff. So there will be a bit P psych sing G and surgery. But the large bulk of your questions is gonna come from medicine, surgery and GP. Um And in a similar vein, the therapeutic groups of drugs that must be included in all PSA exams are your kind of bread and butter um prescriptions. So for opioids, anticoagulants, insulins, antibiotics and infusion fluids. Now, in terms of drug monitoring, generally, the most likely things that you will be tested on is insulins, antibiotics. Um possibly anticoagulants as well and then possibly opioids, I think fluids, yes, is something that you consider. But you're more likely to see that in the prescribing section. But with factoring those two features in, you can start to predict um vaguely what clinical settings these different drugs might crop up in. So I thought it would be useful just to look at how your questions are likely to be structured um based on how the PSA actually formulates and structures, their exam, a lot of good exam technique comes out of knowing what your examiner is looking for in each question, the kind of distractors that they'll put in and, and kind of small little points that will really, really help you optimize before you enter the exam. So y you can find this information all on the P SA website, but I've broken it down for you into the salient points. But obviously, every scenario is gonna be based on a clinical scenario for this is specifically for drug monitoring. And it's usually going to be about someone starting a medication. Um, and you're being asked to identify the best way of monitoring its beneficial or adverse effect. Um, having said that you will get questions where someone's established on a treatment and I will look at that as well. Um And usually you'll be given a list of five different options relating to the treatment identifies and you'll be asked to select the most appropriate. So how are your questions likely to be structured in terms of that? So they're gonna generally avoid over elaborate clinical scenarios. Um And they're gonna contain, you know, pl plenty of information that's gonna help you delineate the best option and choose something fairly unambiguously. Um, a really important point um That might help you differentiate between two answers is that the most likely option is going to be something which can be measured objectively. So that may might be liver function might be renal function if appropriate and you try and avoid um picking symptoms that have no or are subjective sort of parameters. Um So that that might be fatigue, nausea, headache, something which you can't pin down as a clear monitored um level. And generally, you know, the out of the five questions, four of those questions will be distracting options. So they might be plausible. They might even be, they might not be incorrect, but there's usually going to be an option that is the best option or the most appropriate in relation to monitoring the beneficial adverse effects. Um And it usually includes some kind of timescale and generally what you'll see is that each question will kind of follow this form that I've select the most appropriate option to monitor for a good or a bad thing over hours, day months and then you'll be asked to mark it with a tick or whatever. Um, alternative ways they might structure is select the most appropriate monitoring option required before starting the treatment or something to help guide ongoing treatment, assessing how they're doing on that treatment. So, jumping straight into a sort of drug monitoring question, we've got a 55 year old woman who attends her outpatient rheumatology clinic to review her rheumatoid arthritis treatment. She's been experiencing increasing pain and swelling of her wrists and knees and her current medications are hydroxychloroquine. She's on 200 mg, um po twice daily. She's on naproxen twice daily as well. And then she's also on paracetamol, which is 1 g er Q DS as needed. So, the rheumatologist who's seen her in the clinic um has prescribed her leflunomide, which is a, 100 mg a day for three days, then 20 mg per day to continue. So I want you to select the most appropriate option and I'm gonna pull it pile up Ok. So the options are blood glucose T FT S weight, lipids, liver function test. So I'm just gonna start that one. Now. I think that should have worked. Can you, is that, has that come up? Yeah. So just wait for a few more responses. Ok. Anyone else? So, I think there is about 60 of you. So. Ok. Ok. So the correct answer is eight. So that's the liver function test and we'll talk through why the liver function test. Obviously, most of you have, er picked up that, that's the correct answer. So that's great. Um And we'll talk through why the other options are less appropriate. Um So hopefully what, what you've been able to do is um either you knew this off the top of your head if so very impressive. But I'm assuming most of you they've had the B NF up and I've managed to look up leflunomide very quickly and essentially the monitoring requirements for leflunomide list a few different things. So they want you to monitor full blood count and they want you to monitor liver function and they want you to monitor uh BP. Um So of the options, obviously, liver function was the only one, only monitored aspect um listed in the B NF, which you can choose an option. Therefore, it was the most appropriate thing. Um Other options were less appropriate. So, hyperlipidemia, it is a um feature of er, or an uncommon side effect of leflunomide. But you can see, yeah, it's uncommon if you look at the side effects, it's not a classically listed issue. Um So it would be less appropriate. Um And whilst weight loss is common, um it's not usually significant in the context of um starting leflunomide. Um and blood glucose and T FT S aren't even part of their monitoring criteria. So, yeah, good. That was a good one to start off with. Um And just a bit of information about leflunomide. So I guess the overall point is that you, you might not necessarily know every drug or medication that you see, um that comes up on the exam, but the idea of the exam is to, you know, help you appreciate that when you're an F one or F two, you're gonna come across um scenarios where you are asking a specialist advice. Um either from G PE D assess um acute medical unit wherever you are. Um And you're seeking that specialist advice for that reason, but they might not prescribe that drug. They might just tell you what to give and then it will often be your responsibility to make sure you're doing it correctly. But then also looking at um the monitoring of that drug, either making sure the GP is doing the right thing or making sure as an inpatient on the ward, um it's being monitored correctly. Um But yeah, for your information, if you're interested, Leflunomide is a immunomodulatory drug essentially works on the pyrimidine pathway. Um And the thought is it down regulates cytokine activity, um proliferation of lymphocytes and, and, and potentially inhibits cox two inducibility. So, in the context of severe inflammatory arthritis, it's helpful. Um but it would always be guided by a rheumatologist or another specialist. Ok, good. Oh, yeah. So I think you've already demonstrated this. But if you can search the B NF effectively and utilize control and f then you shouldn't have any major issues monitoring. Um But we'll just look at another example. So um question two. we've got a 87 year old woman who's been taking digoxin for a, for 15 years. Er, she's now complaining of nausea and reduced mobility. Our current dose of DGE is 100 and 82.5 mics daily. Uh Her rate's been controlled on this for many years and there's no tacky or Brady arrhythmia on her A CG today. But E eg fr is 29. Her digi level is 2.9 and the therapeutic range is 1 to 2.6 of the following options, which is the most appropriate course of action. So, do you want to continue the current dose? Prescribe dijs specific antibodies, reduce the dose, stop the DJ and restart at a lower dose once the level's therapeutic or stop the DJ and restart at the same dose. Um So we'll start pulling that one. Ok. So maybe a little bit more of a tricky one to think about. Um, so yeah, we'll just wait for a few more responses. OK? Just see if there's anywhere else. Ok. Great. I think that's the majority of you. So the answer is, uh, the answer is d so, yeah, the majority of you got this right. So we wanna stop the digoxin and restart at a lower dose once the level is therapeutic. Um, and we'll talk about why the other options are less appropriate. Um, so essentially when you look at the B NF again, um, when you look at prescribing digoxin, and this takes a little bit more digging, that is something that you could very easily get asked about in the exam. So I thought it was a good one to stick in. Um, so stopping the digox digoxin and restarting it at a lower dose once the level's therapeutic. And that's important because, um, this is a lady who is, um, elderly, she's on a sort of second line rate control for, er, presumably for AF um, and, you know, normally in someone who's looking at these criteria, when you look at, um, someone who's elderly and who's got a G fr of less than 30 is on greater than 100 and 25 mcg per daily, it meets that kind of, er, stop criteria which we'll talk about, um, which suggests that you should s actually stop or cease the medication and review it either with pharmacy or with a specialist or with a GP. Um in terms of er, what, what you should do and II guess the main issue is here. So, um you know, she, the usual maintenance dose of digoxin in older patients is about 100 and 25 MS. This is taken from the B NF again. Um So lower doses, doses often can be inadequate, but toxicity can be common in those who are given higher doses. And then the stop tool essentially stands for screening tool of older persons, potentially inappropriate prescriptions. Um So I just got a little message. So I think that's a good question Ruby's asking. So if her eg fr was less than 30 would you stop it? Even if above the therapeutic range? I think to be honest, in practicality, you probably would still stop it. Um And I think if someone's showing early signs of toxicity, so she's feeling nauseated. Um The vignette hasn't given you any other clues as to why she might be nauseated. There's nothing saying she's got abdominal pain or any other thing going on. You're just given a, you will be just given that sort of level of information, someone who's nauseated, showing signs of digoxin toxicity, you should stop the medication. Um If they're showing they've got um therapeutic levels abo sorry levels above the therapeutic range. Um So yeah, that's a good question. I think for the purpose of the exam, I'd hope that, yeah, they'd make it crystal for you by say, providing you with their eg fr but if they don't and their therapeutic levels are above um the therapeutic, sorry, if their D level is above the therapeutic range. Um and they're showing signs of toxicity, like nausea, feeling unwell. Um any concerns like that, then you just stop it. Yeah. Um So yeah, and then yeah, we'll just talk about the other reasons why, why the other reasons are less appropriate. So part a being wrong is hopefully very obvious. So we'll continue on the current dose despite identifying that she's above the therapeutic range. Um And she's displaying symptoms of dige toxicity. Um in as someone else just asked, what would we regard as very old patients? So good question. I think anyone above 80 can be classed as geriatric as a broad stroke of brush. Um But they in the vignette are going to make it fairly apparent that this person's geriatric. Um And I'd hope that you could establish that someone who's 87 years old is very old. Um I guess if you're hitting, hitting the realms of 70 it's a bit of a difficult one, but I think you're unlikely to see younger patients say people younger than 70 on ditch because it's just not prescribed as much in the younger population uh for a number of reasons. Um And then yeah, so, so in terms of prescribing the digoxin specific antibody fragments, we'll talk about that a bit more in a sec. Um, but essentially the vignette, um, it suggests that she, er, is not showing any signs of, er, ventricular or, er, arrhythmia or any kind of brady arrhythmia, which is, um, refractory to atropine. So you would only give the antibodies if you thought there was a life threatening arrhythmia. Basically reducing the dose is helpful, but it's not the most appropriate option. Um, because we already know she's, um, accumulated digoxin. So, um, so yeah, yeah, that's not the safest choice and then stopping the ditch and restarting it at the same level is likely to lead you to a similar outcome, several months down the line line. So less appropriate than just reducing the dose. Um stopping it and reducing the dose. Um, in practicalities, you would obviously weigh up with a specialist whether you would might change their digoxin to something else. But I think what they're trying to get at here is that they're on an established treatment. Um, that's been working for 15 years and it might be that her, she's got C KD or something else where her renal functions just crept down and you might just have to have a bit of a rethink about her medications. Um And then yeah, so stop criteria applies to anyone over 65. Um Which is right. Um Yeah, and then where do we find the doses for elderly or reduced renal function? It just says to consider reducing the doses. Um So they're unlikely to ask you what to change the dose to. Um, but you can kind of see from the prior information that um, lower doses. Um, so someone with 62.5 mcg in those with renal disease might be appropriate, but it's all, it's all just, um, a bit of chopping and changing really. And the likelihood is they're not gonna ask you for the exact dose to change it to in the exam and then just again for a little bit of consolidation. So what is digoxin? Digoxin is a cardiac glycoside? Um So it acts on the sodium potassium A TPA S pump and has two mechanisms of action. So it's aim is to increase intracellular calcium and increase my myocardial contractility with that. And it also increases vagal activity. So, reduce, reduces a V node conduction. There's generally now a second line or even third line drug for rate control for AF and it does have a role in heart failure as well. Um But that would be guided by a, a heart failure specialist. Uh And then just some general things about digoxin. Um These are just lifted from cautions from the B NF. But generally, you wanna be very cautious about anyone with things like Wolf Parkinson white, anyone who's had a known previous arrhythmia on digoxin um or another cardiac glycoside, people with conduction problems such as complete heart block. Um anyone in VT or VF or people with cu as well. And then you can look at your own leisure at kind of people to be a bit cautious, um, and prescribing, er DJ for people with recent MRI S sick sinus hypokalemia renal impairment. And then, you know, it's, it's a bit vague but you need to reduce the dose in the elderly and then just, um, digoxin specific antibody. I've never given it myself. Um, but you would again be guided by a toxicologist or um you know, a consultant in Itu. Um or Ed, it's basically where you're looking at um using the antibodies to antibody fragments to mop up um excess free digoxin. And the aim is to reduce the er levels of free digoxin in the bloodstream. Um But yeah, just a little snippet of extra info info for you. So question three of drug monitoring. Um We have a 48 year old woman who attends a GP practice. She has known bipolar disorder and has attended the GP clinic for a routine lithium level. She's been taking lithium for two years now and her last lithium level was nt 0.6 millimoles per liter. Uh The nurse practitioner has asked you when she should take the lithium level that she's come to have done. So, choose the most appropriate action. So should we take the lithium 12 hours after her morning dose, six hours after the dose, one hour pre dose? Um or actually your lithium levels after one year. Do we need to measure the lithium levels. Oh A um does the timing matter? But actually her last levels indicate that. So naught 0.6 was too high. So do we need to stop the lithium? Um So I'll just open that one up. Uh Cool. Ok. Just wait for a few more responses and then we'll move on to the answer. Ok, great. So yeah, the answer is a, so you wanna take the lithium level 12 hours after a morning dose. So, looking through the BNF, um as you know, lithium salts have a narrow therapeutic window. Um and so need to be monitored in an appropriate facility, whether that is a specific GP blood service or in an outpatient psych setting. Um and they need to be taken 12 hours after the dose to achieve a level that's between naught 0.4 and one. And you're ba basically aiming for a lower end of the range for maintenance therapy or elderly people. And so we can also see in the BNF that routine serum lithium monitoring. When you first start the medication, it should be performed weekly. Um after initiation and then after each dose change, it should also be done weekly until the concentrations are stable. So then after that every three months for the first year and then every six months thereafter. So, er, essentially when we look at the er other answers, so six hours after the dose is incorrect, one hour is incorrect. Um we can see that lithium levels are the answer. Lithium levels aren't r routinely measured after one year. Yes, they are. Um, lithium levels. Once someone's on lithium they're monitored in some form or another for the rest of their life until they're off lithium. Or, and the likelihood is once you start lithium, generally people will be on it for the rest of their life unless they have some serious adverse effects. Um, and yeah, the timing does matter as we know. Um and her last levels were actually fine. So naught 0.6 millimoles per liter is absolutely in the lower end of the range for maintenance and completely appropriate. So, um if it stays at the same level, that's perfect and you don't need to change the dose. OK. So that was just a little bit on da uh drug monitoring. Um We're now gonna look at data interpretation. Um Now I think anecdotally or based on like based on statistics from previous PSA exams, people often drop the most marks or find this one of the most challenging aspects of the exam. And I think anecdotally, I th I think the difficult or the more challenging aspects might be that you're assessing an individual case. So where you're given y you know, unfamiliar data, so data about someone you've never looked at before, you're in a time pressured environment. Um and you're coming towards the end of the exam. Um So it's expected that you might only allocate about seven minutes for the data interpretation section. So it's a lot of info to assimilate in a short space of time. But it can be a really straightforward area to pick up easy marks. So we'll just um go through a few questions for that as well. But first of all, similarly, and feel free to feedback if you don't think this is useful, but I've always found to improve exam technique. One of the best things to do is look at how the actual examiners will plan to structure a paper. And ever since I've looked at that kind of thing, I've always dramatically improved my exam technique and dramatically improved my scores um both in exams and interviews. Um So similarly to the monitoring, the data interpretation instruction in a certain way, and you'll have six items or six questions. Um Each of which requires identification of the most appropriate answer from a list of five. Um and each of those six items or questions is worth two marks. So there's 12 possible marks to pick up in this section. Um And the main aspects or the way they structure, each question is to allow you to demonstrate reasoning and and the judgment required. So being able to decide on the meaning of the results of a new investigation um and how they relate to ongoing drug therapies. Um looking at what measurable action needs to be assessed. So making an appropriate change to a prescription based on those data and then the content involved in this. So, um generally, it's gonna be about withdrawing a medicine, reducing its dose, changing it, not changing it, increasing its dose or prescribing a new medicine. And the things you're likely that are likely to come up are things like drug concentrations. HB white cell count, liver or renal functions, cholesterol or looking at a nomogram or a combination of looking at a nomogram with drug concentrations. Um So that's just an important thing to look at. And basically, it's always gonna be about treatment decision, whether it's gonna be about um deciding on a dose change or looking at a physiological mea measurement. Um And yy, again, you'll be given five different prescribing options and you're asked to select the most appropriate um er, yep. So there's slides and recording should be made available after the talk. Um And yeah, there'll be a feedback form as well. Yeah, uh release the feedback form at the end. Um And then, yeah, so again, similarly, you're gonna be looking at four distracting options that while plausible are clearly less appropriate generally in terms of those five options. So example, one can you all see that it's coming up a lot smaller than it was? Um when I, when I, when I was looking at this before, um but I'm hoping you can just about uh make out the nomogram. But basically the, the question is looking at a 68 year old woman who's been treated for urosepsis. She's been prescribed gentamicin five mix per kig IV daily for three days. Um and the result of her serum gent level, 12 hours post dose has been thrown through to the ward as 5 mg per liter. Your hospital provides the below or um nomogram or to the side to interpret serum measurements. And I want you to select the most appropriate decision option with regard to gentamicin prescription based on these data. So option A is gent three mix per kick daily. B is withhold the gent C is change it to every 48 hours but keep the same dose. Um OSD is keep it at daily and E is change it to every 36 hours. Um So we'll just open that pole now, just wait on a few more answers. Um How long is this session scheduled for um aiming for 45 50 minutes? So, um just got a couple more questions to go through. Um I hope this has been useful. Um But yeah, so thank you. Uh So the co correct answer is, see, so well done. The majority of you got that right. Um And I appreciate that some of this might be telling you how to suck eggs. Um And I appreciate that um generally in a relaxed setting, this can be quite an easy thing to do. Um But sometimes when you're under time pressure and you're at the end of the exam and your brain's fried from asking, answering 100s of other questions. Um It can become a little bit difficult. So it's good just to have a structure of how you're gonna approach these questions. And generally you just wanna be able to pluck out the key facts. So it doesn't really matter what this lady is on treatment for in this context. All you need to know is that she's on five mgs per kig IV daily of gentamicin. So that's the current dosing regimen or regime we can see from the nomogram. The key information is that um she gets that she, the nomogram gives you some guidance about what her next dose should be based on um the time. So we know it's taken 12 hours post dose. Um and then er looking at er er the dose, the concentrations actually come through. So the five mgs per liter is the actual concentration of the gentamicin. Um So from that, we can easily extrapolate that um at if the dose is taken 12 hours after the start of the infusion and it's at five mgs per liter that tells us that it's in within this area. And therefore, we should give the same dose every 48 hours as most of you have identified. Um So if we wanted to withhold the dose, um we'd have to have had a serum gen level a bit higher than five mg per liter, not loads higher. Um but it would have been about 5.45 0.4 mix per liter would have suggested that actually at 12 hours we would, um, we would have stopped, er, that dose and rechecked it at a later date. Um, and then, yeah, obviously, depending on the time it was taken, the earlier the time it was taken, the higher threshold, you have to withhold the dose, obviously, because the more likely you have a, you're going to have a concentration, higher concentration of that in your blood. Um And then in terms of giving the same dose every 24 hours. Similarly, in a similar way, you can just look if we wanted to do that realistically, um they'd need to be at a level of er 2.2 0.62 0.7 or less. Um I think ideally in the exam, they're probably gonna make it a bit clearer, the exact numbers that they want for it um for the cut offs. But, you know, as long as you can interpret a nomogram like that and sort of just quickly look at the X axis and Y axis and look at that, make sure it's for the right dosing regimen. So this is definitely for once daily high dose uh gentamicin five mg per kig um you know that you're in the money and you'll be able to answer the question very quickly. Um but it, but it's something that you will do every day as a junior or every other day, as a junior when you're on the medical wards, surgical wards, lots of patients have Gentamicin, Vancomycin, things like that. So, it's something to, even if you don't enjoy it, it's, it's something that you're definitely gonna have to do. So it's really useful to know how to do it. And it's a few key things don't get bogged down with thinking about. Well, in my trust we do it this way when I've seen on the wards as a medical student, we do it. Um we do the dose at six hours or, or whatever it's different in every hospital. So just go with the facts that you've got in front of you on that mammogram, on that piece of paper um or on the screen in front of you. Um So the same and just be aware that there might be different nomograms for the same drug, but for different indications. So they could in theory give you two nomograms. So they might give you one for treating gentamicin in urosepsis and they might give you another one for giving gentamicin the treatment of endocarditis. So just be aware of little um sort of red herrings or caveats to that, um which might um just catch you out, but generally, yeah, the answer is right in front of you and that's why they are easy marks to pick up. Um And then just a little bit about gentamicin as well. Just I always find it's helpful to have a bit of information about something I'm learning about just to consolidate or just remind myself what, how to look at things. So, very quickly gentamicins an aminoglycoside antibiotics, bactericidal. Generally, it's used against gram negative bacteria. So pseudomonas klebsiella um potentially E coli. Um so the way it works is essentially it's a gram, it acts on gram negative bacteria. So it passes through their membrane and it, that's an aerobic process. So an oxygen dependent dependent active transport binds to a subunit, a 30 S ribosome or subunit and disturbs Mrna translation. So it's not useful against anaerobes. So it's not useful um against things er like Strongyloides, um C diff things like that. So it's just just helpful to be aware of. Um it's not something you might remember when you were an F one. Um Could I please explain the multiple daily dose regimens for gentamicin? Uh Yes, I can do. Um It might be helpful to know is there a particular aspect that you don't feel comfortable with? What um what I what is it that you're not sure about? Um because in, in, in general, if you're given a multiple daily dose regimen question for say gentamicin, usually what it's going to be getting at is looking at how many. So it'll have been a patient's just been initiated on treatment for gentamicin. Sorry, with gentamicin. So it might be for EPS or it might be for infective endocarditis, something like that. Um And usually the only way the question will differ is that um looking at the nomogram, what you might have is a sort of question where it says patient's been on the medication for two days, they've had three doses and then it wants you to calculate what their next dose should be. And this nomogram might say um once so um it might say gentamicin dosing after third dose instead of saying once daily high dosing and then it'll just be about looking at what the, what time that dose um of medication was given. Um what time the serum level was taken? Correlating it to the time hours after the start of that say third dose and that will help you prescribe the fourth dose um and time it so it might be just establishing whether they need another fourth dose within 24 hours or it might be that actually the three doses they've had so far, put them way above the threshold. And what you need to do is wait 48 hours. So you'll be able to see that. Um And usually what it will say is, yeah, it will, instead of this thing once daily high dose g dosing regime regimen, it will say that er multiple daily dosing regimen after the third dose or something like that, that's usually how gent works in practice. Um Is there anything else you weren't sure about with that may or Are you happy for me to move on? I'm going to take the silence as yes, you're happy. And cos I haven't asked anything else about that, but let me know at any point if you would like me to explain that further. But yeah, basically gen worse on gram negative bacteria alters translation, not useful against anaerobes. Um And then you, I'm sure you've had this all hammered into you. But gentamicin, why do we look at the monitoring? It's because it's associated with a reasonably high degree of evidence base that's associated with ototoxicity. Um And that's because it's renally excreted. So it can accumulate in renal impairment and you might need a reduced dose. Um So generally, if you're giving gentamicin in prac, in clinical practice as a one off dose, you're not gonna have any issues. Um But if you're giving it for multiple doses, like we talked about multiple daily dose regime regimens, then you need to be much more judicious with it and you need to um be monitoring it much more closely and have a think about whether you need to chat to microbiology about changing it to another antibiotic that is less renally excreted. So, um question two on data interpretation. Um and there's only one more after this. So don't worry, I'm not gonna keep you here all night. Um He's a 30 year old male. He's been reviewed on the medical ward. He's type one diabetic. Um doesn't matter why he's in hospital. He's, he's in hospital. Um The current treatment is insulin glargine and brackets Lantus. So which which is 12 units subcut daily in the evening. And then they're also being given no rapid six unit subcut with meals and their hospital charts below documents their waking, premeal and bedtime blood glucose concentrations. So, um we've got a little table here and I want you to select the most appropriate decision option with regard to insulin prescriptions based on these data. So, um you can see here we've got prebreakfast pre lunch, pre evening meal and before bed, um blood sugar levels. Um and then the dates are corresponding down there. So do we continue the current insulin regime increase the novorapid dose in the evening to eight units subcut. Do we actually stop the Lantus and change it to Levemir and give it morning and evening? Do we increase the evening insulin Lantus to 14 units or do we increase the novorapid to eight units subcut for all meals? So I'll just open up that pile now. Ok. So just waiting for a few more answers. Ok. Anyone else? Ok. In the interest of time, uh we're just gonna move on to the answer which is d so we want to increase the evening incident Lantus to 14 units. So well done. The majority of you got that right. You've all been very good and you're obviously not gonna have any problems with this exam and let me know if I've made this too easy, but I think this is representative of what you'll actually get in the exam in general. Um But generally, what we can see is from the vignette or from the information we've been told that the patient's on a basal bile regimen. So the time where there is, you know, suboptimal glycemic control is at night. So what we can see is that prelunch sugars are ok, very happy with those pre evening meal. Very happy with those before bed, even very happy. But then after bed and when they wake in the morning, those sugars suddenly just creeping into a realm which we're not quite so happy with. Um, so we change the Lantus because Lantus is a long acting, it's a glargine insulin. So it gives good background insulin overnight. Um You can increase the novorapid, but it's not going to have any impact overnight on their sugar control. You could increase their novorapid and all you'd probably be risking doing. It's putting them into a hypo before bed and then they might sleep a bit too heavily and then the sugars are gonna be no better in the morning. Um So d is the most appropriate option because you're gonna get a good background of insulin overnight and just increasing it um slightly is the best option. So just looking at the, sorry, looking at the other options. So if you were to continue the current insulin regime, you're not really making any meaningful, meaningful change. You've identified that their sugars are too high prebreakfast and we need to fix that. Um, increasing the novorapid dose in the evening isn't good isn't good, as we've said. Um, there's no real reason to stop the Lantus. It's not like their sugar control is absolutely horrible. Um, and Levemir is just another long acting medication. Um, but we're giving it morning and evening and there's no indication that we need to give it in the morning. They've got good glycemic control throughout the day and, and then if you increase the no rapid again to eight units subcu for all meals, again, you're not tackling the problem. So there we go. And just to maybe help you understand that a little bit better. So insulin aspart or novorapid um is essentially a short acting insulin. As I'm sure you're aware, it's something that regulates the metabolism of glucose, promotes storage of glucose and inhibits the breakdown of glucose, fat and amino acids. So it lowers blood glucose by increasing the peripheral blood glucose uptake in SPT muscle and fat. So it's got faster onset than endogenous insulin within an hour or two or even less and it lasts only a few hours. Um as and that kind of pathway is illustrated in this little diagram here. Insulin glargine, however, is a long acting insulin and has a synthetic version of human insulin. And the way that works is it I in summary, it basically binds to insulin receptors and then on the beta subunit of those receptors, it, it activates it intrinsic, um it activates er tyrosine kinase and then there's se several downstream signaling pathways which you don't need to know for the purpose of the PSA. Um after it, it, it sort of sends off several metabolic regulators. Um and then essentially the way it works is when you inject insulin, it's um neutralized at normal Ph. So it then forms micro precipitates which allow small amounts of insulin to be released basally over a 24 hour period without any pronounced peak. And that is the reason that Lantus another long acting. Um That's why you give it in the evening so that you, um so, um so yeah, you give the long acting insulin in the evening so that you get a good basal control overnight into the morning and then you're happy because looking at those that table, you can see that he's, they've got good glycemic control. Otherwise during the day, you don't need to add in a long acting in the morning. Um So ma asked, do you also increase the long acting insulin if the blood glucose is high during the day? I guess it depends on the clinical context. Um So I guess if we go back to that table, so if their blood glucose is high during the day, you're looking at the timing of when the long acting insulin's been given. So, Lantus is generally given in the evening and we can identify that their sugars a highest in the morning prebreakfast. Um, if the sugars will say high prelunch, but ok, pre evening meal, then the likelihood is you might just wanna give some novorapid at lunch time rather than um, introducing another long acting agent in the morning. Um, because you potentially risk hypos in the evening. But I guess if, if, um, they are, they have got, yeah, if they've got very high sugars throughout the day and small amounts of no rapid aren't helping, then you might want to give them, switch them to a morning and evening regime. Um, but the likelihood is the sort of question you'll get asked is one about their bedtime or overnight glycemic control cos that's where most diabetics go wrong. Does that, um, does that make sense? If, if that doesn't make sense, then please just put a little message through and we can try and talk through it. Um, but essentially I just want you to be aware that insulin aspart and insulin glargine are often used in combination um in a basal bolus regime. Um And then generally, yeah, so the thing that you might want to remember for the exam, but you will have it if you look at sort of, um, insulin in, in insulin treatment, summaries, um in the B NF, it's, it's best to try and aim for a blood glucose concentration between four and nine. and then 4 to 7 before meals and less than nine after meals. And that might just help you make a decision about whether glycemic control is adequate or not. Um And then final, last, last question for the evening. Um I hope I haven't bored you too much. Um But we have one more data interpretation question. So you've got a 70 year old woman presented to her GP for the results of a blood test taken one week ago. She says she's been feeling tired and lacking in energy. Uh She's got hypercholesterolemia, hypertension and low thyroid. Um She's on amLODIPine, atorvastatin, levothyroxine and she's on levothyroxine 100 mics daily. Um And she's had some investigations. So her TSH is eight and, and the reference range is NT 0.4 to 5.0 and her serum free T four is 8.6 and the normal range or reference range is 10 to 22. So I want you to select the most appropriate decision option with regard to levothyroxine based on these data. Um So do we reduce the levothyroxine to 75? Keep the le levothyroxine at the same dose, increase it to 100 and 25 increase it to 100 and 50 or do we stop it altogether? Uh So let me just sorry, let me just release that. Um The pole just disappeared for a second. There we go. So last, last question and then you can, then you don't have to listen to me pratt a lot anymore. Ok. Good stuff I think, got enough answers there. Um So the, yeah, yeah, the, the answer is c see you, the correct answer is C so we wanna increase the levothyroxine to 100 and 25 mics daily. So why do we wanna do that? So we've identified that she's sort of creeping into the borders of elderly arguable. But yeah, she's 70. Um So you generally wanna adjust someone's levothyroxine in 25 mcg increments and then you look at their T four according to their response and you're aiming for maintenance doses of between 50 to 200 mics. Um and then that needs to be taken premal ideally. So generally, when you're looking at hypothyroid questions, um generally there's some key things you wanna stick in your head that you've clearly, you clearly got it cos you've all got the answer very easily. But thyroid function tests are indications of the adequacy of the replacement regimen alongside a patient's symptoms. So the T four level is helpful in assessing patients adherence to the medication. So, if someone's T four is very low, despite them being on T four rep er replacement IE E levothyroxine that suggests they're not adhering to the medication. In this case, the TSH is mildly raised. Um and the T four is just below the target range. So it indicates good, sorry, excuse, the typo indicates good adherence but sub a sub optimal dose. Um So the most appropriate action is to increase it by 25 mics. Er, and the reason we do that is to try and avoid ramping them up on the dose and potentially putting them at risk of sort of thyrotoxic crises or um you know, side effects such as tachycardia, palpitations, arrhythmia, making them feel generally a bit unwell. And, and then, so the rationale behind that is essentially we give levothyroxine um because it's at four analog. Um So generally in a normal person, someone ha um would secrete uh the hypothalamus secretes trh. Um So, so thio tropin releasing hormone um that stimulates the anterior pituitary to secrete TSH and then the thyroid will then 80% T four and 20% T three, 50% of that T four gets converted to LTT three. And that binds to the thyroid receptor proteins within the cell nucleus. And that directly influences uh increased metabolic state essentially. So, promotes growth development, catecholamine release or that whole shebang. Um And then levothroxine mimics endogenous T four in cases where people uh have an inhibited T four release process. So, primary secondary or tertiary hypothyroidism and then generally absorption of T four or levothyroxine is increased by fasting. So it's generally given before meals. So that's why you'll always see, you'll start to realize that prescriptions for le levothyroxine are written at 630 or 7 a.m. to try and prevent people from taking it after meal. Um And because things like dietary fiber, reduce the bioavailability, bioavailability of T four. Um So important things to consider when monitoring T um levothyroxine people on levothyroxine is to look at their TSH level every three months until they're stabilized. Um And then yearly thereafter. And if anyone has persistent hypothyroidism, you need to look at their T four level after starting levothyroxine because it might be that they're not adherent and then some useful things just to remember which I'm sure you're all very familiar with is levothyroxine has some fairly substantial side effects. It can cause chest pain, anxiety, worsening of symptoms, such as diarrhea, difficulty breathing fevers, flushing headaches, not very nice in general. And then you just gotta be aware of sort of the risk of them developing thyrotoxic storm, vomiting, loss of weight um and being in a real state. So in summary today, um what we've discussed is obviously drug monitoring, data interpretation um For the PPS A I generally want you to remember to choose the most appropriate answer which fits most clearly with the B NF Guidance. I don't want you to get bogged down as distractors. Um And just remember that the info is always gonna be there for you in the data interpretation. It's probably an area where you don't need to heavily look at the B NF, just look at the numbers that are in front of you and the graph that or table that's in front of you. Cherry pick the right information. Don't get bogged down with, why are they in hospital or blah, blah, blah. What, what, what are they just look at their dosing their timing? Um And what the exact question is asking you? So what, what would be the most appropriate next dose or what would be the next, most appropriate next timing for that thing? And just remember control and effort as your friend throughout the entire exam. And just remember in general, if you're not sure, I'm sure other people have told you this but just put something because the exam isn't negatively marked. So you've got a, you've got a chance of getting the right answer even if you just stab in the dark and close your eyes and push a button. Um So, yeah, thanks for listening. Um Let me know if you have any questions. Um I'm gonna send you all a feedback form as well now. Um So I hope that's helpful. Um So thanks. So, yeah, so is it reasonable to spend an hour on section one and two or would we need to be going through that a bit quicker to finish the exam in time? Um I just need to remind myself because in my defense, it's been four years since I've done the exam. Uh So just give me a sec. Uh Let's have a look. So, yeah, so the exam, yeah, so sections one and two as I said, heavily weighted to have, you've got 100 and 12 marks for a 200 marked paper. It's difficult to say. But I think, yeah, you wanna spend the bulk of your time. II think it would be reasonable to spend a large proportion of time on the first sections. But you just wanna make sure that you've got enough time to answer every section. Um Yes, I think an hour is probably reasonable. Um Given that the bulk of your questions are there. So there's eight items of 10 marks each and eight items of four marks each in those things. So you've got 100 and 12 marks potentially to gain out of that one section. So, you know, I can't remember the exact pass mark for the P SA I think it's quite high. Um But you're potentially gaining a huge amount of marks if you can get those first bits nailed down. Um And I don't think there's any other questions there. I'm glad you've guys have found it helpful. Um It's been a couple of years since I've done one of these sessions. But um yeah, if you could feed um fill out the feedback form, that would be really helpful to me. It's just helpful for my portfolio um and things like that. Um And just yeah, happy to do more teaching sessions and other things if you find it useful. Um I was looking at potentially. So I'm, I'm I'm an anesthetic trainee. I'm only a C CSC T one but I quite like doing things about ventilators and stuff like that. So I'd be keen to do teaching on N IV if any of you are interested. Yeah, that's great. Um, so I think I've had a chat to Naima who sort of runs these sessions. Um, and so I can, I can always, it's, it wouldn't be so much on ventilators, sorry, it would be on non invasive ventilation. Um and looking like interpret, interpreting gasses, er and knowing kind of what you do in terms of um I A pap looking at positive and expiratory pressure, all that kind of stuff. Some of you might be doing academic stuff already and probably can tell me more than I know. But um I can tell you about the practicalities for the clinical scenario. Um when you're, when you're maybe an F one or F two and faced with these difficult ABG S or unwell hypoxic patients, can I just double check that you guys received the feedback form request cos I I've not used this platform in ages, so I think I think you have, but I just wanna double check that you have got the feedback form. Great. Thanks. Thanks very much. And yeah, just let me know if any other questions. Uh ok, I think, I think the majority are more or less there, there's still a couple of people in the chat room. So I'm guessing you're still doing feedback for them. So that's all good. All right, I'm just gonna, I'll, I'll let whoever else is still in the room just um presume you're still just filling out feedback. Um But I'm just gonna turn off my mic and camera cos I've relegated my partner to the other room whilst I'm doing this. Or you want me to share the feedback again? Yeah, no worries. Uh I'll just send it again. Did you get that? Um Rajat? Um I think I just have shared it again. Can you, can you see it again? C do you need me to share it again? Rajat? Ok. I'll, I'll send it one more time just for. Ok. I'm probably gonna turn off my mic now and uh I'll just let anyone else who's still there sort out their feedback forms and then, yeah, thanks very much. Been a pleasure to do a little teaching session. So I hope it's been useful. Thank you.