How to Pass the FRACP Written Examination. Jonathan Gleadle

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 secretions to assist digestion and absorption further down the gastrointestinal tract. The proximal to mid‐end of the jejunum is anastomosed to the gastric pouch for malabsorption. This creates the common limb. The food and enzymes ingested are mixed only in the small area of the common limb, compromising absorption of certain nutrients.

      Macro‐ and micronutrient deficiencies are common in patients after obesity surgery. It is estimated that BPD with or without duodenal switch can cause a 25% decrease in protein absorption and a 75% reduction in fat absorption. Ten vitamins and minerals that depend on fat absorption for optimal bioavailability, such as vitamins A, D, E, and K and zinc, will have impaired absorption. Moreover, the delay in gastrointestinal transit time may increase the risk of many other micronutrient deficiencies, including iron, calcium, vitamin B12, and folate. Low serum levels of fat‐soluble vitamins (vitamin A, K and E) have been found after BPD and RYGB. Water‐soluble vitamins such as thiamine deficiency can occur in up to 49% of patients after surgery as a result of bypass of the jejunum, where it is primarily absorbed, or in the presence of impaired nutritional intake from persistent, severe vomiting. Patients may have preexisting thiamin deficits. Thiamin deficiency can cause high‐output heart failure, wet beriberi. Gastric banding patients also may be at risk, particularly if they experience intractable vomiting because thiamin has a short half‐life, meaning that thiamin stores last only a few days in the body.

      A vitamin B12 deficiency is uncommon among gastric banding patients. A study found a 10 to 26% prevalence of vitamin B12 deficiency among gastric sleeve patients. Clinical manifestation of vitamin B12 deficiency includes paraesthesias, difficulty maintaining balance, poor memory, depression, loss of proprioception and vibratory sensation, peripheral neuropathy, gait abnormalities, cognitive impairment, glossitises, and macrocytic anemia.

      Zinc is a mineral that helps maintain the immune system and is associated with cell division, cell growth, wound healing, and carbohydrate metabolism. A zinc deficiency also exacerbate hair loss, which is common within the first six months after bariatric surgery. Furthermore, patients who are zinc deficient may experience a metallic taste in their mouths. Studies had shown that BPD and RYGB patients are more likely to be at risk of zinc deficiency. However, one study found that 34% of gastric sleeve patients experienced zinc deficiency post‐surgery.

During routine clinic follow‐up after bariatric surgery, it is important to monitor weight loss progress and complications each visit, monitor adherence to appropriate diet and physical activity levels, review medications (avoid NSAIDs, adjust antihypertensives, cholesterol‐lowering medications, and diabetes medications as appropriate). Changes in drug absorption and bioavailability in post‐bariatric surgery patients make dosage adjustment important for some of the prescribed medications. The requirement for diabetes medications often reduced after bariatric surgery.

      In terms of nutritional supplements, patients should be taking adult multivitamin and multimineral which contain iron, folic acid, thiamine,