Question 1
A 64 year old male with hypercalcaemia presents with rapid weight gain, episodic light headedness, palpitations and diaphoresis that is relieved by eating a meal. His FBC and UEC are unremarkable. Corrected calcium is elevated at 2.93, as are his parathyroid hormone levels. Which of the following is the most appropriate next investigation?
(A) inpatient 72 hour fast with BGL measurements co-incident with insulin and c-peptide levels
(B) insulin and c-peptide levels
(C) three 15-hour fasts with outpatient glucose estimation
(D) food diary
(E) pro-insulin
C: In the diagnosis of an insulinoma, the first investigation is usually a 15 hour fast. If this does not bring out the hypoglycaemia (due to inappropriate insulin secretion) then exercise may be used of a prolonged in-patient fast. During symptoms, measurement of BGL, c-peptide and insulin levels may be diagnostic. Lancet 1983; 1:1094.
Question 2
What is the time to nadir of calcium levels when intravenous bisphosphonates are used for the treatment of hypercalcaemia of malignancy?
(A) 1 day
(B) 2 day
(C) 4 day
(D) 7 day
(E) 14 days
C: Effects start on day 1, nadir occurs day 4 and effects last for 1 - 3 weeks. N Engl J Med 2005; 352:373-379
Question 3
A 56 year old female is undergoing hormone replacement therapy for post-menopausal symptoms. What is correct regarding the outcomes of the women's health initiative study database?
(A) In patients aged <60 years there was reduced mortality
(B) There was a decreased risk of stroke
(C) There was an increased risk of colorectal cancer
(D) There was an increased risk of hip fracture
(E) There was a decreased risk of breast cancer
A: In patients aged <60 years old, HRT was associated with decreased mortality. There is a decrease on colorectal cancer, an increase in strokes, PEs, breast cancer and myocardial infarction. J Gen Intern Med. 2004 Jul;19(7):791-804.
Question 4
What is FALSE following Roux-en-Y gastric bypass surgery for patients who are obese (BMI >30 - 35)
(A) Greater rates of secondary hyperparathyroidism
(B) Greater rates of vitamin D deficiency
(C) Greater durable weight loss compared to non-surgical measures
(D) Greater short term (1 - 2 year) remission of type 2 diabetes compared to conventional non surgical methods
(E) 30 day post operative mortality approaching 10%
E: Unfortunately the longest RCT reported has a duration of 3 years (N Engl J Med 2014; 370:2002-2013). In this RCT, bariatric surgery added on to conventional treatment improved glycaemic control compared to conventional treatment alone. A large observational study over 10 years showed durable diabetes remission rates of 36%.
A 64 year old male with hypercalcaemia presents with rapid weight gain, episodic light headedness, palpitations and diaphoresis that is relieved by eating a meal. His FBC and UEC are unremarkable. Corrected calcium is elevated at 2.93, as are his parathyroid hormone levels. Which of the following is the most appropriate next investigation?
(A) inpatient 72 hour fast with BGL measurements co-incident with insulin and c-peptide levels
(B) insulin and c-peptide levels
(C) three 15-hour fasts with outpatient glucose estimation
(D) food diary
(E) pro-insulin
C: In the diagnosis of an insulinoma, the first investigation is usually a 15 hour fast. If this does not bring out the hypoglycaemia (due to inappropriate insulin secretion) then exercise may be used of a prolonged in-patient fast. During symptoms, measurement of BGL, c-peptide and insulin levels may be diagnostic. Lancet 1983; 1:1094.
Question 2
What is the time to nadir of calcium levels when intravenous bisphosphonates are used for the treatment of hypercalcaemia of malignancy?
(A) 1 day
(B) 2 day
(C) 4 day
(D) 7 day
(E) 14 days
C: Effects start on day 1, nadir occurs day 4 and effects last for 1 - 3 weeks. N Engl J Med 2005; 352:373-379
Question 3
A 56 year old female is undergoing hormone replacement therapy for post-menopausal symptoms. What is correct regarding the outcomes of the women's health initiative study database?
(A) In patients aged <60 years there was reduced mortality
(B) There was a decreased risk of stroke
(C) There was an increased risk of colorectal cancer
(D) There was an increased risk of hip fracture
(E) There was a decreased risk of breast cancer
A: In patients aged <60 years old, HRT was associated with decreased mortality. There is a decrease on colorectal cancer, an increase in strokes, PEs, breast cancer and myocardial infarction. J Gen Intern Med. 2004 Jul;19(7):791-804.
Question 4
What is FALSE following Roux-en-Y gastric bypass surgery for patients who are obese (BMI >30 - 35)
(A) Greater rates of secondary hyperparathyroidism
(B) Greater rates of vitamin D deficiency
(C) Greater durable weight loss compared to non-surgical measures
(D) Greater short term (1 - 2 year) remission of type 2 diabetes compared to conventional non surgical methods
(E) 30 day post operative mortality approaching 10%
E: Unfortunately the longest RCT reported has a duration of 3 years (N Engl J Med 2014; 370:2002-2013). In this RCT, bariatric surgery added on to conventional treatment improved glycaemic control compared to conventional treatment alone. A large observational study over 10 years showed durable diabetes remission rates of 36%.