Oet 2.0 Reading Home Work Book

OET 2.
0
Reading
Home Work Book
- the limb is warm
- the limb (if swollen) is throbbing or getting bigger
- peripheral pulses are palpable
Management:
• Splint the site of the fracture/dislocation using a plaster backslab to reduce pain
• Elevate the limb – a sling for arm injuries, a pillow for leg injuries
• If in doubt over an injury, treat as a fracture
• Administer analgesia to patients in severe pain. If not allergic, give morphine (preferable);
if allergic to morphine, use fentanyl
• Consider compartment syndrome where pain is severe and unrelieved by splinting and
elevation or two doses of analgesia
• X-ray if available
Text C
Drug Therapy Protocol:
Authorised Indigenous Health Worker (IHW) must consult Medical Officer (MO) or Nurse Practitioner
(NP). Scheduled Medicines Rural & Isolated Practice Registered Nurse may proceed.
Drug Form Strength Route of Recommended dosage Duration
administration
Adult only:
IM/SC 0.1-0.2 mg/kg to a max. of
10 mg Stat
Further
Morphine Ampoule 10 mg/Ml Adult only: doses on
IV Initial dose of 2 mg then MO/NP
(IHW may not 0.5-1 mg increments slowly, order
administer IV) repeated every 3-5
minutes if required to a
max. of 10 mg
Use the lower end of dose range in patients ≥70 years.

Provide Consumer Medicine Information: advise can cause nausea and vomiting, drowsiness.
Respiratory depression is rare – if it should occur, give naloxone.
Text D
Technique for plaster backslab for arm fractures – use same principle for leg fractures
1. Measure a length of non-compression cotton stockinette from half way up the middle finger to just
below the elbow. Width should be 2–3 cm more than the width of the distal forearm.
2. Wrap cotton padding over top for the full length of the stockinette — 2 layers, 50% overlap.
3. Measure a length of plaster of Paris 1 cm shorter than the padding/stockinette at each end.
Fold the roll in about ten layers to the same length.
4. Immerse the layered plaster in a bowl of room temperature water, holding on to each end.
Gently squeeze out the excess water.
5. Ensure any jewellery is removed from the injured limb.
6. Lightly mould the slab to the contours of the arm and hand in a neutral position.
7. Do not apply pressure over bony prominences. Extra padding can be placed over bony
prominences if applicable.
8. Wrap crepe bandage firmly around plaster backslab.
PART A -QUESTIONS
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once
Fractures, dislocations and sprains: Questions

Questions 1-7
1 procedures for delivering pain relief?
2 the procedure to follow when splinting a fractured

limb?
3 what to record when assessing a patient?
4 the terms used to describe different types of

fractures?
5 the practitioners who administer analgesia?
6 what to look for when checking an injury?
7 how fractures can be caused?
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both
8. What should be used to elevate a patient’s fractured leg?
9. What is the maximum dose of morphine per kilo of a patient’s weight that
can be given using the intra-muscular (IM) route?
10. Which parts of a limb may need extra padding?
______________________________________________________
11 What should be used to treat a patient who suffers respiratory depression?
12 What should be used to cover a freshly applied plaster backslab?
13 What analgesic should be given to a patient who is allergic to morphine?
14 What condition might a patient have if severe pain persists after
splinting, elevation and repeated analgesia?
Questions 15-20
Complete each of the sentences, 15- 20, with a word or short phrase from one of the texts. Each
answer may include words, number or both. Your answers should be correctly spelled
15. Falling on an outstretched hand is a typical cause of a of the elbow
16. Upper limb fractures should be elevated by means of a______________.
17.Make sure the patient isn’t wearing any on the

part of the body where the plaster backslab is going to be placed.
18. Check to see whether swollen limbs are or

increasing in size.
19. In a plaster backslab, there is a layer of closest to the skin.
20. Patients aged and over shouldn’t be

given the higher dosages of pain relief.
END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED
READING SUB-TEST : PART B
In this part of the test, there are six short extracts relating to the work of health professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best according to the text.
Write your answers on the separate Answer Sheet
Questions 1-6
1. The manual informs us that the Blood Pressure Monitor
A is likely to interfere with the operation of other medical equipment.
B may not work correctly in close proximity to some other devices.
C should be considered safe to use in all hospital environments
Instruction Manual: Digital Automatic Blood Pressure Monitor
Electromagnetic Compatibility (EMC)

With the increased use of portable electronic devices, medical equipment may be
susceptible to electromagnetic interference. This may result in incorrect operation of
the medical device and create a potentially unsafe situation. In order to regulate the
requirements for EMC, with the aim of preventing unsafe product situations, the
EN60601-1-2 standard defines the levels of immunity to electromagnetic interferences
as well as maximum levels of electromagnetic emissions for medical devices. This
medical device conforms to EN60601-1-2:2001 for both immunity and emissions.
Nevertheless, care should be taken to avoid the use of the monitor within 7 metres of
cellphones or other devices generating strong electrical or electromagnetic fields
2. The notice is giving information about
A ways of checking that an NG tube has been placed correctly.
B how the use of NG feeding tubes is authorised.
which staff should perform NG tube placement.

C
NG feeding tubes
Displacement of nasogastric (NG) feeding tubes can have serious implications if undetected.
Incorrectly positioned tubes leave patients vulnerable to the risks of regurgitation and
respiratory aspiration. It is crucial to differentiate between gastric and respiratory placement
on initial insertion to prevent potentially fatal pulmonary complications. Insertion and care
of an NG tube should therefore only be carried out by a registered doctor or nurse who has
undergone theoretical and practical training and is deemed competent or is supervised by
someone competent. Assistant practitioners and other unregistered staff must never insert
NG tubes or be involved in the initial confirmation of safe NG tube position.
3. What must all staff involved in the transfusion process do?
A check that their existing training is still valid
B attend a course to learn about new procedures
C read a document that explains changes in policy
'Right Patient, Right Blood' Assessments
The administration of blood can have significant morbidity and mortality. Following the
introduction of the 'Right Patient, Right Blood' safety policy, all staff involved in the
transfusion process must be competency assessed. To ensure the safe administration of
blood components to the intended patient, all staff must be aware of their responsibilities in
line with professional standards.
Staff must ensure that if they take any part in the transfusion process, their competency
assessment is updated every three years. All staff are responsible for ensuring that they
attend the mandatory training identified for their roles. Relevant training courses are
clearly identified in Appendix 1 of the Mandatory Training Matrix.
4. The guidelines establish that the healthcare professional should
A aim to make patients fully aware of their right to a chaperone.
B
evaluate the need for a chaperone on a case-by-case basis.
respect the wishes of the patient above all else.

C
Extract from ‘Chaperones: Guidelines for Good Practice’
A patient may specifically request a chaperone or in certain circumstances may nominate

one, but it will not always be the case that a chaperone is required. It is often a question of
using professional judgement to assess an individual situation. If a chaperone is offered and
declined, this must be clearly documented in the patient’s record, along with any relevant
discussion. The chaperone should only be present for the physical examination and should
be in a position to see what the healthcare professional undertaking
the examination/investigation is doing. The healthcare professional should wait until the
chaperone has left the room/cubicle before discussion takes place on any aspect of the
patient’s care, unless the patient specifically requests the chaperone to remain.
5. The guidelines require those undertaking a clinical medication review to
A involve the patient in their decisions.
B consider the cost of any change in treatments.
C
recommend other services as an alternative to medication.
Annual medication review
To give all patients an annual medication review is an ideal to strive for. In the meantime
there is an
argument for targeting all clinical medication reviews to those patients likely to benefit most.
Our guidelines state that ‘at least a level 2 medication review will occur’, i.e. the minimum
standard is a treatment review of medicines with the full notes but not necessarily with
the patient present. However, the guidelines go on to say that ‘all patients should have the
chance to raise questions and highlight problems about their medicines’ and that ‘any
changes resulting from the review are agreed with the patient’.
It also states that GP practices are expected to
• minimise waste in prescribing and avoid ineffective treatments.
• engage effectively in the prevention of ill health.

• avoid the need for costly treatments by proactively managing patients to recovery
through
the whole care pathway.
6. The purpose of this email is to
A report on a rise in post-surgical complications.
B explain the background to a change in patient care.
C
remind staff about procedures for administrating drugs.
To: All staff
Subject: Advisory Email: Safe use of opioids
In August, an alert was issued on the safe use of opioids in hospitals. This reported
the incidence of respiratory depression among post-surgical patients to an average
0.5% – thus for every 5,000
surgical patients, 25 will experience respiratory depression. Failure to recognise
respiratory depression and institute timely intervention can lead to cardiopulmonary
arrest, resulting in brain injury or
death. A retrospective multi-centre study of 14,720 cardiopulmonary arrest cases showed

that
44% were respiratory related and more than 35% occurred on the general care floor. It
is therefore recommended that post-operative patients now have continuous monitoring,
instead of spot checks, of both oxygenation and ventilation.
READING SUB-TEST : PART C
In this part of the test, there are two texts about different aspects of healthcare.
For questions 7-22, choose the answer (A, B, C or D) which you think fits best according to
the text. Write your answers on the separate Answer Sheet
Text 1: Sleep deprivation
Millions of people who suffer sleep problems also suffer myriad health burdens. In
addition to emotional distress and cognitive impairments, these can include high
blood pressure, obesity, and metabolic syndrome. ‘In the studies we’ve done,
almost every variable we measured was affected. There’s not a system in the body
that’s not affected by sleep,’ says University of Chicago sleep researcher Eve Van
Cauter. ‘Every time we sleep-deprive ourselves, things go wrong.’
A common refrain among sleep scientists about two decades ago was that sleep
was performed by the brain in the interest of the brain. That wasn’t a fully elaborated
theory, but it wasn’t wrong. Numerous recent studies have hinted at the purpose of
sleep by confirming that neurological function and cognition are messed up during
sleep loss, with the patient’s reaction time, mood, and judgement all suffering if they
are kept awake too long.
In 1997, Bob McCarley and colleagues at Harvard Medical School found that when
they kept cats awake by playing with them, a compound known as adenosine
increased in the basal forebrain as the sleepy felines stayed up longer, and slowly
returned to normal levels when they were later allowed to sleep. McCarley’s team
also found that administering adenosine to the basal forebrain acted as a sedative,
putting animals to sleep. It should come as no surprise then that caffeine, which
blocks adenosine’s receptor, keeps us awake. Teaming up with Basheer and others,
McCarley later discovered that, as adenosine levels rise during sleep deprivation,
so do concentrations of adenosine receptors, magnifying the molecule’s sleep-
inducing effect. ‘The brain has cleverly designed a two-stage defence against the
consequences of sleep loss,’ McCarley says. Adenosine may underlie some of the
cognitive deficits that result from sleep loss. McCarley and colleagues found that
infusing adenosine into rats’ basal forebrain impaired their performance on an
attention test, similar to that seen in sleep-deprived humans. But adenosine levels
are by no means the be-all and end-all of sleep deprivation’s effects on the brain or
the body.
Over a century of sleep research has revealed numerous undesirable outcomes
from staying awake too long. In 1999, Van Cauter and colleagues had eleven men
sleep in the university lab. For three nights, they spent eight hours in bed, then for
six nights they were allowed only four hours (accruing what Van Cauter calls a
sleep debt), and then for six nights they could sleep for up to twelve hours (sleep
recovery). During sleep debt and recovery, researchers gave the participants a
glucose tolerance test and found striking differences. While sleep deprived, the
men’s glucose metabolism resembled a pre-diabetic state. ‘We knew it would be
affected,’ says Van Cauter. ‘The big surprise was the effect being much greater
than we thought.’
Subsequent studies also found insulin resistance increased during bouts of
sleep restriction, and in 2012, Van Cauter’s team observed impairments in
insulin signalling in subjects’ fat cells. Another recent study showed that sleep-
restricted people will add 300 calories to their daily diet. Echoing Van Cauter’s
results, Basheer has found evidence that enforced lack of sleep sends the brain
into a catabolic, or energy-consuming, state. This is
because it degrades the energy molecule adenosine triphosphate (ATP) to
produce adenosine monophosphate and this results in the activation of AMP
kinase, an enzyme that boosts fatty acid synthesis and glucose utilization. ‘The
system sends a message that there’s a need for more energy,’ Basheer says.
Whether this is indeed the mechanism underlying late-night binge-eating is still
speculative.
Within the brain, scientists have glimpsed signs of physical damage from sleep
loss, and the time-line for recovery, if any occurs, is unknown. Chiara Cirelli’s team
at the Madison School of Medicine in the USA found structural changes in the
cortical neurons of mice when the animals are kept awake for long periods.
Specifically, Cirelli and colleagues saw signs of mitochondrial activation – which
makes sense, as ‘neurons need more energy to stay awake,’ she says – as well as
unexpected changes, such as undigested cellular debris, signs of cellular aging
that are unusual in the neurons of young, healthy mice. ‘The number [of debris
granules] was small, but it’s worrisome because it’s only four to five days’ of sleep
deprivation,’ says Cirelli. After thirty-six hours of sleep recovery, a period during
which she expected normalcy to resume, those changes remained.
Further insights could be drawn from the study of shift workers and insomniacs,
who serve as natural experiments on how the human body reacts to losing out on
such a basic life need for chronic periods. But with so much of
our physiology affected, an effective therapy − other than sleep itself – is hard
to imagine. ‘People like to define a clear pathway of action for health
conditions,’ says Van Cauter. ‘With sleep deprivation, everything you measure
is affected and interacts synergistically to produce the effect.’
Part C -Text 1: Questions 7-14
7. In the first paragraph, the writer uses Eve Van Cauter’s words to
A
explain the main causes of sleep deprivation.
B reinforce a view about the impact of sleep deprivation.
C question some research findings about sleep deprivation.
D describe the challenges involved in sleep deprivation research.
8. What do we learn about sleep in the second paragraph?
A Scientific opinion about its function has changed in recent years.
B There is now more controversy about it than there was in the past.
C Researchers have tended to confirm earlier ideas about its purpose.
D Studies undertaken in the past have formed the basis of current research.
9. What particularly impressed Bob McCarley of Harvard Medical School?
A the effectiveness of adenosine as a sedative
B the influence of caffeine on adenosine receptors
C the simultaneous production of adenosine and adenosine receptors
D the extent to which adenosine levels fall when subjects are allowed to sleep
10. In the third paragraph, what idea is emphasised by the phrase ‘by no means the be-all and end-
all’?
A Sleep deprivation has consequences beyond its impact on adenosine levels.
B Adenosine levels are a significant factor in situations other than sleep deprivation.
C The role of adenosine as a response to sleep deprivation is not yet fully understood.
D The importance of the link between sleep deprivation and adenosine should not be
underestimated.
11. What was significant about the findings in Van Cauter’s experiment?
A the rate at which the sleep-deprived men entered a pre-diabetic state
B the fact that sleep deprivation had an influence on the men’s glucose levels
C the differences between individual men with regard to their glucose tolerance
D the extent of the contrast in the men’s metabolic states between sleep debt and recovery
12. In the fifth paragraph, what does the word ‘it’ refer to?
A an enzyme
B new evidence
C a catabolic state
D enforced lack of sleep
13. What aspect of her findings surprised Chiara Cirelli?
A There was no reversal of a certain effect of sleep deprivation.
B The cortical neurons of the mice underwent structural changes.
C There was evidence of an increased need for energy in the brains of the mice.
D The neurological response to sleep deprivation only took a few hours to become apparent.
14. In the final paragraph, the quote from Van Cauter is used to suggest that
A the goals of sleep deprivation research are sometimes unclear.
B it could be difficult to develop any treatment for sleep deprivation.
C opinions about the best way to deal with sleep deprivation are divided.
D there is still a great deal to be learnt about the effects of sleep deprivation.
Text 2: ADHD
The American Psychiatric Association (APA) recognised Attention Deficit

Hyperactivity Disorder (ADHD) as a childhood disorder in the 1960s, but it wasn’t
until 1978 that the condition was formally recognised as afflicting adults. In recent
years, the USA has seen a 40% rise in diagnoses of ADHD in children. It could be
that the disorder is becoming more prevalent, or, as seems more plausible, doctors
are making the diagnosis more frequently. The issue is complicated by the lack of
any recognised neurological markers for ADHD. The APA relies instead on a
set of behavioural patterns for diagnosis. It specifies that patients under 17
must display at least six symptoms of inattention and/or hyperactivity; adults
need only display five.
ADHD can be a controversial condition. Dr Russell Barkley, Professor of

Psychiatry at the University of Massachusetts insists; ‘the science is
overwhelming: it’s a real disorder, which can be managed, in many cases, by using
stimulant medication in combination with other treatments’. Dr Richard Saul, a
behavioural neurologist with five decades of experience, disagrees; ‘Many of us
have difficulty with organization or details, a tendency to lose things, or to be
forgetful or distracted. Under such subjective criteria, the entire population could
potentially qualify. Although some patients might need stimulants to function well
in daily life, the lumping together of many vague and subjective symptoms could
be causing a national phenomenon of misdiagnosis and over-prescription of
stimulants.’
A recent study found children in foster care three times more likely than others
to be diagnosed with ADHD. Researchers also found that children with ADHD in
foster care were more likely to have another disorder, such as depression or
anxiety. This finding certainly reveals the need for medical and behavioural
services for these children, but it could also prove the non-specific nature of the
symptoms of ADHD: anxiety and depression, or an altered state, can easily be
mistaken for manifestations of ADHD.
ADHD, the thinking goes, begins in childhood. In fact, in order to be diagnosed

with it as an adult, a patient must demonstrate that they had traits of the condition
in childhood. However, studies from the UK and Brazil, published in JAMA
Psychiatry, are fuelling questions about the origins and trajectory of ADHD,
suggesting not only that it can begin in adulthood, but that there may be two
distinct syndromes: adult-onset ADHD and childhood ADHD. They echo earlier
research from New Zealand. However, an editorial by Dr Stephen Faraone in
JAMA Psychiatry highlights potential flaws in the findings. Among them,
underestimating the persistence of ADHD into adulthood and overestimating the
prevalence of adult-onset ADHD. In Dr Faraone’s words, ‘the researchers found a
group of people who had sub-threshold ADHD in their youth. There may have
been signs that things weren’t right, but not enough to go to a doctor. Perhaps
these were smart kids with particularly supportive parents or teachers who
helped them cope with attention problems. Such intellectual and social
scaffolding would help in early life, but when the scaffolding is removed, full ADHD
could develop’.
Until this century, adult ADHD was a seldom-diagnosed disorder. Nowadays
however, it’s common in mainstream medicine in the USA, a paradigm shift
apparently driven by two factors: reworked – many say less stringent – diagnostic
criteria, introduced by the APA in 2013, and marketing by manufacturers of ADHD
medications. Some have suggested that this new, broader definition of ADHD was
fuelled, at least in part, to broaden the market for medication. In many instances,
the evidence proffered to expand the definitions came from studies funded in
whole or part by manufacturers. And as the criteria for the condition loosened,
reports emerged about clinicians involved in diagnosing ADHD receiving money
from drug-makers.
This brings us to the issue of the addictive nature of ADHD medication. As Dr Saul
asserts, ‘addiction to stimulant medication isn’t rare; it’s common. Just observe the
many patients periodically seeking an increased dosage
as their powers of concentration diminish. This is because the body stops
producing the appropriate levels of neurotransmitters that ADHD drugs replace − a
trademark of addictive substances.’ Much has been written about the staggering
increase in opioid overdoses and abuse of prescription painkillers in the USA, but
the abuse of drugs used to treat ADHD is no less a threat. While opioids are more
lethal than prescription stimulants, there are parallels between the opioid epidemic
and the increase in problems tied to stimulants. In the former, users switch from
prescription narcotics to heroin and illicit fentanyl. With ADHD drugs, patients are
switching from legally prescribed stimulants to illicit ones such as
methamphetamine and cocaine. The medication is particularly prone to abuse
because people feel it improves their lives. These drugs are antidepressants, aid
weight-loss and improve confidence, and can be abused by students seeking to
improve their focus or academic performance. So, more work needs to be done
before we can settle the questions surrounding the diagnosis and treatment of
ADHD.

15. In the first paragraph, the writer questions whether
A adult ADHD should have been recognised as a disorder at an earlier date.
B ADHD should be diagnosed in the same way for children and adults.
C ADHD can actually be indicated by neurological markers.
D cases of ADHD have genuinely increased in the USA.
16. What does Dr Saul object to?
A the suggestion that people need stimulants to cope with everyday life
B the implication that everyone has some symptoms of ADHD
C the grouping of imprecise symptoms into a mental disorder
D the treatment for ADHD suggested by Dr Barkley

17. The writer regards the study of children in foster care as significant because it
A highlights the difficulty of distinguishing ADHD from other conditions.
B focuses on children known to have complex mental disorders.
C suggests a link between ADHD and a child’s upbringing.
D draws attention to the poor care given to such children.
18. In the fourth paragraph, the word ‘They’ refers to
A syndromes.
B questions.
C studies.
D origins.
19. Dr Faraone suggests that the group of patients diagnosed with adult-onset ADHD
A had teachers or parents who recognised the symptoms of ADHD.
B should have consulted a doctor at a younger age.
C had mild undiagnosed ADHD in childhood.
D were specially chosen by the researchers.
20. In the fifth paragraph, it is suggested that drug companies have

been overly aggressive in their marketing of ADHD medication.
A
B influenced research that led to the reworking of ADHD diagnostic criteria.

12 crêpe/crepe bandage
13 fentanyl
14 compartment syndrome
Part A - Answer key 15 – 20

15 dislocation
16. sling
17. jewellery
18. throbbing
19. (cotton / non-compression) stockinette
20. 70 / seventy (years / yrs)
Reading test - part B – answer key

1 B may not work correctly in close proximity to some other devices.
2 C which staff should perform NG tube placement.
3 A check that their existing training is still valid
4 B evaluate the need for a chaperone on a case-by-case basis.
5 A involve the patient in their decisions.
6 B explain the background to a change in patient care.
Reading test - part C – answer key

Text 1 - Answer key 7 – 14
7 B reinforce a view about the impact of sleep deprivation.
8 C Researchers have tended to confirm earlier ideas about its purpose.
9 C the simultaneous production of adenosine and adenosine receptors
10 A Sleep deprivation has consequences beyond its impact on adenosine levels.
11 D the extent of the contrast in the men’s metabolic states between sleep debt and recovery
12 D enforced lack of sleep
13 A There was no reversal of a certain effect of sleep deprivation.
14 B it could be difficult to develop any treatment for sleep deprivation.

15 D cases of ADHD have genuinely increased in the USA.
16 C the grouping of imprecise symptoms into a mental disorder
17 A highlights the difficulty of distinguishing ADHD from other conditions.
18 C studies.
19 C had mild undiagnosed ADHD in childhood.
20 B influenced research that led to the reworking of ADHD diagnostic criteria.
21 A a physiological reaction.
22 C Insufficient attention seems to have been paid to it.
PART A -QUESTIONS
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from. You may
use any letter more than once
In which text can you find information about
1 the various symptoms of patients who have taken too much
paracetamol?
2 the precise levels of paracetamol in the blood which require urgent

intervention?
3 the steps to be taken when treating a paracetamol overdose patient?
4 whether paracetamol overdose was intentional?
5 the number of products containing paracetamol?
6 what to do if there are no details available about the time of the
Que 7 dealing with paracetamol overdose patients who have not received
stio adequate nutrition?
ns
8-
13
Answer each of the questions, 8-4, with a word or short phrase from one of the texts.
Each answer may include words, number of the both. Your answers should be correctly spelled.
8.If paracetamol is used as a long-term painkiller, what symptom may get worse?
9. It may be dangerous to administer paracetamol to a patient with which viral condition?

__________________________________________
10 What condition may develop in an overdose patient who presents with jaundice?
_____________________________________________
11. What condition may develop on the third day after an overdose?
12. What drug can be administered orally within 10 - 12 hours as an alternative to acetylcysteine?
13. What treatment can be used if a single overdose has occurred less than an hour ago?
Questions 14-20
14. If a patient has taken metoclopramide alongside paracetamol, this may affect the
of the paracetamol.
15. After 24 hours, an overdose patient may present with pain in the .
16. For the first 24 hours after overdosing, patients may only have such symptoms as
17. Acetylcysteine should be administered to patients with a paracetamol level above the
high-risk treatment line who are taking any type of medication.
18. A non-high-risk patient should be treated for paracetamol poisoning if their paracetamol level is
above_________________ mg/litre 8 hours after overdosing.
19. A high-risk patient who overdosed hours ago
should be given acetylcysteine if their paracetamol level is 25 mg/litre or higher.
20. If a patient does not require further acetylcysteine, they should be given treatment categorised as
only.
END OF PART A
Questions 1-6
1. This guideline extract says that the nurse in charge
A must supervise the opening of the controlled drug cupboard.
B should make sure that all ward cupboard keys are kept together.
C can delegate responsibility for the cupboard keys to another ward.
Medicine Cupboard Keys

The keys for the controlled drug cupboard are the responsibility of the nurse in charge. They
may be passed to a registered nurse in order for them to carry out their duties and returned to
the nurse in charge. If the keys for the controlled drug cupboard go missing, the locks must
be changed and pharmacy informed and an incident form completed. The controlled drug
cupboard keys should be kept separately from the main body of keys. Apart from in
exceptional circumstances, the keys should not leave the ward or department. If necessary,
the nurse in charge should arrange for the keys to be held in a neighbouring ward or
department by the nurse in charge there.
2. When seeking consent for a post-mortem examination, it is necessary to
A give a valid reason for conducting it.
B allow all relatives the opportunity to decline it.
C only raise the subject after death has occurred.
Post-Mortem Consent
A senior member of the clinical team, preferably the Consultant in charge of the care, should raise
the possibility of a post-mortem examination with the most appropriate person to give consent. The
person consenting will need an explanation of the reasons for the post-mortem examination and
what it hopes to achieve. The first approach should be made as soon as it is apparent that a post-
mortem examination may be desirable, as there is no need to wait until the patient has died. Many
relatives are more prepared for the consenting procedure if they have had time to think about it
beforehand.
3. The purpose of these notes about an incinerator is to
A help maximise its efficiency.
B give guidance on certain safety procedures.
C recommend a procedure for waste separation.
Low-cost incinerator: General operating notes

3.2.1 Hospital waste management
Materials with high fuel values such as plastics, paper, card and dry textile will help maintain high
incineration temperature. If possible, a good mix of waste materials should be added with each
batch. This can best be achieved by having the various types of waste material loaded into
separate bags at source, i.e. wards and laboratories, and clearly labelled. It is not recommended
that the operator sorts and mixes waste prior to incineration as this is potentially hazardous. If
possible, some plastic materials should be added with each batch of waste as this burns at high
temperatures. However, care and judgement will be needed, as too much plastic will create
dense dark smoke.
4. What does this manual tell us about spacer devices?
A Patients should try out a number of devices with their inhaler.
B They enable a patient to receive more of the prescribed medicine.
C Children should be given spacers which are smaller than those for adults.
Manual extract: Spacer devices for asthma patients

Spacer devices remove the need for co-ordination between actuation of a pressurized metered-
dose inhaler and inhalation. In addition, the device allows more time for evaporation of the
propellant so that a larger proportion of the particles can be inhaled and deposited in the lungs.
Spacer devices are particularly useful for patients with poor inhalation technique, for children, for
patients requiring higher doses, for nocturnal asthma, and for patients prone to candidiasis with
inhaled corticosteroids. The size of the spacer is important, the larger spacers with a one-way
valve being most effective. It is important to prescribe a spacer device that is compatible with the
metered-dose inhaler. Spacer devices should not be regarded as interchangeable; patients
should be advised not to switch between spacer devices.
5. The email is reminding staff that the
A benefits to patients of using bedrails can outweigh the dangers.
B number of bedrail-related accidents has reached unacceptable levels.
C patient’s condition should be central to any decision about the use of bedrails.
To: All Staff
Subject: Use of bed rails
Please note the following.

Patients in hospital may be at risk of falling from bed for many reasons including
poor mobility, dementia or delirium, visual impairment, and the effects of treatment
or medication. Bedrails can be used as safety devices intended to reduce risk.
However, bedrails aren’t appropriate for all patients, and their use involves risks.
National data suggests around 1,250 patients injure themselves on bedrails annually,
usually scrapes and bruises to their lower legs. Statistics show 44,000 reports of
patient falls from bed annually resulting in 11 deaths, while deaths due to bedrail
entrapment
occur less than one every two years, and are avoidable if the relevant advice is
6. What does this extract from a handbook tell us about analeptic drugs?
A They may be useful for patients who are not fully responsive.
B Injections of these drugs will limit the need for physiotherapy.
C Care should be taken if they are used over an extended period.

Analeptic drugs
Respiratory stimulants (analeptic drugs) have a limited place in the treatment of ventilatory failure
in patients with chronic obstructive pulmonary disease. They are effective only when given by
intravenous injection or infusion and have a short duration of action. Their use has largely been
replaced by ventilatory support. However, occasionally when ventilatory support is contra-
indicated and in patients with hypercapnic respiratory failure who are becoming drowsy or
comatose, respiratory stimulants in the short term may arouse patients sufficiently to co-operate
and clear their secretions. Respiratory stimulants can also be harmful in respiratory failure since
they stimulate non-respiratory as well as respiratory muscles. They should only be given under
expert supervision in hospital and must be combined with active physiotherapy. At present, there
is no oral respiratory stimulant available for long- term use in chronic respiratory failure.
Text 1: Patient Safety
Highlighting a collaborative initiative to improve patient safety
In a well-documented case in November 2004, a female patient called Mary was admitted to a
hospital in Seattle, USA, to receive treatment for a brain aneurysm. What followed was a tragedy,
made worse by the fact that it needn’t have occurred at all. The patient was mistakenly injected
with the antiseptic chlorhexidine. It happened, the hospital says, because of ‘confusion over the
three identical stainless steel bowls in the procedure room containing clear liquids —
chlorhexidine, contrast dye and saline solution’. Doctors tried amputating one of Mary’s legs to
save her life, but the damage to her organs was too great: she died 19 days later.
This and similar incidents are what inspired Professor Dixon-Woods of the University of
Cambridge, UK, to set out on a mission: to improve patient safety. It is, she admits, going to be
a challenge. Many different policies and approaches have been tried to date, but few with
widespread success, and often with unintended consequences.
Financial incentives are widely used, but recent evidence suggests that they have little effect.
‘There’s a danger that they tend to encourage effort substitution,’ explains Dixon-Woods. In
other words, people concentrate on the areas that are being incentivised, but neglect other areas.
‘It’s not even necessarily conscious neglect. People have only a limited amount of time, so it’s
inevitable they focus on areas that are measured and rewarded.’
In 2013, Dixon-Woods and colleagues published a study evaluating the use of surgical
checklists introduced in hospitals to reduce complications and deaths during surgery. Her
research found that that checklists may have little impact, and in some situations might even
make things worse. ‘The checklists sometimes introduced new risks. Nurses would use the
lists as box-ticking exercises – they would tick the box to say the patient had had their
antibiotics when there were no antibiotics in the hospital, for example.’ They also reinforced the
hierarchies – nurses had to try to get surgeons to do certain tasks, but the surgeons used the
situation as an opportunity to display their power and refuse.
Dixon-Woods and her team spend time in hospitals to try to understand which systems are in place
and how they are used. Not only does she find differences in approaches between hospitals, but
also between units and even between shifts. ‘Standardisation and harmonisation are two of the
most urgent issues we have to tackle. Imagine if you have to learn each new system wherever
you go or even whenever a new senior doctor is on the ward. This introduces massive risk.
Dixon-Woods compares the issue of patient safety to that of climate change, in the sense that it is a
‘problem of many hands’, with many actors, each making a contribution towards the outcome, and
there is difficulty in identifying where the responsibility for solving the problem lies. ‘Many patient
safety issues arise at the level of the system as a whole, but policies treat patient safety as an issue
for each individual organisation.’
Nowhere is this more apparent than the issue of ‘alarm fatigue’, according to Dixon-Woods.
Each bed in an intensive care unit typically generates 160 alarms per day, caused by machinery
that is not integrated. ‘You have to assemble all the kit around an intensive care bed manually,’
she explains. ‘It doesn’t come built as one like an aircraft cockpit. This is not something a
hospital can solve alone. It needs to be solved at the sector level.’
Dixon-Woods has turned to Professor Clarkson in Cambridge’s Engineering Design Centre to

help. ‘Fundamentally, my work is about asking how we can make it better and what could possibly
go wrong,’ explains Clarkson. ‘We need to look through the eyes of the healthcare providers to
see the challenges and to understand where tools and techniques we use in engineering may be
of value.’ There is a difficulty, he concedes: ‘There’s no formal language of design in healthcare.
Do we understand what the need is? Do we understand what the requirements are? Can we think
of a range of concepts we might use and then design a solution and test it before we put it in
place? We seldom see this in healthcare, and that’s partly driven by culture and lack of training,
but partly by lack of time.’ Dixon-Woods agrees that healthcare can learn much from engineers.
‘There has to be a way of getting our two sides talking,’ she says. ‘Only then will we be able to
prevent tragedies like the death of Mary.’
7. What point is made about the death of a female patient called Mary?
A It was entirely preventable.
B Nobody was willing to accept the blame.
C Surgeons should have tried harder to save her life.
D It is the type of incident which is becoming increasingly common.
8. What is meant by the phrase ‘effort substitution’ in the second paragraph?
A Monetary resources are diverted unnecessarily.
B Time and energy is wasted on irrelevant matters.
C Staff focus their attention on a limited number of issues.
D People have to take on tasks which they are unfamiliar with.
9. By quoting Dixon-Woods in the second paragraph, the writer shows that the professor
A understands why healthcare employees have to make certain choices.
B doubts whether reward schemes are likely to put patients at risk.
C believes staff should be paid a bonus for achieving goals.

D feels the people in question have made poor choices.
10. What point is made about checklists in the third paragraph?
A Hospital staff sometimes forget to complete them.
B Nurses and surgeons are both reluctant to deal with them.
C They are an additional burden for over-worked nursing staff.
D The information recorded on them does not always reflect reality.
11. What problem is mentioned in the fourth paragraph?
A failure to act promptly
B outdated procedures
C poor communication
D lack of consistency
12. What point about patient safety is the writer making by quoting Dixon-Woods’
comparison with climate change?
A The problem will worsen if it isn’t dealt with soon.
B It isn’t clear who ought to be tackling the situation.
C It is hard to know what the best course of action is.
D Many people refuse to acknowledge there is a problem
13. The writer quotes Dixon-Woods’ reference to intensive care beds in order to
A present an alternative viewpoint.
B
illustrate a fundamental obstacle.
C show the drawbacks of seemingly simple solutions.
D give a detailed example of how to deal with an issue
14. What difference between healthcare and engineering is mentioned in the final paragraph?
A the types of systems they use
B the way they exploit technology
C the nature of the difficulties they face
D the approach they take to deal with challenges
Text 2: Migraine – more than just a headache
When a news reporter in the US gave an unintelligible live TV commentary of an awards

ceremony, she became an overnight internet sensation. As the paramedics attended, the worry
was that she’d suffered a stroke live on air. Others wondered if she was drunk or on drugs.
However, in interviews shortly after, she revealed, to general astonishment, that she’d simply
been starting a migraine. The bizarre speech difficulties she experienced are an uncommon
symptom of aura, the collective name for a range of neurological symptoms that may occur just
before a migraine headache. Generally aura are visual – for example blind spots which increase
in size, or have a flashing, zig-zagging or sparkling margin, but they can include other odd
disturbances such as pins and needles, memory changes and even partial paralysis.
Migraine is often thought of as an occasional severe headache, but surely symptoms such as
these should tell us there’s more to it than meets the eye. In fact many scientists now consider
it a serious neurological disorder. One area of research into migraine aura has looked at the
phenomenon known as Cortical Spreading Depression (CSD) – a storm of neural activity that
passes in a wave across the brain’s surface. First seen in 1944 in the brain of a rabbit, it’s
now known that CSD can be triggered when the normal flow of electric currents within and
around brain cells is somehow reversed. Nouchine Hadjikhani and her team at Harvard
Medical School managed to record an episode of CSD in a brain scanner during migraine aura
(in a visual region that responds to flickering motion), having found a patient who had the rare
ability to be able to predict when an aura would occur. This confirmed a long-suspected link
between CSD and the aura that often precedes migraine pain. Hadjikhani admits, however, that
other work she has done suggests that CSD may occur all over the brain, often unnoticed, and
may even happen in healthy brains. If so, aura may be the result of a person’s brain being
more sensitive to CSD than it should be.
Hadjikhani has also been looking at the structural and functional differences in the brains of
migraine sufferers. She and her team found thickening of a region known as the somatosensory
cortex, which maps our sense of touch in different parts of the body. They found the most
significant changes in the region that relates to the head and face. ‘Because sufferers return to
normal following an attack, migraine has always been considered an episodic problem,’ says
Hadjikhani. ‘But we found that if you have successive strikes of pain in the face area, it actually
increases cortical thickness.’
Work with children is also providing some startling insights. A study by migraine expert Peter
Goadsby, who splits his time between King’s College London and the University of California, San
Francisco, looked at the prevalence of migraine in mothers of babies with colic - the uncontrolled
crying and fussiness often blamed on sensitive stomachs or reflux. He found that of 154 mothers
whose babies were having a routine two-month check-up, the migraine sufferers were 2.6 times
as likely to have a baby with colic. Goadsby believes it is possible that a baby with a tendency to
migraine may not cope well with the barrage of sensory information they experience as their
nervous system starts to mature, and the distress response could be what we call colic
Linked to this idea, researchers are finding differences in the brain function of migraine sufferers,
even between attacks. Marla Mickleborough, a vision specialist at the University of Saskatchewan
in Saskatoon, Canada, found heightened sensitivity to visual stimuli in the supposedly ‘normal’
period between attacks. Usually the brain comes to recognise something repeating over and over
again as unimportant and stops noticing it, but in people with migraine, the response doesn’t
diminish over time. ‘They seem to be attending to things they should be ignoring,’ she says.
Taken together this research is worrying and suggests that it’s time for doctors to treat the condition
more aggressively, and to find out more about each individual’s triggers so as to stop attacks from
happening. But there is a silver lining. The structural changes should not be likened to dementia,
Alzheimer’s disease or ageing, where brain tissue is lost or damaged irreparably. In migraine, the
brain is compensating. Even if there’s a genetic predisposition, research suggests it is the disease
itself that is driving networks to an altered state. That would suggest that treatments that reduce the
frequency or severity of migraine will probably be able to reverse some of the structural changes too.
Treatments used to be all about reducing the immediate pain, but now it seems they might be able to
achieve a great deal more
15. Why does the writer tell the story of the news reporter?
A to explain the causes of migraine aura
B to address the fear surrounding migraine aura
C to illustrate the strange nature of migraine aura
D to clarify a misunderstanding about migraine aura
16. The research by Nouchine Hadjikhani into CSD
A has less relevance than many believe.
B did not result in a definitive conclusion.
C was complicated by technical difficulties.
D overturned years of accepted knowledge.
17. What does the word ‘This’ in the second paragraph refer to?
A the theory that connects CSD and aura
B the part of the brain where auras take place
C the simultaneous occurrence of CSD and aura
D the ability to predict when an aura would happen

18. The implication of Hadjikhani’s research into the somatosensory cortex is that
A migraine could cause a structural change.
B a lasting treatment for migraine is possible.
C some diagnoses of migraine may be wrong.
D having one migraine is likely to lead to more.
19.What does the writer find surprising about Goadsby’s research?
A the idea that migraine may not run in families
B the fact that migraine is evident in infanthood
C the link between childbirth and onset of migraine
D the suggestion that infant colic may be linked to migraine
20. According to Marla Mickleborough, what is unusual about the brain of migraine sufferers?
A It fails to filter out irrelevant details.
B It struggles to interpret visual input.
C It is slow to respond to sudden changes.
D It does not pick up on important information.
21. The writer uses the phrase ‘a silver lining’ in the final paragraph to emphasise
A the privileged position of some sufferers.
B a more positive aspect of the research.

15 right upper quadrant
16 nausea OR vomiting OR nausea and vomiting OR vomiting and nausea
17 enzyme-inducing
18 100 OR a hundred OR one hundred
19 12 OR twelve
20 supportive (treatment)

PART B: QUESTIONS 1-6
1 C can delegate responsibility for the cupboard

2 A keys
give atovalid
another ward.
reason for conducting it.
3 A help maximise its efficiency.
4 B They enable a patient to receive more of the
5 A prescribed medicine.
benefits to patients of using bedrails can
6 A outweigh
They maythe be dangers.
useful for patients who are not
fully responsive.
PART C: QUESTIONS 7-14
7 A It was entirely preventable.

8 C Staff focus their attention on a limited number of
9 A issues.
understands why healthcare employees have to
10 D makeinformation
The certain choices.
recorded on them does not
11 D always reflect reality.
lack of consistency
12 B It isn’t clear who ought to be tackling the situation.
13 B illustrate a fundamental obstacle.
14 D the approach they take to deal with challenges
PART C: QUESTIONS 15-22
15 C to illustrate the strange nature of

16 B migraine aurain a definitive conclusion.
did not result
17 C the simultaneous occurrence of CSD
18 A and aura could cause a structural
migraine
19 D change.
the suggestion that infant colic may be
20 A linked
It fails to
to migraine
filter out irrelevant details.
21 B a more positive aspect of the research.
22 B They are unlikely to be permanent.
ability to produce new cells
Text C
While there are many different causes of anaemia, laboratory studies and
unique features of the patient can be used to help differentiate between
various aetiologies.
Laboratory studies used to diagnose anaemia include:

 Haemoglobin (Hb) a measure of the protein that transports oxygen in
the red blood cell.
 Haematocrit (Hct) a measure of the percentage of red blood cells in the
blood.
 Red blood cell amount (erythrocyte count) a measure of the number of
red blood cells in the blood.
A general diagnosis of anaemia can be determined by the following values:
Haemoglobin level:
• Males: less than 13.5 g/dl
• Females: less than 12.5 g/dL (women have a generally lower
haemoglobin because of blood loss during the monthly menstrual
cycle)
Haematocrito:
• Males: less than 45% red blood cells.
• Females: less than 37% red blood cells (women have a generally lower
haematocrit because of blood loss during the monthly menstrual cycle)
Red blood cell amount:

• Male: less than 4.7 million cells/mL
• Female: less than 4.2 million cells/mL (women have a generally lower
red blood cell amount because of blood loss during the monthly
menstrual cycle)
While these laboratory tests are good estimates of the red blood cell mass,
they are not perfect. Red blood cell mass is very difficult to measure, and
therefore these laboratory tests are used together to assess whether or not
someone has anaemia.
Text D
The treatment of anaemia depends heavily on the type of anaemia that the
patient is experiencing. However, there are several overarching goals of
treatment.
If possible, treat the underlying cause of the red blood cell loss.
For example, if the patient has anaemia because of blood loss, give a blood
transfusion.
Identify and treat any complications that have occurred because of the
anaemia.
Educate the patient on how to manage their anaemia.
For example, a patient with anaemia because of iron deficiency can
supplement their treatment with iron rich foods, such as leafy green
vegetables.
Alternatively, a patient with anaemia caused by vitamin deficiency should be
advised to increase their intake of folic acid and B-12. Note that patients who
follow vegetarian or vegan diets may struggle to meet B-12 requirements, so
eating fortified foods and using supplements should be advised
PART A -QUESTIONS
Questions 1-6
For each of the questions, 1-6, decide which text (A, B, C or D) the
information comes from. You may use any letter more than once
1. treating patients with anaemia?

2. the symptoms of hypoxia?
3. methods used to identify anaemic patients ?
4. the different types of anaemia?
5. the levels of haemoglobin in a woman with anaemia?
6. how red blood cell size affects anaemia?
Questions 7-14
Each answer may include words, number of the both. Your answers should be correctly
spelled.
7. What should vegan patients with vitamin deficiency anaemia be

encouraged to add to their diets?
8. If there is a decreased number of young red blood cells, what of anaemia
is being dealt with?
9. How will a patient's breathing sound when experiencing a significant
reduction of oxygen in the body's tissues?
10. A male with anaemia must have less than what percentage of red blood
cells?
11. What is an increase in the number of reticulocytes an indication of?
12. What reduces the amount of red blood cells in some patients?
13. What should be treated in anaemic patients, after identifying the cause?
14. How are the different types of anaemia most commonly distinguished?
Questions 15-20
Complete each of the sentences, 15- 20, with a word or short phrase from one of the
texts. Each answer may include words, number or both. Your answers should be correctly
spelled
 Anaemia caused by (15)_________ should be treated with a blood

transfusion.
 Patients suffering from hypoxia and chest pain are likely to also have a
(16)___________
 If (17)__________ is functioning properly, high reticulocyte anaemia is
likely to be present.
 A number of tests may be necessary to diagnose anaemia, due to the
difficulties involved in measuring (18)__________
 Patients with anaemia caused by (19)__________ should be instructed
to adjust their diet.
 When identifying the type of aetiology, (20)___________ of the patient
should be considered, in addition to laboratory studies.
END OF PART A THIS TEXT BOOKLET WILL BE COLLECTED
In this part of the test, there are six short extracts relating to the work of health
professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best according
to the text. Write your answers on the separate Answer Sheet
Questions 1-6
1. Why is epinephrine added to Lidocaine injections?
A. to numb the area

B. to prolong the effects
C. to reduce patient discomfort
Preparation of Injection:
Lidocaine is a local anesthetic that is often injected subcutaneously before
minor medical procedures such as laceration repair, excisional biopsy, and
hormone implantation. A key step to prepare for this procedure is clearing a
suitable workspace and obtaining any necessary supplies. First, be sure to
check with your provider about the concentration and mixture of Lidocaine to
be used. Epinephrine is often included to constrict local blood vessels for
longer duration, but can increase the risk of causing ischemia in areas with
poor blood supply (fingers, ears, toes). Sodium bicarbonate can also be
added to avoid pain during injection due to Lidocaine acidic pH.
Be sure to obtain the proper size needle and syringe, which will be
dependent on the location of the injection and the size of the area requiring
anesthesia, respectively.
2. The policy document on collateral information offers advice to staff about

how to
A. gather information from colleagues about specific patients.

B. collect information about patients from their friends and relatives
C. inform patients and their carers about recent diagnoses over the phone
Policy Reminder: Collecting Collateral Information

Collateral information is an important factor in determining appropriate
disposition for psychiatric patients in the Emergency Department. Often,
patients with psychiatric complaints are unable to accurately or thoroughly
describe their medical history, baseline condition, or events leading up to
their arrival at the hospital. Thus, it becomes imperative to contact those who
might know the patient best or were in the patient's company prior to their
arrival. Contact information can be obtained from the patient themselves,
persons accompanying the patient, or the medical record. When initiating
contact, confirm the other person's identity before revealing the patient's
name or the reason you are speaking with them. If you reach voicemail and
the answering machine does not clearly identify the person you are looking
for, do not reveal any information about the patient - simply state your name,
number, position, and whom you are requesting a callback from.
3. When dealing with patients with symptoms of peripheral arterial disease,

staff should
A. look for signs of swelling in the upper body

B. confirm that the patient has a history of poor diet.
C. identify the cause through physical examination and tests
Assessing and Managing Peripheral Arterial Disease

Staff should assess patients who have symptoms suggestive of peripheral
arterial disease or diabetes with non-healing wounds for the presence of
peripheral arterial disease.
• Ask about the presence of intermittent claudication and critical limb

ischaemia.
• Examine the lower limbs for evidence of critical limb ischaemia.
• Examine pulses in the lower limbs: femoral, popliteal and feet.
• Measure the ankle brachial pressure index.
Imaging is possible for patients with peripheral arterial disease:

duplex ultrasound is the first-line imaging technique. If patients require
additional imaging, contrast-enhanced magnetic resonance angiography is
used. If this is contraindicated or not possible, use computed tomography
angiography instead.
Lifestyle changes are the first-line treatment for peripheral arterial disease,
this includes: smoking cessation, better control of diabetes, better
management of hypertension, management of high cholesterol, in
combination with antiplatelet drugs. Finally, regular exercise has shown to
beneficially revascularise tissues in those with claudication.
4. The guidelines on alcohol withdrawal treatment informs healthcare
professionals about
A. determining the quantity of medication required.

B. reducing the dosage as the symptoms improve.
C. various types of drugs to prescribe to patients.
Guidelines: Alcohol Withdrawal Treatment

Alcohol withdrawal can present as a life-threatening emergency and requires
treatment at a hospital. Providers use algorithms to determine when and how
much medication to administer for a safe and optimal outcome. A key
component of this assessment is determining the severity of alcohol
withdrawal using the Clinical Institute Withdrawal Assessment for Alcohol
(CIWAAr). The scale contains 10 subjective and objective items that can be
queried and scored in minutes. Symptoms asked about include nausea,
vomiting, tremors, sweating, anxiety, agitation, tactile/auditory/visual
disturbances, headache, and cognitive dysfunction. Every hospital has
different cutoffs for treatment, but as a general rule, treatment with
benzodiazepines begin starting at a score 8-10, with higher scoring indicating
increasing amount and frequency of medication.
5. The memo is advising staff dealing with agitated patients on how to
A. identify the cause of the agitation.

B. avoid adding to the feelings of agitation.
C. deal with violent behaviour caused by the agitation.
For the attention of all staff:

RE: AGITATED PATIENTS
Agitated patients are a common occurrence in the Emergency Department.
There are many reasons for agitation, ranging from medical conditions,
substance intoxication, psychiatric illness, and distressing circumstances.
While both physical and chemical restraints are available to providers, these
are items of last resort as their use creates significant risk to the patient,
staff, and other persons in the area. Verbal de-escalation is a proven,
effective technique that can be used to calm a patient down and promote a
safe treatment environment. When de-escalating, designate one person to
speak for the group. Agitated patients can be easily confused by multiple
speakers and a unified message must be presented. Respect personal
space to prevent the patient from feeling 'trapped' and maintain sufficient
distance to avoid any resultant physical aggression. Remember to introduce
yourself and your role on the treatment team to the patient. Use their name
and orient them to their surroundings and why they are here in the hospital.
6. The guidelines advise that patients with heart problems
A. may need to avoid ibuprofen.

B. should be given lidocaine for pain relief.
C. must receive a lower dose of acetaminophen.
Extract from Appropriate Treatment for Pain

Pain is one of the most common complaints that will be brought to a
physician's attention. This section will cover treatment of mild to moderate
pain without the use of opioids. More severe pain may require judicious use
of short-acting opioid medications or a consult to pain medicine. For most
patients, the first line medications for pain are acetaminophen and ibuprofen.
Maximum daily dosage of acetaminophen is suggested to be 4grams,
reduced to under 2 grams for patients with liver issues such as a cirrhosis.
Ibuprofen is particularly effective in patients whose pain is caused by
inflammation, though caution is urged in elderly patients, patients with
diagnosed bleeding issues (especially gastrointestinal bleeds), or any cardiac
issues. Maximum daily dosage suggested is 2.4 grams. A combination of
acetaminophen and ibuprofen can be used if either one used alone is not
sufficient. For more localised pain relief, consider using lidocaine dermal
patches over non-broken areas of skin.
For questions 7-22, choose the answer (A, B, C or D) which you think fits best
according to the text. Write your answers on the separate Answer Sheet
Part C -Text 1
Delivering Serious News

Delivering serious news to patients and relatives: it's many healthcare
professionals' most dreaded task. Unfortunately, it's not something that can
be avoided, and it's something that must be done right. Patients and relatives
need our guidance and support, particularly when the prognosis is serious. In
this article, we use the phrase 'serious news' or 'life-altering news' rather than
choosing a term with negative connotations, such as bad news', for example,
as it helps to reframe the discussion. If you discuss serious news' with a
patient, they can decide how to respond, whereas giving a patient bad news',
may prevent them from being able to accept the news in a more constructive
light.
Studies show the vast majority of patients would prefer to be informed of a

life altering diagnosis, rather than remain in ignorance. However, the amount
of information they wish to receive can vary, with most wanting to know
details concerning the different treatment options, and the effectiveness of
proposed treatments, while they may want to hear less about the specific
details of their prognosis. According to statistics, in western cultures, the
majority of patients may not wish to know certain details, such as life
expectancy. Healthcare workers may also find families asking that diagnoses
be kept from the patient, or that patients prefer to have care wholly managed
by their family, rather than themselves.
One model for delivering serious news is called SPIKES, developed by

Walter Baile and initially used for discussions with cancer patients. The first
step in SPIKES is setting up the interview. A quiet private area such as an
exam room or family meeting room is an ideal setting. The patient should be
able to choose family members or friends to be present for support. For
those who don't speak fluent English, a hospital-contracted medical
interpreter should be used. The healthcare professional should be prepared
to answer difficult queries about prognosis, treatment, and overall plan going
forward, but also know when to refer to a specialist for more esoteric
information. If there is a multi-disciplinary approach, every team member
should be on the same page with regards to the care plan to avoid confusion.
The second item in SPIKES is the patient's perception. Last week, I asked a
patient, let's call him Harry, if he understood his current condition. Of course,
he said he did, but when he came to explain it to me, I saw that there were
many gaps in his knowledge that needed to be addressed. A good way to
assess the patient's understanding is to ask what the patient already knows
about their condition and what they have been told so far. Make sure to
assess the level of their understanding, as well as their awareness of the
basic facts. This will allow you to assess their level of background
knowledge, their current knowledge, and where to begin your own
discussion.
The third item in SPIKES is the patient's invitation for discussion. Different
patients desire different levels of information about their condition. Some of
the more technical-minded or younger patients may want to know their
diagnosis, prognosis, treatments, course of illness, etc. Others, including
older patients, may simply wish to know the diagnosis and accept the
recommendations of the treatment team as being in their best interests.
Before beginning to discuss their condition, you might find it helpful to ask
"Would you like me to discuss all the information we know about your
condition or just certain parts? What would you like us to tell your family?"
The fourth item in SPIKES is giving knowledge to the patient. You should be
direct, but avoid being unfeeling or blunt when you discuss their condition,
and utilise non-technical terms in small chunks. Prognosis and course of
illness should be realistic, but also convey hope and planning for the future.
An appropriate opening for our patient would be, "I'm afraid, we have some
serious news about the CT scan that was performed. It showed that the
cancer in your liver has spread to your spine." Take note of how the words
'hepatocellular carcinoma' and 'metastasis' were rephrased into layman's
terms.
The fifth item in SPIKES is addressing the patient's emotions. You should
identify the emotion the patient is experiencing, the reasoning, and provide
support during this difficult time. Don't try to change the patient's emotions,
just help them to express how they feel. For example, in a patient who is
dysphoric and crying, you can offer a tissue box and physical support if
appropriate. You might say something like, "I know these results weren't
what you wanted to hear. I wish we had better news for you." Other
responses can range from asking the patient to elaborate on their reaction,
"Can you tell me what you're worried about?" to validating their concerns, "I
can understand why you felt that way. Many other patients have had similar
reactions."
The sixth item in SPIKES is strategy and summary. Patients who receive
serious news will often feel that they are in over their head, so you should
make sure that they leave with a clear plan for the future. This will help them
to feel less anxious and more hopeful. Patients should know what options are
available for them and what follow-up is planned. You should also recheck
that they understand what has just been discussed and have had all their
questions answered. A good opening statement could be, "I understand this
is a lot to take in, but you have several options available. A decision does not
need to be made now, but we would like to refer you to an oncologist and
follow-up with us in a week to discuss your next steps."
Giving serious news is one of the most difficult parts of being a healthcare
professional. However, with careful planning and an effective protocol,
patients can leave feeling well-informed and in control of their own outcome.
7. Why does the writer prefer the term ‘serious news'?
A. It enables doctors to avoid unnecessary conversations.

B. It avoids influencing the patient's emotional response.
C. It helps patients to better understand their condition.
D. It offers a more specific definition of the information.
8. The writer's purpose in the second paragraph is to highlight
A. the treatment options available to most patients.

B. the difficulty of knowing what a patient wants to be told.
C. the trends concerning what patients and relatives want to hear.
D. the different topics that healthcare workers should cover with patients.
9. What does the word ‘those’ refer to?
A. healthcare staff
B. treatment experts
C. language translators
D. patients and relatives
10. In the fourth paragraph, the writer mentions the patient, Harry, in order to
explain that
A. patients are often reluctant to ask for help.

B. patients may not be aware of their ignorance
C. healthcare professionals often find it hard to relate to patients.
D. healthcare professionals may not always explain thingseffectively.
11. The writer suggests that older patients may be more likely to
A. require more information.

B. limit their family's involvement
C. accept the staff's suggested plan.
D. inquire further about their treatment plans.
12. In the sixth paragraph, the writer offers an example to emphasise that
when explaining information professionals should
A. avoid using complex medical language.

B. prevent patients from becoming upset
C. discuss how the illness was identified.
D. repeat information multiple times.
13. The seventh paragraph focuses on
A. ensuring the patient understands how to react.

B. helping the patient to feel more positive.
C. comparing different patient responses.
D. empathising with the patient's reaction.
14. The expression ‘in over their head' is used to stress that patients might
A. find the information overwhelming.

B. struggle to remember information.
C. make a choice about their treatment quickly.
D. have difficulty understanding their prognosis.
Part C -Text 2
TREATING OPIUM ADDICTION:

In the United States alone, there are around 115 deaths caused by opioid
addiction every day. The addiction impacts individuals rapidly and drastically,
damages families, and costs the US huge amounts of money: the total
economic burden of prescription opioid abuse is estimated to be $78.5 billion
a year, while the economic burden of non-prescription opioid abuse simply
cannot be calculated. Measures are constantly being improved to prevent
patients from developing opioid addictions to begin with, but it is also
imperative that we continue to provide treatment for those already in the
thrall of opioid addiction.
Jane's story is one heard over and over again in opioid addiction clinics.
When she was 20, she had a bad automobile accident that required two
surgeries. She was soon home from the hospital but her residual pain meant
she was prescribed scheduled opiates. Jane's body soon became tolerant of
the dosage; however, and she needed higher and higher doses in order to
achieve the same pain relieving effect. She eventually reached a level that
her physician felt uncomfortable prescribing. Unable to find another
prescriber in time, Jane turned to alternative sources of narcotics.
Unfortunately, when purchased on the street, these pills are exorbitantly
expensive and increasingly hard to come by in an era of prescription
monitoring throughout the United States. Heroin is much cheaper and, when
delivered by IV, produces a much more potent high and greater pain relief.
Eventually, after destroying relationships with her loved ones, bankrupting

hersavings, and hitting rock-bottom, Jane turned to a local opioid addiction
clinic for help. At the clinic, they put her on Methadone, a long-acting opioid
agonist that is standard for addiction treatment. It binds to the mu-opioid
receptors, prevents withdrawal symptoms, reduces cravings, and can also
provide a level of pain relief. Of course, as an opioid agonist, methadone
serves as a substitute for the primary addiction, meaning many of the issues
associated with long-term opioid usage remain. Patients must often begin
treatment with daily visits, which can be disruptive. Fortunately for Jane,
these visits are her first steps towards putting her life back together. As
Jane's road to recovery is likely to be long and fraught with difficulty, many
doctors are led to wonder: does she have any other options?
One of the increasingly popular alternatives to methadone is buprenorphine,
a partial mu-opioid agonist. Aside from its unique mechanism of action
(MOA),there are two major differences when compared to Methadone: first, it
can be administered as oral tablets, sublingual/buccal films, and a long-
acting implant, second, It can be prescribed month-to-month from a
clinician's office directly to a local pharmacy. These factors make it much
easier to use in the community and are ideal for patients who cannot visit a
methadone clinic every day.
To initiate buprenorphine, a patient must already be in a mild state of

withdrawal due to the high affinity for the mu-opioid receptor displacing other
opioids. This means that patients generally transition best from a short-acting
opioid like heroin or oxycodone rather than a long-acting opioid agonist like
Methadone, given the length of time needed until mild withdrawal occurs. As
Jane had been using opioids for a long time prior to her admission, however,
she was better suited to treatment with Methadone, as there is no ceiling
effect to this drug, and Jane had developed a high tolerance to opioids.
Buprenorphine, being a partial agonist, has a maximum level of effect which
it cannot be increased beyond. For this reason, buprenorphine can be used
as a maintenance therapy in some patients, but it can also be tapered down
over time. This allows patients to resume their normal lives with minimal
interruptions and avoid relapse through pharmacological blocking.
Alongside treatment with medication, patients recovering from opioid

addiction must also deal with recovery at a mental level. As with many
healing processes the first stage is acceptance. Jane was not able to seek
the treatment she needed until she had nowhere else to hide. Once
everything was lost, she couldn't deny that she was in trouble anymore, so
she came to the clinic. Many patients suffering from opioid addictions are
reluctant to admit that they are addicted, and reluctant to ask for help.
Patients are often worried about being judged, being treated like a criminal,
and meeting with disapproval from the healthcare professionals who must
treat them.
When patients do seek aid, healthcare professionals need to help them to

build a support network around themselves, so that they are protected when
they feel the need to relapse. Opioid addicts are likely to have burned
bridges with friends and family who have not enabled their addiction, so
patients beginning recovery may not have positive role models to support
and influence their recovery. Talking therapies, such as cognitive behavioural
therapy (CBT) can be offered to recovering patients experiencing anxiety or
depression, though patients may find it more useful to join local confidential
support groups, such as Narcotics Anonymous, as they can discuss recovery
with those who have first-hand experience. Though Jane was hesitant to
discuss her experiences with anyone when she was first admitted to the
clinic for treatment, she has since gone on to attend weekly sessions at
Narcotics Anonymous, where she not only listens to others share their stories
of recovery, but where she also is beginning to tell her own.
15. In the first paragraph, the writer highlights that opioid addiction in theUS
A. has been gradually increasing for a number of years.

B. is largely influenced by the illegal sale of drugs.
C. causes more deaths than any other addiction
D. has a significant financial and social impact.
16. In the second paragraph, the writer outlines Jane's case in order to
emphasise that
A. opioid addiction is increasingly rare.

B. it can be remarkably easy for a patient to become addicted.
C. in some cases, heroin is less harmful to addicts than opioids.
D. healthcare professionals must take responsibility for opioid addiction.
17. The writer uses the phrase ‘hitting rock bottom' about the patient Jane
in order to describe
A. how her addiction led to the most distressing point in her life.
B. her sudden awareness that she had to recover.
C. the large tolerance she developed for opioids.
D. the physical pain she felt at that time.
18. In the fourth paragraph, the writer suggests that buprenorphine may be
preferable because
A. it is less addictive than alternatives

B. it can be easier for patients to access
C. it does not interfere with other treatments
D. it can be picked up more often than other medications.
19. What does ‘this means that’ refer to?
A. The effectiveness of buprenorphine when combating opioid displacement.

B. The requirement for the medication to be reserved for heroin addicts.
C. The need for patients to have begun to experience withdrawals.
D. The impact of mu-opioids on recovered opioid addicts.
20. In the fifth paragraph, the writer suggests that Jane was prescribed
methadone, rather than buprenorphine because
A. buprenorphine is too similar to heroin.

B. the effects of methadone last for longer
C. she was dependent on high doses of opioids.
D. it is more readily available at addiction clinics.
21. According to the seventh paragraph, why do patients often delay seeking
treatment for opioid addiction?
A. They are unwilling to face the damage they have caused.

B. They do not realise they are addicted until it's too late.
C. They think that they can recover without help.
D. They do not want to be labelled as an addict.
22. In the final paragraph, the writer suggests that recovering addicts may
prefer to discuss their experiences with
A. those who have experienced addiction.

B. people who are not aware of their history.
C. healthcare professionals.
D. friends and family
7. B
8. C
9. D
10. B
11. C
12. A
13. D
14. A

15. D
16. B
17. A
18. B
19. C
20. C
21. D
22. A
Text B
Lung Function Tests in Asthma

Asthma tests should be undertaken to diagnose and aid management of the
condition. This is particularly important in asthma, because it presents slightly
differently with each patient. Spirometry is the most important test, however
several different types of test are available:
Peak expiratory flow rate (PEFR): this is the maximum flow rate during
exhalation, after full lung inflation. Diurnal variation in PEFR is a good
measure of asthma and useful to the long-term management of patients and
the response to treatment. Monitor PEFR over 2-4 weeks in adults if there is
uncertainty about diagnosis. It is measured with a peak flow meter a small,
handheld device - into which the patient blows, giving a reading in 1/min.
Spirometry: measures volume and flow of air that can be exhaled or inhaled
during normal breathing. Asthma can be diagnosed with a > 15%
improvement in FEV1 or PEF following bronchodilator inhalation.
Alternatively, consider FEV1/FVC 70% as a positive result for obstructive
airway disease. A spirometry test usually takes less than 10 minutes, but will
last about 30 minutes if it includes reversibility testing.
Direct bronchial challenge test with histamine or methacholine:

In this test, patients breathe in a bronchoconstrictor. The degree of
narrowing can be quantified by spirometry. Asthmatics will react to lower
doses, due to existing airway hyperactivity.
Exercise tests:
these are often used for the diagnosis of asthma in children. The child should
run 6 minutes (on a treadmill or other) at a workload sufficient to increase
their heart rate > 160/min. Spirometry is used before and after the exercise -
an FEV1 decrease > 10% indicates exercise-induced asthma.
Allergy testing:
can be useful if year-round allergies trigger a patient's asthma. This will be
recommended if inhaled corticosteroids are not controlling symptoms. Three
different tests are used to measure the patient's reaction to allergens: nitric
oxide testing, sputum eosinophils and bloodeosinophils.
Text C
Patients with asthma of any severity may find their attacks panic-inducing.
Remember that the patient's struggle to breathe can cause stress, panic and
a feeling of helplessness. There is a strong link between people who suffer
from asthma and those who experience panic attacks. Staff must keep this in
mind when treating patients with asthma, as some sufferers will require
additional emotional support.
Patients may find breathing exercises beneficial. Advise patients to practice

daily, to allow these exercises to become habitual. When experiencing an
attack, patients should make a conscious effort to relax their muscles and
maintain steady breathing. Advise patients to breathe deeply in through the
nose and out through the mouth.
Smokers are at a higher risk of developing both panic attacks and asthma. In
addition, smoking can irritate the airways in patients with asthma, causing
neutrophilic inflammation, and exacerbating breathing problems in those with
asthma. Ensure that patients who smoke are fully aware of the risks of
smoking with asthma.
Text D
Management of Acute Asthma

Rapid treatment and reassessment is of paramount importance. It is
sometimes difficult to assess severity. Maintaining a calm atmosphere is
helpful to resolvingan acute asthmatic attack
Assess the severity of the attack

Immediate Treatment
1. Check peak expiratory flow (PEF)
2. Is the patient able to speak? 1. Maintain 02 saturation with oxygen (94-98%)
2. Salbutamol Smg with 0 2(nebulised)
3. Check respiratory rate (RR)
3. lpratropium Smg every 6 hours if severe
4. Check pulse rate
5. Check 02 saturation 4. Prednisolone 40-SOmg PO
or Hydrocortisone 1 OOmg IV
If life-threatening or severe: warn ICU
Every 15 minutes: re-assess

1. PEF < 75%: salbutamol repeated every 15-30 minutes, or 1Omg every hour continuously.
If not yet given, add ipratropium.
2. Monitor ECG and check for arrhythmias
3. Magnesium Sulfate (Mg50 4), 1.2-2g IV over 20 minutes is an option in severe cases not
responding to therapy
No improvement Improvement within 15 - 30 minutes

1. Refer to ICU for ventilator support 1. Continue salbutamo l every 4-6 hours
2. Escalation of medical therapy 2. Check peak PEF and 02 saturation
3. Check for: 3. Prednisolone 40-50 mg PO OD for 5-7 days
- PEF deteriorating 4. If PEF>75% an hour after treatment,
- hypoxia consider discharge with follow-up
- hypercapnia
- ABG: low pH or high H+
- Exhaustion
- Drowsiness and confusion
- Respiratory arrest
PART A -QUESTIONS
Questions 1-6
1. relaxation techniques for those suffering from an asthma attack?

2. measuring the respiration abilities in patients with asthma?
3. identifying the intensity of asthma attacks in patients?
4. the procedure to follow when treating an asthma attack?
5. symptoms of asthma in patients?
6. how to diagnose asthma in patients?
Questions 7-12
spelled.
• To understand how severe an asthma attack is, (7)_________ must be
measured, in addition to PEF.
• For patients who do not respond to therapy, an IV of (8)_________ can
be used to treat severe asthma attacks.
• Nitric oxide testing can be used to determine (9)_______ in patients.
• A patient suffering from arrhythmia and a peak expiratory flow of
greater than 33% would be diagnosed with (10)________ asthma
attacks.
• Spirometry tests that contain (11)_________ typically last for half an
hour
• (12)_________ can cause neutrophilic inflammation in patients with
asthma
Questions 13-20
Complete each of the sentences, 13- 20, with a word or short phrase from one of the texts.
Each answer may include words, number or both. Your answers should be correctly spelled
13. How often should patients be advised to practice breathing exercises?

14. How often should patients with a peak expiratory flow of less than 75%be
given 10 mg of salbutamol?
15. When should patients be given 2mg of magnesium sulfate?
16. Which patients will typically need to run when completing spirometry
tests?
17. What should staff do when assessing a patient suffering from a life
threatening panic attack?
18. Which lung function test is helpful for understanding how the patient
responds to treatment?
19. What sort of noise might patients with asthma make when breathing?
20. What is used to measure peak expiratory flow rate?
professionals .
Questions 1-6
1. The notice reminds staff that patients who are dying
A. will need to be prescribed anti-emetics.

B. might not need to continue with certain medication.
C. should be encouraged to discuss their condition with loved ones.
End-of-Life Decision Making

Remember the five priorities when caring for a dying patient:
 Recognise that the end of life may be approaching.

 Communicate with patients, families, carers and staff.
 Involve patients and those close to them in decision making.
 Support the needs of families and carers.
 Develop an individualised plan of care for the patient.
An end-of-life care plan must ensure the physical, psychological, social and
spiritual comfort of the patient, and should strive for the best possible quality
of life for the patient's remaining time.
This includes prescribing anticipatory medications which can be given as
required, falling under the following categories which staff are encouraged to
remember as the ‘Four As':
Analgesia (pain relief), Anxiolytics (anti-anxiety), Anti-emetics (for nausea
and vomiting), and Anti-secretory (for respiratory and airway secretions).
Any unnecessary medications, such as long-term diabetes control and blood
pressure medications can be stopped.
A Do-Not-Resuscitate (DNACPR) decision also needs to be made.
2. The guidelines inform us that multiple anaesthetics can be used
A. to increase the numbing effects

B. to prevent bleeding throughout the procedure.
C. to more accurately control how long it will last.
Anaesthesia use at Harlow Dental Centre

At this practice, preference is given to the use of local anaesthetics in
combination with conscious sedation.
Many local anaesthetics may be used in order to reversibly block specific

pain pathways and/or cause paralysis of muscles. The most commonly used
local anaesthetic at the centre is lidocaine - remember that the half-life of
lidocaine in the body is about 1.5 to 2 hours. Other local anaesthetic agents
include articaine, bupivacaine, prilocaine and mepivacaine. Often, a
combination of local anaesthetics may be used, sometimes with adrenaline
or another vasoconstrictor to modulate the metabolism of the local
anaesthetic and control local bleeding.
Sedation during procedures should mostly be limited to conscious sedation.

Benzodiazepines enhance the effect of neurotransmitter gamma-
aminobutyric acid (GABA) at the GABAA receptor. This results in a sedative,
hypnotic, anxiolytic, anticonvulsant and muscle relaxant properties.
3. The purpose of this memo is to explain
A. how to treat multi-resistant pathogens

B. the causes of bacterial infections.
C. when to prescribe antibiotics
For the attention of all medical staff:

Microbial resistance to antibiotics is on the rise and infection with multi-
resistant pathogens, such as Clostridium difficile and MRSA amongst others,
is becoming more common.
Patients receiving antibiotics are at increased risk of such infections. As

such, please be aware of our antimicrobial prescribing guidelines, which
ensure that antibiotics are only prescribed with clear, clinical justification;
evidence of infection; and/or guaranteed medical benefit.
It is recommended that specimens should be cultured and results obtained

before commencing treatment with antibiotics, thus only prescribing the
therapy to which the microbe is sensitive. Prescription of broad-spectrum
antibiotics should be avoided where possible, as these not only damage the
normal bacteria of the human body, but also increase microbial exposure to
antimicrobial medications, increasing their potential for developing
resistance. Review narrow-spectrum antibiotic prescriptions within 5 days,
and broad-spectrum prescriptions within 48 hours.
4. This guidelines on autism in young people inform us that
A. the disorder is more difficult to identify in patients with ADHD

B. most children with autism are diagnosed before the age of three.
C. young people with autism are more likely to suffer from other conditions.
Autism in Young People

More than 1% of the UK population has an autism spectrum disorder. Signs
can vary widely between individuals and at different stages of an individual's
development. When children present with other conditions such as ADHD
(attention deficit hyperactivity disorder) or other learning difficulties, autism
spectrum disorders often go undiagnosed.
In children with autism spectrum disorders, symptoms are present before

three years of age but diagnosis can be made after this age to. Individuals
with autism spectrum disorder tend to have issues with social interaction and
communication, including difficulty with eye contact, facial expressions, body
language and gestures. Often, children with autism spectrum disorders may
lack awareness or interest in other children and tend to play alone.
The causes of autism spectrum disorder are unknown but are linked to
several complex genetic and environmental interactions
5. The memo reminds all staff to avoid
A. challenging a patient's criticisms.

B. handling grievances of a sensitive nature.
C. recording complaints that are not legitimate.
Subject: Fielding Patient Complaints

For the attention of all hospital staff:
At County Green Hospital, we endeavour to provide our patients and families
with the highest quality of services. Unfortunately, there may be times where
performance does not meet expectation. We routinely survey our patients on
how we can do better, but members of the treatment team may also be
approached with patient feedback, so all employees must be aware of the
correct procedure for handling patient complaints. The first step is to listen to
what patients have to say and document details appropriately. Whether or
not you feel there is a legitimate grievance, it is important to keep a record for
later examination. While listening to the complaint, the employee should
validate the patient or family member's experience. This does not mean there
needs be agreement about the nature of the complaint, but that the employee
demonstrates a clear understanding of why the patient or family member
might be feeling this way
6. Patients with delirium are more likely to recover quickly if

A. kept in a darkened environment.
B. staff changes are kept to a minimum.
C. treatment ensures they receive adequate rest
Diagnostic Criteria for Delirium

Delirium affects up to 87% of patients in intensive care and is particularly
common among the elderly. Delirium can have serious adverse effects and
even lead to mortality and must therefore be treated as a medical
emergency.
All hospital staff must know how to prevent, detect, and rapidly assess and
treat delirium on the hospital wards. Risk factors for developing delirium
include: change of environment, loss of vision/hearing aids, inappropriate
noise or lighting, sleep deprivation, severe pain, dehydration, drug
withdrawal, infections of any kind, recent surgery, and old age. For patients
at risk of delirium, think of the mnemonic DELIRIUM which indicates the
common causes: Drugs or Dehydration, Electrolyte Imbalance, Level of pain,
Infection or Inflammation (such as post-surgery),Respiratory failure,
Impaction of faeces (severe constipation), Urinary retention, Metabolic
disorder (such as liver or renal failure).
Management requires re-orientation of the patient to where they are and who
everybody around them is, as well as re-assurance and a non-
confrontational, empathetic approach towards agitated and distressed
patients. Please refrain from changing the staff of the medical team
responsible for a delirious patient care, in order to ensure consistency for the
patient. Avoid unfamiliar noises, equipment and staff in the immediate vicinity
of the patient, and facilitate visits from family and friends as much as
possible.
Part C -Text 1
Work-Related Stress & Medical Errors

Stress is a term that crops up all too often in modern conversation, used to
describe every unfortunate circumstance, every out-of-sequence event, and
every foot out of line. What is stress? Most definitions of stress cover any
internal or external stimulus which results in a negative response or
disturbance in one's physical, social or mental wellbeing. Unfortunately,
stress is common, and it can be devastating to people's lives and health
when it is maintained over long periods of time, and when it gains the
capacity to overwhelm one's coping abilities and mechanisms.
In the medical profession, daily stress is almost guaranteed. Recently,

changes to many healthcare workers' contracts in the UK have resulted in
longer and more antisocial working hours, as well as an increased workload,
greater bed crises in hospitals and larger budget cuts, so stress levels
amongst UK healthcare professionals are on the rise. A 1996 questionnaire
study in the Lancet reported that 27% of doctors in the UK believed that the
stress they experienced was triggered by poor management, low job
satisfaction, financial concerns, and patients' suffering, amongst other factors
Over two decades later, these problems still exist; some healthcare workers
argue that conditions have actually deteriorated. A 2013 report by the British
Medical Association stated that over 50% of UK doctors had experienced an
increase in work-related stress over the preceding year, in addition to an
increase in the complexity of their work. 25% of junior doctors in hospitals
also reported a reduced quality of care for patients due to high levels of
stress and the pressures put on individual members of staff, with levels of
stress exacerbated by longer working hours. In many healthcare jobs, stress
is the elephant in the room, particularly with junior staff, who may feel
unable to voice concerns about their workload. Unfortunately, however, these
factors have the potential to lead to medical mistakes, which could be
detrimental to patient lives. In such a circumstance, who is really to blame?
The overworked medical staff, or the poor management of modern hospitals?
We do not need to look far to examine the effect that stress can have on
doctors today. In 2015, Dr Hadiza Bawa-Garba was found guilty of
manslaughter after failing to provide life-saving treatment to a patient when
needed, resulting in the unfortunate death of a six-year-old child, Jack
Adcock. In 2018, this experienced senior paediatrician with a previously
unblemished record was struck off the medical register, unable to ever
practice again as a doctor. The case of Dr BawaGarba infuriated many in the
medical profession, as fingers were pointed at an overworked doctor working
under immense pressure who was blamed for gross negligence. But who is
the truly negligent one in our current healthcare system? While the death of
young Jack is extremely saddening, it is important to explore the
circumstances around his death in order to prevent such tragedies from
reoccurring. On the day of the incident, Dr Bawa-Garba was covering her
own workload as well as that of two senior colleagues who were away,
across six wards, spanning four floors, with malfunctioning IT software and
out-of-order results systems. Did Dr Bawa-Garba make detrimental
mistakes? Yes. But one must ask, are we creating a recipe for disaster when
we require our medical staff to work under such immense pressures? Could
this be one tragic event of many waiting to happen? Such mistakes ruin lives.
Studies have shown that the most common cause of medical errors is the
use of heuristics in medical decision-making, leading to bias. Heuristics are
shortcuts taken to reach decisions quickly, based on previous patterns of
disease and similar cases seen by the doctor. Mistakes are more likely when
such shortcuts are used by junior doctors who lack the experience necessary
to make such fast decisions accurately. Tversky and Kahneman outlined
seven types of heuristics in their 1974 article: Availability heuristics are based
on how easy specific diagnoses are to recall, resulting in over-diagnosis of
rare but memorable conditions; Representativeness heuristics are based on
similarity of patient presentations to previous typical cases, leading to
delayed or missed diagnoses in a typical or non-characteristic patients;
Anchoring heuristics occur when a diagnosis is based on one piece of
information only, leading to rapid conclusions which lack evidence and early
diagnosis without consideration of all available information: Confirmation bias
occurs when a diagnosis is based on a preconceived idea, where the doctor
pays attention to the information that supports their theory, and evidence
which challenges the diagnosis is consciously or subconsciously ignored;
Commissioning bias where a doctor acts too soon rather than waiting to
gather and review all the information first; Gambler's Fallacy which is where
consecutive patients have the same diagnosis and so the doctor assumes a
similar patient who follows must also have the same diagnosis; Fundamental
Attribution Error which is the tendency to blame patients rather than their
circumstances for their poor health.
Research shows that the best way to avoid medical errors in diagnosis is to
consider several hypotheses, known as "differential diagnoses", and
investigate them all equally until the one with the most supporting evidence
is found and agreed upon. Use of heuristics and the resultant flawed
decision-making could be prevented by reducing work stresses and
pressures on medical professionals. One way to achieve this would be to
reduce working hours and shift durations in order to prevent sleep deprivation
in medical staff, which is known to hinder focus, thus creating a safer medical
environment for both staff and patients.
7. The first paragraph explains that stress
A. is usually caused by a factor than cannot be controlled.

B. is interpreted in various ways by different people.
C. is unusual when it lasts for an extended time.
D. generally impacts people's behaviour.
8. In the second paragraph, doctors are said to claim that stress
A. is often improperly managed by chronic sufferers.

B. could be improved by increasing the welfare budget.
C. generally resulted in their having to work longer hours.
D. was caused by a number of issues including money worries.
9. The writer uses the phrase ‘the elephant in the room' to emphasise the
fact that
A. levels of stress experienced by staff has declined.

B. senior staff generally experience less stress than their juniors
C. many healthcare professionals do not discuss the stress they
experience.
D. junior doctors have reported a lower quality personal life as a result of
stress.
10. Why does the writer comment on Dr Hadiza Bawa-Garba and her patient
Jack?
A. to suggest that doctors are more likely to make significant errors when
stressed
B. to outline a scenario where a doctor's concerns about stress were ignored
C. to demonstrate that stress in healthcare professionals is unacceptable
D. to emphasise the impact the death of a patient can have onstress
11. The writer suggests that Jack Adcock's death was partly caused by
A. technology that was out of date and faulty.

B. a hospital ward overcrowded with patients.
C. an insufficient number of nursing team staff.
D. a lack of experience among the clinical team.
12. Why might doctors who use heuristics be at a greater risk of making
clinical errors?
A. heuristics are more likely to be used by junior doctors

B. doctors might take too long to complete their tasks
C. doctors might skip over the relevant information
D. the different types of heuristics are confused
13. The writer claims that confirmation bias might cause doctors to ignore
relevant information if
A. they have recently treated a patient with the same condition.
B. they are very familiar with the evidence being presented
C. the patient displays extreme symptoms.
D. it does not support their existing theory.
14. What does the word 'them’ refer to in the final paragraph?
A. the team of healthcare staff

B. a variety of possible causes
C. the mistakes in patient care
D. a number of different texts
Part C -Text 2
Electroconvulsive therapy (ECT)
Electrodes. Wires. Bite Blocks. For many these terms bring to mind a sinister
mental asylum and the foreboding image of a patient about to suffer a
tortuous electric shock. Literature written in the 20th century did much to
criticise this practice, with writers frequently describing electroconvulsive
therapy (ECT) as a form of torture, reserved for the most vulnerable
members of society. Interestingly enough, ECT has actually been used in the
healthcare field for hundreds of years. Before the advent of effective
antipsychotic medications, a wide variety of therapies were trialled for serious
mental illnesses. One of these involved the therapeutic use of inducing
seizures in patients. As early as Benjamin Franklin's 17051790 time, an
electrostatic machine could be used to cure someone of 'hysterical fits'
Through the 19th century, British asylums began to employ electroconvulsive

therapy in a widespread effort to cure diseases of the mind. In the early
20thcentury, a neuropsychiatrist by the name of Ladislas J. Meduna
promoted the idea that schizophrenia and epilepsy were antagonistic
disorders, and that precipitating seizures could serve as a potential treatment
of schizophrenia. There were several methods used to induce seizures,
including insulin coma, seizure-inducing medications (metrazol), and most
famously, ECT.
While many of these practices are now seen as barbaric, there were very
few options for psychiatric treatment before the development of
antipsychotics, mood stabilisers, and anti-depressants. With the rise of these
new treatment options came an increase in the public awareness of the often
inhuman conditions of electroshock. The revelations resulted in widespread
backlash, and the use of ECT therapy began to swiftly decline. However, in
the later part of the 20th century, after much debate and research, the
National Institute of Mental Health in the US came to a consensus that ECT
was both safe and effective when proper guidelines were implemented. In the
US today, ECT treatment is routinely covered by insurance for severe and
treatment-resistant forms of mental illness.
The exact mechanism of action for ECT is unknown, but there are several
hypotheses: Firstly, increased release of monoamine neurotransmitters such
as dopamine, serotonin, and norepinephrine; secondly, enhanced
transmission of monoamine neurotransmitters between synapses; thirdly,
release of hypothalamus or pituitary gland hormones and fourthly,
anticonvulsant effect. ECT has several indications, the most notable being
refractory major depression, catatonia, persistent suicidality, and bipolar
disorder. It is also used in pregnancy as it is effective and does not have the
teratogenic effects of some other psychiatric medications. While there are no
absolute contraindications, it goes without saying that when using ECT, the
risks involved will carry more weight with certain patients. Those with
unstable cardiovascular conditions, those who have recently suffered a
stroke, and those with increased intracranial pressure, severe pulmonary
conditions, or a high risk in anaesthesia may not be suitable candidates for
ECT. To further explore the appropriateness of using of ECT on specific
patients, consider the following case study.
The patient, let's call her Dana, is a 35 year old female who has a history of
schizophrenia. She was taken to the hospital by ambulance because her
parents found her motionless in her bed, staring blankly, not responding to
external stimuli, and not eating or drinking for two days. The psychiatrist
caring for her is understandably concerned, because this represents
symptoms of catatonia. If Dana does not eat or drink, she may develop life-
threatening nutritional deficiencies and electrolyte imbalances. If she does
not move, Dana may end up developing a blood clot that could result in a
fatal pulmonary embolism. The first-line treatment is benzodiazepines, but in
this particular case, there is no improvement in her condition. The psychiatrist
decides that that ECT is the next best option. There is the issue of informed
consent. Legal jurisdiction handles this differently throughout the world, but if
a patient lacks capacity or is too ill to provide consent, a court must provide
substitute consent to ensure adequate legal oversight. Once this happens,
Dana is medically screened and prepped for treatment.
A course of ECT treatments does not have a standard regimen. Generally,

most patients require between six to twelve treatments, but the actual
endpoint is determined by the level of improvement. ECT is often given two
to three times a week, usually on a Monday Wednesday/Friday schedule with
psychiatric symptoms and testing carried out on a regular basis to monitor
progress. Dana starts Monday by being NPO (nothing by mouth) except for
any necessary medications. This reduces the chance for aspiration under
anaesthesia during the seizure. She will be taken down to the ECT suite
where an anaesthesiologist, psychiatrist, and nurse will greet her. She will be
placed in a supine position with EEG monitoring to determine the quality of
the seizure given. She will have electrodes placed on her head bitemporally,
bifrontally, or unilaterally on the right. In this case, given her life-threatening
catatonia, we will use the bitemporal position. The anesthesiologist will then
induce anaesthesia, first preoxygenating the patient, then administering
anticholinergic agent to reduce oral secretions, anaesthetic medication,
muscle relaxation medication, and any cardiovascular prophylaxis as
needed.
Once the patient is sufficiently sedated, a brief (0.5 to 2.0 milliseconds)

electrical pulse will be introduced at a level determined to reliably cause a
seizure. A therapeutic ECT seizure should last at least 15 seconds but no
more than 180seconds. Dana will be monitored for thirty to sixty minutes
once this has finished, to ensure her recovery. The goal is for further
treatments to reduce her symptoms and enable her to eat, drink,
communicate, and move again. Of course, there are adverse effects that
must be considered. Anaesthesia can cause nausea, aspiration pneumonia,
dental and tongue injuries. The seizure itself can cause cardiovascular
issues, and fractures in patients with osteoporosis, and can temporarily
impair cognition and memory. It is advised that patients do not make any
major or financial decisions during or after ECT treatment, and patients must
refrain from driving until a few weeks after the last session
For most patients, one treatment may be all that is needed. For some
continuation of ECT as a single session every couple of weeks may help to
prevent relapse. Maintenance treatment for patients with chronically recurring
psychiatric illness may also be appropriate. The scheduling of these sessions
generally depends on the patient's needs and episodes, sometimes even
going on indefinitely. In Dana's case, a few treatments are all that is needed
to resolve her catatonia and soon she will be healthy enough to be
discharged home without patient follow-up for her mental health
management.
15. In the first paragraph, the writer mentions the role of 20th century
literature in
A. informing patients of the side effects of antipsychotic medication.

B. preventing the mistreatment of defenceless people.
C. increasing the number of patients receiving ECT.
D. promoting a negative image of ECT.
16. What do we learn about schizophrenia in the second paragraph?
A. It was less prevalent in patients who experienced seizures.

B. It had a significant impact on the treatment of epilepsy.
C. Many asylums in the UK were not prepared to treat it
D. The medication metrazol could be used to induce it.
17. What did the US National Institute of Mental Health decide in the 20th
century?
A. Practitioners must follow identical treatment plans when using ECT.

B. Patients should be given the right to refuse ECT treatment.
C. ECT should only be used as a treatment in severe cases.
D. ECT was accepted as a safe treatment for patients.
18. In the fourth paragraph, what idea does the writer emphasise with the
phrase ‘it goes without saying'?
A. Some women find ECT treatments successful while carrying a child.

1. C
2. B
3. A
4. D
5. A
6. B

7. arterial saturation
8. magnesium sulfate
9. allergies
10. life-threatening
11. reversibility testing
12. smoking

13. daily
14. every hour
15. in severe cases
16. children
17. warn ICU
18. peak expiratory flow rate OR PEFR
19. a whistling sound
20. a peak flow meter

1. B
2. C
3. C
4. A
5. A
6. B

7. B
8. D
9. C
10. A
11. A
12. C
13. D
14. B

15. D
16. A
17. D
18. B
19. C
20. A
21. B
22. C
PART A -QUESTIONS AND ANSWER SHEET
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.

1. considerations when treating children with iron deficiency?
2. essential steps for identifying iron deficiency?
3. evaluating iron deficiency by testing for blood in stool?
4. risk factors associated with dietary iron deficiency?
5. different types of iron solutions?
6. a treatment for iron deficiency that is no longer supported?
7. appropriate dosage when administering IV iron infusions?
Questions 8-14
Each answer may include words, numbers or both. Your answers should be correctly spelt.
8. What level of serum ferritin leads to a diagnosis of iron deficiency?

9. What is the most likely cause of iron deficiency in children?
10. Which form of iron can also be injected into the muscle?
11. What should a clinician do if iron stores are normal and anaemia is still present?
12. How long after iron replacement therapy should a patient be re-tested?
13. Which form of iron is presented in a vial?
14. What is the first type of treatment iron deficient patients are typically given?
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both. Your answers should be correctly spelt.
In comparison to breast milk and infant formula, cows’ milk is (15).........................

Special procedures should be used because (16)........................ may be poisonous for children.
Men over 40 and women over 50 with a recurring iron deficiency should have an (17).............
Iron sucrose can be given to a patient no more than (18).........................
Although serum ferritin level is a good indication of deficiency, interpreting the results is
sometimes difficult (19).........................
IV iron infusions are a safe alternative when patients are unable to (20).........................
END OF PART A, THIS QUESTIONS PAPER WILL BE COLLECTED

In this part of the test, there are six short extracts relating to the work of health professionals.
For questions 1-6, choose answer (A, B or C) which you think fits best according to the text.
Questions 1-6
1. The code of conduct applies to

A. doctors friending patients on Facebook.
B. privacy settings when using social media.
C. electronic and face to face communication.
Professional obligations
The Code of conduct contains guidance about the required standards of professional behaviour,
which apply to registered health practitioners whether they are interacting in person or online.
The Code of conduct also articulates standards of professional conduct in relation to privacy and
confidentiality of patient information, including when using social media. For example, posting
unauthorised photographs of patients in any medium is a breach of the patient’s privacy and
confidentiality, including on a personal Facebook site or group, even if the privacy settings are
set at the highest setting (such as for a closed, ‘invisible’ group).
2. Why does dysphagia often require complex management?
A. Because it negatively influences the cardiac system.
B. Because it is difficult contrast complex and non-complex cases.
C. Because it seldom occurs without other symptoms.
6.1- General principles
Dysphagia management may be complex and is often multi-factorial in nature. The speech
pathologist’s understanding of human physiology is critical. The swallowing system works with
the respiratory system. The respiratory system is in turn influenced by the cardiac system, and
the cardiac system is affected by the renal system. Due to the physiological complexities of the
human body, few clients present with dysphagia in isolation.
6.2- Complex vs. non-complex cases
Broadly the differentiation between complex and non-complex cases relates to an

appreciation of client safety and reduction in risk of harm. All clinicians, including new
graduates, should have sufficient skills to appropriately assess and manage noncomplex cases.
Where a complex client presents, the skills of an advanced clinician are
required. Supervision and mentoring should be sought for newly graduated clinicians or
those with insufficient experience to manage complex cases.
3.The main point of the extract is
A. how to find documents about infection control in Australia.
B. that dental practices must have a guide for infection control.
C. that dental infection control protocols must be updated.
1- Documentation
1.1 Every place where dental care is provided must have the following documents in
either hard copy or electronic form (the latter includes guaranteed Internet access).
Every working dental practitioner and all staff must have access to:
a). a manual setting out the infection control protocols and procedures used in that
practice, which is based on the documents listed at sections 1.1(b), (c) and (d) of these
guidelines and with reference to the concepts in current practice noted in the documents listed
under References in these guidelines
b). The current Australian Dental Association Guidelines for Infection Control (available at:
http://www.ada.org.au)
4. Negative effects from prescription drugs are often
A. avoidable in young people.
B. unpredictable in the elderly.
C. caused by miscommunication.
Reasons for Drug-Related Problems: Manual for Geriatrics Specialists
Adverse drug effects can occur in any patient, but certain characteristics of the elderly make
them more susceptible. For example, the elderly often take many drugs (polypharmacy) and have
age-related changes in pharmacodynamics and pharmacokinetics; both increase the risk of
adverse effects. At any age, adverse drug effects may occur when drugs are prescribed and taken
appropriately; e.g., new-onset allergic reactions are not predictable or preventable.
However, adverse effects are thought to be preventable in almost 90% of cases in the elderly
(compared with only 24% in younger patients). Certain drug classes are commonly involved:
antipsychotics, antidepressants, and sedative-hypnotics.
In the elderly, a number of common reasons for adverse drug effects, ineffectiveness, or both are
preventable. Many of these reasons involve inadequate communication with patients or
between health care practitioners (particularly during health care transitions).
5. The guideline tries to use terminology that
A. presents value-free information about different social groups.
B. distinguishes disadvantaged groups from the traditional majority.
C. clarifies the proportion of each race, gender and culture.
Terminology
Terminology in this guideline is a difficult issue since the choice of terminology used to
distinguish groups of persons can be personal and contentious, especially when the groups
represent differences in race, gender, sexual orientation, culture or other characteristics.
Throughout the development of this guideline the panel end eavoured to maintain neutral and
non-judgmental terminology wherever possible. Terms such as “minority”, “visible minority”,
“non-visible minority” and “language minority” are used in some areas; when doing so the panel
refers solely to their proportionate numbers within the larger population and infers no value on
the term to imply less importance or less power. In some of the recommendations the term
“under-represented groups” is used, again, to refer solely to the disproportionate
representation of some citizens in those settings in comparison to the traditional majority.
6. What is the purpose of this extract?
A. To illustrate situations where patients may find it difficult to give negative feedback.
B. To argue that hospital brochures should be provided in many languages.
C. To provide guidance to people who are victims of discrimination.
Special needs
Special measures may be needed to ensure everyone in your client base is aware of your
consumer feedback policy and is comfortable with raising their concerns.
For example, should you provide brochures in a language other than English?
Some people are less likely to complain for cultural reasons. For example, some Aboriginal people
may be culturally less inclined to complain, particularly to non-Aboriginal people. People with
certain conditions such as hepatitis C or a mental illness, may have concerns about discrimination
that will make them less likely to speak up if they are not satisfied or if something is wrong.
For questions 7-22, choose the answer (A, B, C or D) which you think fits best according to the text.
Text 1: Difficult-to-treat depression

Depression remains a leading cause of distress and disability worldwide. In one country’s
survey of health and wellbeing in 2007, 7.2% of people surveyed had experienced a mood
(affective) disorder in the previous 12 months. Those affected reported a mean of 11.7
disability days when they were “completely unable to carry out or had to cut down on their
usual activities owing to their health” in the previous 4 weeks. There was also evidence of
substantial under-treatment: amazingly only 35% of people with a mental health problem had
a mental health consultation during the previous 12 months. Three-quarters of those seeking
help saw a general practitioner (GP). In the 2015–16 follow-up survey, not much had
changed. Again, there was evidence of substantial unmet need, and again GPs were the
health professionals most likely to be providing care.
While GPs have many skills in the assessment and treatment of depression, they are often
faced with people with depression who simply do not get better, despite the use of proven
psychological or pharmacological therapies. GPs are well placed in one regard, as they often
have a longitudinal knowledge of the patient, understand his or her circumstances, stressors
and supports, and can marshal this knowledge into a coherent and comprehensive
management plan. Of course, GPs should not soldier on alone if they feel the patient is not
getting better.
In trying to understand what happens when GPs feel “stuck” while treating someone with
depression, a qualitative study was undertaken that aimed to gauge the response of GPs to
the term “difficult-to-treat depression”. It was found that, while there was confusion around
the exact meaning of the term, GPs could relate to it as broadly encompassing a range of
individuals and presentations. More specific terms such as “treatment-resistant depression”
are generally reserved for a subgroup of people with difficult-to-treat depression that has
failed to respond to treatment, with particular management implications.
One scenario in which depression can be difficult to treat is in the context of physical illness.
Depression is often expressed via physical symptoms, however it is also true is that people
with chronic physical ailments are at high risk of depression. Functional pain syndromes
where the origin and cause of the pain are unclear, are particularly tricky, as complaints of
pain require the clinician to accept them as “legitimate”, even if there is no obvious physical
cause. The use of analgesics can create its own problems, including dependence. Patients
with comorbid chronic pain and depression require careful and sensitive management and a
long-term commitment from the GP to ensure consistency of care and support.
It is often difficult to tackle the topic of depression co-occurring with borderline personality
disorder (BPD). People with BPD have, as part of the core disorder, a perturbation of affect
associated with marked variability of mood. This can be very difficult for the patient to deal
with and can feed self-injurious and other harmful behaviour. Use of mentalisation-based
techniques is gaining support, and psychological treatments such as dialectical behaviour
therapy form the cornerstone of care. Use of medications tends to be secondary, and
prescription needs to be judicious and carefully targeted at particular symptoms. GPs can
play a very important role in helping people with BPD, but should not “go it alone”, instead
ensuring sufficient support for themselves as well as the patient.
Another particularly problematic and well-known form of depression is that which occurs in
the context of bipolar disorder. Firm data on how best to manage bipolar depression is
surprisingly lacking. It is clear that treatments such as unopposed antidepressants can make
matters a lot worse, with the potential for induction of mania and mood cycle acceleration.
However, certain medications (notably, some mood stabilisers and atypical antipsychotics)
can alleviate much of the suffering associated with bipolar depression. Specialist psychiatric
input is often required to achieve the best pharmacological approach. For people with bipolar
disorder, psychological techniques and long-term planning can help prevent relapse. Family
education and support is also an important consideration.
7. In the first paragraph, what point does the writer make about the treatment of depression?
A. 75% of depression sufferers visit their GP for treatment.
B .GPs struggle to meet the needs of patients with depression.
C .Treatment for depression takes an average of 11.7 days a month.
D .Most people with depression symptoms never receive help.
8. In the second paragraph, the writer suggests that GPs

A. are in a good position to conduct long term studies on their patients.
B. lack training in the treatment and assessment of depression.
C. should seek help when treatment plans are ineffective.
D. sometimes struggle to create coherent management plans.
9. What do the results of the study described in the third paragraph suggest?
A. GPs prefer the term “treatment resistant depression” to “difficult-to-treat depression”.
B. Patients with “difficult-to-treat depression” sometimes get “stuck” in treatment.
C. The term “difficult-to-treat depression” lacks a precise definition.
D. There is an identifiable sub-group of patients with “difficult-to-treat depression”.
10. Paragraph 4 suggests that

A. prescribing analgesics is unadvisable when treating patients with depression.
B. the co-occurrence of depression with chronic conditions makes it harder to treat.
C. patients with depression may have undiagnosed chronic physical ailments.
D. doctors should be more careful when accepting pain complaints as legitimate.
11. According to paragraph 5, people with BPD have
A. depression occurring as a result of the disorder
B. noticeable mood changes which are central to their disorder.
C. a tendency to have accidents and injure themselves.
D. problems tackling the topic of their depression.
12. In paragraph 5, what does the phrase ‘form the cornerstone’ mean regarding BPD treatment?
A. Psychological therapies are generally the basis of treatment.
B. There is more evidence for using mentalisation than dialectical behaviour therapy.
C. Dialectical behaviour therapy is the optimum treatment for depression..
D. In some unusual cases prescribing medication is the preferred therapy.
13. In paragraph 6, what does the writer suggest about research into bipolar depression
management?
A. There is enough data to establish the best way to manage bipolar depression.
B. Research hasn’t provided the evidence for an ideal management plan yet.
C. A lack of patients with the condition makes it difficult to collect data on its management.
D. Too few studies have investigated the most effective ways to manage this condition.
14. In paragraph 6, what does the writer suggest about the use of medications when treating
bipolar depression?
A. There is evidence for the positive and negative results of different medications.
B. Medications typically make matters worse rather than better.
C. Medication can help prevent long term relapse when combined with family education.
D. Specialist psychiatrists should prescribe medication for bipolar disorder rather than GPs.
Text 2: Are the best hospitals managed by doctors?
Doctors were once viewed as ill-prepared for leadership roles because their selection and
training led them to become “heroic lone healers.” However, the emphasis on patientcentered
care and efficiency in the delivery of clinical outcomes means that physicians are
now being prepared for leadership. The Mayo Clinic is America’s best hospital, according to
the 2016 US News and World Report (USNWR) ranking. Cleveland Clinic comes in second.
The CEOs of both — John Noseworthy and Delos “Toby” Cosgrove — are highly skilled
physicians. In fact, both institutions have been physician-led since their inception around a
century ago. Might there be a general message here?
A study published in 2011 examined CEOs in the top-100 hospitals in USNWR in three key
medical specialties: cancer, digestive disorders, and cardiovascular care. A simple question
was asked: are hospitals ranked more highly when they are led by medically trained doctors
or non-MD professional managers? The analysis showed that hospital quality scores are
approximately 25% higher in physician-run hospitals than in manager-run hospitals. Of
course, this does not prove that doctors make better leaders, though the results are surely
consistent with that claim.
Other studies find a similar correlation. Research by Bloom, Sadun, and Van Reenen
revealed how important good management practices are to hospital performance. However,
they also found that it is the proportion of managers with a clinical degree that had the
largest positive effect; in other words, the separation of clinical and managerial knowledge
inside hospitals was associated with more negative management outcomes. Finally, support
for the idea that physician-leaders are advantaged in healthcare is consistent with
observations from many other sectors. Domain experts – “expert leaders” (like physicians in
hospitals) — have been linked with better organizational performance in settings as diverse
as universities, where scholar-leaders enhance the research output of their organizations, to
basketball teams, where former All-Star players turned coaches are disproportionately
linked to NBA success.
What are the attributes of physician-leaders that might account for this association with
enhanced organizational performance? When asked this question, Dr. Toby Cosgrove, CEO
of Cleveland Clinic, responded without hesitation, “credibility … peer-to-peer credibility.” In
other words, when an outstanding physician heads a major hospital, it signals that they have
“walked the walk”. The Mayo website notes that it is physician-led because, “This helps
ensure a continued focus on our primary value, the needs of the patient come first.” Having
spent their careers looking through a patient-focused lens, physicians moving into executive
positions might be expected to bring a patient-focused strategy.
In a recent study that matched random samples of U.S. and UK employees with employers,
we found that having a boss who is an expert in the core business is associated with high
levels of employee job satisfaction and low intentions of quitting. Similarly, physician-leaders
may know how to raise the job satisfaction of other clinicians, thereby contributing to
enhanced organizational performance. If a manager understands, through their own
experience, what is needed to complete a job to the highest standard, then they may be
more likely to create the right work environment, set appropriate goals and accurately
evaluate others’ contributions.
Finally, we might expect a highly talented physician to know what “good” looks like when
hiring other physicians. Cosgrove suggests that physician-leaders are also more likely to
tolerate innovative ideas like the first coronary artery bypass, performed by René Favaloro at
the Cleveland Clinic in the late ‘60s. Cosgrove believes that the Cleveland Clinic unlocks
talent by giving safe space to people with extraordinary ideas and importantly, that
leadership tolerates appropriate failure, which is a natural part of scientific endeavour and
progress.
The Cleveland Clinic has also been training physicians to lead for many years. For example,
a cohort-based annual course, “Leading in Health Care,” began in the early 1990s and has
invited nominated, high-potential physicians (and more recently nurses and administrators)
to engage in 10 days of offsite training in leadership competencies which fall outside the
domain of traditional medical training. Core to the curriculum is emotional intelligence (with
360-degree feedback and executive coaching), teambuilding, conflict resolution, and
situational leadership. The course culminates in a team-based innovation project presented
to hospital leadership. 61% of the proposed innovation projects have had a positive
institutional impact. Moreover, in ten years of follow-up after the initial course, 48% of the
physician participants have been promoted to leadership positions at Cleveland Clinic.
15. In paragraph 1, why does the writer mention the Mayo and Cleveland Clinics?
A. To highlight that they are the two highest ranked hospitals on the USNWR
B. To introduce research into hospital management based in these clinics
C. To provide examples to support the idea that doctors make good leaders
D. To reinforce the idea that doctors should become hospital CEOs
16. What is the writer’s opinion about the findings of the study mentioned in paragraph 2?
A. They show quite clearly that doctors make better hospital managers.
B. They show a loose connection between doctor-leaders and better management.
C. They confirm that the top-100 hospitals on the USNWR ought to be physician-run.
D. They are inconclusive because the data is insufficient.
17. Why does the writer mention the research study in paragraph 3?
A. To contrast the findings with the study mentioned in paragraph 2
B. To provide the opposite point of view to his own position
C. To support his main argument with further evidence
D. To show that other researchers support him
18. In paragraph 3, the phrase ‘disproportionately linked’ suggests

A. all-star coaches have a superior understanding of the game.
B. former star players become comparatively better coaches.
C. teams coached by former all-stars consistently outperform other teams.
D. to be a successful basketball coach you need to have played at a high level.
19. In the fourth paragraph, what does the phrase “walked the walk,” imply about physician
leaders?
A. They have earned credibility through experience.
B. They have ascended the ranks of their workplace.
C. They appropriately incentivise employees.
D. They share the same concerns as other doctors.
20. In paragraph 6, the writer suggests that leaders promote employee satisfaction because
A. they are often cooperative.
B. they tend to give employees positive evaluations.
C. they encourage their employees not to leave their jobs.
D. they understand their employees’ jobs deeply.
21. In the seventh paragraph, why is the first coronary artery bypass operation mentioned?
A. To demonstrate the achievements of the Cleveland clinic
B. To present René Favaloro as an exemplar of a ‘good’ doctor
C. To provide an example of an encouraging medical innovation
D. To show how failure naturally contributes to scientific progress
22. In paragraph 8, what was the outcome of the course “Leading in Health Care”?
A. The Cleveland Clinic promoted almost half of the participants.
B. 61% of innovation projects lead to participants being promoted.
C. Some participants took up leadership roles outside the medical domain.
D. A culmination of more team-based innovations.
END OF READING TEST , THIS BOOKLET WILL BE COLLECTED

1. C
2. C
3. B
4. C
5. A
6. A

7. D
8. C
9. C
10. B
11. B
12. A
13. B
14. A

15. C
16. A
17. C
18. B
19. A
20. D
21. C
22. A
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
In which text can you find information about...

1. What GPs should say to patients requesting codeine?
2. basic indications of an opioid problem?
3. different medications used for weaning patients off opioids?
4. decisions to make before beginning treatment of dependence?
5. defining features of a use disorder?
6. the development of a common goal for both prescriber and patient?
7. sources of further information on pain management?
Questions 8-14
Each answer may include words, numbers or both. Your answers should be correctly spelled.
8. What will reduced doses of opioids lead to a reduction of?

9. What is the most effective medication for tapering opioid dependence?
10. How long should over the counter codeine analgesics be used for?
11. When should doctors consider referring a patient to a pain expert or clinic?
12. What might a patient give permission to before starting treatment?
13. What might be increasingly neglected as a result of opioid use?
14. How many Buprenorphine patches are needed to taper from codeine tablets?
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both. Your answers should be correctly spelled.
The use of Buprenorphine-naxolone requires a (15)........ before treatment.
The use of symptomatic medications for the treatment of opioid dependence has been found to
have (16)........ than tramadol.
Different definitions of opioid dependence share the same (17).........
Once it is decided that opioid taper is a suitable treatment the doctor and patient should create a
(18).........
Recent research indicates that (19)........ can work as well as combination analgesics including
codeine and oxycodone.
The ICD-10 defines a patient as dependent if they have (20)........ key symptoms simultaneously.
END OF PART A, THIS QUESTIONS PAPER WILL BE COLLECTED

In this part of the test, there are six short extracts relating to the work of health professionals.
For questions 1-6, choose answer (A, B or C) which you think fits best according to the text.
Write your answers on the separate Answer Sheet.
1. The purpose of the memo about IV solution bags is to remind health practitioners
A. of the procedures to follow when using them.
B. of the hazards associated with faulty ones.
C. why they shouldn’t be reused.
Memo to staff - Intravenous solution bags
IV fluids are administered via a plastic IV solution bag which collapses on itself as it empties.
When a bag is disconnected by removing the giving set spike, air can enter the bag. If it is then
reconnected to an IV line, air can potentially enter the patient’s vein and cause an air
embolism. For this reason, partially used IV bags must never be re-spiked. All IV bags are
designed for single use only - for use in one patient and on one occasion only.
All registered large volume injections, including IV bags, are required to have this warning (or
words to the same effect) clearly displayed on the labelling. In addition to the potential risk of
introducing an air embolus, re-spiking can also result in contamination of the fluid, which may
lead to infection and bacteraemia.
2. What do we learn about the use of TENS machines?
A. Evidence for their efficacy is unconfirmed.
B. They are recommended in certain circumstances.
C. More research is needed on their possible side effects.
Update on TENS machines
The Association of Chartered Physiotherapists in Women’s Health has an expert panel which
could not find any reports suggesting that negative effects are produced when TENS has
been used during pregnancy. However, in clinical practice, TENS is not the first treatment of
choice for women presenting with musculoskeletal pain during pregnancy. The initial
treatment should be aimed at correcting any joint or muscle dysfunction, and a rehabilitation
programme should be devised. However, if pain remains a significant factor, then TENS is
preferable to the use of strong medication that could cross the placental barrier and affect
the foetus. No negative effects have been reported following the use of this modality during
any of the stages of pregnancy. Therefore, TENS is preferable for the relief of pain.
3. If surgical instruments have been used on a patient suspected of having prion disease, they
A. must be routinely destroyed as they cannot be reused.
B. may be used on other patients provided the condition has been ruled out.
C. should be decontaminated in a particular way before use with other patients.
Guidelines: Invasive clinical procedures in patients with suspected prion disease
It is essential that patients suspected of suffering from prion disease are identified prior to any
surgical procedure. Failure to do so may result in exposure of individuals on whom any surgical
equipment is subsequently used. Prions are inherently resistant to commonly used
disinfectants and methods of sterilisation. This means that there is a possibility of transmission
of prion disease to other patients, even after apparently effective methods of decontamination
or sterilisation have been used. For this reason, it may be necessary to destroy instruments
after use on such a patient, or to quarantine the instrument until the diagnosis is either
confirmed, or an alternative diagnosis is established. In any case, the instruments can be used
for the same patient on another occasion if necessary.
4. The email suggests that POCT devices
A. should only be used in certain locations.
B. must be checked regularly by trained staff.
C. can produce results that may be misinterpreted.
To: All Staff

Subject: Management of Point of Care Testing (POCT) Devices
Due to several recent incidents associated with POCT devices, staff are requested to read
the following advice from the manufacturer of the devices.
The risks associated with the use of POCT devices arise from Management of Point of Care
Testing Devices Version 4 January 2014, the inherent characteristics of the devices
themselves and from the interpretation of the results they provide. They can be prone to
user errors arising from unfamiliarity with equipment more usually found in the laboratory.
User training and competence is therefore crucial.
5. It’s permissible to locate a baby’s identification band somewhere other than the ankles when
A. the baby is being moved due to an emergency.
B. the bands may interfere with treatment.
C. the baby is in an incubator.
Identification bands for babies

The identification bands should be located on the baby’s ankles with correct identification
details unless the baby is extremely premature and/or immediate vascular access is required.
If for any reason the bands need to be removed, they should be relocated to the wrists or if this is
not possible, fixed visibly to the inside of the incubator. Any ill-fitting or missing labels should be
replaced at first check. Identity bands must be applied to the baby’s ankles at the earliest
opportunity as condition allows and definitely in the event of fire evacuation or transportation.
6. What is the memo doing?
A. providing an update on the success of new guidelines
B. reminding staff of the need to follow new guidelines
C. announcing the introduction of new guidelines
Memo: Administration of antibiotics
After a thorough analysis and review, our peri-operative services, in conjunction with the
Departments of Surgery and Anaesthesia, decided to change the protocols for the
administration of pre-operative antibiotics and established a series of best practice
guidelines. This has resulted in a significant improvement in the number of patients
receiving antibiotics within the recommended 60 minutes of their incision. A preliminary
review of the total hip and knee replacements performed in May indicates that 88.9% of
patients received their antibiotics on time.
For questions 7-22, choose the answer (A, B, C or D) which you think fits best according to the text.
answers on the separate Answer Sheet.
Text 1: Detecting Carbon Monoxide Poisoning

Carbon Monoxide (CO) poisoning is the single most common source of poisoning injury
treated in US hospital emergency departments. While its presentation is not uncommon, the
diverse symptoms that manifest themselves do not lead most clinicians to consider
carboxyhemoglobinemia when attempting a diagnosis. The symptoms can be mistaken for
those of many other illnesses including food poisoning, influenza, migraine headache, or
substance abuse.
What's more, in an attempt to find the causative agent for the symptoms, many
unnecessary, and sometimes resource-intensive, diagnostics may be ordered, to no avail.
For example, because the symptoms of CO poisoning may mimic an intracranial bleed, the
time needed to obtain a negative result may hold up a proper diagnosis as well as
needlessly increasing healthcare costs. Of even greater concern, however, is that during
such delays patients may find that their symptoms abate and their health improves as the
hidden culprit, CO, is flushed from the blood during the normal ventilation patterns.
Indeed, multiple reports have shown patients being discharged and returned to the very
environment where exposure to CO took place. Take the case of a 67-year-old man who sought
medical help after three days of lightheadedness, vertigo, stabbing chest pain,cough, chills and
headache. He was admitted, evaluated and discharged with a diagnosis of viral syndrome. Ten
days later, he returned to the Emergency Department with vertigo, palpitations and nausea but
was sent home for outpatient follow-up. Four days later, he presented again with diarrhea and
severe chest pain, collapsing to the floor. This time, he was admitted to the Coronary Care Unit
with acute myocardial infarction. Among the results of a routine arterial blood gas analysis there,
it was found that his carboxyhemoglobin (COHb) levels were 15.6%. A COHb level then obtained
on his wife was 18.1%. A rusted furnace was found to be the source.
There are two main types of CO poisoning: acute, which is caused by brief exposure to a
high level of carbon monoxide, and chronic or subacute, which results from long exposure to
a low level of CO. Patients with acute CO poisoning are more likely to present with more
serious symptoms, such as cardiopulmonary problems, confusion, syncope, coma, and
seizure. Chronic poisoning is generally associated with the less severe symptoms. Low-level
exposure can exacerbate angina and chronic obstructive pulmonary disease, and patients
with coronary artery disease are at risk for ischemia and myocardial infarction even at low
levels of CO.
Patients that present with low COHb levels correlate well with mild symptoms of CO
poisoning, as do cases that register levels of 50-70%, which are generally fatal. However,
intermediate levels show little correlation with symptoms or with prognosis. One thing that is
certain about COHb levels is that smokers present with higher levels than do non-smokers.
The COHb level in non-smokers is approximately one to two percent. In patients who
smoke, a baseline level of nearly five percent is considered normal, although it can be as
high as 13 percent. Although COHb concentrations between 11 percent and 30 percent can
produce symptoms, it is important to consider the patient's smoking status.
Regardless of the method of detection used in emergency department care, several other
variables make assessing the severity of the CO poisoning difficult. The length of time since
CO exposure is one such factor. The half-life of CO is four to six hours when the patient is
breathing room air, and 40-60 minutes when the patient is breathing 100 percent oxygen. If
a patient is given oxygen during their transport to the emergency department, it will be
difficult to know when the COHb level hit its highest point. In addition, COHb levels may not
fully correlate with the clinical condition of CO-poisoned patients because the COHb level in
the blood is not an absolute index of compromised oxygen delivery at the tissue level.
Furthermore, levels may not match up to specific signs and symptoms: patients with
moderate levels will not necessarily appear sicker than patients with lower levels.
In hospitals, the most common means of measuring CO exposure has traditionally been
through the use of a laboratory CO-Oximeter. A blood sample, under a physician order, is
drawn from either venous or arterial vessel and injected into the device. Using a method
called spectrophotometric blood gas analysis, this then measures the invasive blood
sample. Because the CO-Oximeter can only yield a single, discrete reading for each aliquot
of blood sampled, the reported value is a non-continuous snapshot of the patient's condition
at the particular moment that the sample was collected. It does, however, represent a step in
the right direction. One study found that in hospitals lacking such a device, the average time
it took to receive results of a blood sample sent to another facility was over fifteen hours,
compared to a ten-minute turnaround in CO-Oximeter equipped hospitals.
Part C – Text 1 : Questions 7 to 14
7.In the first paragraph, what reason for the misdiagnosis of CO poisoning is highlighted?
A. the limited experience physicians have of it
B. the wide variety of symptoms associated with it
C. the relative infrequency with which it is presented
D. the way it is concealed by pre-existing conditions
8. In the second paragraph, the writer stresses the danger of delays in diagnosis leading to
A. the inefficient use of scarce resources.

B. certain symptoms being misinterpreted.
C. a deterioration in the patient's condition.
D. the evidence of poisoning disappearing.
9. The 67-year-old man's CO poisoning was only successfully diagnosed as a result of
A. attending an outpatient clinic.

B. his wife being similarly affected.
C. undergoing tests as an inpatient.
D. his suggesting the probable cause.
10. In the fourth paragraph, confusion is given as a symptom of

A. short-term exposure to high levels of CO.
B. repeated exposure to varying levels of CO.
C. a relatively low overall level of exposure to CO.
D. sustained exposure to CO over an extended period.
11. In the fifth paragraph, what point is made about COHb levels?
A. They fail to detect CO poisoning in habitual smokers.
B. They are a generally reliable indicator of CO poisoning.
C. They correlate very well with extreme levels of CO poisoning.
D. They are most useful in determining intermediate levels of CO poisoning.
12. The phrase 'one such factor' in the sixth paragraph refers to
A. a type of care.
B. a cause of difficulty.
C. a method of detection.
D. a way of making an assessment.
13. One result of administering oxygen to CO poisoned patients in transit is that

A. it becomes harder to ascertain when the COHb level peaked.
B. it may lead to changes in the type of symptoms observed.
C. it could artificially inflate the COHb level in the short term.
D. it affects the ability to assess the effects at tissue level.
14. What reservation about the CO-Oximeter does the writer express?
A. It does not always give an immediate result.
B. Its use needs to be approved by a physician.
C. It requires a skilled analyst to interpret the readings.
D. It does not show variations in the patient's condition
END OF READING TEST ,THIS BOOKLET WILL BE COLLECTED

1. C
2. B
3. B
4. C
5. B
6. A

7. B
8. D
9. C
10. A
11. C
12. B
13. A
14. D
Text B
Text C
Intermediate High risk

Head injury clinical features – child
risk factors factors
Age < 1 year
Witnessed loss of consciousness < 5 minutes > 5 minutes
Anterograde or retrograde amnesia Possible > 5 minutes
Mild agitation or Abnormal
Behaviour
altered behaviour drowsiness
Episodes of vomiting without other cause 3 or more
Seizure in non-epileptic patient Impact only Yes
Non-accidental injury is suspected/parental
No Yes
history is inconsistent with injury
History of coagulopathy, bleeding disorder
No Yes
or previous intracranial surgery
Comorbidities Present Present
Persistent or
Headache Yes
increasing
Motor vehicle accident < 60 kph > 60 kph
Fall 1-3 metres > 3 metres
Moderate impact High speed /
Force or unclear heavy projectile or
mechanism object
Glasgow Coma Scale 14-15 < 14
Focal neurological abnormality Nil Present
Penetrating injury
Haematoma,
/ Possible
Injury swelling or
depressed skull
laceration > 5 cm
fracture.
Text D
Advice for patients who have received an injury to the head

● Rest quietly for the day.
● Use ‘ice packs’ over swollen or painful areas. Wrap ice cubes,
frozen peas or a sports ice pack in a towel. Do not put ice directly
on the skin.
● Take simple painkillers for any headache.
● If an injured patient is discharged in the evening, make sure they
are woken several times during the night.
● Do not let the injured patient drive home.
● Do not leave them alone for the next 24 hours.
● Do not let them drink alcohol for at least 24 hours.
● Do not let them eat or drink for the first six to 12 hours (unless
advised otherwise by the MO). Then offer them food and drink in
moderation.
● Do not let them take sedatives or other medication unless
instructed.
● Return to the clinic immediately if the patient has repeated
vomiting, ‘blacks out’, has a seizure/fit or cannot be woken or is
not responsive.
● Patient to return to clinic if they have any symptoms they or the
carer are concerned about.
Questions 1-5
1. What patients should and shouldn’t do when they return home?
2. The possible cause of abnormality apparent in a patient’s eyes?
3. Reasons why patients should seek medical attention after being

discharged?
4. Procedures to follow dependent on the type of head injury?
5. Past interventions and conditions to be considered when assessing

risk?
Questions 6-11
spelled.
Children presenting with head injuries are assessed as high risk if they have:
Had memory loss lasting [6] or more
Fallen [7] or more
Been hit by a weighty object or one moving at [8] unusual
levels of [9]
A [10] which gets worse over time
Escalation: Children assessed as intermediate or high risk should
undergo a [11]
Questions 12 – 16
Complete the sentences below by using a word or short phrase from the text. Each
answer may include words, numbers or both.
. .
 All patients presenting with (12) head injuries must be referred
straight to the MO.
 Patients with GCS below 8 may need (13)
 The MO should be informed without delay if there is a drop in BP or change in
a patient's level of (14)
 Staff should be especially careful when administering (15) to
head injury patients.
 Head injury patients may also have an injury to their (16) .
Questions 17 – 20
Answer the questions below. For each answer use a word or short phrase from the
text. Each answer may include words, numbers or both.
17 If there are no significant risk factors, how long after a head injury can you
discharge a patient?
18 What should you provide head injury patients with when you discharge them?
19 What should you advise patients to take to control headaches?

__
20 What can patients use to avoid contact between ice packs and their skin?

professionals .
Questions 1-6
1. According to the guidelines nurses must
A. advise the practice as soon as they get to the next home visit.
B. call the patient to confirm a time before they make a home visit.
C. inform fellow staff members when they return from a home visit.
Home Visit Guidelines
The nurse will complete all consultation notes in the patient’s home
(unless not appropriate), prior to beginning the next consultation. With a
focus on nurse safety, the nurse will call the practice at the end of each
visit before progressing to the next home visit and will also communicate
any unexpected circumstances that may delay arrival back at the
practice (more than one hour).
Calling from the patient’s home to make a review appointment with the
GP is sufficient and can help minimise time making phone calls. On
return to the practice the nurse will immediately advise staff members of
their return. This time will be documented on the patient visit list,
scanned and filed by administration staff
2. In progressive horizontal evacuation.
A. patients are evacuated through fire proof barriers one floor at a

time.
B. patients who can't walk should not be moved until the fire is under
control.
C. patients are moved to fire proof areas on the same level to safely
wait for help.
Progressive horizontal evacuation
The principle of progressive horizontal evacuation is that of moving

occupants from an area affected by fire through a fire-resisting barrier to
an adjoining area on the same level, designed to protect the occupants
from the immediate dangers of fire and smoke (a refuge). The occupants
may remain there until the fire is dealt with or await further assisted
onward evacuation by staff to a similar adjoining area or to the nearest
stairway. Should it become necessary to evacuate an entire storey, this
procedure should give sufficient time for non-ambulant and partially
ambulant patients to be evacuated vertically to a place of safety.
3. The main purpose of the extract is to
A. provide information of the legal requirements for disposing of

animal waste.
B. describe rules for proper selling and export of animal products.
C. define the meaning of animal by-products for healthcare

researchers.
Proper disposal of animal waste
Animal by-products from healthcare (for example research facilities)

have specific legislative requirements for disposal and treatment. They
are defined as “entire bodies or parts of animals or products of animal
origin not intended for human consumption, including ova, embryos and
semen.” The Animal By-Products Regulations are designed to prevent
animal by-products from presenting a risk to animal or public health
through the transmission of disease. This aim is achieved by rules for
the collection, transport, storage, handling, processing and use or
disposal of animal byproducts, and the placing on the market, export
and transit of animal by-products and certain products derived from
them
4. According to the extract, what is the outcome of reusing medical

equipment meant to be used once?
A. The maker will take no legal responsibility for safety.
B. Endoscopy units will save on equipment costs.
C. There is a higher incidence of cross infection.
Foreword
Cleaning and disinfection of endoscopes should be undertaken by

trained staff in a dedicated room. Thorough cleaning with detergent
remains the most important and first step in the process. Automated
washer/disinfectors have become an essential part of the endoscopy
unit. Machines must be reliable, effective, easy to use and should
prevent atmospheric pollution by the disinfectant if an irritating agent is
used. Troughs of disinfectant should not be used unless containment or
exhaust ventilated facilities are provided.
Whenever possible, “single use” or autoclavable accessories should be

used. The risk of transfer of infection from inadequately decontaminated
reusable items must be weighed against the cost. Reusing accessories
labelled for single use will transfer legal liability for the safe performance
of the product from the manufacturer to the user or his/her employers
and should be avoided unless Department of Health criteria are met.
5. According to the extract what is the purpose of the guidelines?
A. To present statistics on the incidence of melanoma in Australia

and New Zealand.
B. To support the early detection of melanoma and select the best

treatments.
C. To explain the causes of melanoma in populations of Celtic origin.
Australia and New Zealand have the highest incidence of melanoma in

the world. Comprehensive, up-to-date, evidence-based national
guidelines for its management are therefore of great importance. Both
countries have populations of predominantly Celtic origin, and in the
course of day-to-day life their citizens are inevitably subjected to high
levels of solar UV exposure. These two factors are considered
predominantly responsible for the very high incidence of melanoma (and
other skin cancers) in the two nations. In Australia, melanoma is the
third most common cancer in men and the fourth most common in
women, with over 13, 000 new cases and over 1, 750 deaths each year.
The purpose of evidence-based clinical guidelines for the management

of any medical condition is to achieve early diagnosis whenever
possible, make doctors and patients aware of the most effective
treatment options, and minimise the financial burden on the health
system by documenting investigations and therapies that are
inappropriate.
6. What should employees declare?
A. Every item received from one donor.
B. Each item from one donor valued at over $50.
C. Every item from one donor if the combined value is more than $50.
Reporting of Gifts and Benefits
Employees must declare all non-token gifts which they are offered,
regardless of whether or not those gifts are accepted. If multiple gifts,
benefits or hospitality are received from the same donor by an employee
and the cumulative value of these is more than $50 then each individual
gift, benefit or hospitality event must be declared.
The Executive Director of Finance will be responsible for ensuring the

gifts and benefits register is subject to annual review by the Audit
Committee. The review should include analysis for repetitive trends or
patterns which may cause concern and require corrective and
preventive action. The Audit Committee will receive a report at least
annually on the administration and quality control of the gifts, benefits
and hospitality policy, processes and register.

Text 1: The case for and against e-cigarettes
Electronic cigarettes first hit European and American markets in 2006

and 2007, and their popularity has been propelled by international trends
favouring smoke-free environments. Sales reportedly have reached
$650 million a year in Europe and were estimated to reach $3. 6 billion
in the US in 2018.
Although research on e-cigarettes is not extensive, a picture is
beginning to emerge. Surveys suggest that the vast majority of those
who use e-cigarettes treat them as smoking-cessation aides and self-
report that they have been key to quitting. Data also indicate that e-
cigarettes help to reduce tobacco cigarette consumption. A 2011 survey,
based on a cohort of first-time e-cigarette purchasers, found that 66. 8
percent reported reducing the number of cigarettes they smoked per day
and after six months, 31 percent reported not smoking. These results
compare favorably with nicotine replacement therapies (NRTs) like the
patch and nicotine gum. Interestingly, a randomized controlled trial
found that even e-cigarettes not containing nicotine were effective both
in achieving a reduction of tobacco cigarette consumption and longer
term abstinence, suggesting that “factors such as the rituals associated
with cigarette handling and manipulation may also play an important
role. ” Some tobacco control advocates worry that they simply deliver an
insufficient amount of nicotine to ultimately prove effective for cessation.
Nevertheless, the tobacco control community has embraced FDA

approved treatments—NRTs, as well as the drugs bupropion and
varenicline —that have relatively low success rates. In a commentary
published in the Journal of the American Medical Association, smoking
cessation experts Andrea Smith and Simon Chapman of the University
of Sydney said that smoking cessation drugs fail most of those who try
them. “Sadly, it remains the case that by far the most common outcome
at 6 to 12 months after using such medication in real world settings is
continuing smoking. Few, if any, other drugs with such records would
ever be prescribed, ” they wrote.
Amongst smokers not intending to quit, e-cigarettes—both with and

without nicotine—substantially reduced consumption in a randomized
controlled trial, not only resulting in decreased cigarette consumption but
also in “enduring tobacco abstinence. ” In a second study from 2013, the
authors reported that after 24 months, 12. 5 percent of smokers
remained abstinent while another 27. 5 percent reduced their tobacco
cigarette consumption by 50 percent. Finally, a third study
commissioned in Australia has come to the same conclusion, though a
high dropout rate (42 percent) makes these findings questionable.
Users widely perceive e-cigarettes to be less toxic. While the FDA has
found trace elements of carcinogens, levels are comparable to those
found in nicotine replacement therapies. Results from a laboratory study
released in 2013 found that that while e-cigarettes do contain
contaminants, the levels range from 9 to 450 times lower than in tobacco
cigarette smoke. These are comparable with the trace amounts of toxic
or carcinogenic substances found in medicinal nicotine inhalers. A
prominent anti-tobacco advocate, Stanton Glantz, has warned of the
need to protect people from secondhand emissions. While one
laboratory study indicates that passive “vaping, ” as smoking an e-
cigarette is commonly known, releases volatile organic compounds and
ultrafine particles into the indoor environment, it noted that the actual
health impact is unknown and should remain a chief concern. A 2014
study concluded that e-cigarettes are a source of second hand exposure
to nicotine but not to toxins. Nevertheless, bystanders are exposed to 10
times less nicotine exposure from e-cigarettes compared to tobacco
cigarettes.
There are a number of interesting points of agreement among

proponents and skeptics of e-cigarettes. First, all agree that regulation to
ensure the quality of e-cigarettes should be uniform. Laboratory
analyses have found sometimes wide variation across brands, in the
level of carcinogens, the presence of contaminants, and the quality of
nicotine. Second, proponents and detractors of e-cigarettes tend to
agree that — considered only at the individual level—e-cigarettes are a
safer alternative to tobacco cigarette consumption. The main concern is
how e-cigarettes might shape tobacco use patterns at the population
level. Proponents stress the evidence base that we have reviewed.
Skeptics remain worried that e-cigarettes will become “dual use”
products. That is, smokers will use e-cigarettes, but will not reduce their
smoking or quit.
Perhaps most troubling to public health officials is that e-cigarettes will

"renormalize" smoking, subverting the cultural shift that has occurred
over the past 50 years and transforming what has become a perverse
habit into a pervasive social behaviour. In other words, the fear is that
e-cigarettes will allow for re-entry of the tobacco cigarette into public
view. This would unravel the gains created by smoke-free indoor (and,
in some scientifically-unwarranted instances) outdoor environments.
Careful epidemiological studies will be needed to determine whether
the individual gains from e-cigarettes will be counteracted by
population-level harms. For policy makers, the challenge is how to act
in the face of uncertainty.
7. What does the writer suggest about the research into e-cigarettes?
A. Not enough research is being carried out.
B. Early conclusions are appearing from the evidence.
C. Too much of the available data is self-reported.
D. An extensive picture of e-cigarette use has emerged.
8. What explanation does the writer offer for the effect of non-nicotine e-
cigarettes?
A. They deliver an insufficient volume of nicotine to help smoking
cessation.
B. They compare well with patches, nicotine gum and other NRT's.
C. First time e-cigarette buyers tend to use them
D. Behavioural elements are significant in quitting smoking.
9. What is the attitude of Andrea Smith and Simon Chapman to the use
of smoking cessation drugs?
A. They approve of and embrace these treatments.
B. They consider them largely unsuccessful as treatments.
C. They think they should be replaced with other treatments.
D. They believe they should never be prescribed as treatment.
10. What problem with one of the studies is mentioned in paragraph 4?

A. The research questions the study asked.
B. The number of participants who left the study.
C. The similarity of the conclusion to other studies.
D. The study used e-cigarettes without nicotine.
11. What is "these" in paragraph 5 referring to?
A. Laboratory study results
B. Nicotine inhalers
C. Contamination levels
D. Tobacco cigarettes
12. Research mentioned in paragraph 5 suggests that

A. E-cigarettes release dangerous toxins into the air.
B. E-cigarettes should be banned from indoor environments.
C. E-cigarettes are more toxic than nicotine replacement therapies
D. cigarettes present a far greater risk of secondhand exposure to
toxins
13. The word uniform in paragraph 7 suggests that e-cigarettes should

A. Be clearly regulated against.
B. Only come in one brand.
C. Be of a standard quality.
D. Contain no contaminants.
14. What do both critics and supporters of e-cigarettes agree?

A. Available research evidence must be reviewed.
B. E-cigarette use may not result in quitting.
C. Smoking tobacco is more dangerous than vaping.
D. E-cigarettes are shaping the public's tobacco use.
Text 2: Vivisection
In 1875, Charles Dodgson, under his pseudonym Lewis Carroll, wrote a

blistering attack on vivisection. He sent this to the governing body of
Oxford University in an attempt to prevent the establishment of a
physiology department. Today, despite the subsequent evolution of one
of the most rigorous governmental regulatory systems in the world, little
has changed. A report sponsored by the UK Royal Society, “The use of
non-human primates in research”, attempts to establish a sounder basis
for the debate on animal research through an in-depth analysis of the
scientific arguments for research on monkeys.
In the UK, no great apes have been used for research since 1986. Of
the 3000 monkeys used in animal research every year, 75% are for
toxicology studies by the pharmaceutical industry. Although expenditure
on biomedical research has almost doubled over the past 10 years, the
number of monkeys used for this purpose (about 300) has tended to fall.
The report, which mainly discusses the use of monkeys in biomedical
research, pays particular attention to the development of vaccines for
AIDS, malaria, and tuberculosis, and to the nervous system and its
disorders. The report assesses the impact of these issues on global
health, together with potential approaches that might avoid the use of
animals in research. Other research areas are also discussed, together
with ethics, animal welfare, drug discovery, and toxicology.
The report concludes that in some cases there is a valid scientific

argument for the use of monkeys in medical research. However, no
blanket decisions can be made because of the speed of progress in
biomedical science (particularly in molecular and cell biology) and
because of the available non-invasive methods for study of the brain.
Every case must be considered individually and supported by a fully
informed assessment of the importance of the work and of alternatives
to the use of animals.
Furthermore, the report asks for greater openness from medical and
scientific journals about the amount of animal suffering that occurred in
studies and for regular publication of the outcomes of animal research
and toxicology studies. It calls for the development of a national strategic
plan for animal research, including the dissemination of information
about alternative research methods to the use of animals, and the
creation of centres of excellence for better care of animals and for
training of scientists. Finally, it suggests some approaches towards a
better-informed public debate on the future of animal research.
Although the report was received favourably by the mass media, animal-
rights groups thought that it did not go far enough in setting priorities for
development of alternatives to the use of animals. In fact, it investigates
many of these approaches, including cell and molecular biology, use of
transgenic mice (an alternative to use of primates), computer modelling,
in-silico technology, stem cells, microdosing, and
pharmacometabonomic phenotyping. However, the report concludes
that although many of these techniques have great promise, they are at
a stage of development that is too early for assessment of their true
potential.
The controversy of animal research continues unabated. Shortly after
publication of the report, two highly charged stories were published in
the media. A study that used systematic reviews to compare treatment
outcome from clinical trials of animals with those of human beings
suggested that discordance in the results might have been due to bias,
poor design, or inadequacies of animals for modelling of human disease.
Although the study made some helpful suggestions for the future, its
findings are not surprising. The imperfections of animals for study of
human disease and of drug trials are documented widely.
The current furore about the UK Government's ban on human nuclear-

transfer experiments involving animals should not surprise us either.
This area of research had a bad start when this method of production of
stem cells was labelled as therapeutic cloning, thus confusing it with
reproductive cloning - a problem that, surely, licensing bodies and the
scientific community should have anticipated. The possibilities that
insufficient human eggs will be available, and that insertion of human
nuclei into animal eggs might be necessary, have been discussed by the
scientific community for several years, but have been aired rarely in
public, leaving much room for confusion
Biomedical science is progressing so quickly that maintenance of an

adequate level of public debate on ethical issues is difficult. Hopefully
the sponsors of the recent report will now activate its recommendations,
not least how better mechanisms can be developed to broaden and
sustain interactions between science and the public. Although any form
of debate will probably not satisfy the extremists of the antivivisection
movement, the rest of society deserves to receive the information it
needs to deal with these extremely difficult issues.

15. How does the writer characterise Lewis Carroll's attitude to
vivisection?
A. He was in favour of clear regulations to control it.
B. He felt the Royal Society should not support it.
C. He was strongly opposed to it.
D. He supported its use in physiology.
16. The word rigorous in paragraph 1 implies that the writer thinks UK
vivisection laws are
A. Strict and severe
B. Careful and thorough
C. Ambiguous and unhelpful
D. Accurate and effective
17. What is the major focus of the report mentioned in paragraph 2?

A. Animal experimentation in the pharmaceutical industry
B. Recent increases in spending on Biomedical research

C. Testing new treatments for serious disease on monkeys
D. Possible alternatives to testing new drugs on animals
18. What is the main conclusion of the report?

A. Scientific experimentation on monkeys is justified.
B. Rapid development in biomedicine makes it hard to draw
conclusions.
C. Non-invasive techniques should be preferred in most cases.
D. Research that requires monkeys should be evaluated
independently.
19. What conclusion is drawn about alternative techniques to

vivisection?
A. Developing alternatives should be prioritised.
B. Transgenic mice are a viable alternative to monkeys.
C. Many alternative techniques are more promising than animal
7. B
8. D
9. B
10. B
11. C
12. D
13. C
14. C
15. C
16. B
17. C
18. D
19. D
20. A
21. B
22.B
ADHD: Overview
Contrary to common belief, ADHD is not just a disorder of childhood. At least 40 to
50% of children with ADHD will continue to meet criteria in adulthood, with ADHD
affecting about one in 20 adults. ADHD can be masked by many comorbid disorders
that GPs are typically good at recognising such as depression, anxiety and substance
use. In patients with underlying ADHD, the attentional, hyperactive or organisational
problems pre-date the comorbid disorders and are not episodic as the comorbid
disorders may be. GPs are encouraged to ask whether the complaints are of recent
onset or longstanding. Collateral history can be helpful for developing a timeline of
symptoms (e.g. parent or partner interview). Diagnosis of underlying ADHD in these
patients will significantly improve their treatment outcomes, general health and quality
of life.
Text C
Text D
Treatment of ADHD
It is very important that the dosage of medication is individually

optimised. An analogy may be made with getting the right pair of
glasses – you need the right prescription for your particular
presentation with not too much correction and not too little. The optimal
dose typically requires careful titration by a psychiatrist with ADHD
expertise. Multiple follow-up appointments are usually required to
maximise the treatment outcome. It is essential that the benefits of
treatment outweigh any negative effects. Common side effects of
stimulant medication may include:
• appetite suppression
• insomnia
• palpitations and increased heart rate

• feelings of anxiety
• dry mouth and sweating
PART A -QUESTIONS
Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or
D) the information comes from. You may use any letter
more than once
In which text can you find information about...
1 different types of ADHD medication?
2 possible side effects of medication?

3 conditions which may be present alongside ADHD?
4 a doctor’s control over a patient’s medication?
5 positive perspectives on having ADHD?
6 when patients should take their ADHD medicine?
7 figuring out a patient’s optimal dosage of medication?
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the
texts. Each answer may include words, numbers or both. Your answers should
be correctly spelled.
8 What is the maximum recommended dose of Dexamfetamine?
9 What is typically needed to get the best results from ADHD treatment?
10 How can GP’s collect information about their patient’s collateral history?
11 What causes symptoms such as palpitations and anxiety in some patients?
12 What proportion of children with ADHD will carry symptoms into adulthood?
13 What positive personality traits are sometimes associated with ADHD?
14 Which medication has dose recommendations related to patient weight?
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both. Your answers
should be correctly spelled.
Sleep, exercise and nutrition comprise the (15) of further ADHD

treatment.
When diagnosing ADHD, it is important to ask if the issues arose recently or
are (16)
It is possible to move to (17) after one month of immediate-release

methylphenidate.
Signs of ADHD can be disguised by (18) which GPs are more likely to
recognise.
GPs should regularly check the (19) of patients prescribed stimulant

medication.
Establishing the ideal dose of ADHD medication needs (20) by an

expert psychiatrist.

professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best
Questions 1-6
1. According to the extract, to prevent the spread of infection, emergency

department isolation rooms
A. should be placed away from the main entry doors.

B. are more numerous than those of other departments.
C. ought to be situated near where people enter the unit.
DESIGN PRINCIPLES FOR ISOLATION ROOMS
The aim of environmental control in an isolation room is to control the airflow,

thereby reducing the number of airborne infectious particles that may infect
others within the environment.
This is achieved by:
 controlling the quality and quantity of intake and exhaust air;

 diluting infectious particles in large volumes of air;
 maintaining differential air pressures between adjacent areas; and
 designing patterns of airflow for particular clinical purposes.
The location and design of isolation rooms within a particular department or

inpatient unit should ideally enable their separation from the rest of the unit.
Multiple isolation rooms should be clustered and located away from the main
entrance of the unit. An exception is an emergency department where it is
recommended that designated isolation rooms be located near the entry to
prevent spread of possible airborne infection throughout the unit.
2. What do staff need to be conscious of when working in Anterooms?
A. Keeping used and unused medical clothing apart.

B. Ensuring the ambient pressure in the room is a minimum 15 Pascal.
C. Keeping the door closed at all times.
ANTEROOMS
Anterooms allow staff and visitors to change into, and dispose of, personal
protective equipment used on entering and leaving rooms when caring for
infectious patients. Clean and dirty workflows within this space should be
considered so that separation is possible. Anterooms increase the effectiveness
of isolation rooms by minimising the potential escape of airborne nuclei into a
corridor area when the door is opened.
For Class N isolation rooms the pressure in the anteroom is lower than the
adjacent ambient (corridor) pressure, and positive with respect to the isolation
room. The pressure differential between rooms should be not less than 15
Pascal.
Anterooms are provided for Class N isolation rooms in intensive care units,
emergency departments, birthing units, infectious diseases units, and for an
agreed number of patient bedrooms within inpatient units accommodating
patients with respiratory conditions.
3. What is the basic principle of flexible design?
A. Creating systems which match current policy and can adjust to other
possible guidelines.
B. Designing healthcare facilities which strictly adhere to current policy.
C. Changing healthcare policies regularly to match changes in the
marketplace.
FLEXIBLE DESIGN
In healthcare, operational policies change frequently. The average cycle may be

as little as five years. This may be the result of management change,
government policy, and turnover of key staff or change in the marketplace. By
contrast, major healthcare facilities are typically designed for 30 years, but may
remain in use for more than 50 years. If a major hospital is designed very tightly
around the operational policies of the day, or the opinion of a few individuals,
who may leave at any time, then a significant investment may be at risk of early
obsolescence. Flexible design refers to planning models that can not only
adequately respond to contemporary operational policies but also have the
inherent flexibility to adapt to a range of alternative, proven and forward-
looking policies.
4. When prescribing antibiotics for a human bite, what should the medical
professional remember?
A. Not all patients should be given antibiotics given the nominal infection
risk.
B. The bacterium Streptococcus spp. is the most common in bite
patients.
C. Eikenella corrodens is not susceptible to several antibiotics often used
for skin infections.
Human bites
Human bite injuries comprise clenched-fist injuries, sustained when a closed fist
strikes the teeth of another person, and occlusive bites, resulting from direct
closure of teeth on tissue. Clenched-fist injuries are more common than
occlusive bites, particularly in men, with most human bites occurring on the
hands. Human bites result in a greater infection and complication rate than
animal bites. Cultures of human bites are typically polymicrobial. Mixed aerobic
and anaerobic organisms are common, with the most common isolates
including Streptococcus spp. and Eikenella corrodens, which occurs in up to
one-third of isolates.
Some authors suggest that all patients with human bites should be commenced
on antibiotic prophylaxis, given the high risk of infection. The choice of
antibiotic therapy should cover E. corrodens, which is resistant to first-
generation cephalosporins (such as cefalexin), flucloxacillin and clindamycin,
antibiotics that are often used for skin and soft tissue infections.
5. The extract informs us that a model of care.
A. is only implemented at certain times and places.

B. should include its own application and assessment.
C. involves the development of a project management tool.
What is a MoC?
A “Model of Care” broadly defines the way health services are delivered. It
outlines best practice care and services for a person, population group or
patient cohort as they progress through the stages of a condition, injury or
event. It aims to ensure people get the right care, at the right time, by the right
team and in the right place.
When designing a new MoC, the aim is to bring about improvements in service
delivery through effecting change. As such creating a MoC must be considered
as a change management process. Development of a new MoC does not finish
when the model is defined, it must also encompass implementation and
evaluation of the model and the change management needed to make that
happen. Developing a MoC is a project and as such should follow a project
management methodology.
6. What is the basic difference between delegation, referral, and handover?
A. How many practitioners are involved in each part of the process.

B. How much authority is attributed to each practitioner.
C. How long each of the processes take a practitioner to complete.
4.3 Delegation, referral and handover
Delegation involves one practitioner asking another person or member of staff

to provide care on behalf of the delegating practitioner while that practitioner
retains overall responsibility for the care of the patient or client.
Referral involves one practitioner sending a patient or client to obtain an
opinion or treatment from another practitioner. Referral usually involves the
transfer in part of responsibility for the care of the patient or client, usually for a
defined time and a particular purpose, such as care that is outside the referring
practitioner’s expertise or scope of practice.
Handover is the process of transferring all responsibility to another
practitioner.
Text 1: Personal devices and hearing loss
Most of us have experienced walking past someone and being able to hear every
sound coming from their headphones. If you’ve ever wondered whether this
could be damaging their hearing, the answer is yes. In the past, noise-induced
hearing loss typically affected industrial workers, due to prolonged exposure to
excessive levels of noise with limited or non-existent protective equipment.
There are now strict limits on occupational noise exposure and many medico-
legal claims have been filed as a result of regulation. The ubiquitous use of
personal music players has, however, radically increased our recreational noise
exposure, and research suggests there may be some cause for concern.
The problem is not just limited to children and teenagers either; adults listen to
loud music too. According to the World Health Organization, hearing loss is
already one of the leading causes of disability in adults globally, and noise-
induced hearing loss is its second-largest cause. In Australia, hearing loss is a big
public health issue, affecting one in six people and costing taxpayers over A$12
billion annually for diagnosis, treatment, and rehabilitation.
When sounds enter our ear, they set in motion tiny frequency-specific hair cells
within the cochlea, our hearing organ, which initiate the neural impulses which
are perceived by us as sounds. Exposure to high levels of noise causes excessive
wear and tear, leading to their damage or destruction. The process is usually
gradual and progressive; as our cochlea struggles to pick up sounds from the
damaged frequencies we begin to notice poorer hearing. Unfortunately, once
the hair cells are gone, they don’t grow back.
A number of US studies have shown the prevalence of noise-induced hearing

loss in teenagers is increasing, and reports from Australia have suggested
there’s an increased prevalence of noise-induced hearing loss in young adults
who use personal music players. This is a worrying trend considering the
widespread usage of these devices. Even a slight hearing loss can negatively
affect a child’s language development and academic achievement. This is of
significant concern considering some studies have reported a 70% increased
risk of hearing loss associated with use of personal music players in primary
school-aged children.
Some smartphones and personal music players can reach up to 115 decibels,
which is roughly equivalent to the sound of a chainsaw. Generally, 85 decibels
and above is considered the level where noise exposure can cause permanent
damage. Listening at this level for approximately eight hours is likely to result in
permanent hearing loss. What’s more, as the volume increases, the amount of
time needed to cause permanent damage decreases. At 115 decibels, it can take
less than a minute before permanent damage is done to your hearing.
In Australia a number of hearing education campaigns, such as Cheers for Ears,

are teaching children and young adults about the damaging effects of excessive
noise exposure from their personal music players with some encouraging
results. Hopefully, this will lead to more responsible behaviour and prevent
future cases of noise-induced hearing loss in young adults.
Currently, there are no maximum volume limits for the manufacturers of
personal music players in Australia. This is in stark contrast to Europe, where
action has been taken after it was estimated that 50 and 100 million Europeans
were at risk of noise-induced hearing loss due to personal music players. Since
2009, the European Union has provided guidance to limit both the output and
usage time of these devices. Considering the impact of hearing loss on
individuals and its cost to society, it’s unclear why Australia has not adopted
similar guidelines. Some smartphones and music players allow you to set your
own maximum volume limits. Limiting the output to 85 decibels is a great idea if
you’re a regular user and value preserving your hearing. Taking breaks to avoid
continued noise exposure will also help reduce your risk of damaging your
hearing.
Losing your hearing at any age will have a huge impact on your life, so you
should do what you can to preserve it. Hearing loss has often been referred to as
a “silent epidemic”, but in this case it is definitely avoidable.

7. The writer suggests that the risks from exposure to excessive industrial noise
A. Have become better regulated over time.
B. Have increased with the spread of new media devices.
C. Were limited or non-existent in the past.
D. Are something most people have experienced.
8. The word 'ubiquitous' in paragraph 1 suggests that use of personal media

players is
A. Getting out of control.

B. Radically increasing.
C. Extremely common.
D. A serious health risk.
9. In the second paragraph, the writer aims to emphasise the

A. Impacts of hearing loss on young people.
B. Significant global effect of noise related hearing loss.
C. WHO's statistical information on hearing loss.
D. Huge cost of hearing loss treatment in Australia.
10. What does the word 'their' in paragraph 3 refer to?

A. Smart phones and music players
B. People with hearing loss
C. Neural impulses entering our ear
D. Tiny hair cells in the ear
11. What does the research mentioned in paragraph four show?

A. A higher prevalence of personal music devices in primary schools.
B. The negative impact of device related hearing loss on academic and
linguistic skills.
C. An increasing number of teens and young adults suffering noise
related hearing loss.
D. The widespread trend for increased use of personal music devices.
12. In paragraph 5, the writer suggests that
A. Chainsaws and smartphones are negatively impacting the public's

hearing
B. Listening to music on a smartphone will damage your hearing.
C. Smartphones are designed to play music at dangerously high
volumes.
D. More rules should be in place to control how loud smartphones
can go.
13. Why does the writer mention the Australian education programs in
paragraph 6?
A. To encourage schools to adopt the Cheers for Ears program.

B. To suggest that education could lead to safer behaviour in young
people
C. To criticise governments for not educating youths on the danger of
excessive noise.
D. To highlight a successful solution to the issue of hearing loss in young
people.
14. What is the writer's attitude to the lack of manufacturing guidelines for
music devices in Australia?
A. There is no clear reason why Australia has not created guidelines.

B. The implementation of guidelines in Australia is unnecessary.
C. Guidelines probably won't be created in Australia.
D. It will be difficult to create guidelines in Australia.
Text 2: What is herd immunity?
A recent outbreak of chickenpox is a reminder that even in countries where

immunisation rates are high, children and adults are still at risk of vaccine-
preventable diseases. Outbreaks occur from time to time for two main reasons.
The first is that vaccines don’t always provide complete protection against
disease and, over time, vaccine protection tends to diminish. The second is that
not everyone in the population is vaccinated. This can be for medical reasons,
by choice, or because of difficulty accessing medical services. When enough
unprotected people come together, infections can spread rapidly. This is
particularly the case in settings such as schools where large numbers of children
spend long periods of time together.
When a high proportion of a community is immune it becomes hard for diseases
to spread from person to person. This phenomenon is known as herd immunity.
Herd immunity protects people indirectly by reducing their chances of coming
into contact with an infection. By decreasing the number of people who are
susceptible to infection, vaccination can starve an infectious disease outbreak
in the same way that firebreaks can starve a bushfire: by reducing the fuel it
needs to keep spreading. If the immune proportion is high enough, outbreaks
can be prevented and a disease can even be eliminated from the local
environment. Protection of “the herd” is achieved when immunity reaches a
value known as the “critical vaccination threshold”. This value varies from
disease to disease and takes into account how contagious a disease is and how
effective the vaccine against it is.
For a disease outbreak to “grow”, each infected person needs to pass their
disease on to more than one other person, in the same way that we think about
population growth more generally. If individuals manage only to “reproduce”
themselves once in the infectious process, a full-blown outbreak won’t occur.
For example, on average someone with influenza infects up to two of the people
they come into contact with. If one of those individuals was already fully
protected by vaccination, then only one of them could catch the flu. By
immunising half of the population, we could stop flu in its tracks.
On the other hand, a person with chickenpox might infect five to ten people if
everyone were susceptible. This effectively means that we need to vaccinate
around nine out of every ten people (90% of the population) to prevent
outbreaks from occurring. As mentioned earlier, vaccines vary in their ability to
prevent infection completely, particularly with the passing of time. Many
vaccines require several “booster” doses for this reason. When vaccine
protection is not guaranteed, the number of people who need to be vaccinated
to achieve herd immunity and prevent an outbreak is higher. Chickenpox
vaccine is one such example: infections can occur in people who have been
vaccinated. However, such cases are typically less severe than in unimmunised
children, with fewer spots and a milder symptom course.
In Australia, overall vaccine coverage rates are high enough to control the
spread of many infectious diseases. Coverage shows considerable geographic
variation, though, with some communities recording vaccination levels of less
than 85%. In these communities, the conditions necessary for herd immunity
may not be met. That means localised outbreaks are possible among the
unvaccinated and those for whom vaccination did not provide full protection. In
the Netherlands, for example, high national measles vaccine uptake was not
enough to prevent a very large measles outbreak (more than 2, 600 cases) in
orthodox Protestant communities opposed to vaccination.
Australia’s National Immunisation Strategy specifically focuses on achieving

high vaccine uptake within small geographic areas, rather than just focusing on
a national average. Although uptake of chickenpox vaccine in Australia was
lower than other infant vaccines, coverage is now comparable.
Media attention has emphasised those who choose not to vaccinate their
children due to perceived risks associated with vaccination. However, while the
number of registered conscientious objectors to vaccination has increased
slightly over time, these account for only a small fraction of children. A recent
study found only 16% of incompletely immunised children had a mother who
disagreed with vaccination. Other factors associated with under vaccination
included low levels of social contact, large family size and not using formal
childcare.
Tailoring services to meet the needs of all parents requires a better

understanding of how families use health services, and of the barriers that
prevent them from immunising. To ensure herd immunity can help protect all
children from preventable disease, it’s vital to maintain community confidence
in vaccination. It’s equally important the other barriers that prevent children
from being vaccinated are identified, understood and addressed.

15. According to the writer what causes occasional outbreaks of preventable
diseases?
A. A high prevalence of disease.

B. Limited access to vaccination.
C. A low prevalence of vaccination.
D. Attitudes towards vaccination.
16. Why does the writer mention bushfires in paragraph 2?

A. To emphasise the effectiveness of herd immunity.
B. To describe a method for eliminating disease.
C. To warn of the risks of of vaccination.
D. To highlight the severity of the flu.
17. The phrase "stop flu in its tracks" in paragraph 3 refers to the
A. Prevention of flu spreading.
B. Eradication of the flu virus.
C. Minimisation of flu victims.
D. Reduction in severity of flu symptoms.
18. Information in paragraph 4 implies that

A. The chickenpox vaccine is highly unreliable.
B. Chickenpox is more contagious than the flu.
C. Booster vaccines should be given in schools.
D. Outbreaks of chickenpox are on the rise.
19. In paragraph 5, the writer emphasises the importance of

A. How geographical variation contributes to outbreaks.
B. Differences in global vaccination guidelines.
C. The influence of religious beliefs on vaccination.
D. Enforcing high vaccine coverage rates.
20. Why does the writer mention Australia's National Immunisation Strategy?
A. To serve as a counter argument.
B. To engage Australian readers.
C. To reinforce a previous point.
D. To introduce a new topic.
21. The research quoted in paragraph 7 reinforces that

A. The media presents vaccination negatively.
B. Many factors contribute to under vaccination.
C. Parental objections account for most unvaccinated children.
D. The number of conscientious objectors has increased over time.
22. In the final paragraph, the writer focuses on

A. The importance of widespread faith in vaccination.
B. The difficulty of tailoring health services to all parents.
C. The identification of barriers to overcoming under vaccination.
D. The different kinds of preventable disease that need to be overcome.
END OF READING TEST, THIS BOOKLET WILL BE COLLECTED
15. building blocks
16. longstanding / underlying
17. longer-acting formulations of methylphenidate / longer acting formulations

of methylphenidate / longer-acting formulations / longer acting formulations
18. comorbid disorders
19. blood pressure
20. careful titration / titration

1. C
2. A
3. A
4. C
5. B
6. B

1. A
2. C
3. D
10. D
11.C
12.C
13. B
14. A
15. C
16. B
17. A
18. B
19. A
20. C
21. B
22. C
• unintended weight loss
Treatment
Treatment aims to relieve the symptoms and prevent them returning, and
includes specific diets, lifestyle changes, medicines and surgery.
Medicines used to treat ulcerative colitis or Crohn's disease include:

• aminosalicylates or mesalazines.
• immunosuppressants such as steroids or azathioprine to reduce the
activity of the immune system .
• biologics - specific antibody-based treatments given by injection that
target a specific part of the immune system.
• antibiotics.
An estimated 1 in 5 people with ulcerative colitis have severe symptoms

that don't improve with medication. In these cases, surgery may be
necessary to remove an inflamed section of large bowel (colon).
Around 60-75% of people with Crohn's disease will need surgery to repair
damage to their digestive system and treat complications of Crohn's
disease. Regular bowel check-ups (colonoscopies) are recommended to
reduce the risk of colon cancer.
Text B
Extract: Pathogenesis of Inflammatory Bowel Disease

There is no doubt that environmental factors play an important role in the
development of IBD. A large number of environmental factors are
considered risk factors for IBD, including smoking, diet, drugs, geography,
social stress, and psychology. Among them, smoking remains the most
widely studied and replicated environmental prompter for IBD. Since the
first described inverse association between UC and smoking in 1982,
subsequent studies have confirmed the protective effect of heavy smoking
on the development of UC with a lower rate of relapse. Contrary to its effect
on UC, smoking increases the risk of CD and is associated with a higher
rate of postoperative disease.
Text C
Highest annual incidence rates and reported prevalence rates for
ulcerative colitis (UC) and Crohn's disease (CD
Highest annual incidence Highest reported prevalence values

(per 100,000 person-years) (per 100,000 persons)
UC CD UC CD
Europe 24.3 12.7 505 322

Asia / 6.3 5.0 114 29
Middle East
North 19.2 20.2 249 319

America
11.2 17.4 145 155
Australasia
The prevalence of CD appears to be higher in urban areas than in rural

areas, and also higher in higher socio-economic classes. Most studies
show that when the incidence first starts to increase, it is mostly among
those of higher social class, but that the disease becomes more ubiquitous
with time.
If individuals migrate to developed countries before adolescence, those

initially belonging to low-incidence populations show a higher incidence of
IBD. This is particularly true for the first generation of these families born in
a country with a high incidence.
Text D
Classification of Inflammatory Bowel Disease

Infection, ischaemia, physical damage, or specific immunologic sensitivity
should be excluded as far as possible before a diagnosis of non-specific
inflammatory bowel disease is made. Non-specific inflammation can be
subdivided on the basis of macroscopic and microscopic anatomical
criteria. Macroscopic structural abnormalities can be recognized by clinical
examination, endoscopy, radiology, and inspection of an operation
specimen. These complementary methods of data collection combine with
microscopic examinations of tissue to separate disorders that differ in
prognosis and possible response to treatment. Anatomic classifications do
not necessarily imply differences in aetiology and may change with
advances in knowledge.
PART A -QUESTIONS
Questions 1-7
1) how to distinguish IBD from other conditions?

2) the relationship between social status and IBD?
3) the number of people with IBD in different parts of the world?
4) the proportion of IBD sufferers who require an operation?
5) how to prevent IBD-related cancer?
6) the parts of the digestive system affected by different types of IBD?
7) lifestyle factors that may cause IBD?
Questions 8-14
spelled.
8) What should be examined under a microscope to differentiate between

types of IBD?
9) Which is the only region where Crohn's disease is more prevalent than
ulcerative colitis?
10) How are biologics administered?
11) Which environmental risk factor for IBD has received the most attention
from researchers?
12) To which group of drugs do steroids belong?
13) Which two parts of the digestive tract are affected by ulcerative colitis?
14) Incidence of which type of IBD may be reduced by smoking?
Questions 15-20
texts. Each answer may include words, number or both. Your answers should be
correctly spelled
Non-specific IBD should not be diagnosed until other possible causes have
been (15)_________
Ulcerative colitis and Crohn's disease may cause sufferers to lose
(16)________ unexpectedly.
A 1982 study reported an (17)___________ between smoking and
ulcerative colitis.
Modifications to a patient's (18) __________ are among the treatments for
IBD.
Crohn's disease is more common among higher social classes and those
who live in (19) ___________.
Medication is ineffective in around (20) ____________ % of ulcerative
colitis patients.
professionals . For questions 1-6, choose the answer (A, B or C) which you think
fits best according to the text. Write your answers on the separate Answer Sheet
Questions 1-6
1) Overweight and obese children's data have not been used to make the
new table because
A. they reduced the number of accurate diagnoses of high blood pressure.

B. they lowered the cutoff point for diagnosis of high blood pressure.
C. they increased the risk of hypertension in children.
Summary: Updated pediatric blood pressure guidelines

A new screening table listing 90th percentile BP values by age and sex for
children at the 5thpercentile of height makes it easier to identify youngsters
requiring additional evaluation. The values have also been recalibrated.
Tables establishing cutoff percentiles for pediatric BP levels (normal,
elevated, stage 1 and stage 2 hypertension) are now based on normal
weight children. In the earlier guidelines, they were based on population
data that included overweight and obese children and adolescents, thereby
scaling the values upward since excess weight is known to be a risk factor
for hypertension. The new tables, therefore, set BP values several
millimeters lower for each cutoff percentile. The practical effect is that more
children and adolescents will be correctly identified as having elevated BP.
2) The purpose of this memo is to
A. establish a definition of valid consent.

B. explain the importance of obtaining a patient's consent
C. give information on the legal obligations of healthcare workers.
Memo: Consent for Examination or Treatment Policy

Patients have a fundamental legal and ethical right to determine what
happens to their own bodies. Valid consent to treatment is therefore
absolutely central in all forms of healthcare, from providing personal care to
undertaking major surgery. Seeking consent is also a matter of common
courtesy between health professionals and patients.
The Department of Health has issued a range of guidance documents on

consent and these should be consulted for details of the law and good
practice requirements on consent. While these documents are primarily
concerned with healthcare, social care colleagues should also be aware of
their obligations to obtain consent before providing certain forms of social
care, such as those that involve touching the patient or client
3) The guidelines suggest using a mirror instead of a head-mounted light

because it
A. is easier to use
B. directs light more effectively
C. can be used with a variety of light sources
Physical examination of a dental patient

A thorough inspection requires good illumination, a tongue blade, gloves,
and a gauze pad. Complete or partial dentures are removed so that
underlying soft tissues can be seen.
Most physicians use a head-mounted light. However, because the light

cannot be precisely aligned on the axis of vision, it is difficult to avoid
shadowing in narrow areas. Better illumination results with a head-mounted
convex mirror; the physician looks through a hole in the center of the
mirror, so the illumination is always on-axis. The head mirror reflects light
from a source (any incandescent light) placed behind the patient and
slightly to one side and requires practice to use effectively.
4) The instructions indicate that the device
A. can only be used for a short time for epidural administration.

B. has full functionality when used for epidural administration
C. must be used with appropriate equipment for epidural administration.
Instruction manual: Volumetric Infusion Pump

The instrument can be used for epidural administration of anesthetic and
analgesic drugs. This application is only appropriate when using analgesics
and anesthetics labelled for continuous epidural administration and
catheters intended specifically for epidural use. The instrument's secondary
features must not be used when the instrument is being used for epidural
administration of anesthetic and analgesic drugs.
• Epidural administration of anesthetic drugs: Use indwelling catheters

specifically indicated for short-term (96 hours or less) anesthetic
epidural drug delivery.
• Epidural administration of analgesic drugs: Use indwelling catheters

specifically indicated for either short-term or long-term analgesic
epidural drug delivery
5) The advice stresses the importance of
A. communicating regularly with the patient.

B. adapting the care plan to the severity of the condition
C. consulting appropriate professionals about the care plan
Care planning for motor neurone disease patients

Everyone with MND is affected differently, so a care plan must be
developed with the individual and those close to them to ensure a
comprehensive and appropriate plan of care is developed.
Because MND progresses so rapidly, this plan needs to be reviewed

regularly to respond to any changes. The plan may involve several
organisations and should be coordinated by a key worker.
This may be the person with MND or a relative.
Key points to creating a care plan and maintaining it are:

• the wishes of the person with the condition are paramount.
• communication issues should not prevent an assessment of needs.
• a care plan should provide sufficient information to guide those
involved in delivering care.
• the plan should be updated regularly as the condition progresses.
• a single point of contact for coordination of care should be
established.
6) The effect of Vancomycin on the skin may be minimized by
A. using antihistamine
B. injecting it quickly
C. adding water to it
Vancomycin Administration
Vancomycin is very irritating to tissue and should not be given
intramuscularly as this causes injection site necrosis. It must be given by
slow intravenous infusion using a dilute solution to reduce the risk of tissue
necrosis if extravasation (leaking) occurs. Vancomycin should not be given
rapidly due to the risk of infusion reactions. The intravenous use of
vancomycin may be associated with the so-called 'red-neck' or 'red-man'
syndrome, characterised by erythema, flushing, or rash over the face and
upper torso, and sometimes by hypotension and shock-like symptoms. The
effect appears to be due in part to the release of histamine and is usually
related to rapid infusion. It may also cause pain or muscle spasm.
Part C -Text 1
Premature birth
Premature birth is an issue that occupies scientists throughout the world.
The USA's preterm birth rate rose from the early 1980s until 2006, when
one in every eight babies arrived at least three weeks early. In the UK, the
figure is one in 13. According to the World Health Organisation, around 15
million babies worldwide are born before the 37th week of pregnancy every
year, and while most babies born prematurely in developed countries
survive, many have lifelong disabilities such as cerebral palsy, as well as a
greater risk of delayed development of language and motor skills.
In the United States, the most common causes of death for premature
babies are extreme immaturity, breathing problems, brain injury, infections
and the bowel disease necrotizing enterocolitis. About 40 percent of these
deaths occur within 12 hours of birth: 95 percent happen before the baby is
three months old. In less developed countries, they die because of a lack of
basic medical care such as adequate warmth, low-tech respiratory support
and antibiotics. The World Health Organisation estimates that providing
such measures could save three-quarters of these infants, but predicting
and preventing early labour would be even better.
"Preterm birth remains an intractable problem, and one that is very poorly
understood," says Dr David Stevenson of the Prematurity Research Centre
at Stanford University. Risk factors include infection, placental problems
and genetic problems, but in many cases the origin is unknown. Yet the
need to come to terms with the phenomenon is urgent: prematurity recently
replaced infectious disease as the leading cause of death in young children
around the world.
Prematurity research centres worldwide are working to better understand

the biology of preterm birth, with the aim of establishing tests that can
predict which pregnancies are most likely to result in early births. Until now,
the best available tests have worked only in high-risk women, such as
those who have already given birth prematurely, and are correct only about
20 percent of the time. One of the most significant challenges in improving
testing accuracy is also one of the most basic: understanding how human
babies are born.
The human birth process is unusual, which renders animal models of
labour mostly useless for research purposes. In most mammals, the level
of the hormone progesterone drops before birth and triggers labour, while
in humans, progesterone levels reach a peak at the time of delivery. But
new scientific tools, including several non-invasive techniques, are finally
giving researchers safe ways to explore what brings human pregnancy to a
conclusion. Developed at Stanford, blood test for pregnant women detects
with a high degree of accuracy whether their pregnancies will end in
premature birth. The technique can also be used to estimate a foetus's
gestational age or the mother's due date as reliably as and less
expensively than ultrasound.
The tests focus on maternal, placental and foetal genetic activity and
measure maternal blood levels of cell-free RNA, microscopic pieces of
genetic code that prompt the body to produce proteins. The research team
collected blood samples from 38 pregnant women in the USA and used
them to identify which genes gave reliable signals about gestational age
and prematurity risk. "We found that a handful of genes are very highly
predictive of which women are at risk for preterm delivery," said Dr Mads
Melbye, visiting professor of medicine at Stanford and a senior author of
the new report. "I've spent a lot of time over the years working to
understand preterm delivery. This is the first real, significant scientific
progress on this problem in a long time."
The test to assess gestational age resulted from a study of blood samples
given weekly by 31 Danish women throughout their pregnancies. The
women all carried their babies to term. Scientists took blood from 21 of
them and used it to construct a statistical model, which identified nine cell-
free RNAs produced by the placenta that predict gestational age, and
validated the model using samples from the remaining 10 women. The
estimates of gestational age given by the model were accurate about 45
percent of the time, which is comparable to the 48 percent accuracy of first-
trimester ultrasound estimates.
Obstetricians currently use ultrasound scans from the first trimester of
pregnancy to estimate a woman's due date, but ultrasound gives less
reliable information as pregnancy progresses, making it less useful for
women who don't get early prenatal care. Ultrasound also requires
expensive equipment and trained technicians, which are unavailable in
much of the developing world. In contrast, the researchers anticipate that
the blood test will be simple and cheap enough to use in low-resource
settings
7) Which of the following is suggested by the first paragraph?
A. The mortality rate for premature babies is rising.

B. The premature birth rate in the UK is rising.
C. The mortality rate for premature babies is higher in developing countries.
D. The premature birth rate in the USA was higher in the 1980s
8) In the second paragraph, what does the phrase 'such measures' refer
to?
A. basic medical care

B. adequate warmth
C. low-tech respiratory support
D. antibiotics
9) The main purpose of the third paragraph is to
A. explain the main causes of premature birth.

B. highlight the relationship between infectious disease and prematurity.
C. summarise recent research into premature birth.
D. emphasise that more research into premature birth is necessary
10) What does the writer draw attention to in the fourth paragraph?
A. the methods used by prematurity research centres

B. the increased accuracy of new testing methods
C. the increased risk of premature birth for certain women
D. the limitations of current testing methods
11) What point is made about the ways that humans and animals give
birth?
A. they are similar in some respects

B. they are opposite in some respects
C. they are abnormal in some respects
D. they are unhelpful in some respects
12) What is the 'real, significant scientific progress' that Dr Melbye

refers to?
A. the findings of the tests on pregnant women's cell-free RNA levels

B. increased knowledge of the relationship between gestational age and
prematurity
C. the discovery that cell-free RNA plays a role in the production of proteins
D. the conclusion that premature birth is a factor in cell-free RNA levels
13) What was significant about the results of the study of 31 Danish
women?
A. None of the subjects gave birth prematurely.

B. The results differed between the two groups of subjects
C. The model produced results that were about as accurate as ultrasound
testing.
D. The model produced results that were less accurate than ultrasound
testing.
14) Which of these is NOT suggested in the final paragraph as an

advantage of the new blood test over ultrasound?
A. It gives better results later in a woman's pregnancy.

B. It is more suitable for use in developing countries.
C. It is a reliable substitute for early prenatal care.
D. It can be administered by personnel with little training.
Part C -Text 2
Body-Focused Repetitive Behaviours

From time to time, most of us bite our fingernails, pull on our hair or pick at
our skin, but for an estimated 146 million people around the world, these
behaviours are compulsive and have a serious and potentially debilitating
effect. Although body-focused repetitive behaviours (BFRBs), as they are
known, are commonly regarded as simple tics or habits, their
consequences are extensive and range from embarrassment, shame and
social isolation to physical harm and, in exceptional cases, death. Due to
the lack of research into BFRBs and the lack of awareness of them among
physicians, sufferers often avoid seeking treatment out of a fear of being
ignored or ridiculed.
Annie was 14 years old when she began to exhibit signs of excoriation
disorder, a BFRB also known as dermatillomania, which causes the
sufferer to repeatedly rub, pick at or scratch their skin. Her classmates took
the marks on her face and neck for acne and teased her to the extent that
she began missing school to avoid them. Annie, now 25 and an activist
working to help other BFRB sufferers, says, "I was worried about picking at
my skin so much, but the way I was treated at school made me feel far
worse." It didn't help that, when she finally persuaded her parents to take
her to see the family doctor, she was told that she was going through a
phase and should try to fit in at school by joining a club.
Research suggests that the causes of BRFBs are partly genetic: they have
been shown to be more prevalent among people with sufferers in their
immediate family, and identical twins are more prone to be affected than
fraternal twins. However, environmental and stress factors are also thought
to contribute to their onset. Scientists have drawn parallels between the
behavior of humans and animals and noted that birds sometimes pull out
their feathers when stressed, and cats and dogs have been observed to
compulsively lick parts of their bodies until bald spots and skin damage
appear. Understanding the neurological reasons for these actions in
animals may shed light on people's motivation to perform similar
behaviours.
While BFRBs are similar in some respects to obsessive compulsive

disorder (OCD) and self-harming behaviours such as cutting of the skin
with knives or other sharp objects, consensus has not yet been reached as
to how they should be classified. The American Psychiatric Association's
Diagnostic and Statistical Manual recently recategorized BFRBs, grouping
them with obsessive compulsive and related disorders rather than placing
them, as previously, in the impulse control category. BFRB advocates
argue that, while OCD sufferers may compulsively perform actions such as
counting objects, switching lights on and off and locking and unlocking
doors, behaviours like repeated washing of the hands are symptomatic of a
broader problem and only incidentally focused on the body, whereas in
BFRBs, the bodily component is central to the disorder. This, they contend,
means that the psychiatric community should focus treatment on the
behaviours themselves rather than their underlying cause.
BFRBs were largely overlooked or misunderstood by doctors for decades,

and although there has been research in recent years, support for sufferers
is still limited and no treatment has proven to be universally effective.
Experts tend to agree that increasing a sufferer's awareness of their
condition is an important first step in dealing with it, but beyond that, there
is no established course of action. Various combinations of cognitive
behavioural therapy, social support and medication have been shown to
produce positive results, but all of this depends on the affected person
seeking help in the first place, which often means overcoming feelings of
shame and helplessness.
One therapy that has shown promising results is habit reversal training, in
which the sufferer is encouraged to become familiar with the urges that
cause them to pick pull, and to substitute a different behaviour when they
feel compelled to act, such as clenching a fist or squeezing a rubber ball. A
majority of subjects in are cent study managed to reduce their compulsive
behaviours in the short term by using these methods, but lasting
improvements have been more elusive, as many patients find it hard to
maintain the level of motivation required.
For Annie, the journey from teenage secrecy about her condition to adult
advocacy and campaigning to improve the lives of other sufferers has not
been an easy one. Believing that she would be rejected by potential friends
and partners because of her appearance, she retreated into solitude and
spent years barely working or even leaving her home. But with the help of
support groups and organisations, she has learned to live with her scars
and the urges that produce them and is now working on a book about her
experiences. "I want people to know that they're not alone" she says "Just
knowing that someone else is struggling with the same issues can be the
validation you need to overcome them.
15) In the first paragraph, the writer makes the point that BFRBs are
A. more common than people think

B. more serious than people think
C. more complex than people think
D. more treatable than people think
16) Which word best describes Annie's doctor's attitude in the second
paragraph?
A. passive
B. sympathetic
C. optimistic
D. dismissive
17) What does the second paragraph tell us about BFRBs?

A. They have the same origins in humans and animals.
B. They are usually inherited.
C. They are caused by stress.
D. Their causes are unknown.
18) What is meant by the phrase 'shed light on'?
A. make a connection between

B. have an effect on
C. help to explain
D. help to reduce
19) The fourth paragraph suggests that the difference between BFRBs and
OCD lies in
A. the way they are treated

B. the type of harm they cause
C. their level of severity
D. the reasons behind them
20) Which of these factors is NOT mentioned in the fifth paragraph as a

difficulty in treating BFRBs?
A. Sufferers do not know that they have a problem.

B. Sufferers find it difficult to talk about their problems.
C. There is not enough help available for people with the condition.
D. There is not a form of therapy that works foreveryone
21) According to the sixth paragraph, what is the disadvantage of habit-

reversal training?
A. Its benefits are rarely permanent.

B. It is only effective for a small number of people.
C. There has not been enough research to prove that it works.
15. excluded
16. weight
17. inverse association
18. lifestyle
19. urban areas
20: 1 in 5, one in five

1. A
2. B
3. B
4. C
5. B
6. C

7. C
8. A
9. D
10. D
11. B
12. A
13. C
14. C

15. B
16. D
17. D
18. C
19. D
20. A
21. A
22. B
.
Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once.
1. Importance of data collections in epidemics?
2. Case fatality ratios in each region?
3. Adjusted odds ratio of case fatalities?
4.Psychological symptoms following SARS treatment? _________________
5. Symptoms associated with the infection?
6. Hong Kong being the second highest regarding number of cases? ________________
7. Modes of spread of the virus?
Questions 8-14
Each answer may include words, numbers or both.
8.What are the two factors that make an infected person more likely to die?
____________________________________________
9. What is the percentage of health-care workers who were infected in Singapore?
_____________________________________________
10.How do coronaviruses look like under the microscope?
11. How many people have died around the world in the 2002-2003 SARS outbreak?
___________________________________________________________________
12. What is the percentage of people who were below average for measures of
general health in 2004 according to the study that took place in Canada ?
___________________________________________________________________
13. What variables does the abstract explore the influence of on the CFRs between the
three regions?
_______________________________________________________________________
14. How was the proportion of fatalities to cases in Hong Kong when compared to
China?
_______________________________________________________________________________
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the
texts. Each answer may include words, numbers or both.
15. Researchers in Canada investigated the psychological and ....................................

health of 40 people who had been infected with SARS.
16. SARS which stands for ............................................................syndrome started to

affect humans in the late 2002 and the first half of 2003.
17. The reasons for the variation in the .............................................. among the three areas
were explored.
18. The ............................................... of an infected person may release droplets

containing the virus into the air.
19. There were .............................. ....... cases in total worldwide who got infected by the
organism.
20. Symptoms of the disease include headache, ......................................., cough and

shortness of breath.
END OF PART A
professionals. For
questions, 1-6, choose the answer (A, B or C) which you think fits best according to the
textREADING
SUB-TEST – QUESTION PAPER: PARTS B & C
1.According to the extract:
A-Overall responsibility of the patient is retained by the alternative health practitioner
when the medical practitioner who has performed the procedure is not there.
B-The medical practitioner may formally refer the patient to another health practitioner.
C-If the medical practitioner is not qualified, responsibility of the patient will be
automatically retained by the alternative practitioner.
The medical practitioner is responsible for ensuring that any other person
participating in the patient’s care has appropriate qualifications, training and
experience, and is adequately supervised as required. When a medical practitioner
is assisted by another registered health practitioner or assigns an aspect of a
procedure or patient care to another registered health practitioner, the medical
practitioner retains overall responsibility for the patient. This does not apply when
the medical practitioner has formally referred the patient to another registered
health practitioner
2. What is the exact weight that should be entered if the two reading are 70 Kg and
70.25 Kg?
A- 70 Kg.
B- 70.02 Kg.
C- 70.13 Kg.
The SECA model 815 floor scale is used to measure weight in this component. It
has a digital display indicator head fitted at the back of the platform with the
connecting cable stored in the compartment underneath the head. The scale is a
load cell model with a weighing
range of 0-136 kilograms (kg). It operates with a standard 9 V alkaline battery. In
order to open the battery compartment, open the battery lid underneath the head.
Connect the battery terminals, then insert the battery and close the cover. The
reading of the scale is accurate to 0.25 kg over the entire weighing range. If two
values are displayed alternately in the 0.25 kg. range, then the exact weight is
between the two values and the intermediate weight should be entered.
3.Based on this extract:
A- Effective post-exposure prophylaxis needs to be accessible when needed.
B - OSHA requires that all employees must be vaccinated against rubella.

C- Some agencies require that health care employers must be immunized against
measles.
A variety of measures is needed for optimal infection control among employees,

both before and during the period of employment. OSHA mandates that all
employees should be immunized against HBV, although the risk of HBV infection
to endoscopy unit personnel is small. Other agencies and medical societies have
gone further and recommended that health care personnel should have
documented immunity or be immunized against a number of other vaccine-
preventable diseases. Such vaccinations include annual influenza
immunizations, measles/ mumps/rubella, varicella (if the individual has not had
chickenpox in the past), tetanus/diphtheria/pertussis, and meningococcus.
Additionally, a majority of states have immunization laws for health care workers
with which institutions must comply. Last, an effective and readily accessible
employee health service may play a critical role in the management of after-
exposure prophylaxis
A- The hospital must provide the employees with the cost of coffee.
B- Employees get 90 mins of unpaid breaks every day.
C- Some of the employees may leave the hospital after 5 PM.
The Medical Clinic is open 0900h to 1700h, Monday through Friday. Employees are
expected to be at their work stations logged into their computers when the doors
open at 0900h. During the 8 hour work day, employees are allowed a one hour
unpaid lunch break and two paid fifteen minute coffee breaks time permitting each
day. As staff are being paid for their coffee breaks we ask that they remain in the
clinic and available to help doctors and patients when required. Scheduling of
breaks will be done such as to ensure continuous service to our patients
throughout the day. In the event there are still patients in the clinic after 1700h, at
least one employee will be required to remain in the building until all patients have
left.
5. According to the extract:

A-Probation period may take up to three or even four months.
B- Employee get to evaluate his physician lead during his probation period.
C- After the probation period, the employee is permanently employed.
A new employee is considered to be on probation during the first three months of
employment. During this time, the employee will be able to evaluate the job and
work environment, and the Clinic Manager(s) and Physician Lead(s) (Personnel)
will evaluate the suitability of the employee for the job. At the end of the probation
period if mutually agreeable, permanent employment will be offered. At the
discretion of the Managers this period may be extended.
6. The contents of the INS published guidelines include:

A-Inconsistent process measures of quality based on guidelines are sometimes non-
beneficial.
B- Neurosurgical guidelines can be applied in a meaningful way to the majority of
neurosurgical practices.
C- The quality of research determines the evidence base on which guidelines rest.
The evidence base on which clinical guidelines rest is determined by the quality
and applicability of the clinical trials. Because of the profound limitations of many
prospective, randomized trials in neurosurgery (non-representative patient and
surgeon selection, cross-overs and non-blinded evaluation of unclear endpoints) I
question whether any neurosurgical guidelines can be applied in a meaningful way
to the majority of neurosurgical practices. Using clinical guidelines
recommendations as quality indicators and holding physicians accountable for
many, sometimes contradictory, process measures of quality based on these
guidelines is unlikely to benefit anyone. I believe that the emphasis on such
measures will divert attention from more clinically relevant issues, increase the
cost and complexities of care, and decrease the quality of life for our patients.
Text1: Why getting motivated is hard
As a trainer, I consider it a personal failure if I am unable to motivate a client to
make important health and lifestyle changes. Sure, there are people who just do not
care, but I can spot them from 100 meters away. I am not talking about them. I am
referring to the clients who really want to lose the weight. They actually do care, but
it just does not happen. They struggle to muster even half the motivation required to
do the work, self-sabotage and eventually feel so defeated that they quit. It hurts to
watch. On the flipside, other clients get in and get the job done. Their sights are set
and they just plough ahead until mission accomplished. By this point, exercise and
eating healthily are non-negotiable parts of their lifestyle. It is who they have
become.
So, what separates my clients who achieve their weight loss goals from those who
do not? Is it a difference in brain chemistry? The answer is yes … and no. "There is a
system in your brain that impacts your levels of motivation called the reward
network" explains Fiona Kumfor, senior research fellow at the University of Sydney's
Brain and Mind Centre. "That involves two regions: the ventral striatum and parts of
the pre-frontal cortex," Dr Kumfor says. "Together they're involved in our
willingness to work, our motivation to engage in behaviors, and our willingness to
persist in that effort over time. "Really importantly, it influences our decisions on
what's working for us and what's not." Dopamine, a chemical messenger, is the star
quarterback in this reward network — it is released during pleasurable situations,
and the ventral striatum and pre-frontal cortex have receptors that are sensitive to
it. An increase in our dopamine levels to those areas is what gives you that sense of
reward, regardless of whether the stimulus is food, sex, exercise, fat loss or winning
at Mario Kart. This dopamine boost is what encourages you to repeat the activity
that got you the reward, so you get can it again. However, here is the kicker: you do
not get that reward rush until after you engage in the behavior. Getting someone to
engage in the behaviour for long enough to value that dopamine rush in the first
place is where I and many other well-meaning health professionals get stuck. What
makes one person see getting healthy as achievable and another person see it as
insurmountable is the Nobel Prize-winning question, Dr Kumfor says, and
unfortunately science isn't quite there yet. "But what we do know is that humans
are bad at focusing on distant future and less tangible
rewards," she explains. For example, studies have shown that given the choice
between getting $10 right now and $100 next month, most of us will go for the
instant gratification. That makes sense when you think of it in terms of making
massive lifestyle changes: substantial weight loss seems ages away and might not
happen, whereas that schnitzel and six schooners is tonight and guaranteed
delicious
We're probably better off with setting short-term rewards along the way to the big
one, rather than just focusing on the far off and hard-to-imagine pot of gold at the
end of the rainbow. Maintaining goal-directed motivation behaviour is hard. Instead,
focus on creating habits that will help you along the way, suggests Dr Kumfor. "If
there's a way to harness habit, rather than forcing ourselves to be goal-directed,
that's undoubtedly going to be easier. "So, break it all down into small, manageable,
bite-sized parts." For example, if you are trying to lose weight, have your ducks in a
row well in advance. Schedule in regular times, pre-book and pay for classes, pre-
pack workout gear and have it on-hand if you are exercising after work. Do not go
home first. Train yourself to operate on autopilot so your brain does not get
involved. Otherwise, you will be veering straight onto instant gratification highway,
without stopping off in exercise city.
At the end of the day, in order to do any of that you need to decide whether your
goal is actually worth the effort. There is a complex relationship between how
meaningful a reward is and the amount of effort required to achieve it. You will only
make the sacrifices if your goal is truly important to you. Think of motivation as a
spectrum. Within that, some people will be highly motivated, some moderately and
others will find it really challenging. In addition, motivation can change depending
on the person and situation. That is partly due to differences in the way our brains
work. Take me for example, while I do not (usually) have trouble being motivated to
exercise, I had much rather clean the oven than start my statistics assignment that's
due in three days. This is where intrinsic (internal) motivation can help. Intrinsic
motivation is when you are driven to do something purely because you find it
enjoyable; it does not matter if there is a pot of gold at the end. You are choosing to
do it, rather than of out of obligation. Extrinsic motivation (external), on the other
hand, is when you're driven to do an activity because you're avoiding pain or
punishment, you're doing it for someone else, or feel like it's being forced on you.
Sure, it might get you started, but it will not keep you on the wagon for long.
"People who are more intrinsically motivated tend to work at a higher intensity and
are more consistent with their exercise routine," explains exercise physiologist Alex
Budlevskis.
___________________________________________________________________
Text 2: How to eat more green vegetables
In Australia, less than one in 10 people eat enough vegetables. This is tragic,
given high vegetables intakes are associated with better health, including a
lower risk of heart disease, some cancers, and type 2 diabetes. For every
extra 200 grams of vegetables and fruit eaten each day, there's an 8 per
cent reduction in the risk for heart disease, a 16 per cent risk reduction for
stroke and a 10 per cent reduction in risk of dying from any cause, according
to research using data from 95 individual studies. When the researchers
drilled deeper into some types of vegetables and fruit, they found that eating
more apples and pears, citrus fruits, cruciferous vegetables (like bok choy,
broccoli, Brussels sprouts, cauliflower, radish, swede, turnip, and
watercress), green leafy vegetables and salads were all associated with a
lower risk for heart disease and death. They also found a lower risk of
getting any type of cancer among those with the highest intakes of green-
yellow vegetables such as carrots, corn, pumpkin, zucchini, green beans and
cruciferous vegetables.
Across the globe, about 7.8 million deaths are attributed to low intakes of
vegetables and fruit. But in a country like Australia, you'd think it would be
easy to eat your greens, as well as a range of other vegetables. Reasons for
not eating them include not liking the taste, a perceived lack of time or
cooking skills, and lack of access to fresh produce. These are all barriers to
boosting our vegetable intakes — so let's check them out in more detail.
If you hate vegetables, it could be because you have inherited "super-taster"

genes. About 20 per cent of the population are supertasters and rate
cruciferous vegetables as tasting up to 60 per cent more bitter compared to
non-tasters, who make up about 30 per cent of the population. What they are
"tasting" is a naturally occurring chemical called glucosinolate that is released
more when vegetables are cut, cooked or chewed. Being a super-taster
probably offered a survival advantage in ancient times, because it would have
meant you were better able to detect poisonous substances (which tend to be
bitter), and work out which plants were safer to eat and which to avoid. The
good news is that repeated exposure to these bitter tastes means you do
learn to like them over time. If you hang around with others eating lots of
vegetables, or if your parents and household members eat a lot of
vegetables, then you will end up eating more too. True supertasters will like
vegetables that are not bitter more, including beans, beetroot, carrots, corn,
eggplant, lettuce, onion, peas, pumpkin and sweet potato.
If vegetables are off your menu because of how they taste, it is worth a
rethink on the way you're preparing them. How you cook vegetables can
improve their taste and for super tasters, can mask the bitterness. Try some
of these fast and easy tricks at home: Add a "decoy" flavor. Piperine is the
'hot' taste in black pepper. Adding it, or chilli or other spices, distracts your
taste buds from noticing the bitter taste of vegetables. Mask the taste by
using cheese sauce. Make it fast by dissolving a heaped teaspoon of
cornflour into a half cup of reduced fat milk in a microwave-proof jug. Cook
on high for 30 seconds, stir and add a cheese slice broken into pieces, and
cook for another 30 seconds. Stir again, cook for another 30 seconds, then
stir until the melted cheese is fully dissolved and the sauce thickens. Cook
briefly by stir-frying, microwaving or steaming, so they're still a bit crunchy.
In some regions of Australia, getting good quality fresh vegetables at a
reasonable cost is a major challenge. Prices of vegetables can be more than
double the cost of supermarkets in cities. This is where modular farms —
small indoor farms the size of a shipping container — could potentially help in
terms of access and freshness. A modular farm can be placed just about
anywhere from a busy city to a rural community, with the caveat that these
farms still need water, although the amount is conservative. However,the
power usage is high because they need to run lights 24 hours a day. Another
way to improve your access to a regular supply of vegetables, if distance or
affordability is a concern, is by using canned and frozen varieties. For
canned vegetables, choose the salt-reduced varieties where possible. Frozen
vegetables on the other hand, are frozen within hours of being harvested and
can be even "fresher" that what you buy at the supermarket.
Text 1: Questions 7-14
7. What do we learn in the first paragraph?
Ⓐ Failure to lose weight is mostly due to lack of motivation
Ⓑ Too much care may hinder the ability to lose weight
Ⓒ Acting on your goals is the way to achieve them
Ⓓ Even if you work very hard, you may not achieve your goals for different reasons
8. In the second paragraph, the writer uses Fiona Kumfor's words to
Ⓐ illustrate the routine-reward system loop
Ⓑ Outline the role of dopamine in the brain
Ⓒ Prove that chemical transmitters in the brain are the ones responsible for motivation
Ⓓ Inform us that dopamine level is affected by your degree of motivation
9. In the second paragraph, the word The refers to
Ⓐ The brain
Ⓑ The reward network
Ⓒ Levels of motivation
Ⓓ The brain's chemistry
10. What is the main point that the writer wants to deliver by mentioning the study in the
third paragraph?
Ⓐ Long-term goals need bigger rewards
Ⓑ Science has not been able to come up with ways to increase dopamine levels in the brain
Ⓒ Goals that are far in the future are unachievable
Ⓓ Perceptible outcomes drive a greater motivation
11. What advice is the writer giving in the fourth paragraph?
Ⓐ Break your goals down
Ⓑ Do not set long-term goals
Ⓒ Stop your bad habits
Ⓓ Do not set goals unless you are prepared
12. What idea is emphasized by the phrase 'have your ducks in a row well' in the fourth
paragraph?
Ⓐ Get motivated
Ⓑ Force yourself
Ⓒ Organize your thoughts
Ⓓ Be prepared
13. In the fifth paragraph, the writer suggests that intrinsic motivation produces an outcome
which is.
Ⓐ Achievable
Ⓑ Durable
Ⓒ Enjoyable
Ⓓ Not forced on you to do
14. In the final paragraph, Within that refers to
Ⓐ Challenges
Ⓑ Motivation
Ⓒ People
Ⓓ Spectrum
Text 2: Questions 15-22
15. What do we learn about the consumption of vegetables in the first paragraph?
Ⓐ People who consume 200 grams of green vegetables daily are 0.16 less likely to develop
stroke.
Ⓑ Those whose intake of food involve more vegetables do not suffer from heart diseases.
Ⓒ 90% of people do not eat enough vegetables
Ⓓ High intake of carrots may help protect against cancer.
16.Drilled deeper in the first paragraph implies that scientists looked into the matter in a
more ……………………… manner.
Ⓐ Frequent
Ⓑ Specific
Ⓒ Sensational
Ⓓ Serious
17.According to the second paragraph, which of the following is mentioned as a reason

for people's decreased intake of vegetables?
Ⓐ Not being able to fit it into their schedule
Ⓑ Vegetables being unavailable in the market
Ⓒ Their bad taste

Ⓓ The lack of time to cook
18.Which of the following is mentioned in the third paragraph?
Ⓐ 6 out of 10 of the cruciferous vegetables have a bitter taste
Ⓑ 2 out of 10 people have stronger tasting abilities
Ⓒ 3 out of 10 people do not find cruciferous vegetables to be of a bitter taste
Ⓓ Vegetables which are cut produce more glucosinolate.
19. It in the third paragraph refers to
Ⓐ Being able to survive
Ⓑ Being a super-taster
Ⓒ Living in ancient times
Ⓓ Eating poisonous chemicals
20. In the third paragraph, what does the writer consider as a pleasant fact?
Ⓐ Increased tolerance is produced following more frequent exposure.
Ⓑ Having a family that eat a lot of vegetables
Ⓒ Eventually, everybody is going to like vegetables
Ⓓ Those with stronger tasting abilities tend to like certain types of vegetables
21.The main aim behind what the writer is saying in the fourth paragraph is
16. severe acute respiratory syndrome
17. CFR
18. cough or sneeze
19. 8422
20. high fever
1. B
2. C
3. A
4. C
5. A
6. C
07. C
08. A
09. B
10. D
11. A
12. D
13. C
14. D
15.D
16.B
17.A
18.B
19.B
20.A
21.D
22.D
PART A -QUESTIONS
Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes from.
1. Importance of abdominal examination?
2. Indications of surgery in hemorrhoids?
3 Factors precipitating for blood vessels swelling?
4 Role of chemicals injection in treating piles?
5 Ethics of examining a patient with piles?
6 Symptoms associated with hemorrhoids?
7 Advantages of ligasure hemorrhoidectomy?
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
8.What does ligasure hemorrhoidectomy help reduce when compared with other methods?
________________________________________________________
9.How do the lumps protruding from the anus look and feel like?
________________________________________________________________________
10. What are the dietary habits that should be adopted to reduce the
risk of piles?
_____________________________________________________________________________
11. What is the mean operating time when performing ligasure hemorrhoidectomy?
______________________________________________________
12. What do surgeons use to snare hemorrhoids?
___________________________________________________________
13. What does abdominal examination help us rule out?
______________________________________________________________
14. What is the color of blood that you may notice on the toilet paper in cases of
complicated piles?
__________________________________________________________________
Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each
15. .......................... out of every ten people aged over 40 have some degree of hemorrhoidal
disease.
16. Hemorrhoids develop from pads of ........................... around the anal canal.
17. An ............................ examination should be done to exclude other possible conditions.
18. ................................. of chemicals is used to reduce the size of hemorrhoids.
19. People who are overweight, pregnant or .......................... are more liable to develop
hemorrhoids.
20. Surgical intervention is indicated in cases of ............................. and ..............................
degree hemorrhoids.
END OF PART A

In this part of the test, there are six short extracts relating to the work of health professionals. For
questions, 1-6, choose the answer (A, B or C) which you think fits best according to the text.
Questions 1-6
1.The guidelines establish that:
A-The student should always be under supervision when performing high risk procedure.
B-The student should not be under supervision when performing naso-gastric tube
insertion.
C-A student who is uncomfortable with performing a simple procedure, should be forced
to do it in order to learn properly.
Students performing high risk and most moderate risk procedures should
always be supervised. Exceptions would be NG tube placement and
suturing. A student who wants to be supervised for any procedure should
be, and no student who feels uncomfortable should ever be made to feel
pressured to do it without supervision.

A-Only the patient has the right to or not to perform the procedure.
B-The doctor should advice the patient against performing the procedure.
C-Refusing to do the procedure is a decision that a doctor can make even if the patient
is refusing this decision.
The medical practitioner who will perform the procedure should discuss
other options with the patient, including medical procedures or treatment
offered by other health practitioners and the option of not having the
procedure. A medical practitioner should decline to perform a cosmetic
procedure if they believe that it is not in the best interests of the patient.
3.This policy states that in case of overpayment by the organization:

A- Initiation of recovery should be made within 45 days.
B- refund should be made within 24 months.
C-The organization may overcharge you on the next payment you make.
In the event of any overpayment, duplicate payment, or other payment

by us in excess of the member's benefits payable according to the
member's benefit plan ("Overpayment") and all Blue Cross NC policies,
you shall promptly remit the overpayment to Blue Cross NC. In addition
to other remedies, if within forty-five (45) days of a request for a refund
by us, the requested refund has not been made we may recover the
overpayment amount by offset of future amounts payable to you.
Neither Blue Cross NC nor you may initiate recovery of overpayments
or underpayments, respectively, any later than twenty-four (24) months
after the date of the original claim payment with the following
exceptions: Fraud, misrepresentations and other intentional misconduct
4.The allowance is:

A- 100% for the first lower limb X-ray performed for the patient.
B- 80% for the third ECHO performed for the patient.

C- 75% for the second fundoscopy performed for the patient.
When multiple diagnostic cardiovascular services are performed during the same
outpatient patient session, the allowance for the technical component of the
primary procedure is 100%. The allowance for the technical component of the
second and each subsequent imaging procedure is 75%. When multiple diagnostic
ophthalmology services are performed during the same outpatient patient session,
the allowance for the technical component of the primary procedure is 100%. The
allowance for the technical component of the second and each subsequent
imaging procedure is 80%. The multiple procedure payment reduction on
diagnostic imaging applies when multiple services are furnished by the same
physician or physicians in the same group practice, to the same patient, in the
same session, on the same day. The allowance for the technical component of the
primary procedure is 100%. The allowance for the technical component of the
second and each subsequent imaging procedure is 50%.

A- The device automatically downloads your HR and BP to the computer.
B- The device automatically measures your HR and BP when turned on.

C- When measured, systolic BP number flashes on the top left corner of the monitor.
The Colin STBP-780 is an automated electronic heart rate and blood pressure (BP) monitor
capable of accurate readings at rest and during exercise. The unit assesses heart rate via
wires connected to four electrodes placed on the thorax and abdomen. Blood pressure is
assessed during deflation of the cuff via two microphones in the cuff. The front display
provides clear, easy to read measurements of heart rate, systolic and diastolic BP, elapsed
time, and error messages. When turning the system on, a Self-Check is performed
automatically. The field for the systolic blood pressure at the top left corner of the blood
pressure monitor displays an estimate of systolic BP during deflation.
This number flashes as the measurement is being taken. Once the systolic and diastolic
blood pressure and the heart rate are measured, all three values are displayed on the
monitor and downloaded to the computer screen and system database during the test.
6. According to the extract, choose in INCORRECT answer:

A-The endoscope cannot withstand repeated cycles of sterilization.
B-Flexible endoscopes are easier to clean when compared to fixed ones.
C- Data that is available to assess the efficiency of sterilization over HLD is not enough.
Traditionally, sterilization of endoscopes and accessories has been indicated for the rare
occasions when they are to be used as critical medical devices, when there is a potential
for contamination of an open surgical field.
Sterilization can be achieved by using a variety of methods, including ethylene oxide gas
treatment, and it can be achieved with appropriately long exposure to liquid chemical
germicides. Because of the complexity of the instrument channel design, sterilization of
flexible endoscopes is difficult to accomplish. In addition, endoscope durability and
function are potentially compromised with repeated cycles of sterilization. Users report
that endoscopes experience a shortened use life because of material degradation issues
when processed repeatedly in ethylene oxide. Because of these factors as well as a lack of
data for demonstrable benefits to the further reduction in endoscope bacterial spore
counts achieved by sterilization instead of HLD, sterilization with ethylene oxide is not
recommended over HLD for standard GI endoscopes.
However, an FDA-cleared liquid chemical sterilant processing system has been approved
to provide sterilization of cleaned, immersible, reusable, and heat- sensitive critical and
semi critical medical devices.
Text1: Building a human heart in a dish
Stem cell transplants smell like creamed corn, apparently. Petras learned this as he was
undergoing treatment for non-Hodgkin's lymphoma. He'd already received chemotherapy
to kill the cancerous cells coursing through his lymphatic system, but the disease had
bounced back. The best option to save his life was to carpet-bomb his immune system —
killing the cancer-ridden cells alongside the healthy ones — then reboot it with a
transplant of healthy bone marrow stem cells harvested before the treatment. The
approach is a modern take on the oldest form of stem cell therapy, namely bone marrow
transplants, the first of which was performed nearly half a century ago. Since then, stem
cell scientists have been working to understand just what stem cells are, how to control
them, and — most importantly — what can be done with them.
At the recent International Society for Stem Cell Research conference in Melbourne, stem
cells showed they are ready for prime time. "There was a big buzz because it was really
clear that this is now moving to translation, and that's very exciting," says Melissa Little,
program leader of Stem Cells Australia and head of the Kidney Research laboratory at the
Murdoch Children's Research Institute. "I'm really pleased to see over the 16 years that
this society has existed, that we've moved from a fundamental fascination with what a
stem cell is, and what it can do, to clinical trials, which is an amazing outcome in a pretty
short period of time."
Stem cells are the cells from which every other cell in the body originates. They are the
progenitors of every cell type including heart muscle cells, neurons, bone marrow cells,
skin cells — even the light-sensitive cells at the back of your eye. For a long time, embryos
were the only source of stem cells. Then in a Nobel prize-winning discovery in 2006,
Japanese scientist Shinya Yamanaka and colleagues took ordinary adult skin cells and
reprogrammed them back into the most basic form of stem cell — a pluripotent stem cell.
This discovery opened up the field of stem cell science. Now stem cells could be created
from adult skin cells, then turned into whatever cell type was needed, such as
cardiomyocytes for hearts, glial cells for brains, islet cells for the pancreas, even the cells
that make teeth and bone. But contrary to the promises made by the countless
unregulated clinics that have sprung up like mushrooms after rain, offering a host of
untested and dubious treatments, stem cell medicine is still very much in its infancy. Well-
tested and research-proven stem cell-based treatments are only just beginning to emerge
on the market. But not far behind are potentially game-changing treatments for
everything from age-related macular degeneration and Parkinson's disease to type 1
diabetes and HIV infection.
So-called "autologous" stem cell transplants — transplants using a patient's own stem
cells, such as bone marrow stem cells — are well-established as part of treatment for
cancers such as lymphoma and myeloma. But these transplants are also being taken in
extraordinary new directions with gene-editing technologies. Last year, Italian doctors
treated a young Syrian refugee with skin grafts derived from his own stem cells. However,
the cells had also been engineered to correct the genetic mutation responsible for a
devastating blistering disease called junctional epidermolysis bullosa. At the time of
treatment, the boy had lost around 80 per cent of the skin on his body because of the
disease. But the skin grafts took, grew and now behave just like healthy skin should. In the
United States, a trial is currently underway in people with HIV. The aim is to reboot their
immune systems with their own harvested stem cells. But these cells have been
engineered to resist infection with HIV by introducing a genetic mutation to the receptor
that HIV uses to gain access to the cells.
Autologous stem cell treatments, however, are very costly and labour-intensive, as they
require effectively creating a new treatment for every single patient. A more attractive
possibility is allogeneic stem cell treatments, which use donor cells that are selected or
engineered so as not to trigger the recipient's immune response.
Australian biotech company Mesoblast has developed a donor stem cell-based treatment
for graft-versus-host disease, a potentially deadly side effect of organ and bone marrow
transplants.
Their product, which is licensed in Japan and recently completed advanced clinical trials
for the US Food and Drug Administration (FDA), uses a class of stem cells that are invisible
to the immune system. One effect of these mesenchymal stem cells, as they're known, is
to dampen down the patient's immune reaction against their transplant. One of the most
exciting medical applications for stem cells is to replenish adult cells that have been lost
to disease, damage or simply old age. Earlier this year, British scientists managed to grow
cells from the back of the eye in a dish, using stem cells derived from embryos. These
retinal cells were implanted into the eyes of two people with age-related macular
degeneration, a leading cause of blindness. The patches grafted successfully, and both
patients showed significant improvements in their eyesight. Another application still a
few years from clinical trials is using stem cells to regrow the insulin-producing cells of the
pancreas in people with type 1 diabetes, a disease in which the body's immune system
attacks and destroys those cells. Researchers are also working on how to use stem cells to
replace damaged heart muscle cells, and regrow injured or defective brain cells or liver
cells, to name just a few examples. Further down the track, it's even foreseeable that a
patient with a new diagnosis will have some skin cells taken, stem cells grown from them,
and a model of the affected system or organ developed in a dish so that it can be used to
test which drug that person is most likely to respond well to.
Text 2: Anxiety has a cost, but can also be a power for good
Anxiety doesn't recognize class or race. It ignores age and gender. And it gives no
deference to talent, wealth or perceived success. A popular blogger, a media
celebrity, but still at odds with the demands of the life she has chosen, Sarah talked
of the terrible toll taken by modern life: "Anxiety is on the increase. We are
overstimulated. "We used to have boundaries, and we had cultural mores and
structures that protected us from these kinds of primal blowouts. "We had a
Sabbath because we all had an understanding that we needed a day of rest just to
be able to cope with the toil of hoeing a field, and also to spend time with family;
and we had set bedtime hours and we had set work hours. There were boundaries
that were placed by our culture and structures. That has gone out the window in
literally less than a generation." In the past Sarah shut herself away, taking time off
from the outside world — a forced retreat. But her new way of dealing with her
anxiety is to embrace it. To acknowledge its dangers, to be wary, and then to try to
harness it to her advantage as a tool for positive change.
A bit of anxiety in the right place at the right time could be a positive thing, agreed
Black Dog Institute clinical director Josephine Anderson — within limits. "A little
anxiety, for example, will generally improve our performance — whether it's running
a race, working to a deadline or performing at a writers' festival — and of course,
the flight or fight response saves lives every day. "But too much anxiety can really
get in the way of our doing what we want or need to do. "When anxiety threatens to
overwhelm our minds, then doing something mindful — meditating, exercising,
writing, for example — can help us focus, calm and filter out distracting, distressing
anxiety-driven thoughts."
For acclaimed British novelist, Matt Haig, catastrophic thinking, brought on by

anxiety, has been a lifelong burden. "It's a total vicious circle, this is a total mental
illness thing. The human brain, said Haig, struggles to make sense of our frenetic
and chaotic world, where enough is never enough. "We are still essentially cave
people. We haven't actually evolved for 30,000 years, and we are all trying to run
the software of 21st century society on our systems and we need to switch
ourselves off-and-on again a few times. We live ever more unnatural lives, he said,
and often the best solution is to declutter, to undertake what he calls a "life-edit".
"We are in an overloaded world and an overloaded culture and we've got
overloaded lives," he said. When people look for a solution to things, they are
often wanting something to be added into their life, but if you are in an overloaded
culture, the solution is often just taking things away
For first-time novelist Jarrah Dundler, being a finalist in this year's Vogel Australian
literary award brought pain, as well as a sense of achievement. A feeling of anxiety
along with the accolade. But that was to be expected. His novel Hey Brother
centers on a cast of characters dealing with the complexities and frustrations of
mental illness; and as a peer-support mental-health worker, he has his own and
others' experiences to draw upon. His personal experience of anxiety centers on
fixation, where thoughts get "stuck in his head" and become so exaggerated and
urgent that they often lead to physical, as well as mental illness: "I can be stuck on
something for a week, and that's the only thing I can focus on. "For whole days
that's all I'm thinking of. Insane stuff and really getting completely worked up about
it." Jarrah lives and works in regional northern New South Wales. He acknowledged
a change in the way society now deals with mental illness, but there's still a stigma.
For Jarrah, like Sarah and Matt, writing about mental illness is as much a form of
therapy as it is a literary decision. "I can't write when I'm depressed, I can't write
when I'm anxious. I can try but ... so it helps for me because I get a lot out of
writing, like the buzz from when you are writing. "It's also a very mindful activity.
When you are in the flow of writing, you are lost, and your mind is occupied on
something, focused on something." But anxiety, he said, is never far away. A last-
minute decision by his publisher to change the name of his book saw him spiral into
catastrophism.
Michael Abelman comes from a farming background, but his career has morphed
over the years into what his website calls "social enterprise" work. It's the largest
such urban farming scheme in North America. And as he told it, it's about
producing healthy, affordable food, reconnecting with the environment and helping
the disadvantaged deal with their anxiety and mental health.
"It's where the term 'Skid Row' was actually coined," he explained. "It's about 20
square blocks, entirely inhabited by folks who are dealing with long-term addiction,
mental illness and material poverty." "I'm not a mental health professional,
addiction expert or social worker," said Abelman. "We produce 25 tons of food on
four acres of pavement, and we do it with the hands of people that no one ever
expected could accomplish anything. These are the untouchables. "These are
people that you see in broad daylight on the sidewalks with a needle in their arm or
pirouetting in the middle of the street high on crack. And yet, this work has
provided a reason for people to get out of bed each day, kind of a touchstone, a
place to go." Echoing the words of Sarah Wilson, he described anxiety as a gift:
"For me anxiety has been the trigger, the thing that gets me up every day and
gets me out there doing good work. "And if I didn't feel that way, I probably would
not get out of bed." Dr Anderson from the Black Dog Institute urged people not to
try to weather anxiety disorders alone. "It's important to remember that anxiety
disorders are common and can be severe and impairing," she said. "If, despite
your best efforts, anxiety is interfering with your life or your relationships, then it's
important to get help. There are many effective treatments available so don't delay
— speak to your GP and or your mental health professional."
7. In the first paragraph, what was the best option that was used to save Petras' life?
Ⓐ Repeated cycles of chemotherapy
Ⓑ Sacrificing his immune cells to achieve a greater purpose
Ⓒ Targeting the cancerous cells more aggressively
Ⓓ Bone marrow transplantation from a donor
8. In the second paragraph, the reason behind Melissa Little cheering up is
Ⓐ The application of theoretical concepts
Ⓑ The great impact of the use of stem cells
Ⓒ The international co-operation
Ⓓ Exciting cure rates and outcomes

9. In the third paragraph, what do we learn about stem cells?
Ⓐ Skin is the only source to harvest them
Ⓑ Pluripotent stem cells are highly specialized
Ⓒ Embryos are no longer used as sources of stem cells
Ⓓ Stem cells are precursors for skin cells
10.The writer uses the phrase sprung up like mushrooms after rain to state
that these clinics are emerging
Ⓐ Suddenly and rapidly
Ⓑ without certain plans
Ⓒ illegally
Ⓓ in a way that is not organized
11. According to the fourth paragraph, gene-editing technologies had already been
used is the field of
Ⓐ Trans-species bone marrow transplantation
Ⓑ Preventive medicine
Ⓒ Infection control
Ⓓ Dermatology
12. In the fifth paragraph, the writer states that using the patient's own stem cells is
Ⓐ Unaffordable
Ⓑ Non-effective
Ⓒ Non-efficient
Ⓓ unavailable
13. In the fifth paragraph, the writer is particularly impressed by
Ⓐ The ability to renew damaged cells
Ⓑ Implanting embryonic derived stem cells into a diseased eye
Ⓒ Our ability to treat type 1 DM
Ⓓ Our ability to replace damaged cardiac tissues
14. In the final paragraph, The word foreseeable means
Ⓐ unexpected
Ⓑ hoped
Ⓒ needless to say
Ⓓ being studied
15.In the first paragraph, What does Sarah think is the reason behind the increased
prevalence of anxiety in society?
Ⓐ Increased life demands.
Ⓑ Loss of consistent cultural structure.
Ⓒ Lack of sufficient rest.
Ⓓ Not spending enough time with family.
16. In the first paragraph , The word it refers to
Ⓐ The new way
Ⓑ Dangers
Ⓒ Anxiety
Ⓓ Advantages
17. In the second paragraph, Josephine Anderson believes that anxiety might be vital to
Ⓐ Win at sport competitions
Ⓑ Finish duties on time
Ⓒ Get to a hyperarousal protective state
Ⓓ None of the above

18. Matt Haig believes that the best way to solve the problem is by
Ⓐ Addressing the problem more clearly
Ⓑ Changing the approach that we adopt to solve it
Ⓒ Seeking perfection
Ⓓ Not trying to fight it
19.That in the fourth paragraph refers to
Ⓐ winning the award
Ⓑ his sense of achievement
Ⓒ being a finalist
Ⓓ being anxious
20. According to Jarrah, what is it about writing can temporarily relieve anxiety?
Ⓐ Writing down the thoughts that bother you.
Ⓑ Providing a way to divert attention.
Ⓒ Providing a sense of purpose
Ⓓ A way to escape the stigma brought on by society.

15. Six
16. tissue
17. abdominal
18. Injection
19. constipated
20. 3rd and 4th
1. A
2. C
3. C
4. A
5. A
6. B
07. B
08. A
09. D
10. A
11. D
12. C
13. A
14. C
15. B
16. C
17. C
18. B
19. D
20. B
21. D
22. A
PART A -QUESTIONS
Questions 1-7
Questions 1-7
1. Studies about the effects of steroids on pregnancy?
2. Sun exposure and cancer?
3. What to do if you are concerned that you have a problem?

4. Comparison between hydroquinone and steroids?
5. Malignant melanoma in Wales?
6. Effects of radiation on the eyes?

7. Dermatologists stating the dangers of skin creams?
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.
8. What should be done when encountering a problem with a skin-lightning cream?
9. How many people die in Wales each year as a result of malignant melanoma?
_________________________________________________________________
10. What are the short term effects of radiation on the skin?
_____________________________________________________________________________________-
11. What is the cause of tanning of human skin?
________________________________________________
12. What is the effect of steroids on the placenta?
_________________________________________________
13. Who has done the survey about the opinions of dermatologists on the matter?
_________________________________________________
14. How was the incidence rate of malignant melanoma in Wales in 1996 in comparison to 2006?
_______________________________________________________________________________
Questions 15-20
15.Some sorts of skin lighteners may have .................. systemic effects.
16.Steroids can be useful in treating some skin conditions such as ................. and .......................
17.Over exposure to .................... through sunbeds increases the risk of developing skin cancer.
18. Mutation to the ................... through UV radiation can cause cancer.
19.The use of high dose steroids can cause a lot of problems if its use is .......................
20...................................... infants may be a consequence of using steroids.
END OF PART A
professionals. For questions, 1-6, choose the answer (A, B or C) which you think fits best
according to the text.
Questions 1-6
1. The guidelines establish that:
A- The student should always be under supervision when performing a procedure.
B- How dangerous the procedure is, determines the appropriate supervision that is
required.
C- A student should be under supervision by a fellow when performing a phlebotomy
for the first time.
The first time any procedure is performed on a patient, the student should be
adequately and appropriately supervised. What constitutes adequate and appropriate
supervision depends on the level of risk of the procedure. For example, phlebotomy
or IV placement could be supervised by an intern or a nurse, but central line or
arterial line placement should be supervised by a fellow or highly experienced
resident. In all cases, the supervisor should have a level of expertise with the
procedure that allows him or her to perform it comfortably and independently.

A- The patient's agent is the one who performs the procedure.
B- Patient's consultations should be with a medical practitioner.
C- A patient advisor is not a registered health practitioner.

The patient’s first consultation should be with the medical practitioner who will
perform the procedure or another registered health practitioner who works with the
medical practitioner who will perform the procedure. It is not appropriate for the
first consultation to be with someone who is not a registered health practitioner –
for example, a patient advisor or an agent
3. The medical policy states that Ambulatory monitors could:
A- Only be used to monitor asymptomatic patients with the risk of arrhythmia.
B- Be used to monitor the effect of therapy.

C- Not be covered to avoid heat.
"When not Covered" section revised to state: "Other uses of ambulatory event
monitors, including outpatient cardiac telemetry and mobile applications, are
considered investigational, including but not limited to monitoring asymptomatic
patients with risk factors for arrhythmia, monitoring effectiveness of antiarrhythmic
therapy and detection of myocardial ischemia by detecting ST segment changes."
Policy guidelines and references updated. Policy noticed 6/8/18 for effective date
8/10/18. Medical Director review.

A- Cimzia may be given to treat active rheumatoid arthritis.
B- Cimzia may be given to treat Crohn's.

C- Cimzia may be given instead of conventional therapy.
Cimzia (certolizumab pegol) for subcutaneous injection may be considered

medically necessary for adult patients to reduce signs and symptoms of Crohn's
disease and to maintain clinical response in adults with moderately to severely
active disease who have had inadequate response to conventional therapy; for
treatment of adults with moderately to severely active rheumatoid arthritis, active
psoriatic arthritis or active ankylosing spondylitis.

A- WHO Patient Safety develops recommendation to insure patient's safety.
B- Gathers experts from all-over the globe.

C- Hand hygiene is the primary measure to reduce the risk of infectious diseases.
Hand hygiene is a primary measure to reduce infections, including CLABSIs. A

core part of WHO Patient Safety work is related to Global Patient Safety
Challenges. These challenges are international campaigns that bring together
expertise and evidence on important aspects of patient safety.
Recommendations are developed to ensure the safety of patients receiving care
globally. WHO Patient Safety works to make these recommendations widely
available and provides tools to implement the recommendations in a variety of
health care settings worldwide.
6.The contents of the INS published guidelines include:

A- The choice of the type of the device.
B- The choice of the site of insertion.
C- A framework for doctors in order to guide clinical practice.
The INS publication Infusion Nursing Standards of Practice provides a framework

that guides clinical practice. The standards are used to define and develop
organizational infusion-based policies and procedures for all practice settings. The
comprehensive contents include standards of nursing practice and patient care
practices, vascular access device selection and placement, use of access devices, site
care and maintenance, and infusion-related complications.

In this part of the test, there are two texts about different aspects of healthcare. For
questions, 7-22, choose the answer (A, B, C or D) which you think fits best
according to the text.
Text1: Understanding OCD
Obsessive-Compulsive Disorder (OCD) is a surprisingly common psychological
problem. Only 25 years ago, it was believed to be a relatively rare condition. In part,
owing to newer and more effective treatments for it, OCD is now known to affect many
millions of people at any given time. If left untreated, in most cases, OCD can
straightjacket a person's life with immobilizing anxiety. What's worse, many people
with OCD will develop depression that not only intensifies suffering, but often
complicates and lengthens treatment. Nevertheless, as debilitating as it can be, when
treated with skillfully done, cognitive-behavior therapy (CBT) that
emphasizes a crucial method called exposure and response or ritual prevention
(ERP), OCD's anxiety and depression producing grip can be significantly loosened.
In general terms, the main features of OCD are intrusive, horrific, and relentless
irrational thoughts or images (obsessions) that drive tremendous anxiety and specific,
usually excessive, repetitive, or unrelated behaviors (compulsions) that are
performed in an effort to neutralize or reduce the anxious thoughts, feelings and
sensations. In essence, when someone has OCD his or her brain's danger detection
region is hypersensitive and dramatically overreacts to certain triggers thus launching
a massive, often panic level, anxiety attack (i.e., an exaggerated or inappropriate fight
or flight reaction). At the same time, the brain region that usually indicates safety is
very sluggish, and slow to signal the "all's clear." Hence, the OCD sufferer will
experience needless or greatly exaggerated surges of intense anxiety related to
terrifying, irrational thoughts that drive him/her to engage in rituals in an effort to drive
down anxiety and restore feelings and sensations of safety. In other words, since the
person's "automatic" safety signaler is very slow to relieve anxiety, he or she will try
to do it "manually" with a ritual. In the long run, however, rituals don't work
consistently to reduce anxiety due to a process called "negative reinforcement" that,
ironically, further energize the brain's anxiety triggers and makes its safety signaler
even weaker and slower.
Neuroimaging studies using PET scans have identified several hypermetabolic, brain
structures that are almost always associated with OCD. Specifically,
a neural pathway referred to as the supraorbital-cingulate-thalamic circuit - the SOCT
circuit - appears overactive in brain scans of people with OCD. Interestingly, when
OCD sufferers were randomly given either an SSRI or underwent intensive CBT for
OCD with exposure and ritual prevention, those who improved significantly had
follow up PET scans that showed much less activity in their SOCT circuit. Thus,
regardless of whether or not the person got better through CBT or took medication,
both therapies produced essentially the same result on brain activity.
As it was with our remote ancestors, our recognition of danger and safety involves at
least three psychological dimensions - namely, cognitive appraisal (thoughts and
images about the situation), emotional activation (feelings of danger and/or safety),
and sensory stimulation (viscerally sensing the danger or the safety). Usually,
people are good at discriminating between the psychological experience of danger
and safety. That is, we typically experience congruence among these psychological
zones. Therefore, when we perceive safety, we have no significant anxious or
intrusive thoughts, dreadful emotions, or anxious sensations. Our minds, moods, and
sensations are all in alignment and reflect a deep feeling of safety and security in the
situation. And when we perceive actual danger, we usually have worries about the
situation, fearful feelings, and a lot of nervous system arousal that results in various
physical sensations of anxiety, such as muscle tension, clenching gut, dry mouth,
racing heart, rapid breathing, shaking, sweating, etc.
People suffering with OCD try to achieve a specific, physical sensation of safety and
have great difficulty grasping factual safety. For example, a person who feels dirty or
contaminated might wash extensively, far beyond the point of actual
cleanliness. Thus, someone with [this specific type of] OCD will wash (and wash, and
wash) until he/she senses and feels clean even if takes a long, long time to achieve
the desired sensation. In most cases, especially when the illness is first developing,
the person will eventually feel clean enough (i.e., safe from germs, disease, toxins,
etc.) at which time the ritual stops. Unfortunately, as mentioned above, this only
strengthens anxiety and other OCD symptoms because of a process called negative
reinforcement.
Text 2: Addressing the Tuberculosis Epidemic
Tuberculosis (TB) is the leading cause of infectious disease mortality and continues to
be a major challenge to global health. Each day, roughly 5000 people die of TB
disease, resulting in nearly 2 million deaths in 2016 alone. More than 1 billion people
died from TB during the last 200 years, more deaths than from malaria, influenza,
smallpox, HIV/AIDS, cholera, and plague combined. Recently, the global health
community intensified efforts to end TB as a global health scourge. The broad global
strategy to confronting and halting the TB epidemic involves a multifaceted approach,
and biomedical research is a key component of that strategy. Despite considerable
progress in preventing, diagnosing, and treating TB using the current armamentarium
of tools (most are decades old), substantial gaps exist in the current understanding of
the pathogenesis of TB disease and in applying modern scientific advances to the
goal of ending this global health scourge. Although the pathogenesis of this ancient
disease has been studied for 200 years, current TB drugs and the only available
vaccine are inadequate.
Diagnosing TB remains a significant challenge, and each year an estimated 4 million

new TB cases remain undiagnosed.1 Current diagnostics typically require expensive
equipment and highly trained personnel unavailable in many high-burden TB areas
and may be unsuitable for diagnosis in some populations, including children and
PLWH. Current tests are also generally unable to detect drug-resistant and non
pulmonary TB cases or infections with low numbers of MTB. In addition, a clear
understanding of TB latency and what drives progression to active disease is lacking,
as are data on host- pathogen dynamics underlying pathogenesis or the
pharmacokinetic and pharmacodynamics properties of existing drugs.
To address these and other gaps and to facilitate the development and application of
emerging technologies to TB, the National Institute of Allergy and Infectious Diseases
(NIAID) at the US National Institutes of Health has developed a TB research strategic
plan outlining a multipronged effort to address fundamental TB research questions and
to stimulate applied research and the clinical translation of promising diagnostic,
therapeutic, and vaccine candidates. Developed to complement the World Health
Organization End TB Strategy, the US Government Global TB Strategy, and the
National Action Plan for Combating Multidrug-Resistant Tuberculosis, the NIAID
Strategic Plan for Tuberculosis Research builds on current efforts and focuses on
some strategic priorities critical to giving TB research a 21st century footing.
There is a compelling need to develop rapid, accurate, and inexpensive point-of-care

diagnostics for different forms of TB and for use in all populations. NIAID will support
research on state-of-the art approaches and emerging technologies and will identify
host and microbial biomarkers or bio signatures that can be integrated into platforms
that diagnose infection, indicate risk of progression, or predict disease recurrence.
These efforts will leverage existing clinical infrastructure, study protocols, and clinical
cohorts.
Expanding the existing repertoire of TB research resources will play a major role in
the implementation of the NIAID Strategic Plan for Tuberculosis Research. Access to
biosafety level 3 facilities and infrastructure as well as databases to facilitate the
analysis and sharing of large, diverse data sets derived from systems biology and
“omics” approaches are critical to answering fundamental questions in TB research.
NIAID will foster opportunities for early-stage investigators to assume their role as the
next generation of TB researchers, ensure continuity, and bring fresh perspective to
the field. NIAID also will support improved animal models that recapitulate human
disease and will promote expansion of preclinical and clinical capacity, including
human cohorts. In addition, NIAID will facilitate the development of assays, reagents,
and other tools to assess diagnostic, therapeutic, and vaccine candidates in the
developmental pipeline.
7.What do we learn about OCD in the first paragraph?
Ⓐ Its prevalence has been increasing for the past 25 years
Ⓑ Greater awareness of its significance has developed recently.
Ⓒ Its manifestations take time to become apparent
Ⓓ OCD is the reason why people develop anxiety
8.In the second paragraph, the writer is saying that compulsions are
Ⓐ solution to the problem
Ⓑ intrusive thoughts
Ⓒ part of the problem
Ⓓ behavioral treatment
9.In the third paragraph, the writer states that OCD is …………..………………….. Problem
Ⓐ a functional
Ⓑ a structural
Ⓒ a sensational
Ⓓ an overestimated
10. In the third paragraph, the word its refers to
Ⓐ Anxiety
Ⓑ Triggers
Ⓒ The brain
Ⓓ Safety signaler
11. What particularly impressed the writer regarding the study in the fourth paragraph?
Ⓐ The importance of medication in treating OCD
Ⓑ The anatomical changes of a region of the brain
Ⓒ The brain's response to treatment
Ⓓ The almost equal effectiveness of both medication and psychotherapy
12. What do we learn about danger and safety in the fifth paragraph?
Ⓐ How to act when we perceive danger

Ⓑ The exact mechanism that the brain uses to respond to safety
Ⓒ The exposure response prevention cycle

Ⓓ Typical psychological patterns
13. In general, the desired sensation to an OCD patient is being
Ⓐ safe
Ⓑ clean
Ⓒ anxious
Ⓓ dirty
14. In the final paragraph, excessive washing as an act is considered to be
Ⓐ an obsession
Ⓑ a compulsion
Ⓒ a delusion
Ⓓ the process of negative reinforcement
15. In the first paragraph, what does the writer believe to be the cause behind the inability to end this epidemic
Ⓐ Lack of understanding of the disease's nature.
Ⓑ The need for more advanced tools.
Ⓒ The high rate of mortality that is associated with the disease.
Ⓓ The disease being untreatable with the current medication.

16. In the first paragraph, the word scourge was mentioned twice. What does it mean?
Ⓐ Plan
Ⓑ Initiative
Ⓒ Affliction
Ⓓ Interest
17.In the second paragraph, which of the following is NOT mentioned as a reason why a large number of
TB cases remain undiagnosed?
Ⓐ Lack of complete understanding of the pathophysiology of the disease
ⒷLack of complete understanding of the effect of the drug on the organism
Ⓒ Socioeconomic barriers
Ⓓ The organism being resistant to treatment
18. The NIAID research aims to

Ⓐ build a strategy to compact drug-resistant TB
Ⓑ develop technologies to halt the prevalence of infectious diseases
Ⓒ go for the clinical application of some theoretical data
Ⓓ eradicate TB by the end of the 21st century.
19. Developed in the third paragraph refers to
Ⓐ the US Government Global TB Strategy

Ⓑ the NIAID Strategic Plan
Ⓒ the National Action Plan for Combating Multidrug-Resistant Tuberculosis
Ⓓ the World Health Organization End TB Strategy
20. According to the fourth paragraph, improved diagnostic tools are important to develop greater awareness
of
Ⓐ The prognosis of the disease.
1. B
2. C
3. B
4. A
5. A
6. A
07. B
08. C
09. A
10. C
11. C
12. D
13. A
14. B
15. A
16. C
17. D
18. C
19. B
20. A
21. D
22. A
Levels of sedation as described by the American Society of Anesthesiologists
Non-dissociative sedation
 Minimal sedation and analgesia: essentially mild anxiolysis or pain control.
Patients respond
normally to verbal commands. Example of appropriate use: changing burns
dressings
 Moderate sedation and analgesia: patients are sleepy but also aroused by
voice or light
touch. Example of appropriate use: direct current cardioversion
 Deep sedation and analgesia: patients require painful stimuli to evoke a
purposeful response. Airway or ventilator support may be needed.
Example of appropriate use: major joint reduction
 General anesthesia: patient has no purposeful response to even
repeated painful stimuli. Airway and ventilator support is usually
required. Cardiovascular function may also be impaired. Example of
appropriate use: not appropriate for general use in the emergency
department except during emergency intubation.
Dissociative sedation
Dissociative sedation is described as a trance-like cataleptic state
characterised by profound analgesia and amnesia, with retention of protective
airway reflexes, spontaneous respirations, and cardiopulmonary stability.
Example of appropriate use: fracture reduction.
Drug administration: General principles

International consensus guidelines recommend that minimal sedation – for
example, with 50% nitrous oxideoxygen blend – can be administered by a
single physician or nurse practitioner with current life support certification
anywhere in the emergency department. Guidelines recommend that for
moderate and dissociative sedation using intravenous agents, a physician
should be present to administer the sedative, in addition to the practitioner
carrying out the procedure.
For moderate sedation, resuscitation room facilities are recommended, with
continuous cardiac and oxygen saturation monitoring, non-invasive blood-
pressure monitoring, and consideration of capnography (monitoring of the
concentration or partial pressure of carbon dioxide in the respiratory gases).
During deep sedation, capnography is recommended, and competent personnel
should be present to provide
cardiopulmonary rescue in terms of advanced airway management and advanced
life support.
Drugs used for procedural sedation and analgesia in adults in the emergency department
Class Drug Dosage Advantages Cautions
Opioids Fentanyl 0.5-1 µg/kg Short acting May cause apnoea,

over 2 analgesic; reversal respiratory depression,
mins agent (naloxone) bradycardia, dysphoria,
available muscle rigidity, nausea and
vomiting
Morphine Slow onset and peak effect
50-100 µg/kg Reversal agent time; less reliable Difficult
Remifentanil then (naloxone);
to use without an infusion
0.8-1 mg/h prolonged analgesic
0.025-0.1 µg/kg/ pump
Ultra-short acting;
Min no solid organ
involved in
metabolic
clearance
Benzodiazepine Midazolam Small doses of Minimal effect on No analgesic effect; may
s 0.02-0.03 mg/kg respiration; reversal cause hypotension
until clinical agent
(flumazenil)
effect
achieved;
repeat
dosing of 0.5-1
mg total dose
with
≤
5mg
Volatile agents Nitrous 50% nitrous Rapid onset and Acute tolerance may
oxide 50%
oxideoxygen
- cardiovascular
recovery; and develop; specialised
mixture respiratory stability equipment needed
Propofol Propofol Infusion of 100 Rapid onset; short- May cause rapidly
µg/kg/min for 3- acting;
anticonvulsant deepening sedation, airway
5
min then properties obstruction, hypotension
reduce
to~50
Phencyclidines Ketamine µg/kg/min
0.2-0.5 mg/kg Rapid onset; short- Avoid in patients with history
over 2-3 min acting; potent of psychosis; may cause
analgesic even at nausea and vomiting
low doses;
cardiovascular
stability
Etomidate Etomidate 0.1-0.15 mg/kg Rapid onset; short- May cause pain on injection,
may re- acting; nausea, vomiting; caution
administer cardiovascular when using in patients with
stability
seizure disorders/epilepsy –
may induce seizures
PART A -QUESTIONS
Questions 1-7
Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may
use any letter more than once.
1 the point at which any necessary pain relief should be given?
2 the benefits and drawbacks of specific classes of drugs?
3 financial considerations when making decisions about sedation?
4 typical procedures carried out under various sedation levels?
5 measures to be taken to ensure a patient’s stability under sedation?
6 reference to research into alternative sedative agents?
7 patients’ levels of sensory awareness when sedated?
Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
answer
may include words, numbers or both.
8 What class of drug is traditionally administered together with opioids for the purpose of
procedural sedation?
9 What level of sedation is appropriate for changing burns dressings?
10 What is the only emergency department procedure for which it is appropriate to use
general anaesthesia?
11 What procedure may be carried out under dissociative sedation?
12 What class of drugs is unsuitable for patients who have a history of psychosis?
13 What opioid drug should be administered using specific equipment?
14 What is the maximum overall dose of Midazolam which should be given?
Questions 15-20
15] The majority of sedative drugs are administered via the_________ .
16] General anaesthesia is the one form of sedation under which patients may have reduced
________________
17] Patients under minimal sedation will react if they are given_________ .
18] Care should be taken when administering Etomidate to patients who are likely to have
____________
19] It may be helpful to use capnography to keep track of patients’ _________________

levels during moderate sedation.
20] Fentanyl, Morphine and Midozolam each have a__________________ which is used to
cancel out the effects of the drug.
END OF PART A
Questions 1-6
1. The manual states that the wheelchair should not be used
inside buildings.
without supervision.
on any uneven surfaces.
Manual extract: Kuschall ultra-light wheelchair
Intended use
The active wheelchair is propelled manually and should only be used for independent or
assisted transport of a disabled patient with mobility difficulties. In the absence of an assistant,
it should only be operated by patients who are physically and mentally able to do so safely
(e.g., to propel themselves, steer, brake, etc.). Even where restricted to indoor use, the
wheelchair is only suitable for use on level ground and accessible terrain. This active
wheelchair needs to be prescribed and fit to the individual patient’s specific health condition.
Any other or incorrect use could lead hazardous situations to arise.
2. These guidelines contain instructions for staff who
need to screen patients for MRSA.
are likely to put patients at risk from MRSA.
intend to treat patients who are infected with MRSA
MRSA Screening guidelines
It may be necessary to screen staff if there is an outbreak of MRSA within a ward or

department. Results will normally be available within three days, although occasionally
additional tests need to be done in the laboratory. Staff found to have MRSA will be given
advice by the Department of Occupational Health regarding treatment. Even minor skin sepsis
or skin diseases such as eczema, psoriasis or dermatitis amongst staff can result in
widespread dissemination of staphylococci. If a ward has an MRSA problem, staff with any of
these conditions (colonised or infected) must contact Occupational Health promptly, so that
they can be screened for MRSA carriage. Small cuts and/or abrasions must always be
covered with a waterproof plaster. Staff with infected lesions must not have direct contact with
patients and must contact Occupational Health.
3. The main point of the notice is that hospital staff
need to be aware of the relative risks of various bodily fluids.
should regard all bodily fluids as potentially infectious.
must review procedures for handling bodily fluids.
Infection prevention
Infection control measures are intended to protect patients, hospital workers and others in
the healthcare setting. While infection prevention is most commonly associated with
preventing HIV transmission, these procedures also guard against other blood borne
pathogens, such as hepatitis B and C, syphilis and Chagas disease. They should be
considered standard practice since an outbreak of enteric illness can easily occur in a
crowded hospital.
Infection prevention depends upon a system of practices in which all blood and bodily fluids,
including cerebrospinal fluid, sputum and semen, are considered to be infectious. All such
fluids from all people are treated with the same degree of caution, so no judgement is
required about the potential infectivity of a particular specimen. Hand washing, the use of
barrier protection such as gloves and aprons, the safe handling and disposal of ‘sharps’
and medical waste and proper disinfection, cleaning and sterilisation are all part of creating
a safe hospital.
4. What do nursing staff have to do?
train the patient how to control their condition with the use of an insulin pump
determine whether the patient is capable of using an insulin pump appropriately
evaluate the effectiveness of an insulin pump as a long-term means of treatment
Extract from staff guidelines: Insulin pumps
Many patients with diabetes self-medicate using an insulin pump. If you're caring for a
hospitalised patient with an insulin pump, assess their ability to manage self-care while in the
hospital. Patients using pump therapy must possess good diabetes self-management skills.
They must also have a willingness to monitor their blood glucose frequently and record blood
glucose readings, carbohydrate intake, insulin boluses, and exercise. Besides assessing the
patient's physical and mental status, review and record pump-specific information, such as the
pump's make and model. Also assess the type of insulin being delivered and the date when
the infusion site was changed last. Assess the patient's level of consciousness and cognitive
status. If the patient doesn't seem competent to operate the device, notify the healthcare
provider and document your findings.
5.The extract states that abnormalities in babies born to mothers who took salbutamol
are
relatively infrequent.
clearly unrelated to its use.
caused by a combination of drugs.
Extract from a monograph: Salbutamol Sulphate Inhalation Aerosol
Pregnant women
Salbutamol has been in widespread use for many years in humans without apparent ill
consequence. However, there are no adequate and well controlled studies in pregnant women
and there is little published evidence of its safety in the early stages of human pregnancy.
Administration of any drug to pregnant women should only be considered if the anticipated
benefits to the expectant woman are greater than any possible risks to the foetus.
During worldwide marketing experience, rare cases of various congenital anomalies, including
cleft palate and limb defects, have been reported in the offspring of patients being treated with
salbutamol. Some of the mothers were taking multiple medications during their pregnancies.
Because no consistent pattern of defects can be discerned, a relationship with salbutamol use
cannot be established.
6. What is the purpose of this extract?
to present the advantages and disadvantages of particular procedures
to question the effectiveness of certain ways of removing non-viable tissue
to explain which methods are appropriate for dealing with which types of wounds
Extract from a textbook: debridement:

Debridement is the removal of non-viable tissue from the wound bed to encourage wound
healing. Sharp debridement is a very quick method, but should only be carried out by a
competent practitioner, and may not be appropriate for all patients. Autolytic
debridement is often used before other methods of debridement. Products that can be
used to facilitate autolytic debridement include hydrogels, hydrocolloids, cadexomer
iodine and honey. Hydrosurgery systems combine lavage with sharp debridement and
provide a safe and effective technique, which can be used in the ward environment. This
has been shown to precisely target damaged and necrotic tissue and is associated with a
reduced procedure time. Ultrasonic assisted debridement is a relatively painless method
of removing non-viable tissue and has been shown to be effective in reducing bacterial
burden, with earlier transition to secondary procedures. However, these last two methods
are potentially expensive and equipment may not always be available.
Text 1: Cardiovascular benefits of exercise
Cardiovascular disease (CVD) is the leading cause of death for both men and
women in the United States. According to the American Heart Association
(AHA), by the year 2030, the prevalence of cardiovascular disease in the USA
is expected to increase by 9.9%, and the prevalence of both heart failure and
stroke is expected to increase by approximately 25%. Worldwide, it is projected
that CVD will be responsible for over 25 million deaths per year by 2025. And
yet, although several risk factors are non-modifiable (age, male gender, race,
and family history), the majority of contributing factors are amenable to
intervention. These include elevated blood pressure, high cholesterol, smoking,
obesity, diet and excess stress. Aspirin taken in low doses among high risk
groups is also recommended for its cardiovascular benefits.
One modifiable behaviour with major therapeutic implications for CVD is

inactivity. Inactive or sedentary behaviour has been associated with numerous
health conditions and a review of several studies has confirmed that prolonged
total sedentary time (measured objectively via an accelerometer) has a
particularly adverse relationship with cardiovascular risk factors, disease, and
mortality outcomes. The cardiovascular effects of leisure time physical activity
are compelling and well documented. Adequate physical leisure activities like
walking, swimming, cycling, or stair climbing done regularly have been shown
to reduce type 2 diabetes, some cancers, falls, fractures, and depression.
Improvements in physical function and weight management have also been
shown, along with increases in cognitive function, quality of life, and life
expectancy.
Several occupational studies have shown adequate physical activity in the

workplace also provides benefits. Seat-bound bus drivers in London
experienced more coronary heart disease than mobile conductors working on
the same buses, as do office-based postal workers compared to their
colleagues delivering mail on foot. The AHA recommends that all Americans
invest in at least 30 minutes a day of physical activity on most days of the week.
In the face of such unambiguous evidence, however, most healthy adults,
apparently by choice it must be assumed, remain sedentary.
The cardiovascular beneficial effects of regular exercise for patients with a high
risk of coronary disease have also been well documented. Leisure time exercise
reduced cardiovascular mortality during a 16-year follow-up study of men in the
high risk category. In the Honolulu Heart Study, elderly men walking more than
1.5 miles per day similarly reduced their risk of coronary disease. Such people
engaging in regular exercise have also demonstrated other CVD benefits
including decreased rate of strokes and improvement in erectile dysfunction.
There is also evidence of an up to 3-year increase in lifespan in these groups.
Among patients with experience of heart failure, regular physical activity has also
been found to help improve angina-free activity, prevent heart attacks, and
result in decreased death rates. It also improves physical endurance in patients
with peripheral artery disease. Exercise programs carried out under supervision
such as cardiac rehabilitation in patients who have undergone percutaneous
coronary interventions or heart valve surgery, who are transplantation candidates
or recipients, or who have peripheral arterial disease result in significant short-
and long-term CVD benefits.
Since data indicate that cardiovascular disease begins early in life, physical
interventions such as regular exercise should be started early for optimum
effect. The US Department of Health and Human Services for Young People
wisely recommends that high school students achieve a minimum target of 60
minutes of daily exercise. This may be best achieved via a mandated curriculum.
Subsequent transition from high school to college is associated with a steep
decline in physical activity. Provision of convenient and adequate exercise time
as well as free or inexpensive college credits for documented workout periods
could potentially enhance participation. Time spent on leisure time physical
activity decreases further with entry into the workforce. Free health club
memberships and paid supervised exercise time could help promote a
continuing exercise regimen. Government sponsored subsidies to employers
incorporating such exercise programs can help decrease the anticipated future
cardiovascular disease burden in this population.
General physicians can play an important role in counselling patients and

promoting exercise. Although barriers such as lack of time and patient non-
compliance exist, medical reviews support the effectiveness of physician
counselling, both in the short term and long term. The good news is that the
percentage of adults engaging in exercise regimes on the advice of US
physicians has increased from 22.6% to 32.4% in the last decade. The
empowerment of physicians, with training sessions and adequate
reimbursement for their services, will further increase this percentage and ensure
long-term adherence to such programmes. Given that risk factors for CVD are
consistent throughout the world, reducing its burden will not only improve the
quality of life, but will increase the lifespan for millions of humans worldwide, not
to mention saving billions of health-related dollars.

7. In the first paragraph, what point does the writer make about CVD?
Measures to treat CVD have failed to contain its spread.
There is potential for reducing overall incidence of CVD.
Effective CVD treatment depends on patient co-operation.
Genetic factors are likely to play a greater role in controlling CVD.
8. In the second paragraph, what does the writer say about inactivity?
Its role in the development of CVD varies greatly from person to person.
Its level of risk lies mainly in the overall amount of time spent inactive.
Its true impact has only become known with advances in technology.
Its long-term effects are exacerbated by certain medical conditions.
9. The writer mentions London bus drivers in order to
demonstrate the value of a certain piece of medical advice.
stress the need for more research into health and safety issues.
show how important free-time activities may be to particular groups.
emphasise the importance of working environment to long-term health.
10. The phrase 'apparently by choice' in the third paragraph suggests the writer
believes that health education has failed the public.
remains unsure of the motivations of certain people.
thinks that people resent interference with their lifestyles.
recognises that the rights of individuals take priority in health issues.
11. In the fourth paragraph, what does the writer suggest about taking up regular
exercise?
Its benefits are most dramatic amongst patients with pre-existing conditions.
It has more significant effects when combined with other behavioural changes.
Its value in reducing the risks of CVD is restricted to one particular age group.
It is always possible for a patient to benefit from making such alterations to lifestyle.
12. The writer says 'short- and long-term CVD benefits' derive from
long distance walking.
better cardiac procedures.
organised physical activity.
treatment of arterial diseases.
13. The writer supports official exercise guidelines for US high school students because
it is likely to have more than just health benefits for them.
they are rarely self-motivated in terms of physical activity.
it is improbable they will take up exercise as they get older.
they will gain the maximum long-term benefits from such exercise.
14. What does the writer suggest about general physicians promoting exercise?
Patients are more likely to adopt effective methods under their guidance.
They are generally seen as positive role models by patients.
There are insufficient incentives for further development.
It may not be the best use of their time.
Text 2: Power of Placebo

Ted Kaptchuk is a Professor of Medicine at Harvard Medical School. For the last 15 years,
he and fellow researchers have been studying the placebo effect – something that, before
the 1990s, was seen simply as a thorn in medicine’s side. To prove a medicine is
effective, pharmaceutical companies must show not only that their drug has the desired
effects, but that the effects are significantly greater than those of a placebo control group.
However, both groups often show healing results. Kaptchuk’s innovative studies were
among the first to study the placebo effect in clinical trials and tease apart its separate
components. He identified such variables as patients’ reporting bias (a conscious or
unconscious desire to please researchers), patients simply responding to doctors’
attention, the different methods of placebo delivery and symptoms subsiding without
treatment – the inevitable trajectory of most chronic ailments.
Kaptchuk’s first randomised clinical drug trial involved 270 participants who were hoping to
alleviate severe arm pain such as carpal tunnel syndrome or tendonitis. Half the subjects were
instructed to take pain-reducing pills while the other half were told they’d be receiving
acupuncture treatment. But just two weeks into the trial, about a third of participants -
regardless of whether they’d had pills or acupuncture - started to complain of terrible side
effects. They reported things like extreme fatigue and nightmarish levels of pain. Curiously
though, these side effects were exactly what the researchers had warned patients about
before they started treatment. But more astounding was that the majority of participants - in
other words the remaining two-thirds - reported real relief, particularly those in the acupuncture
group. This seemed amazing, as no-one had ever proved the superior effect of acupuncture
over standard painkillers. But Kaptchuk’s team hadn’t proved it either. The ‘acupuncture’
needles were in fact retractable shams that never pierced the skin and the painkillers were
actually pills made of corn starch. This study wasn’t aimed at comparing two treatments. It was
deliberately designed to compare two fakes.
Kaptchuk’s needle/pill experiment shows that the methods of placebo administration are as
important as the administration itself. It’s a valuable insight for any health professional:
patients’ feelings and beliefs matter, and the ways physicians present treatments to patients
can significantly affect their health. This is the one finding from placebo research that doctors
can apply to their practice immediately. Others such as sham acupuncture, pills or other fake
interventions are nowhere near ready for clinical application.
Using placebo in this way requires deceit, which falls foul of several major pillars of medical
ethics, including patient autonomy and informed consent.
Years of considering this problem led Kaptchuk to his next clinical experiment: what if he
simply told people they were taking placebos? This time his team compared two groups of
IBS sufferers. One group received no treatment. The other patients were told they’d be taking
fake, inert drugs (from bottles labelled ‘placebo pills’) and told also, at some length, that
placebos often have healing effects. The study’s results shocked the investigators
themselves: even patients who knew they were taking placebos described real improvement,
reporting twice as much symptom relief as the no-treatment group. It hints at a possible future
in which clinicians cajole the mind into healing itself and the body – without the drugs that
can be more of a problem than those they purport to solve.
But to really change minds in mainstream medicine, researchers have to show biological
evidence – a feat achieved only in the last decade through imaging technology such as
positron emission tomography (PET) scans and functional magnetic resonance imaging
(MRI). Kaptchuk’s team has shown with these technologies that placebo treatments affect the
areas of the brain that modulate pain reception. ‘It’s those advances in “hard science”’, said
one of Kaptchuk’s researchers, ‘that have given placebo research a legitimacy it never
enjoyed before’. This new visibility has encouraged not only research funds but also
interest from healthcare organisations and pharmaceutical companies. As private hospitals in
the US run by healthcare companies increasingly reward doctors for maintaining patients’
health (rather than for the number of procedures they perform), research like Kaptchuk’s
becomes increasingly attractive and the funding follows.
Another biological study showed that patients with a certain variation of a gene linked to the
release of dopamine were more likely to respond to sham acupuncture than patients with a
different variation – findings that could change the way pharmaceutical companies conduct
drug trials. Companies spend millions of dollars and often decades testing drugs; every drug
must outperform placebos if it is to be marketed. If drug companies could preselect people
who have a low predisposition for placebo response, this could seriously reduce the size, cost
and duration of clinical trials, bringing cheaper drugs to the market years earlier than before.

15. The phrase ‘a thorn in medicine’s side’ highlights the way that the placebo effect
varies from one trial to another.
affects certain patients more than others.
increases when researchers begin to study it.
complicates the process of testing new drugs.

16. In the first paragraph, it’s suggested that part of the placebo effect in trials is due to
the way health problems often improve naturally.
researchers unintentionally amplifying small effects.
patients’ responses sometimes being misinterpreted.
doctors treating patients in the control group differently.
17. The results of the trial described in the second paragraph suggest that
surprising findings are often overturned by further studies.
simulated acupuncture is just as effective as the real thing.
patients’ expectations may influence their response to treatment.
it’s easy to underestimate the negative effect of most treatments.
18. According to the writer, what should health professionals learn from Kaptchuk’s
studies?
The use of placebos is justifiable in some settings.
The more information patients are given the better.
Patients value clarity and honesty above clinical skill.
Dealing with patients’ perceptions can improve outcomes.
19. What is suggested about conventional treatments in the fourth paragraph?
Patients would sometimes be better off without them.
They often relieve symptoms without curing the disease.
They may not work if patients do not know what they are.
4B
5C
6A
7B
8 benzodiazepines
9 minimal sedation / minimal
10 emergency intubation / intubation
11 fracture reduction
12 Phencyclidines
13 Remifentanil
14 5mg / 5milligrams / 5 mg / 5 milligrams
15 IV / intravenous route
16 cardiovascular function
17 verbal commands
18 epileptic seizures / seizures / a seizure / an epileptic seizure / seizure disorders
19 carbon dioxide
20 reversal agent
1C 2B 3B 4B 5A 6A
7 B 8 B 9 A 10 B 11 D 12 C 13 D 14 A
15 D 16 A 17 C 18 D 19 A 20 B 21 B 22 D
in the presence of its coreceptor, the Klotho protein, Fibroblast growth factor
23 is regulated by serum phosphorus levels and plays a major role in the
response to elevated serum phosphorus It causes a direct increase in
Urinary phosphorus excretion, a decrease in intestinal phosphorus
absorption (indirectly via inhibition of calcitriol), and decreased bone
resorption via a decrease in parathyroid hormone production. Parathyroid
hormone, in contrast, has a mixed effect. It increases renal excretion of
phosphorus on one hand but increases phosphorus release from bone into
the serum on the other The latter is accomplished by increasing both bone
resorption (directly) and intestinal absorption (indirectly, via stimulation of
calcitriol) of phosphorus FGF23 inhibits parathyroid hormone and calcitriol.
Parathyroid hormone stimulates both FGF23 and calcitriol, whereas
calcitriol inhibits parathyroid hormone.
Text C
Hyperphosphatemia & kidney disease
In chronic kidney disease, phosphorus retention can trigger secondary
hyperparathyroidism, as rising phosphorus levels stimulate fibroblast growth
factor 23. In the early stages of chronic kidney disease, this response can
balance the phosphorus levels, but involving many consequences:
 Calcitriol decreases due to its inhibition by Fibroblast growth factor 23.
 Hypocalcemia due to decreased calcitriol and calcium binding of
retained phosphorus.
 Increased parathyroid hormone due to low calcitriol levels,
hyperphosphatemia, and hypocalcemia.
Increased serum phosphorus levels (normal range 2.48 to 4.65 milligrams

per deciliters) are associated with cardiovascular calcification and
subsequent increases in mortality and morbidity rates. Increase in serum
phosphorus and calcium levels are associated with progression in vascular
calcification and likely account for the accelerated vascular calcification that
is seen in kidney disease. Hyperphosphatemia has been identified as an
independent risk factor for death in patients with end-stage renal disease,
but that relationship is less clear in patients with chronic kidney disease. A
study in patients with chronic kidney disease and not on dialysis found a
lower mortality rate in those who were prescribed phosphorus binders, but
the study was criticized for limitations in its design Hyperphosphatemia can
also lead to adverse effects on bone health due to complications such as
renal osteodystrophy.
Text D
Phosphorus Binders
For people on dialysis, controlling renal diet alone usually won't keep the
phosphorus levels in a healthy range. This is where phosphorus binders
come in Phosphorus binders prevent the body from absorbing the
phosphorus from the food we eat, Phosphorus binders help to excrete
excess phosphorus out of the body through the stool, decreasing the
amount of phosphorus that gets into the blood. Generally phosphate binders
are taken within 5 to 10 minutes before or immediately after meals and
snacks. The doctor and renal dietitian will guide when to take phosphate
binders and how many times to take when taking meals. However, smaller
meals and snacks usually require a lower number of phosphorus binders
and more phosphorus binders suggested with larger meals. Dialysis
patients get monthly lab results that show whether the phosphorus level is in
a healthy range (3.0 to 5.5 milligrams per deciliter) Phosphorus binders
work in one of two ways. Certain phosphate binders, such as Renvela, work
like a sponge and soak up the phosphates in the food so that it doesn't get
into the blood. instead it is carried through the digestive tract and excreted
through the stool. Other phosphorus binders, such as Fosrenol, Phoslo and
Tums, function like a magnet. The phosphorus in the food attaches to the
phosphorus binder and carried through the digestive tract for excretion
Common types of phosphorus binders are: calcium-based phosphorus
binders, aluminum-free, calcium-free phosphorus binders, aluminum-based
phosphorus binders, and magnesium-based phosphorus binders.
PART A -QUESTIONS
Questions 1-7
(1) Target range of phosphorus in dialysis patients

(2) Dietary phosphorus absorption in the jejunum
(3) Influence of serum phosphorus in cardiovascular calcification.
(4) FGF23 is plays a major role in the response to elevated serum

phosphorus
(5) Osteocytes and osteoblasts secrete phosphaturic glycoprotein
(6) Influence of vitamin D in phosphorus absorption
(7) increase in serum phosphorus and calcium levels are likely account for
the accelerated vascular calcification in kidney disease.
Questions 8-14
(8) What influences the phosphorus to shift in and out of the skeleton?
(9) Which part of the body handles the phosphorus excretion process?
(10) What can trigger secondary hyperparathyroidism in chronic kidney

patients?
(11) What is the risk factor of mortality in the end-stage renal disease
patients?
(12) What is the normal range of phosphorus in a healthy body?
(13) What causes increased parathyroid hormone?
(14) What stimulates fibroblast growth factor 23 and calcitriol?
Questions 15-20
(15) Filtered phosphorus is reabsorbed in the proximal tubule

by_____________
(16) _____________is a phosphaturic glycoprote in
(17) FGF23 inhibits parathyroid hormone and_________
(18) Hyperphosphatemia can also result in adverse effects on bone due

to____________
(19) Fibroblast growth factor 23 plays a major role in the response

to____________
(20)_____________ works like a sponge and soak up the phosphates in

the food.
Questions 1-6
(1) The given notice provides information about;
A. Inheritance of choroideremia.
B. General overview of Choroideremia
C. Clinical manifestations of choroideremia
Choroideremia is a rare genetic eye disease that affects the retina, which
is the area at the back of the eye that processes all we see into signals
that are sent to the brain via the optic nerve. Choroideremia affects about
1 in 50,000 individuals and is caused by a genetic defect in one Single
gene called the CHM gene, which is located on the X-chromosome. Male
patients manifest the severe blinding form of the disease and suffer from a
progressive retinal degeneration with obliteration of the light sensing cells,
their support cells and part of the blood supply to these retinal layers. The
healthy orange retina is lost and the pale white sclera can be seen when
you look into the eye. Females are carriers and largely unaffected,
however they can develop mild symptoms of visual impairment such as
night blindness in more in later stages of life. An affected parent has a
50% chance of passing the defective CHM gene to their children, although
as it is positioned on the X-chromosome, affected males can only pass the
disease gene to their daughters and not their sons Female carriers have a
50% risk of passing the disease to their sons.
(2) What information this extract provides on optogenetics?
A. The effectiveness of optogenetics in pain control

B. How the lost vision can be restored using optogenetic techniques
C. How efficiently the optogenetic techniques control the cell behavior
Optogenetics is the science of using light to control the behavior of cells. It

is one of the most rapidly evolving fields of applied research. Optogenetic
techniques enable the control of electrically excitable cells such as muscle
or nerve cells. To make a neuron sensitive to light it is outfitted with
special photosensitive proteins called rhodopsins. These are similar to
those involved in our vision. Depending on the particular rhodopsin used
to modify a neuron, it will either transmit or block the nerve impulse when
illuminated. This allows individual organs, body parts, or even the behavior
of an entire organism to be controlled. For instance, light can be used to
block pain signals. Large numbers of people worldwide experience chronic
pains. All contemporary medicine has to offer are painkillers, which often
cause patients to develop drug dependence or side effects. The notion of
light-sensitive proteins naturally suggests a possibility of eyesight recovery
in blind people. In some cases of damage to retinal cells, this is Indeed an
option. Lost vision can be restored to a certain degree by inducing
photosensitivity in the so-called retinal ganglion cells, which normally
receive visual information from other specialized cells instead of directly
absorbing light.
(3) The given extract provides information about:
A. Complications involved in cataract surgery
B. Biology of posterior capsule opacification
C. How to make improvements in intraocular lens designing
Considerable work has taken place to better understand the underpinning
biology driving posterior capsule opacification. This in turn will help
develop novel targets for future therapies and facilitate improvement in
Intraocular lens designs. Posterior capsule opacification is characterized
by a number of biological events. Fundamentally all PCO exhibits some
level of fibrosis, which is characterized by increased cell numbers, cell
migration, a change in cell type from an epithelial cell to a myofibroblast,
deposition of matrix material and deformation of the matrix In addition,
attempts to regenerate the lens are evident and formation of new lens fiber
cells and fiber-like cells called Elschnig's pearls can also be observed,
which can also cause considerable light scatter. A number of growth
factors and signaling pathways have been identified in association with
many of the characteristic events seen in PCO. An incredible feature of
the lens is that it does not receive a blood supply and actually lives in a
relatively poor environment. In response to these conditions the lens has
an innate capacity to generate molecules that govern lens cell functions.
Following cataract surgery, lens cells retain this ability and thus factors
generated in response to injury can activate corresponding receptors and
contribute to PCO formation through a autocrine mechanism
(4) The given notice describes about

A. Lung plethysmography procedure
B. Dos and Donts during lung plethysmography
C. Preparation for lung plethysmography.
Lung Plethysmography
a physician would ask the patient to refrain from smoking and heavy
exercise for a few hours prior to the procedure. Certain respiratory
medications may also have to be temporarily stopped to avoid any impact
on results. Exposure to environmental pollutants should also be avoided
before the procedure Patients are advised against wearing tight clothes
which might affect normal breathing whilst in-procedure. During lung
plethysmography, the patient sits on a chair kept in an airtight room
resembling a telephone booth. They are asked to hold the mouthpiece and
breathe in, breath out, or exhale with force into the mouthpiece. The nose
remains clipped during the procedure
(5) The given notice talks about
A. Purpose of TIPS surgery

B. Complications of portal hypertension
C. Procedures of TIPS Surgery.
TIPS
The term TIPS stands for Transjugular Intrahepatic Portosystemic Shunt.
The TIPS procedure is usually carried out on patients suffering from
serious liver diseases. Usually the TIPS procedure s suggested for
patients with portal hypertension. This is a condition that occurs when the
blood flow into the liver from the veins draining the stomach, esophagus,
and intestines is blocked because of severe liver injury or obstructions in
the veins of the liver This results in Increased portal blood pressure and
backflow of blood through the portal veins which become stretched,
engorged and tortuous. This drastic increase in portal blood pressure may
lead to rupture of and very severe bleeding from the portal veins.
Complications of portal hypertension include variceal bleeding, the
development of fluid in the abdomen, known as ascites, and the
development of fluid in the chest cavity, called hydrothorax. TIPS thus
regularizes the blood flow from the various parts of the GI tract to some
extent
(6) The given extract describes about;
A. Post kidney biopsy complications

B. Kidney biopsy procedure
C. Complications involved in kidney biopsy.
Kidney Biopsy
A kidney biopsy involves taking one or more tissue samples of the kidney
for clinical examination. In most cases, it takes 3-5 days to get the full
biopsy results from the pathologist however it might be possible to receive
a partial or full report within 24 hours or less.
The patient may require bed rest for 12-24 hours after the kidney biopsy.
Remaining still in bed helps the biopsy site heal. It will also reduce the
chance of bleeding this is the main complication and in order to look for
any signs of internal bleeding the patient will have their blood pressure
and pulse checked. Blood tests are also done. For two weeks after the
biopsy strenuous activities should be avoided - these include contact
sports, and sexual intercourse.
A doctor should also be informed if the patient experiences:

 Worsening pain, bleeding, swelling or redness in the biopsy site
 Fever a or chills
 Faintness and dizziness
 Bloody urine for more than 24 hours after the biopsy
 Inability to urinate

Text- 1
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis is a hip condition that occurs in teens and
kids who are still growing. For unknown reasons, the ball at the head of the
femur slips off the neck of the bone in a backwards direction. In this
condition the epiphysis on the femoral head is displaced posteriorly with
respect to the femoral neck, altering the mechanics and articular structure of
the joint and eventually causing inability to put any weight on the affected
hip without pain. The treatment involves various modes, designed to arrest
slippage of the displaced epiphysis. Early diagnosis and treatment is
essential to provide stability to the hip and avoid long-term complications
such as osteoarthritis. The outcome deteriorates with the severity of the slip.
This is because worsening of the slippage causes femoroacetabular
impingement which causes further damage to the labral cartilage at the
acetabular rim. This alteration in bone morphology and damage to cartilage
is responsible for the development of osteoarthritis over the long term.
The first step after the diagnosis of SCFE is made is preventing any
loadbearing on the affected joint. The decision on which treatment to adopt
will depend on the patient's health: The severity of the slip and prognosis,
Other coexisting medical conditions. The parents' viewpoint.
The surgery is usually planned and carried out on a semi-urgent basis,
within 24-48 hours, to prevent further joint damage. Bone-Peg
Epiphysiodesis- in situ pinning has largely replaced open bone-peg
epiphysiodesis with or without corrective femoral osteotomy. This older
technique popular in the 1950s and 1960s had the advantage of closing the
physis quickly and thus preventing any further displacement of the slipped
epiphysis. It also avoided having to use screws and pins near the joint, as
well as obviating screw removal. It fell out of favor largely due to the risk of
recurrent slippage. In addition to the failure to arrest epiphyseal slippage,
there was a higher rate of complications when bone-peg epiphysiodesis was
utilized.
The most widely used procedure to correct stable slips of mild to moderate
severity is now the single in situ fixation with a center-to-center screw,which
passes across the growth plate to fix the femoral capital epiphysis. It has
several advantages such as. Minimally invasive with one small thigh
incision; Appropriate for all grades of severity and deformity, as well as for
stable or unstable slips. Often produces automatic reduction of the
deformity. Has good to excellent results in 86-95% of slips, If fluoroscopy is
difficult, as in obese individuals, arthrograms may help to introduce the pin
correctly, Lowest rate of osteoarthritis and avascular necrosis.
It is still undecided whether the use of a single or double screw is better

suited to produce stability. While two screws make it more biomechanically
strong, a single screw causes less damage to the articular surface and
growth plate and avoid the risk of avascular necrosis. Osteonecrosis is a
serious complication associated with closed reduction of the displaced
capital epiphysis. Open reduction with internal fixation uses a femoral
osteotomy to reduce the deformity in the treatment of severe and chronic
slips which limit function or are very painful. It is performed after the end of
the growing period. Its use has become more popular in moderate slips, as
well to reduce the risk of hip impingement due to abnormal bone shape and
cartilage damage.
In the modified Dunn's technique, a safe surgical hip dislocation is

performed and a retinacular flap is created to protect the vascular supply to
the femoral neck and thus prevent avascular necrosis. The hip is corrected
by putting it into flexion and valgus position, and derotating it. While this
procedure is thought to reduce the rate of avascular necrosis in unstable
SCFE, it is not a routine procedure and its efficacy is yet to be unequivocally
established.
Some studies have concluded that there is no significant difference in

outcome between in situ pinning and femoral osteotomy. Others show that
the rate of osteoarthritis is higher after femoral osteotomy, about 65% after
28 years of follow up. Another study on moderate to severe slips treated
with realignment found that almost 60% of patients eventually required
some type of hip fusion or replacement or suffered severe osteoarthritis.
Prophylactic pinning of the opposite hip has been practiced widely because
of the high rate of bilateral SCFE with the second hip becoming
symptomatic within 18 months of the first. Surgery is usually coupled with
physical therapy to build up hip and leg muscle strength to further support
and correct hip joint action. Follow up for about 24 months is essential. Any
underlying or coexisting medical conditions are also treated at this time . A
proper mode of treatment following early detection is associated with the
lowest chance of limb shortening, osteoarthritis and limited hip movement
(7) What is the impact of femoroacetabular impingement on acetabular rim?
A. Osteoarthritis
B. Alteration in bone morphology
C. Damage to the labrum cartilage
D. All the above
(8) According to second paragraph, which of the following treatment does

involve using the screws?
A. Corrective femoral osteotomy
B. Bone-peg epiphysiodesis
C. In situ pinning
D. None of the above
(9) Which of the following can guide to fix the femoral capital epiphysis in
normal patients?
A. Center-to-center screw
B. Fluoroscopy
C. Arthrograms
D. B&C
(10) According to fourth paragraph, which of the following result in avascular

necrosis?
A. Use of double screw

B. Closed reduction of the displaced capital epiphysis
C. Use of single screw
D. None of the above.
(11) What is the strategy followed to prevent avascular necrosis?
A. Safe surgical dislocation

B. Use of single screw
C. Retinacular flap
D. B & C
(12) According to the study which of the following treatment resulted in

osteoarthritis?
A. Prophylactic pinning
B. Femoral osteotomy
C. in situ pinning
D. B & C
(13) In the final paragraph, what is the strategy followed to prevent bilateral
SCFE?
A. In situ pinning
B. Prophylactic pinning
C. Femoral osteotomy
Text-2
Prostate Biopsy
Prostate cancer is screened by digital rectal examination and by measuring
serum prostate- specific antigen levels. If these arouse any suspicion of
prostate cancer, a prostate biopsy is usually recommended. Prostate
biopsies are carried out in several different ways. The most commonly
employed techniques are transrectal ultrasound guided systematic biopsy of
the prostate, transurethral biopsy and transperineal prostate biopsy.
Transrectal ultrasound-guided systematic biopsy of the prostate is
considered to be the gold standard for the diagnosis of prostate cancer. The
procedure is done after sedation in most cases. The patient is asked to lie
on the left side with the knees slightly drawn up, which relaxes and exposes
the rectum. In this left lateral position, the doctor inserts an ultrasound probe
into the rectum The probe is only as thick as an ordinary pencil and does
not cause more than slight discomfort or pressure.
Using the probe, the doctor obtains images of the prostate. This guidance
enables the injection of a local anesthetic (usually 1-2 lidocaine) into the
area around the prostate, to numb it by nerve. The needle may cause some
pain, while the anesthetic produces a brief burning sensation followed by
numbness. Still under ultrasound guidance, the doctor inserts an 18 gauge
needle into several areas of the prostate to recover tissue samples from 10-
18 areas. These are prepared for histologic examination. In the standard
systematic biopsy, cores of tissue are taken from 12 sites. However, most of
these are from the posterior part of the prostate. The anterior tumor foci are
often not picked up because of the length of the needle (17 mm) which limits
penetration into this part of the gland. In about 10-20 minutes the patient is
ready to leave the biopsy room. The greatest controversy surrounding this
procedure has to do with its low sensitivity and the false-negative rate,
which has been reported to be up to 20-30%.
Transurethral biopsy is a method that is used less often, but involves the
insertion of a cystoscope. This is a flexible tube with a camera mounted on
the end. This is passed through the urethra and tissue samples are
recovered from the prostate through the urethral wall. The transperineal
prostate biopsy using points mapped to a brachytherapy template grid is
becoming popular because of the better opportunity it offers to sample the
prostate in a systematic manner. It especially adds to the accuracy of
sampling of the anterior and transition points on the template (24-38 points),
based on the ultrasound image. In general, 20 cores are taken from both
sides of the prostate covering all the zones. Each insertion of the needle
may produce a very brief but sharp pain.
Currently, a transperineal template or saturation biopsy, as it is called, is

suggested only if a previous transrectal ultrasound-guided biopsy has been
negative but suspicion of prostate cancer is still high. Spinal or general
anesthesia is sometimes recommended in these patients in order to achieve
adequate analgesia while taking so high a number of tissue samples. The
Transrectal route of prostate biopsy may yield false negatives to the extent
of 20-30%. Many of these tumors are picked up by transperineal biopsy,
and are situated in the anterior part of the prostate. This method allows
better access to this part of the prostate, and thus increases the detection
rate The technique can be used even if the patient does not have a patent
anus, due to prior surgery for rectal cancer. There is a lower risk of major
infection as the needle does not have to traverse the rectum on its way to
the prostate. Thus the transperineal biopsy is often preferred for patients
who are at a higher risk for post-biopsy infectious complications.
Recently techniques which fuse magnetic resonance imaging with

ultrasound are being introduced to achieve targeted prostate biopsy instead
of blind systematic biopsies. This technology allows doctors to map, locate
and track the biopsy sites. The technique is also claimed to allow more
accurate diagnosis with higher detection rates, using fewer biopsies. It can
pick up cancer with Gleason score of 7 or above, and it is also better at
detecting anterior tumors missed by a TRUS systematic biopsy. It is
especially useful in patients undergoing repeat biopsies, with a 41% pick-up
rate of cancers on mpMRI-guided biopsies, and with 87% of these being of
clinical importance Nonetheless, the technique very significant in detecting
the aggressive lesions, achieving greater detection on repeat biopsies of the
prostate in the face of persistent indications for biopsy.
(14) What is the criteria to mentioned in the first paragraph before

performing transrectal ultrasound guided systematic biopsy?
A. Digital rectal examination

B. Measuring serum prostate-specific antigen levels
C. Sedation
D. All the above
(15) Which of the following is true according to the paragraph 2?
A. The samples are taken from anterior tumor foci

B. 17 mm needle is adequate to access anterior tumor foci
C. Anesthesia causes brief burning sensation
D. A&B
(16) What is the significant difference between transurethral biopsy &

transrectal ultrasound guided systematic biopsy?
A. Cystoscope
B. Using points mapped to a brachytherapy template grid
C. Sampling of the anterior and transition zones
D. All the above
(17) What is the strategy to take samples from several points from single
entry point?
A. A brachytherapy template grid

B. A fan-shaped approach
C. A Mapping
D. A&C.
(18) As per fourth paragraph, what is used to avoid multiple punctures to the
perineum?
A. A spring-loaded 18-gauge biopsy needle

B. A coaxial needle
14- Parathyroid hormone

15- Sodium- phosphate cotransporters
16- Fibro Ablest Growth Factor 23
17-Calcitriol
18-Renal osteodystrophy
19-Elevated serum phosphorus
20- Renvela
1- B
2- C
3- B
4- C
5- A
6- A

7- C
8- C
9- B
10- D
11- D
12- B
13- B
14- D
15-C
16-C
17-B
18-B
19- D
20-C
.
Text B
Mechanisms of aspirin resistance

The exact mechanisms are not clear:
True aspirin resistance:
The proposed factors for this type of resistance include:
i. Decreased bioavailability of aspirin.
ii. Accelerated platelet turnover introducing newly formed, non-
aspirinated platelets into the blood stream.
iii. Competition of aspirin with other NSAIDs (like ibuprofen)
preventing aspirin access at Serine 530 of Cox-I
iv. Transcellular formation of TxA2 by aspirinated platelets from
PGH2 released by other blood cells or vascular cells.
v. TxA2 production by aspirin insensitive Cox-2 in newly formed
platelets or other cells.
vi. (Theoretical) presence of variant Cox-I which is less sensitive to
aspirin inhibition.
vii. Poor compliance by the patient.
Text C
Aspirin dosage
According to the Antithrombotic Trialists’ Collaboration, daily doses of
aspirin (75 - 150 mg) are as effective as higher doses for prevention
of thrombotic events and are associated with low risk of bleeding.
Bornstein et al in their study have shown that even 100 mg of aspirin
completely inhibits Cox-1 enzyme, thus further substantiating the fact
that patients with resistance established during low dose aspirin
therapy may respond to higher doses. The results of this study
showed that aspirin in doses of 500 mg/day significantly prolonged
the time between first and second stroke (p= 0.002) compared with
lower doses. Helgason et al revealed that an increase in the dose of
aspirin to 625 that suboptimal reduction of urinary 11-dehydro TxB2
level during aspirin treatment is associated with increased risk for
future MI and cardiovascular death, thereby suggesting that “true
aspirin resistance” may be a clinically relevant phenomenon.
Inadequate inhibition of TxA2 biosynthesis by aspirin can be seen in
patients on ibuprofen therapy, because of competition of these 14
mg/day in five patients who were aspirin resistant with 325 mg/day
showed aspirin sensitivity. Another study has revealed that these
patients remained resistant with aspirin 1,300 mg. This shows that
inadequate dose cannot explain aspirin resistance in all subjects
Text D
Management of aspirin resistance
Currently there are no specific guidelines for the management of

aspirin resistance. The first step is to enquire about the patient’s
compliance. Regarding optimal aspirin dosing, it is controversial. No
convincing data are available showing that the antithrombotic effect of
aspirin is dose related. The meta-analysis by Anti- Thrombotic
Trialist’s Collaboration refuted the claim that high doses of aspirin
(500 - 1,500 mg/day) were effective than low doses (75 - 150
mg/day). Other method to manage aspirin resistance is by addition of
another antiplatelet agent – clopidogrel, because CAPRIE trial has
shown greater benefit of combination of aspirin and clopidogrel
compared with aspirin alone. The combination of aspirin with
clopidogrel is an ideal one since clopidogrel inhibits another pathway
of platelet activation.
However, till date, it is not clear whether the superiority of a
combination of clopidogrel and aspirin over aspirin is due to
clopidogrel compensation for aspirin non-responders. Resistance to
even clopidogrel has been reported, which is associated with an
increased risk of recurrent thrombotic events in patients with acute MI.
PART A -QUESTIONS
Questions 1-7

1. what are the factors of true aspirin resistance?
2. how much of aspirin completely inhibits Cox-1 enzyme?
3. what will happen if aspirin compete with other NSAIDs?
4. how the the true picture of aspirin resistance is revealed?
5. what are the parameters for assessing the efficacy of aspirin?
6. list the methods to manage aspirin resistance?
7. whether true aspirin resistance is a clinically relevant phenomenon?

Questions 8-13
8. How much mg of aspirin is minimum required to completely inhibit Cox-1 enzyme?
9. Which patients show inadequate inhibition of TxA2 biosynthesis by aspirin?
10. Name the antiplatelet agent used to manage aspirin resistance?
11. What are responsible for transcellular formation of TxA2?
12. What is the daily doses range of aspirin according to the Antithrombotic
Trialists’ Collaboration?
13. Which trial has shown greater benefit of combination of aspirin and clopidogrel?
Questions 14-20
14. Aspirin displays good_________________ activity.

15. Few studies have reported aspirin resistance to the tune of ______
16. TxA2 may be produced by aspirin insensitive_____ in newly formed platelets or
other cells.
17. Increase in the dose of aspirin to 625 is associated with increased risk for future MI
and ______________
18. Inadequate inhibition of TxA2______________ by aspirin can be seen in patients
on ibuprofen therapy
19. The first step in management of aspirin resistance is to enquire
about the patient’s ______________
20. The combination of _____________ with clopidogrel is an ideal one.
Questions 1-6
1. The manual is giving information about
A. how to use anaesthetic machines

B. types of anaesthetic machines
C. an overview of anaesthetic machines
Anaesthetic Machines
The anaesthetic machine (or anaesthesia machine in America) is used by
anaesthesiologists and nurse anaesthetists to support the administration of
anaesthesia. The most common type of anaesthetic machine is the
continuous-flow anaesthetic machine, which is designed to provide an
accurate and continuous supply of medical gases (such as oxygen and
nitrous oxide), mixed with an accurate concentration of anaesthetic vapour
(such as halothane or isoflurane), and deliver this to the patient at a safe
pressure and flow. Modern machines incorporate a ventilator, suction unit,
and patient monitoring devices.
2. Why autoclaves are better than boiling water sterilizers?
A. Heat is transferred to water by electricity or flame

B. Autoclaves use high pressure steam
C. Autoclaves generates high temperature within the chamber
Autoclaves and Sterilizers
Sterilization is the killing of microorganisms that could harm patients. It can

be done by heat (steam, air, flame or boiling) or by chemical means.
Autoclaves use high pressure steam and sterilizers use boiling water mixed
with chemicals to achieve this. Materials are placed inside the unit for a
carefully specified length of time. Autoclaves achieve better sterilization
than boiling water sterilizers. Heat is delivered to water either by electricity
or flame. This generates high temperature within the chamber. The
autoclave also contains high pressure when in use, hence the need for
pressure control valves and safety valves. Users must be careful to check
how long items need to be kept at the temperature reached.
3.The guidelines establish that the healthcare professional should
A. aim to make patients fully aware of how ECG works .

B. carefully clean the electrode sites.
C. respect the wishes of the patient above all else.
ECG: How it works
The electrical activity is picked up by means of electrodes placed on the

skin. The signal is amplified, processed if necessary and then ECG tracings
displayed and printed. Some ECG machines also provide preliminary
interpretation of ECG recordings. There are 12 different types of recording
displayed depending upon the points from where the recordings are taken.
Care must be taken to make the electrode sites clean of dirt before applying
electrode jelly. Most problems occur with the patient cables or electrodes.

A. pros and cons of electronic health records
B. necessity of electronic health records
C. demonstrated benefits of electronic health records
Benefits of electronic health records
EHR systems are complex applications which have demonstrated benefits.

Their complexity makes it imperative to have good application design,
training, and implementation. Studies have evaluated EHR systems and
reported on various benefits and limitations of these systems. Benefits
included increase in immunization rates, improved data collection,
increased staff productivity, increased visitor satisfaction with services,
improved communication, quality of care, access to data, reduced medical
errors, and more efficient use of staff time. Some of the disadvantages
noted were: time- consuming data entry, slow access of data and decreased
quality of patient- doctor interaction.
5. The note tells us that the mHealth

A. is a published volume on the GOe
B. is a powerful tool for information transfer
C. makes patient information portable
MHealth
The use of mobile technologies for data collection about individuals and interactive
information services are a part of a growing area of eHealth called mHealth. The GOe
published a volume on this subject in 2011 which documents the uptake of mHealth
worldwide by types of initiatives and main barriers to scale. Mobile technologies are
emerging as a powerful tool for health information transfer including making patient
information portable.
Such technologies can be more fully utilized through electronic patient information
such as EMRs and EHRs. Electronic records will work best, however, if there are
standards in place for their use and interoperability
6. What does this extract from a handbook tell us about Systematized
Nomenclature of Medicine?
A. is a multi-axial and hierarchical classification system

B. is a comprehensive nomenclature of trial medicines
C. is used to described any clinical condition through axis
Systematized Nomenclature of Medicine (SNOMED)
SNOMED was designed to provide a comprehensive nomenclature of clinical

medicine for the purpose of describing records of clinical care in human medicine. It
is a multi-axial and hierarchical classification system. It is multi- axial in that any
given clinical condition can be described through multiple axes such as topography
(anatomy), morphology, organisms such as bacteria and viruses, chemicals such as
drugs, function (signs and symptoms), occupation, diagnosis, procedure, physical
agents or activities, social context, and syntactic linkages and qualifiers. SNOMED is
hierarchical in that each of the axes has a hierarchical tree that proceeds from general
terms to more specific ones. For example topography (anatomic) terms are first
divided into major organs such as lung, heart, and then into the smaller components of
each.
Part C -Text 1
All life is connected: Cancer in Humans and Wildlife

WILDLIFE—HUMAN LINKS
It may be that biologists, rather than physicians, will be the major contributors to
the health of our wildlife caused by the combined action of pesticides planet and
its people. It was Rachel Carson, a biologist, who researched and wrote of the
harm to wildlife caused by the combined action of pesticides and radiation. In the
tradition of the observant biologist is Theo Colborn, who, with her colleagues,
provided a significant breakthrough in understanding the hormonal effects of
environmental contaminants. In July 1991, a gathering of some of the world’s
most astute, - scientists were held at the Wingspread Conference Center in
Wisconsin, where they defined the pattern of diverse endocrine malfunction
seen throughout the animal kingdom. They revealed a gm“: picture of the Brave
New World we should m rigorously seek not to leave as a legacy to our children.
The conferees, studying wildlife over the globe, described ominous findings of
disease an linked to environmental pollution. Exposure to toxic chemicals that
possess unintended h actions has resulted in anatomic, physiologic,
reproductive, carcinogenic, and behavioral abnormalities across all forms of
animal life: in mollusks, fish, birds, seals, and rodents. These creatures are to
we humans as canaries were to the miners. We must understand that the
destruction of eons of evolutionary function and development in wildlife
foreshadows destruction of the entire biosphere, humans included.
These widespread adverse effects were attributed to xenoestrogens. Xeno -

comes from a Greek origin, meaning “foreign.” Foreign itself is not bad: how else
do we share and spread culture and ideas? But xenoestrogens are less
foreigners than invaders, gaining entrance by the Trojan horse of seemingly
harmless routes: milk, meat, cheese, fish, the products we use to nourish
ourselves and families. Like the invaders of Troy, after the xenoestrogens gain
entrance to the bodies of animals and humans alike, they weaken defenses and
wreak their harm of cancer, hormonal disruption, immunological abnormalities,
and birth defects.
Xenoestrogens are an insidious enemy, but they have had help from powerful
allies: the purveyors of products and chemicals, and legislators, regulators, and
scientists reluctant to bite the money- laden hands that feed them.
Wingspread researchers found that birds exposed to xenoestrogens show
reproductive failure, growth retardation, life-threatening deformities, and
alterations in their brains and liver functions.” There is direct experimental
evidence for permanent [organizational] effects of gonadal steroids on the
brain as well as reproductive organs throughout life. This means that offspring
whose brains have been altered are unable to function as had their parents.
They become different in ability or function.
This means that the sea of hormonally active chemicals in which the fetus
develops may change forever the health and function of the adult, and in some
cases, may alter the course of an entire species. Worldwide there are reports
of declining sperm counts and reduced ratio in births of male babies. Without
the capacity to reproduce, a species ceases to exist. Extinction is forever; a
species loss has never been reversed.
The data derived from animal observations are unequivocal: breast and genital
cancers, _ vital abnormalities, interference with sexual development, and
changes in reproductive behavior all expressions of a root cause. A possible
connection between women with breast cancer and those having children with
reversed sexual orientation is a question that bears study. This is not from
science fiction, considering what we have learned from observing wildlife and
the effects inappropriate hormonal influence upon the breast, brain, and
reproductive organs. If an unequivocal answer were to emerge from human
observation, it could have a significant impact upon the prevailing political and
economic landscape, and may finally settle the nature or non issue of sexual
orientation.
SILENT SPRING-SILENT WOMEN

Considering the accumulated knowledge linking chemical and radioactive
contamination environment with increasing breast cancer rates means we
must focus our energies and prevention. Early were the eloquent words and
pleas for prevention from Rachel Carson. Her book, Silent Spring, originally
published in 1962, while she herself was suffering from breast cancer, is still a
best seller. Ms. Carson documented wholesale killing of species; animals,
birds, fish, insects; the destruction of food and shelter for wild creatures; failure
of reproduction; damage to the nervous system; tumors in wild animals;
increasing rates of leukemia in children; and chronicled the pesticides and
chemicals known at that time to cause cancer. This was over 30 years ago!
Carson’s is a book for every citizen, for without understanding of our collective
actions and permissions, we cannot govern democratically. In Australia, a citizen
is required to vote. In the United States, proclaimed by some politicians as the
“greatest democracy on earth,” often fewer than 50% bother to vote in a major
election. Of those who do take the time to register and vote, few are sufficiently
alert and/or educated to vote with intelligence, thought, and compassion.
Requiring participation in the governance of one’s own country is not a bad idea.
Requiring thoughtful voting may be more difficult, especially when it comes to
such issues as cancer, pesticide use, consumer products, nuclear radiation,
toxic chemicals, and environmental destruction. Taking this thought one step
further; this democracy could do far worse than to require reading of Silent
Spring as a requirement to vote!
Radical? Perhaps. But is the ongoing cancer epidemic any less radical?
One successor to Ms. Carson has emerged in the person of Sandra

Steingraber, an ecologist, poet, and scientist. In her book, Living Downstream,
she writes eloquently of the connections between environmental contamination
and cancer. Dr. Steingraber was diagnosed with bladder cancer at age 20, a
highly unusual diagnosis in a woman, a young woman, a nonsmoker and
nondrinker. She pursued the question, why? She realized a connection with our
wild relations and she asks: Tell me, does the St. Lawrence beluga drink too
much alcohol and does the St. Lawrence beluga smoke too much and does the
St. Lawrence beluga have a bad diet. . is that why the beluga whales are ill?
...Do you think you are somehow immune and that it is only the beluga whale
that is being affected?
The portion of Dr. Steingraber’s book that struck me most personally was when
she says: First, even if cancer never comes back, one’s life is utterly changed.
Second, in all the years I have been under medical scrutiny, no one has ever
asked me about the environmental conditions where I grew up, even though
bladder cancer in young women is highly unusual. I was once asked if I had
ever worked with dyes or had been employed in the rubber industry. (No and
no.) Other than these questions, no doctor, nurse, or technician has ever shown
interest in probing the possible causes of my disease-even when I have
introduced the topic. From my conversations with other cancers, patients, I
gather that such lack of curiosity in the medical community is usual.
I take her words as an indictment of the medical and scientific establishment,

whose point of view must be changed. Certainly the lack of curiosity among
physicians, scientists, policymakers, and politicians has contributed to the
epidemic of illness among humans and wildlife alike. An equally talented
woman is Terry Tempest Williams, an ecologist and wildlife researcher whose
book, Refuge: An Unnatural History of Family and Place, tells the story of her
Utah family, whom she “labels “a clan of one—breasted women.” Ms. Williams
contrasts the life-affirming awareness Great Salt Lake wildlife refuge against the
erosion-of-being, as cancer takes away the women in her family: her mother,
her grandmothers, and six aunts. She writes: “I cannot prove that my mother
Diane Dixon Tempest, or my grandmothers, Lettie Romney Dixon and Kathryn
Blackett Tempest along with my aunts, developed cancer from nuclear fallout in
Utah. But I can’t prove that didn’t.”
Times are changing. It is becoming impossible to ignore the carnage of

endocrine-disruption chemicals, nuclear radiation, and chemical carcinogens,
alone and in combination, invading nearly every family with cancer. Facing this
reality may be too much for some people, afraid to look, or afraid of being the
next victim. The story of cancer is not an easy one, and neither is cancer. But if
we do not exert our efforts to prevent this disease, we doom our children and
grandchildren to repeat our collective errors. What does it take to change from
environmental destruction and random killing to affirmation of life? Can the
protection of life for ourselves and our environment be accomplished by women
with breast cancer; the women at risk for breast cancer; the families of breast
cancer victims? Who should lead? If we citizens can’t and don’t try, what are our
alternatives?
7. The author’s main contention is that
A- wildlife all around the world is being linked to environmental pollution

B- fish, birds, seals and canaries are being exposed to toxic chemicals
C-humans need to understand the link between destroying the planet’s
wildlife, through exposure to toxic chemicals, and the destruction of the
entire biosphere — which includes human life itself.
D- humans need to understand the link between destroying the planet’s wildlife,
through exposure to toxic chemicals, and behavioural abnormalities across all
forms of life.
8. The author states that in an environment of “hormonally active chemicals”
A- males with higher sperm counts may result ‘

B- more male babies are born
C- lower sperm count in males may result in a particular species being wiped
out ‘
D- males with more sperm count may result
9. Dr Sandra Steingraber, ecologist, poet and scientist:
A. realised that contracting bladder cancer was not due to her alcohol drinking
B. realised her bladder cancer was not due to her smoking
C. believed her bladder cancer was due to environmental contamination
D. doctors, nurses and technicians were very interested in her unusual cancer
10. The wildlife researcher, Terry Tempest Williams, sees the dichotomy which
exists in the Salt Lake wildlife refuge area:
A. many women in her family have died from breast cancer after a nuclear
fallout in Utah
B. many men in her family have died from breast cancer
C. her family have many one-breasted women — unusual for Utah
D. such wide-spread cancer is probably due to environmental, not genetic
causes
11. Animal observations show:
A. changes in sexual maturity are not only due to a root cause

B. genital abnormalities may be due to a root cause
C. inappropriate hormones adversely affect the development of breast, brain
and reproductive organs
D. humans are not similarly affected.
12. The author puts forward several ideas about governance except for one of
the following:
A. People who participate in elections are not alert and educated enough
B. Unless the wants and needs of the population are known, it is difficult for
politicians to govern democratically
C. People being required to vote, to participate in the decision making
process, is a good idea
D. Reading Carson’s book, Silent Spring, should be made compulsory for all
voters.
13. Rachel Carson’s book Silent Spring, written in 1962, revealed:
A. more had to be done to prevent chemical contamination of the environment

B. there was a link between pesticides, chemicals and cancer
C. chemicals were leading to an inability to reproduce leading to the
eradication of entire species of insects, birds, fish and animals
D. all of the above
14. Research about xenoestrogens reveals.
A. They are everywhere

B. They are harmless
C. They are in our everyday foods
D. They are in our everyday foods and disrupt hormonal function
Part C -Text 2
DoesTamiflu really work?

The British Medical Journal (BMJ) was dominated in 2009 by a cluster of articles
on oseltamivir (Tamiflu). Between them the articles conclude that the evidence
that oseltamivir reduces complications in otherwise healthy people with
pandemic influenza is now uncertain and that we need a radical change in the
rules on access to trial data.
The use of meta-analysis is governed by the Cochrane review protocol.

Cochrane Reviews investigate the effects of interventions for prevention,
treatment and rehabilitation in a healthcare setting. They are designed to
facilitate the choices that doctors, patients, policy makers and others face in
health care. Most Cochrane Reviews are based on randomized controlled trials,
but other types of evidence may also be taken into account, if appropriate.
If the data collected in a review are of sufficient quality and similar enough, they
are summarised statistically in a meta-analysis, which generally provides a
better overall estimate of a clinical effect than the results from individual studies.
Reviews aim to be relatively easy to understand for non-experts (although a
certain amount of technical detail is always necessary). To achieve this,
Cochrane Review Groups like to work with “consumers”, for example patients,
who also contribute by pointing out issues that are important for people
receiving certain interventions. Additionally, the Cochrane Library contains
glossaries to explain technical terms.
Briefly, in updating their Cochrane review, published in late 2009. Tom

Jefferson and colleagues failed to verify claims, based on an analysis of 10
drug company trials, that oseltamivir reduced the risk of complications in
healthy adults with influenza. These claims have formed a key part of decisions
to stockpile the drug and make it widely available.
Only after questions were put by the BMJ and Channel 4 News has the
manufacturer Roche committed to making “full study reports” available on a
password protected site. Some questions remain about who did what in the
Roche trials, how patients were recruited, and why some neuropsychiatric
adverse events were not reported. A response from Roche was published in
the BMJ letters pages and their full point by point response is published online.
Should the BMJ be publishing the Cochrane review given that a more complete
analysis of the evidence may be possible in the next few months? Yes,
because Cochrane reviews are by their nature interim rather than definitive.
They exist in the present tense, always to be superseded by the next update.
They are based on the best information available to the reviewers at the time
they complete their review. The Cochrane reviewers have told the BMJ that
they will update their review to incorporate eight unpublished Roche trials when
they are provided with individual patient data.
Where does this leave oseltamivir, on which governments around the world
have spent billions of pounds? The papers in last years journal relate only to its
use in healthy adults with influenza. But they say nothing about its use in
patients judged to be at high risk of complications- pregnant women, children
under 5, and those with underlying medical conditions; and uncertainty over its
role in reducing complications in healthy adults still leaves it as a useful drug for
reducing the duration of symptoms. However, as Peter Doshi points out on this
outcome it has yet to be compared in head to head trials with non- steroidal
inflammatory drugs or paracetamol. And given the drug’s known side effects,
the risk-benefit profile shifts considerably if we are talking only in terms of
symptom relief.
We don’t know yet whether this episode will turn out to be a decisive battle or
merely a skirmish in the fight for greater transparency in drug evaluation. But it
is a legitimate scientific concern that data used to support important health
policy strategies are held only by a commercial organisation and have not been
subject to full external scrutiny and review. It can’t be right that the public
should have to rely on detective work by academics and journalists to patch
together the evidence for such a widely prescribed drug. Individual patient data
from all trials of drugs should be readily available for scientific scrutiny.
15] A cluster of articles on oseltamivir in the British Medical Journal

conclude
A. complication are reduced in healthy people by oseltamivir

B. the efficacy of Tamiflu in now in doubt
C. complications from pandemic influenza are currently uncertain
D. a series of articles supporting Tamiflu
16] Cochrane Reviews are designed to
A. set randomized controlled trials to specific values

B. compile literature meta-analysis
C. peer review articles
D. influence doctors choice of prescription
17] According to the article, which one of the following statements about Tamiflu
is FALSE?
A. The use of randomized controls is suspect

B. The efficacy of Tamiflu is certain
C. Oseltamivir induces complications in healthy people
D. Cochrane reviews are useful when examining the efficacy of Tamiflu
18] According to the article, Cochrane Review Groups
A. like to work for “consumers”.

B. are being overhauled.
C. use language suitable for expert to expert communication.
D. evaluate a clinical effect better than individual studies.
19] Which would make the best heading for paragraph 4?
A. Analysis of 10 drug company trials

B. The stockpiling of Oseltamivir
C. Risk of complications in healthy adults
D. Tamiflu claims fail verification
20] According to the article, which one of the following statements about Roche
 Answer all the questions within the 15-minute time limit.
 Your answers should be correctly spelt.
PART A -TEXT BOOKLET – MORGELLONS DISEASE
Text A
Morgellons disease
lf you have fatigue, skin lesions, aches and pains and a sensation that insects are
crawling around under your skin, you most probably have Morgellons disease. But
this disease may actually not exist. Whether or not Morgellons is a real disease, no
one knows. Something like the symptoms described above, supplemented by the
appearance of strange fibres or filaments growing on or just beneath the skin, was
reported by the 17th-century physician Thomas Browne. There were no other
reported cases, and the disease seemed to disappear. Then, in 2002, the mother of
a child with a skin ailment championed its comeback. Her child, she insisted, had
Morgellons.
Delve into the medical literature, though, and Morgellons disease is frequently
described as “unexplained dermopathy” or “delusional parasitosis” - a psychiatric
illness that results in people mistakenly believing their skin to be infested with
parasites. We may soon find out more. The US Centers for Disease Control and
Prevention (CDC) is in the middle of a large, systematic study into Morgellons. The
study aims to determine whether there is actually a physiological basis to the
disease. The CDC is keeping an open mind on Morgellons, says Michele Pearson,
who is leading the study. “CDC has approached this as an unexplained condition,”
she says.
Text B
CDC, Kaiser to study puzzling illness
The Centers for Disease Control and Prevention and Kaiser Permanente‘s Northern
California Division of Research announced they are launching a study to learn more
about an unexplained skin condition called Morgellons disease. The CDC will identify
patients with the condition in Kaiser‘s Northern California health plan. The study is
expected to take at least 12 months. Reports of cases have been made in every state
and 15 countries. Many reported cases have been clustered in California, Texas and
Florida, according to the Mayo Clinic.
Text C
Delusional Parasitosis
Delusional Parasitosis is an uncommon psychiatric disorder presented by persons
with an unremitting false belief that they are infested with ectoparasites or infected
with endoparasites. The delusion is usually longstanding and well integrated into the
patient’s persona. Patients with the disorder are predominantly older women, although
younger people and men can be affected. Most cases involve patient beliefs that the
skin has been invaded by insects, but some involve delusions that internal parasites
are the cause of their condition.
Text D
The causes for the disorder are not clear, but sufferers are generally of average or
higher intelligence and are otherwise functional. Patients with delusional parasitosis
generally have a long history of visiting physicians seeking information of their
diagnosis and help with their condition. The patients have certain characteristics or
exhibit behaviors that strongly suggest the presence of the disorder. Moreover, these
patients can be antagonistic and relentless in their need to find someone who will
agree with their self- diagnosis and help them. Because these delusional patients
may seek help from non-physician medical professionals, such as parasitologists,
clinical microbiologists, entomologists, or biologists, such individuals should be
aware of this disorder. Delusional parasitosis can be treated with antipsychotic
medication and psychiatric consultations but generally does not respond well to such
treatment.
PART A -QUESTIONS
Questions 1-7
In which text can you find information about:
1. what is the minimum expected time period for CDC’s study to learn more about
Morgellons disease?
2. what are the treatments for Morgellons disease?
3. name the places where Morgellons disease reported so far?

4. what is the aim for CDC’s study to learn more about Morgellons disease?
5. which are the age groups predominantly affected by Morgellons disease
6. what is the current approach of CDC’s towards Morgellons disease
7. what are the other names of Morgellons disease?
Questions 8-13
spelled.
8. Who reported a medical condition similar to Morgellons disease for the first time
9. Name the person who leads CDC’s study to learn more about Morgellons
disease?
10. Name the type of medications used to treat Morgellons disease?
11. How many countries reported Morgellons disease?
12. Name the type of illness under which the Morgellons disease is classified?
13. what is the popular delusion of the people affected by Morgellons disease?
Questions 14-20
correctly spelled
14. Morgellons disease is frequently described as_______________ or “delusional
parasitosis”.
15. Morgellons disease is a psychiatric illness that results in people

mistakenly believing their skin to be infested with_____________
16. Many reported cases have been clustered in California, Texas and Florida,
according to the_____________
17. The_________ will identify patients with the condition in Kaiser's

NorthernCalifornia health plan.
18. The delusion is usually long-standing and well integrated into the
patient's_____________
19. Patients with delusional parasitosis generally have a long history of

visiting______________
20. Patients with delusional parasitosis can be antagonistic and___________
professionals. For questions 1-6, choose the answer (A, B or C)
which you think fits best according to the text.1.
1. The type of equipment that might not be included in the category of Electronic
Diagnostic Equipment is
A. cardiac analyzers
B. stimulators
C. audiometers
Electronic Diagnostic Equipment

There are many items of equipment in a hospital that use electronics for operation. The
maintenance of such equipment is a task for specialised and trained staff. However,
regular inspection and cleaning will help such equipment last for a long time and
deliver safe function. These are tasks that the equipment user can carry out and
should be done regularly, as laid out on the checklists on the next pages. The types of
equipment that might be included in this category are for instance audiometers, blood
gas analyzers, cardiac monitors, cryoprobes, infusion pumps and stimulators. The
steps in this section can also be applied to most laboratory equipment, although it
should be noted that the WHO publication Maintenance Manual for Laboratory
Equipment deals with these in much better detail.
2. What does this manual tell us about electrocautery?
A. make precise cut with limited blood loss

B. uses high-frequency electric current
C. application of heat to tissue to achieve coagulation
Electrosurgical Units (ESU) and Cautery Machines

Electrosurgery is the application of a high-frequency electric current to biological tissue
as a means to cut, coagulate, desiccate, or fulgurate tissue. Its benefits include the
ability to make precise cuts with limited blood loss in hospital operating rooms or in
outpatient procedures. Cautery, or electrocautery, is the application of heat to tissue to
achieve coagulation. Although both methods are sometimes referred to as surgical
diathermy, this chapter avoids the term as it may be confused with therapeutic
diathermy, which generates lower levels of heat within the body.
3. What does this extract from a handbook tell us about endoscopes?
A. are inserted directly into the organ

B. used to examine the exterior of a hollow organ or cavity of the body
C. there are mainly 7 types
Endoscopy
Endoscopy means looking inside the body using an endoscope, an instrument used to
examine the interior of a hollow organ or cavity of the body. Endoscopes are inserted
directly into the organ. An endoscope can consist of a rigid or flexible tube, a light
delivery system (light source), an optical fibre system, a lens system transmitting the
image to the ewer, an eyepiece and often an additional channel to allow entry of
medical instruments, fluids or manipulators. There are many different types of
endoscopy, including arthroscopy, bronchoscopy, colonoscopy, colposcopy,
cystoscopy, laparoscopy and laryngoscopy.
A. health message should include health data expressed in a standard vocabulary

B. health message should include metadata about the definitions or environment of the
data
C. health message should be precise in any format to be received by a computer
program
Messaging standards
Messaging is the electronic communication of health information from the point of
collection or storage to a point of use. This can be a short distance such as within a
clinic or larger distances across facilities or districts. Messages can be used to retrieve
historical data as well as current data. A health message includes health data that is
expressed in a standard vocabulary. It may also include metadata about the definitions
or environment of the data. The message itself is in a precisely defined format so that it
can be received by a computer program which will understand its meaning.
A. necessity of communication based on appropriate psychological education

B. necessity of establishing interpersonal contacts with patient
C. necessity of appropriate contact based on personal experience
Communication skills during medical examination

An appropriate contact with the patient requires applying professional knowledge about
psychological aspects of interpersonal relations. While examining the patient, most
doctors apply just the experience or abilities to establish interpersonal contacts that
have been acquired on a social level. This knowledge would definitely be insufficient in
unusual and problematic situations. For many years, clinical and social aspects of
doctors' psychological education have been neglected. The ability of conversation
should be based on appropriate education, not only on personal intuition or own
experience.
6. What must all staff involved in liver palpation do?
A. should place right hand flat under right chest

B. should apply pressure at the depth of aspiration
C. should place left hand flat under right chest
Liver Palpation
Liver palpation is performed with the right hand placed flat under right costal chest
border, parallel to the long body axis, then applying pressure at the depth of inspiration
in an attempt to move under the costal border in the right middle clavicular line and
towards its right side. In normal conditions, the lower liver border is not touched. During
the respiration, the lower liver border is slightly moving down and upwards. If the liver
edge can be detected on palpation, some additional features have to be determined as
there are various abnormalities related with specific diseases.

Part C -Text 1
Tufts University faculty debunks common dental myths
Brushing, flossing, and twice-yearly dental check-ups are standard for oral health care,
but there are more health benefits to taking care of your pearly whites than most of us
know. In a review article, a faculty member at Tufts University School of Dental
Medicine (TUSDM) debunks common dental myths and outlines how diet and nutrition
affects oral health in children, teenagers, expectant mothers, adults and elders.
Myth 1: The consequences of poor oral health are restricted to the mouth
Expectant mothers may not know that what they eat affects the tooth development of
the fetus. Poor nutrition during pregnancy may make the unborn child more likely to
have tooth decay later in life. "Between the ages of 14 weeks to four months,
deficiencies in calcium, vitamin D, vitamin A, protein and calories could result oral
defects," says Carole Palmer, EdD, RD, professor at TUSDM and head of the division
of nutrition and oral health promotion in the department of public health and community
service. Some data also suggest that lack of adequate vitamin B6 or B12 could be a
risk factor for cleft lip and cleft palate formation
In children, tooth decay is the most prevalent disease, about five times more common
than childhood asthma. "If a child's mouth hurts due to tooth decay, he/she is less likely
to be able to concentrate at school and is more likely to be foods that are easier to
chew but that are less nutritious. Foods such as donuts and pastries are often lower in
nutritional quality and higher in sugar content than nutritious foods that require
chewing, like fruits and vegetables, "says Palmer. Oral complications combined with
poor diet can also contribute to cognitive and gr problems and can contribute to obesity
Myth 2: More sugar means more tooth decay.

It isn't the amount of sugar you eat; it is the amount of time that the sugar has contact
with the teeth. "Foods such as slowly-dissolving candies and soda are in the mouth for
longer periods of time. This increases the amount of time teeth are exposed to the
acids formed by oral bacteria from the sugars," says Palmer
Some research shows that teens obtain about 40 percent of their carbohydrate intake
from soft drinks. This constant beverage use increases the risk of tooth decay. Sugar-
free carbonated drinks and acidic beverages, such as lemonade, are often considered
safer for teeth than sugary beverages but can also contribute to demineralization of
tooth enamel if consumed regularly
Myth 3: Losing baby teeth to tooth decay is okay

It is a common myth that losing baby teeth due to tooth decay is insignificant because
baby teeth fall out anyway. Palmer notes that tooth decay in baby teeth can result in
damage to the developing crowns of the permanent teeth developing below them. If
baby teeth are lost prematurely, the permanent teeth may erupt mal-positioned and
require orthodontics later on.
Myth 4: Osteoporosis only affects the spine and hips

Osteoporosis may also lead to tooth loss. Teeth are held in the jaw by the face bone,
which can also be affected by osteoporosis. "So, the jaw can also suffer the
consequences of a diet lacking essential nutrients such as calcium and vitamins D and
K," says Palmer. "The jawbone, gums, lips, and soft and hard palates are constantly
replenishing themselves throughout life. A good diet is required to keep the mouth and
supporting structures in optimal shape.
Myth 5: Dentures improve a person's diet

If dentures don't fit well, older adults are apt to eat foods that are easy to chew and low
in nutritional quality, such as cakes or pastries. First, denture wearers should make
sure that dentures are fitted properly. In the mean time, if they are having difficulty
chewing or have mouth discomfort, they can still eat nutritious foods by having cooked
vegetables instead of raw, canned fruits instead of raw, and ground beef instead of
steak. Also, they should drink plenty of fluids or chew sugar-free gum to prevent dry
mouth," says Palmer
Myth 6: Dental decay is only a young person's problem

In adults and elders, receding gums can result in root decay (decay along the roots of
teeth). Commonly used drugs such as antidepressants, diuretics, antihistamines and
sedatives increase the risk of tooth decay by reducing saliva production. "Lack of saliva
means that the mouth is cleansed more slowly. This increases the risk of problems,"
says Palmer. "In this case, drinking water frequently can help cleanse the mouth."
Adults and elders are more likely to have chronic health conditions, like diabetes,
which are risk factors for periodontal disease (which begins with an inflammation of the
gums and can lead to tooth loss). "Type 2 diabetes patients have twice the risk of
developing periodontal disease of people without diabetes. Furthermore, periodontal
disease exacerbates diabetes mellitus, so meticulous oral hygiene can help improve
diabetes control," says Palmer
7. This article is about
A. how the nutritional needs of children, teenagers and expectant mothers has an
effect on oral health
B. how the oral health is affected by nutritional needs of children, teenagers,
expectant mothers and other groups.
C. how diet and nutritional needs of children, teenagers, mothers-to-be, and adults
affects one's oral health
D. disproving some long held beliefs
8. Carole Palmer observes that
A. pies and pastries have low food value and require more chewing
B. lower nutritional quality food needs more chewing
C. nutritious foods like fruits and vegetables have less sugar and require more
chewing
D. too much vitamin B6 or B12 could lead to problems with cleft palate formation
9. According to Palmer
A. asthma is five times less common in childhood than tooth decay

B. school kids with tooth decay pain may have concentration problems at school
C. mouth and dental problems plus a poor diet can affect thinking abilities and be a
factor later on in obesity
D. all of the above
10. According to the article
A. it's important to make sure you retain baby teeth

B. It's important that teeth are not exposed for a long time to acids formed by oral
bacteria as a result of eating sugary foods
C. it's important to look after your baby teeth
D. it's important that teeth are not exposed to acids formed by oral bacteria from
sugary foods
11. According to the article, baby teeth
A. are dispensable
B. develop to help eat food
C. if lost prematurely, may result in poor development of permanent teeth
D. help with correct development of permanent teeth
12. Dental health in older people requires
A. properly fitting dentures

B. a calcium rich diet
C. nutritious food containing vitamins D and K
D. all of the above
13. The article says that Osteoporosis
A. may prevent loss of teeth

B. may affect jaw bones
C. jaw bone health may be affected by chewing sugar-free gum
D. none of the above
14. Lack of saliva
A. all of the following

B. results in mouth being cleansed more slowly
C. can be addressed by chewing sugar-free gum
D. may increase the risk of tooth decay
Part C -Text 2
Global Health Care Workforce
Health care systems worldwide continue to be plagued by difficulties in recruiting and

retaining health workers, resulting in a shortage of health care professionals that is
now considered a global crisis. However, although the gap between the need for health
care workers and the supply is experienced globally, it widens disproportionately, so
that the regions with the greatest need have the fewest workers. For example sub-
Saharan Africa and south-east Asia together have 53% of the global disease burden
but only 15% of the world's health care workforce. Moreover, the shortage experienced
by countries that can least afford it is exacerbated by health worker migration to high-
income countries. South Africa, for example, has fewer than 7 doctors per 10,000
people, but reported in 2002 that 14% of the physicians who had trained there had
emigrated to the US or to Canada.
And the problem is not going away as in the UK, US, Canada and Australia, 23% C: to
28% of all physicians are international graduates. Efforts to reduce migration usually
focus on reducing recruitment by high-income countries, and these efforts are gaining
a higher profile. Improving the working conditions in source countries has not received
the same attention, however even though this would help counter the factors that push
health professionals to seek better conditions elsewhere. It would also make work
healthier for those who remain in low income countries, and thereby reduce
occupational concerns such as injuries violence and stress, and exposure to biological,
chemical and physical hazards.
Although concerns about healthy work conditions exist to varying degrees around the
world, they are greatest in nations with few resources, and particularly in Africa, where
work conditions are the most challenging. It is well documented that health workers in
low and middle-income countries experience fear and frustration when caring for
patients with tuberculosis and blood borne diseases, and that they do so often in
difficult work environmental. Health workers may also be ostracised by their own
communities due to the ever present stigma associated with exposure. It is now also
well established that health workers are indeed at higher risk of acquiring numerous
infectious diseases.
International organizations are recognizing the importance of promoting and protecting

the health of the global health care workforce, which is conservatively estimated to be
59 million, and are undertaking constructive initiatives to do so. The World Health
Organization (WHO) has explicitly recognized the need to improve the environment of
health care workers in order to increase retention and is promoting the use of
workplace audit checklists to help guide the reduction of infectious disease
transmission in health care. WHO is also promoting the immunization of all health care
workers against hepatitis B, and, is working to move forward specific Healthy Hospital
Initiatives, which include projects that involve both infection control and occupational
health practitioners, and that train practitioners along with health and safety
representatives in conducting workplace inspections
Canada and other countries that receive health care workers from low resource
settings compromise the workforce in the source country as they supplement their
own. The situation is inequitable and, over time, will undermine those low resources
further, worsening the already challenging working conditions and creating even more
pressure for health care workers to emigrate. To offset this effect, high-income
countries can reciprocate by improving working conditions in source countries. British
Columbia, which attracts the highest number of South African physicians of all
Canadian provinces, has taken a step in this positive direction by sharing expertise in
occupational health and infectious p disease transmission control through the
Pelonomi Hospital project.
At the university level, researchers and practitioners can contribute to this knowledge
exchange by partnering with their colleagues in low-income countries. Such
collaborations are essential. Also needed are intensified efforts to promote further
integration of worker safety and patient safety. To ensure information systems being
developed support this goal, we need to promote evidence based decision making and
share our information with those who can: benefit from it. That way, each region will
not need to find millions of dollars annually to design, implement and maintain separate
systems that could be easily shared and reproduced.
To achieve this aim, we need international collaboration in order to reach consensus

on a data dictionary and complete the programming of non-proprietary information
systems such as OHASIS, which can be tailored to different technological
environments and made widely available using Creative Commons licensing. Much of
what needs to be done can be accomplished with simple and effective solutions that
benefit both patients and workers. What it will take is commitment from high-income
countries to assist in the development, refinement and implementation of these tools in
collaboration with low-income countries. Such endeavours can be made possible by
making them a priority at the national funding level.
15. The main idea presented in paragraph 1 is
A. Recruiting health care workers is a problem in most countries

B. There is a shortage of health care workers in Sub-Saharan Africa and Southeast
Asia
C. There are not enough health care Workers in places which have the highest
need for medical treatment
D. A significant number of South African doctors are migrating to the US and
Canada
16. The main point raised by the authors in paragraph 2 is that
A. there are too many international graduates in UK, US, Canada and Australia
B. high income countries must reduce recruitment of overseas health professionals
C. more effort is required to improve work conditions in source
D. work conditions in poorer countries are dangerous
17. According to paragraph 3 which of the following is false regarding conditions in low
& middle income countries?
A. Work conditions are most difficult in Africa

B. Health Workers fear exposure to contagious diseases
C. Health Workers feel frustration towards patients
D. Being exposed to infectious diseases may lead to shame within local
communities.
18. Regarding the size of the global health care workforce, we can infer paragraph 4
that
A. there may be more than 59 million Workers

B. there may be less than 59 million workers
C. there are exactly 59 million Workers
D. the number of health care workers in unknown
19. According to paragraph 4, which of the following statements is true regarding

WHO?
A. WHO realises that improvements in the working environment of healthcare

workers is necessary
B. WHO wants to increase immunisation rates of health care workers against
hepatitis B
C. WHO is advancing Healthy Hospital Initiatives including training and infection
control
D. All of the above
20. In paragraph 5 the authors infer that

11. 15
12. psychiatric illness
13. infested by parasites

14. unexplained dermopathy
15. parasites
16. Mayo Clinic
17. CDC
18. persona
19. physicians
20. relentless

1. A
2. C
3. A
4. A
5. A
6. B

7. C
8. C
9. D
10. B
11. C
12. D
13. B
14. A

15. C
16. C
17. C
18. A
19. D
20. A
21. B
22. B
In this group of welfare clients,
the rate of newly diagnosed tuberculosis was 14.8 times that of the age
matched general population of New York City;
the rate of AIDS was 10.0 times as high;
the death rate was 5.2 times as high.

no significant difference in the rate of new cases of tuberculosis between
subjects with positive skin tests and those with negative skin tests at
examination in 2009.
Text C
Deaths in the cohort
There were 183 deaths in the cohort during follow-up (21.3 percent) of the subjects, a
rate of 2842 deaths per 100,000 person-years, 5.2 times that of the age-matched
general population.
Causes of death Table 3
CAUSES OF DEATH IN THE STUDY GROUP
Causes of death No. of subjects (%) Average Age at Death (years)
AIDS 66 (36.1%) 40
Infectious diseases 18 (9.8%) 43
Cirrhosis of the liver 16 (8.7%) 43
TB 11 (6%) 42
Coronary artery disease 10 (5.5%) 47
Pneumonia 9 (4.9%) 42
Cancer 8 (4.4%) 54
Overdose of non- narcotic 8 (4.4%) 42
substance
Other heart disease 7 (3.8%) 43
Drug dependence 4 (2.2%) 37
Alcohol abuse 3 (1.6%) 43
Cerebrovascular disease 3 (1.6%) 47
Diabetes 3 (1.6%) 53
Upper gastrointestinal bleeding 3 (1.6%) 44
Wound 3 (1.6%) 47
Chronic renal failure 2(1.1%) 59
Respiratory arrest 2(1.1%) 46
Other 7 (3.8%) 48
Total 183 43
Text D
Conclusions
 Of the 47 subjects with tuberculosis, 21 (44.7 percent) died before the end of
2017;
 12 (57.1 percent) of those who died also had AIDS.
 Of 15 persons with both tuberculosis and AIDS, 12 (80.0 percent) died before the
end of 2017 and 8 died before completing anti-TB therapy.
 Of the 84 study subjects with AIDS, 68 (81.0 percent) died before the end of
2017
PART A -QUESTIONS
Questions 1-7
1. what was the percentage of deaths caused by diabetes in the study group?
2. what was the rate of incidence per 100,000 person per years for tuberculosis?
3. name the city where the study was conducted?
4. how the incidence rates of diseases and death for the study group were
ascertained?
5. how many died before the end of 2017 without completing anti-TB therapy?
6. what was the average age of subjects died due to other causes in the study group?
7. how many years the cohort was followed?
Questions 8-13
8. How many of the study subjects with only AIDS died before the end of 2017?
9. In how many of the study subjects wound was the cause of death?
10. What was the age limits of the study subjects?
11. When did the study begin?
12. What was the total number of deaths in the study group?
13. What was the percentage of deaths caused by respiratory arrest in the study
group?
Questions 14-20
14. The study shows that number of the incidence of tuberculosis in New York City has
more than______________ during the past decade.
15. In conclusion, 12 of those who died had both AIDS and__________
16. In the cohort during follow-up of the subjects, rate of deaths was 5.2 times that of
the___________ general population.
17. In the group of welfare clients, the rate of___________ was 10.0 times as high.
18. The study was conducted among ____________ who abuse drugs, alcohol, or
both _____________
19.___________ subjects died suffering from coronary artery disease.
20. There were __________ subjects in the study group.
Questions 1-6
1. The extract informs us that the incubators
A. is likely to circulate most of the air again.

B. may not work correctly in close proximity to some other devices.
C. prevents filtered air entering the system.
Incubators for Infant

The general principle is that air is processed before it reaches baby. An electric fan
draws room air through a bacterial filter which removes dust and bacteria. The filtered
air flows over an electric heating element. The filtered and heated air then passes over
a water tank where it is moistened. It then flows into the incubator canopy. The
incubator canopy is slightly pressurized. This allows expired carbon dioxide to pass
back into the room via the vent holes and most of the air to be recirculated. It also
prevent unfiltered air entering the system
A. ways of checking that a nebulizer has been placed correctly

B. how the use of nebulizer is authorized
C. why nebulizer are being used.
Nebulizers
A nebulizer is a device used to administer medication in the form of a mist inhaled into
the lungs. Nebulizers are commonly used for treatment of cystic fibrosis, asthma and
other respiratory diseases. The reason for using a nebulizer for medicine to be
administered directly to the lungs is that small aerosol droplets can penetrate into the
narrow branches of the lower airways. Large droplets would be absorbed by the mouth
cavity, where the clinical effect would below. The common technical principle for all
nebulizers is to use oxygen, compressed air or ultrasonic power as means to break up
medical solutions or suspensions into small aerosol droplets.
3. What does this manual tell us about zeolite granules?
A. leave residual oxygen for patient use

B. selectively absorb nitrogen from air
C. absorb only nitrogen from compressed air.
Oxygen Concentrators.
Atmospheric air consists of approximately 80% nitrogen and 20%oxygen. An oxygen
concentrator uses air as a source of oxygen by separating these two components. It
utilizes the property of zeolite granules to selectively absorb nitrogen from compressed
air. Atmospheric air is gathered, filtered and raised to a pressure of 20pounds per
square inch (psi) by a compressor. The compressed air is then introduced into one of
the canisters containing zeolite granules where nitrogen is selectively absorbed leaving
the residual oxygen available for patient use. After about 20 seconds the supply of
compressed air is automatically diverted to the second canister where the process is
repeated enabling the output of oxygen to continue uninterrupted
4. Which is the main factor behind BP level?
A. the heart minute rejection volume

B. volume and viscosity of the blood
C. elasticity of the arterial wall
Arterial blood pressure

The arterial blood pressure (BP) is connected with the force, which is exerted by the
blood volume on the walls of the arteries. The level of BP is dependent on two factors:
the heart minute ejection volume and the elasticity of arterial walls. Other factors
affecting BP include: the volume and viscosity of the blood, body position and
emotional state. The BP at the top of pulse wave(due to the constriction of heart
ventricles) is called systolic BP, whereas the respective one during the diastole is
called diastolic BP. The difference between systolic and diastolic BP is defined as
amplitude or pulse pressure.
5. What does this manual tell us about cardiopulmonary resuscitation?
A. should be initiated by bystanders

B. should be initiated immediately only for cardiac arrest
C. should be performed by medical services
Basic Life Support

Basic Life Support means saving lives by maintaining airway, supplying ventilation
(rescue breathing by blowing air to the victim's mouth) and supplying circulation
(external cardiac massage chest compressions) performed without additional
equipment. It is the first step in cardio pulmonary resuscitation (CPR) that should be
initiated by bystanders and continued until qualified help arrives. Next step is
Advanced Life Support (ALS), which is performed by medical services. People with
cardiac arrest (CA) need immediate CPR. First aid means BLS that is started by
witnesses before the emergency service arrival and is the key action in achieving
patient survival.
6. What does this extract from a handbook tell us about absorbable threads?
A. absorbing progresses due to enzymatic integration and hydrolysis

B. absorbing time is varied and depends on material properties
C. are divided into monofilament, polifilament, braided, plaits and uncoated ones
Types of surgical threads

Materials, which the threads are made of, are divided into absorbable and non-
absorbable ones or natural and synthetic sutures. Non-absorbable sutures are applied
on the skin and in septic wounds. Absorbable threads depending on their structure are
divided into monofilament, polifilament, braided, plaits, coated and uncoated ones.
Time of their absorbing is varied and depends on material properties; it can take from
14 days to 6 months. Absorbing progresses due to enzymatic disintegration and
hydrolysis.
Part C -Text 1
Targeting two important risk factors for cardiovascular disease and other major
risk factors that can be lowered by modification, treatment or control
(ARA) It's well known that the prevalence of diabetes is on the rise. According to the
Centers for Disease Control and Prevention (CDC), about 23.6 million, or nearly 8
percent of people in the United States, have diabetes, and 1.6 million new cases are
diagnosed each year in people aged 20 and older. Type 2 diabetes is the most
common form, accounting for about 90 to 95 percent of those diagnosed, and occurs
when the body either does not produce enough insulin or does not respond to insulin.
But something that many people may not know is that in addition to having diabetes,
70 percent of adults with type 2 diabetes also have high LDL cholesterol (LDL-C), the
"bad" cholesterol that can cause build-up in the arteries, greatly increasing their risk for
cardiovascular disease. Cholesterol is needed for the body to function normally, but
when there is too much LDL-C in the bloodstream, it is deposited in arteries, including
those of the heart, which can limit blood flow and lead to heart disease.
The American Diabetes Association (ADA) and the American College of Cardiology
(ACC) emphasize that it is critical to control both cholesterol and blood sugar levels.
The ADA recommends that patients with type 2 diabetes aim for an A1C level which
reflects your average blood sugar level for the past two to three months, of less than 7
percent. The National Cholesterol Education Program (NCEP) ATP III recommends
that patients with type 2diabetes target an LDL-C goal of less than 100 mg/dL.
Treating these two diseases can take a combination of efforts, including a healthy diet
and increased exercise. Medications are also sometimes needed. While there are
many drugs approved by the U.S. Food and Drug Administration (FDA) to treat type 2
diabetes and others available to lower LDL-C, a drug called Welchol (colesevelam
HCI) is the first and only medication approved as an adjunct to diet and exercise to
reduce both A1C in adults with type 2 diabetes and LDL-C in adults with elevated
cholesterol. Welchol addresses both of these chronic health conditions with one
medication and offers the convenience of two formulations, Welchol tablets and
Welchol for Oral Suspension. Welchol can be taken alone or with other cholesterol
lowering medications known as statins and can be added to other anti-diabetic
medications (metformin, sulfonylureas, or insulin).
"For patients with type 2 diabetes and high LDL cholesterol, it is important to manage
both conditions," said Yehuda Handelsman, MD, FACP, FACE, Medical Director of the
Metabolic Institute of America in Tarzana, Calif. "Welchol reduces these two risk
factors for cardiovascular disease in adults with type 2 diabetes by significantly
lowering A1C and LDL-C or 'bad' cholesterol, providing a unique therapeutic option." It
is important to note that the effect of Welchol on cardiovascular morbidity and mortality
has not been determined.
What are the major uncontrollable risk factors for coronary heart disease?
The American Heart Association has identified several risk factors for coronary heart
disease. Some of them can be modified, treated or controlled and some can't. The
more risk factors a person has, the greater the chance that he or she will develop heart
disease. Also, the greater the level of each risk factor, the greater the risk. For
example, a person with a total cholesterol of 300 mg/dL has a greater risk than
someone with a total cholesterol of 240mg/dL, even though all people with a total
cholesterol of 240 or higher are considered high risk
Increasing age--- About 82 % of people who die of coronary heart disease are 65 or
older.
Male sex (gender)--- The lifetime risk of developing CHD after age 40 is 49% for men
and 32% for women. The incidence of CHD in women lags behind men 1 years for
total CHD and by 20 years for more serious clinical events such as sudden death
Heredity (including Race)--- Children of parents with heart disease are more likely to
develop it themselves. African Americans have more severe high blood pressure than
Caucasians and a higher risk of heart disease. Heart disease is also higher among
Mexican Americans, American Indians, native Hawaiians and some Asian Americans.
This is partly due to higher rates of obesity and diabetes. Most people with a strong
family history of heart disease have one or more other risk factors. Just as you can't
control your age, sex and race, you can't control your family history. Therefore, it's
even more important to treat and control any other risk factors you have.
Other major risk factors that can be lowered by modification, treatment or

control
Tobacco smoke --- Smokers' risk of developing CHD is two to four times that
nonsmokers'. Smokers who have a heart attack are more likely to die and die suddenly
(within an hour) than nonsmokers. Cigarette smoking also acts with other risk factors to
greatly increase the risk for coronary heart disease. People who smoke cigars or pipes
seem to have a higher risk of death from coronary heart disease (and possibly stroke),
but their risk isn't as great as cigarette smokers. Constant exposure to other people's
smoke-called environmental tobacco smoke, secondhand smoke or passive smoking -
increases the risk of heart disease even for non smokers.
High blood cholesterol levels ---- The risk of coronary heart disease rises as blood
cholesterol levels increase. When other risk factors (such as high blood pressure and
tobacco smoke) are present, this risk increases even more. A person's cholesterol
level is also affected by age, sex, heredity and diet. High blood pressure High blood
pressure increases the heart's workload, causing the heart to enlarge and weaken over
time. It also increases the risk of stroke, heart attack, kidney failure and heart failure.
When high blood pressure exists with obesity, smoking, high blood cholesterol levels
or diabetes, the risk of heart attack or stroke increases several times.
Physical inactivity
An inactive lifestyle is a risk factor for coronary heart disease. Regular, moderate-to-
vigorous physical activity is important in preventing heart and blood vessel disease.
Obesity and overweight People who have excess body fat- especially if a lot of it is in
the waist area-are more likely to develop heart disease and stroke even if they have no
other risk factors. Excess weight increases the strain on the heart, raises blood
pressure and blood cholesterol and triglyceride levels, and lowers HDL (good)
cholesterol levels. It can also make diabetes more likely to develop. Many obese and
overweight people have difficulty losing weight. If you can lose as little as 10 to 20
pounds, you can help lower your heart disease risk.
Diabetes mellitus---- Diabetes seriously increases the risk of developing

cardiovascular disease. Even when glucose levels are under control, diabetes greatly
increases the risk of heart disease and stroke. From two-thirds to three-quarters
people with diabetes die of some form of heart or blood vessel disease
What other factors contribute to heart disease risk? Stress----- Individual response
to stress may be a contributing factor. Some scientists have noted a relationship
between coronary heart disease risk and stress in a person's life, their health behaviors
and socioeconomic status. These factors may affect established risk factors. For
example, people under stress may overeat, start smoking or smoke more than they
otherwise would.
Excessive alcohol intake---- Drinking too much alcohol can raise blood pressure,
cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and
other diseases, and produce irregular heartbeats. It also contributes to obesity,
alcoholism, suicide and accidents. The risk of heart disease in people who drink
moderate amounts of alcohol (an average of one drink for women or two drinks for
men per day) is lower than in nondrinkers. One drink is defined as 1-1/2 fluid Ounces
(fl oz) of 80-proofspirits (such as bourbon, Scotch, vodka, gin, etc.), 1 fl oz of 100-
proofspirits, 4 fl oz of wine, or 12 fl oz of beer. It's not recommended that non drinkers
start using alcohol or that drinkers increase their intake
7. According to paragraph 1 of the article states that
A. Diabetes has stabilised.

B. 1.6 million people aged 20 and older have diabetes
C. Type 2 diabetes is the most common
D. Type 2 diabetes occurs when there is an over-production of insulin
8. In addition to having diabetes
A. 30% of adult with Type 2 diabetes do not have high counts of low density lipids
B. 70% of adults with Type 2 diabetes do have high counts of low density lipids
C. Too many LDLs in the bloodstream go straight to the heart
D. LDLs in the bloodstream cannot hinder blood flow
9. According to the ADA and the ACC
A. Both blood sugar levels and cholesterol levels need to be controlled if diabetes is
avoided
B. Blood sugar levels need to be controlled if diabetes is to be avoided
C. ACA believes less than 7% average blood sugar level over a one month period
indicates diabetes risk
D. The NCEP does not recommend Type 2 diabetics aim for less than 100mg/dL of low
density lipids
10. Welchol, a drug to lower the level of LDLs in the blood
A. has not been approved by the U.S. FDA

B. Welchol must be taken with other statins
C. Welchol should not be added to medications such as metformin,sulfonylureas or
insulin.
D. Welchol needs to be taken together with a healthy diet and an exercise program to
reduce A1C in Type 2 diabetes and LDL-C in adults with elevated cholesterol levels.
11. Welchol's affect on cardiovascular morbidity and mortality…..
A. is supported by the evidence

B. has not been positively established
C. has been positively established
12. Some risk factors can be controlled, or lowered; some cannot be controlled: such
as advancing age, one's gender, and one's genetic inheritance. However, there are
some major risk factors that can be lowered by modifying one's lifestyle - or by medical
intervention. Risk factors such as
A. high blood pressure

B. high cholesterol levels
C. obesity
D. all of the above
13. The article states that stress
A. causes overeating and/or habitual smoking

B. does not interact with lifestyle and socioeconomic status
C. depends on how one reacts to it
D. may depend on how one reacts to it
14. Alcohol contributes to heart failure and strokes
A. if you drink very less amount

B. moderate alcohol intake leads to less risk of heart disease
C. but not contribute to high triglycerides
D. is not a factor in developing cancer .
Part C -Text 2
Fluoride
Globalization has provoked changes in many facets of human life, particularly in diet.
Trends in the development of dental caries in population have traditionally followed
developmental patterns where, as economies grow and populations have access to a
wider variety of food products as a result of more income and trade, the rate of tooth
decay begins to increase. As countries become wealthier, there is a trend to greater
preference for amore "western" diet, high in carbohydrates and refined sugars. Rapid
globalization of many economies has accelerated this process. These dietary
have a substantial impact on diseases such as diabetes and dental caries.
The cariogenic potential of diet emerges in areas where fluoride supplementation is

inadequate. Dental caries is a global health problem and has a significant negative
impact on quality of life, economic productivity, adult and children's general health and
development. Untreated dental caries in pre-school children is associated with poorer
quality of life, pain and discomfort, and difficulties in ingesting food that can result in
failure to gain weight and impaired cognitive development. Since low-income countries
cannot afford dental restorative treatment and in general the poor are most vulnerable
to the impacts of illness, they should be afforded a greater degree of protection.
By WHO estimates, one third of the world's population have inadequate access to
needed medicines primarily because they cannot afford them.
Despite the inclusion of sodium fluoride in the World Health Organization's Essential
Medicines Model List, the global availability and accessibility of fluoride for the
prevention of dental caries remains a global problem. The optimal use of fluoride is an
essential and basic public health strategy in the prevention and control of dental caries,
the most common non communicable disease on the planet. Although a whole range
of effective fluoride vehicles are available for fluoride use (drinking water, salt, milk,
varnish, etc.), the most widely used method for maintaining a constant low level of
fluoride in the oral environment is fluoride toothpaste.
More recently, the decline in dental caries amongst school children in Nepal has been
attributed to improved access to affordable fluoride toothpaste. For many low-income
nations, fluoride toothpaste is probably the only realistic population strategy for the
control and prevention of dental caries since cheaper alternatives such as water or salt
fluoridation are not feasible due to poor infrastructure and limited financial and
technological resources. The use of topical fluoride e.g. in the form of varnish or gels
for dental caries prevention is similarly impractical since it relies on repeated
applications of fluoride by trained personnel on an individual basis and therefore in
terms of cost cannot be considered as part of a population based preventive strategy
The use of fluoride toothpaste is largely dependent upon its socio-cultural integration in
personal oral hygiene habits, availability and the ability of individuals to purchase and
use it on a regular basis. The price of fluoride toothpaste is believed to be too high in
some developing countries and this might impede equitable access. In a survey
conducted at a hospital dental clinic in Lagos, Nigeria 32.5% of the respondents
reported that the cost of toothpaste influenced their choice of brands and 54% also
reported that the taste of toothpastes influenced their choice.
Taxes and tariffs on fluoride toothpaste can also significantly contribute to high prices,
lower demand and inequity since they target the poor. Toothpastes are u; classified as
a cosmetic product and as such often highly taxed by governments. For example,
various taxes such as excise tax, VAT, local taxes as well as taxation on the
ingredients and packaging contribute to25% of the retail cost of toothpaste in Nepal
and India, and 50% of the retail price in Burkina Faso. WHO continues to recommend
the removal taxes and tariffs on fluoride toothpastes. Any lost revenue can be rest by
higher taxes on sugar and high sugar containing foods, which are common risk factors
for dental caries, coronary heart disease, diabetes and obesity.
The production of toothpaste within a country has the potential to make fluoride
toothpaste more affordable than imported products. In Nepal, fluoride toothpaste was
limited to expensive imported products. However, due to successful advocacy locally
manufactured fluoride toothpaste, the least expensive locally manufactured fluoride
toothpaste is now 170 times less costly than the most expensive imported Philippines,
local manufacturers are able to satisfy consumer preferences and compete against
multinationals by discounting the price of toothpaste by as much as 55% against global
brands; and typically receive a 40% profit margin compared to 70% for multinational
producers.
In view of the current extremely inequitable use of fluoride throughout countries and
regions, all efforts to make fluoride and fluoride toothpaste affordable and accessible
must be intensified. As a first step to addressing the issue of affordability of fluoride
toothpaste in the poorer countries in-depth country studies should be undertaken to
analyze the price of toothpaste in the context of the country economies.
15. Which of the following would be the most appropriate heading for the paragraph 1?
A. High sugar intake and increasing tooth decay

B. Globalisation, dietary changes and declining dental health
C. Dietary changes in developing nations
D. Negative health effects of a western diet
16. Which of the following is not mentioned as a negative effect of untreated dental
caries in pre-school children?
A. Decreased mental alertness

B. Troubling chewing and swallowing food
C. Lower life quality
D. Reduced physical development
17. According to paragraph 3, which of the following statement is correct?
A. Dental caries is the most contagious disease on earth.

B. Fluoride in drinking water is effective but rarely used
C. Fluoride is too expensive for a large proportion of the global population.
D. Fluoride toothpaste is widely used by 2/3 of the world's population.
18. Fluoride toothpaste is considered the most effective strategy to reduce dental
caries in low income countries because.
A. it is the most affordable.

B. topical fluoride is unavailable.
C. it does not require expensive infrastructure or training.
D. it was effective in Nepal.
19. Which of the following is closest in meaning to the word impede?
A. stop
B. prevent
C. hinder
D. postpone
20. Regarding the issue of taxation in paragraph 6 which of the following statements is
most correct?
A. Income tax rates are higher in Burkina Faso than India or Nepal.
B. WHO recommends that tax on toothpaste be reduced.
C. Governments would like to reduce tax on toothpastes but can't as it is classified as a
cosmetic.
D. WHO suggests taxing products with a high sugar content instead of toothpastes.
21. Which of the following is closest in meaning to the word advocacy?
A. marketing
B. demand
C. development
D. support
22. Statistics in paragraph 7 indicate that....
A. local products can't compete with global products and make a profit at the same
time.
B. Philippine produced toothpaste is profitable while being less than half the price of
global brands.
C. in Nepal, fluoride toothpaste is limited to imported products which are very
expensive
D. toothpaste produced in the Philippines has a higher profit margin than internationally
produced toothpaste.
Previous research
Venous thrombosis was first linked to air travel in 1954, and as air travel has become
more and more common, many case reports and case series have been published
since. Several clinical studies have shown an association between air travel and the
risk of venous thrombosis. English researchers proposed, in a paper published in the
Lancet, that flying directly increases a person's risk. The report found that in a series of
individuals who died suddenly at Heathrow Airport, death occurred far more often in
the arrival than in the departure area.
Two similar studies reported that the risk of pulmonary embolism in air travelers
increased with the distance traveled. In terms of absolute risk, two studies found
similar results: one performed in New Zealand found a frequency of 1% of venous
thrombosis in 878 individuals who had traveled by air for at least 10 hours. The other
was a German study which found venous thrombotic events in 2.8% of 964 individuals
who had traveled for more than 8 hours in an airplane. In contrast, a Dutch study found
no link between DVT and long distance travel of any kind
Text C
Symptoms
 Pain and tenderness in the leg
 Pain on extending the foot
 Tenderness in calf (the most important sign)
 Swelling of the lower leg, ankle and foot
 Redness in the leg.
 Bluish skin discoloration
 Increased warmth in the leg
Text D
Travel-Related Venous Thrombosis: Results from a Large Population Based
Case Control
Study Background
Recent studies have indicated an increased risk of venous thrombosis after air travel.
Nevertheless, questions on the magnitude of risk, the underlying mechanism, and
modifying factors remain unanswered.
Methods
We studied the effect of various modes of transport and duration of travel on the risk of
venous thrombosis in a large ongoing case-control study on risk factors for venous
thrombosis in an unselected population. also assess the combined effect of travel in
relation to body mass index, height, and oral contraceptive use. Since March 2015,
consecutive patients younger than 70years of age with a first venous thrombosis have
been invited to participate in the study, with their partners serving as matched control
individuals. Information has been collected on acquired and genetic risk factors for
venous thrombosis.
Results
Of 1,906 patients, 233 had traveled for more than 4 hours in the 8 weeks preceding
the event. Traveling in general was found to increase the risk of venous thrombosis.
The risk of flying was similar to the risks of traveling by bus or train. The risk was
highest in the first week after traveling. Travel by bus, or train led to a high relative risk
of thrombosis in individuals with factor V Leiden, in those who had a body mass index
of more than 30, those who were more than 190 cm tall, and in those who used oral
contraceptives. For air travel these people shorter than 160 cm had an increased risk
of thrombosis after air travel as well.
Conclusions
The risk of venous thrombosis after travel is moderately increased for all modes of
travel. Subgroups exist in which the risk is highly increased.
PART A -QUESTIONS
Questions 1-7
1. what are the symptoms of DVT?

2. how much risk of DVT is there in the first week after traveling?
3. what is the most important sign of DVT?
4. when did DVT was first linked to air travel?
5. what are the safe practices to reduce the risk of DVT?
6. which exercises reduce the risk of DVT?
7. what were the conclusions of the Dutch study on DVT?
Questions 8-13
8. What is the type of skin discolouration seen in DVT patients?

9. What type of clothes reduce the risks of DVT?
10. Which type of flights are more suspected of contributing to the formation of DVT?
11. Name the physical activity which was found to increase the risk of DVT in general?
12. Which type of population was the subject for travel related DVT study?
13. Name the body parts were tenderness was observed as a symptom of DVT?
Questions 14-20
14. The risk of flying was similar to the risks of traveling by_________
15. Recent studies have indicated an increased risk of venous thrombosis
after__________
16.____________of the lower leg, ankle and foot is a symptom of DVT
17. Several__________ have shown an association between air travel and the risk of
venous thrombosis.
18. ____________in general was found to increase the risk of venous thrombosis.
19. Venous thrombosis was first linked to air travel in__________
20. Some airlines offer________ to passengers on how to reduce the risk of DVT.

Questions 1-6
1. The purpose of bottles that are fitted with flowmeter is to
A. humidify the oxygen tanks by bubbling it through water

B. humidify the oxygen reaching the patient or user
C. dehumidify the gas in the flowmeter
Flowmeter
A flowmeter is an instrument used to measure the flow rate of a liquid or a gas. In
healthcare facilities, gas flowmeters are used to deliver oxygen at a controlled rate
either directly to patients or through medical devices. Oxygen flowmeters are used on
oxygen tanks and oxygen concentrators to measure the amount of oxygen reaching
the patient or user. Sometimes bottles are fitted to humidify the oxygen by bubbling it
through water.
2. What does this notes tell us about pulse oximeters?
A. levels varies with amount of oxygenation

B. converts percent of light into a % oxygenation
C. probes can be mounted either on finger or earlobe
Pulse Oximeters: Non-invasive monitors

The coloured substance in blood, haemoglobin, is carrier of oxygenand the absorption
of light by haemoglobin varies with the amount of oxygenation. Two different kinds of
light (one visible, one invisible) are directed through the skin from one side of a probe,
and the amount transmitted is measured on the other side. The machine converts the
ratio of transmission of the two kinds of light into a % oxygenation. Pulse oximeter
probes can be mounted on the finger or ear lobe.
3. These notes are reminding staff that the
A. importance of precise reading of scales to monitor health of patient

B. infants should stand in a weighing cot on top of the scale
C. wheelchair bound patients should be suspended in a set up
Measuring Patient Weight

Measuring patient weight is an important part of monitoring health as well as
calculating drug and radiation doses. It is therefore vital that scales continue to operate
accurately. They can be used for all ages of patient and therefore vary in the range of
weights that are measured. They can be arranged for patients to stand on, or can be
set up for weighing wheelchair bound patients. For infants, the patient can be
suspended in a sling below the scale or placed in a weighing cot on top of the scale
4. The purpose of these notes about mammography is to
A. help maximise awareness about its efficiency

B. give guidance on early detection and prognosis
C. decrease probability of metastases
Breast Examination
Detection of changes in the breast depends on routine medical check-ups, especially
by an oncologist, regular breast scanning and mammography, and women's self-
examination. If early detected, a tumor is usually small, and the smaller it is, the less
probability of metastases. Early detection considerably improves prognosis in women
with breast cancer. Mammography enables detection of breast cancer at least one
year ahead of its manifestations. The smallest clinically palpable tumor is about 1 cm in
size.
5. What must all staff involved in the catheterization process do?
A. maintain perfect aseptic conditions

B. use non Lubricant substances
C. inhibit analgesic and sedative drugs
Catheterization
Regardless of the instrumental examination carried out in the urinary tract, it is
obligatory to maintain perfectly sterile conditions, to apply analgesic and sedative
drugs in order to alleviate patient's suffering, and to use gel substances that facilitate
the introduction of the instrument into the urinary tract. While
introducing instruments into the bladder, it is necessary to remember about
overcoming the resistance of the urethral sphincter gently
A. recommend 1% drops of Tropicamide for elderly patients

B. recommend 5% drops of Tropicamide for children
C. recommend 10% drops of Tropicamide for elderly patients
Ophthalmoscopy
Direct ophthalmoscopy is the most common method of examining the eye fundus. It
provides a 15x magnified upright image of the retina. Ophthalmoscopy is much easier
through a dilated pupil. Tropicamide 1% drops (0.5% for children) are recommended.
The pupil mydriasis starts 10 to 20 minutes after installation and lasts for 6-8 hours.
There is a small risk of angle closure glaucoma caused by mydriasis in eyes with
shallow anterior chambers, particularly in elderly patients.

Part C -Text 1
Is ADHD a valid diagnosis in adults
Attention deficit hyperactivity disorder (ADHD) is well established in childhood, with

3.6% of children in the United Kingdom being affected. Most regions have child and
adolescent mental health or paediatric services for ADHD. Follow-up studies of
children with ADHD find that 15% still have the full diagnosis at 25 years, and a further
50% are in partial remission, with some symptoms associated with clinical and
psychosocial impairments persisting
ADHD is a clinical syndrome defined in the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, by high levels of hyperactive, impulsive, and inattentive
behaviours in early childhood that persist overtime, pervade across situations, and lead
to notable impairments. ADHD is thought to result from complex interactions between
genetic and environmental factors.
Proof of validity. Using the Washington University diagnostic criteria, the National
Institute for Health and Clinical Excellence (NICE) reviewed the validity of the system
used to diagnose ADHD in children and adults
Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are
found to cluster together in both clinical and population samples Studies in such
samples also separate ADHD symptoms from conduct problems and neuro
developmental traits. Twin studies show a distinct pattern of genetic and environmental
influences on ADHD compared with conduct problems, and overlapping genetic
influences between ADHD and neuro developmental disorders such as autism and
specific reading difficulties. Disorders that commonly, but not invariably, occur in adults
with ADHD include antisocial personality, substance misuse, and depression.
Symptoms of ADHD are continuously distributed throughout the population. As with

anxiety and depression, most people have symptoms of ADHD at some time. The
disorder is diagnosed by the severity and persistence of symptoms, which are
associated with high levels of impairment and risk for developing co-occurring
disorders. ADHD should not be diagnosed to justify the use of stimulant drugs to
enhance performance in the absence of a wider range of impairments indicating a
mental health disorder.
ADHD symptoms have been tracked from childhood through adolescence

into adult life. They are relatively stable over time with a variable outcome in which
around two thirds show persistence of symptoms associated with impairments. Current
evidence defines the syndrome as being associated with academic difficulties,
impaired family relationships, social difficulties, and conduct problems. Cross sectional
and longitudinal follow-up studies of adults with ADHD have reported increased rates
of antisocial behaviour, drug misuse, mood and anxiety disorders, unemployment, poor
work performance, lower educational performance, traffic violations, crashes, and
criminal convictions.
Several genetic, environmental, and neurobiological variables distinguish ADHD from

non-ADHD cases at group level, but are not sufficiently sensitive or specific to
diagnose the syndrome. A family history of ADHD is the strongest predictor-parents of
children with ADHD and offspring of adults with ADHD are at higher risk for the
disorder. Heritability is around76%, and genetic associations have been identified.
Consistently reported associations include structural and functional brain changes, and
environmental factors (such as maternal stress during pregnancy and severe early
deprivation)
The effects of stimulants and atomoxetine on ADHD symptoms in adults are similar to
those seen in children. Improvements in ADHD symptoms and measures of global
function are greater in most studies than are reported in drug trials of depression. The
longest controlled trial of stimulants in adults showed improvements in these response
measures over six months. Stimulants may enhance cognitive ability in some people
who do not have ADHD, although we are not aware of any placebo controlled trials of
the effects of stimulants on work or study related performance in healthy populations.
This should not, however, detract from their specific use to reduce symptoms and
associated impairments in adults with ADHD
Psychological treatments in the form of psychoeducation, cognitive behavioural

therapy, supportive coaching, or help with organising daily
activities are thought to be effective. Further research is needed because the
evidence base is not strong enough to recommend the routine use of these treatments
in clinical practice.
Conclusions. ADHD is an established childhood syndrome that often in around 65% of
cases) persists into adult life. NICE guidelines are a milestone in the development of
effective clinical services for adults with ADHD.
Recognition of ADHD in primary care and referral to secondary or tertiary care
specialists will reduce the psychiatric and psychosocial morbidity associated with
ADHD in adults.
7. The article reports what proportion of diagnosed children present with ADHD in
adulthood?
A. Half
B. 3.6%
C. A quarter
D. 15%
8. According to the article
A. ADHD is triggered by genetic factors

B. ADHD is the result of environmental factors
C. both A and B
D. neither A nor B
9. According to the article symptoms
A. vary across clinical and population samples.

B. varies across situational factors
C. need to pervade across time and situations for a diagnosis to be made.
D. are not reliably identifiable.
10. Which co-occurring disorders does ADHD frequently present with?
A. Antisocial personality disorder.

B. Substance misuse.
C. Depression
D. All of the above.
11. According to the article, which one of the following statements about ADHD is
FALSE?
A. The use of stimulants is justified in the absence of a wider range of impairments
B. Symptoms of ADHD are evenly prevalent throughout the population
C. The criteria for diagnosis measure the severity and persistence of symptoms.
D. High levels of impairment and risk for developing co-occurring disorders are related
with ADHD
12. Which heading would best describe paragraph 6?
A. Symptoms associated with impairments.

B. ADHD and outcomes in adulthood.
C. Further definition of the syndrome.
13. The strongest predictor of ADHD is
A. Diagnostic and Statistical Manual of Mental Disorders, fourth edition

B. Social and academic impairment.
C. Heritability
D. Family environment.
14. The effectiveness of atomoxetine on ADHD symptoms is
A. less than described in drug trials of depression.

B. greater when measured over six months.
C. reduced in adults with ADHD.
D. known to improve measures of global functioning.
Part C -Text 2
Risks and Benefits of Hormone Replacement Therapy
Several recent large studies have provoked concern amongst both health
professionals and the general public regarding the safety of hormone replacement
therapy (HRT). This article provides a review of the current literature surrounding the
risks and benefits of HRT in postmenopausal women, and how the data can be applied
safely in everyday clinical practice.
Worldwide, approximately 47 million women will undergo the menopause every year
for the next 20 years. The lack of circulating oestrogens which occurs during the
transition to menopause presents a variety of symptoms including hot flushes, night
sweats, mood disturbance and vaginal atrophy, and these can be distressing in almost
50% of women.
For many years, oestrogen alone or in combination with progestogens, otherwise

known as hormone replacement therapy (HRT), has been the treatment of choice for
control of problematic menopausal symptoms and for the prevention of osteoporosis.
However, the use of HRT declined worldwide following the publication of the first data
from the Women's Health Initiative(WHI) trial in 2002
The results led to a surge in media interest surrounding HRT usage, with the
revelation that there was an increased risk of breast cancer and, contrary to
expectation, coronary heart disease (CHD) in those postmenopausal women taking
oestrogen plus progestogen HRT. Following this, both the Heart and
Estrogen/Progestin Replacement Study Follow-up (HERS II) and the Million Women
Study published results which further reduced enthusiasm for HRT use, showing
increased risks of breast cancers and venous thromboembolism (VTE), and the
absence of previously suggested cardio protective effects in HRT users. The resulting
fear of CHD and breast cancer in HRT users left many women with menopausal
symptoms and few effective treatment options
Continued analysis of data relating to these studies has been aimed at understanding
whether or not the risks associated with HRT are, in fact, limited to a subset of women.
A recent publication from the International Menopause Society has stated that HRT
remains the first-line and most effective treatment for menopausal symptoms. In this
article we examine the evidence that has contributed to common perceptions amongst
health professionals and women alike, and clarify the balance of risk and benefit to be
considered by women using HRT
One of the key messages from the WHI in 2002 was that HRT should not be
prescribed to prevent age-related chronic disease, in particular CHD. This was
contradictory to previous advice based on observational studies. However, recent
subgroup analysis has shown that in healthy individuals using HRT in the early
postmenopausal years (age 50-59 years), there was no increased CHD risk and HRT
may potentially have a cardio protective effect.
Recent WHI data has suggested that oestrogen-alone HRT in compliant women under
60 years of age delays the progression of atheromatous disease (as assessed by
coronary arterial calcification). The Nurses Health Study, a large observational study
within the USA, demonstrated that the increase in stroke risk appeared to be modest in
younger women, with no significant increase if used for less than five years.
Hormone replacement therapy is associated with beneficial effects on bone mineral

density, prevention of osteoporosis and improvement in osteoarthritic symptoms. The
WHI clearly demonstrated that HRT was effective in the prevention of all fractures
secondary to osteoporosis. The downturn in HRT prescribing related to the concern
regarding vascular and breast cancer risks is expected to cause an increase in fracture
risk, and it is predicted that in the USA there will be a possible excess of 243,000
fractures per year in the near future.
The WHI results published in 2002 led to a significant decline in patient and clinician
confidence in the use of HRT. Further analysis of the data has prompted a re-
evaluation of this initial reaction, and recognition that many women may have been
denied treatment. Now is the time to responsibly restore confidence regarding the
benefit of HRT in the treatment of menopausal symptoms when used judiciously.
Hormone replacement therapy is undoubtedly effective in the treatment of vasomotor
symptoms, and confers protection against osteoporotic fractures.
The oncologic risks are relatively well characterised and patients considering HRT
should be made aware of these. The cardiovascular risk of HRT in younger women
without overt vascular disease is less well defined and further work is required to
address this important question. In the interim, decisions regarding HRT use should be
made on a case-by-case basis following informed discussion of the balance of risk and
benefit. The lowest dose of hormone necessary to alleviate menopausal symptoms
should be used, and the prescription reviewed on a regular basis.
15. Which statement is the closest match to the description of the recent studies in
Paragraph 1?
A. They demand a prompt review of current HRT practices

B. They have shown that HRT can be used safely in clinical practice.
C. They have decreased the confidence of doctors and the public in HRT
D. They have given menopausal women a new confidence to undergo HRT.
16. Which statement is the closest match to the description of projected menopause
figures in Paragraph 2?
A. 47 international women will enter menopause annually for the next 20years
B. All women are likely to go through menopause if they live long enough.
C. 47 million women globally will enter menopause each year for the next 20years
D. Most women will succumb to menopause if they do not undertake HRT.
17. What cause does the article cite for the symptoms of menopause?
A. Lack of circulation
B. Age
C. Low progesterone levels
D. Low circulating estrogen levels
18. What has been the effect of the 2002 WHI study?
A. HRT has become less popular

B. HRT has increased in popularity as the treatment of choice for problematic
menopause symptoms
C. There has been an increase in combined estrogen and progesterone therapy
D . The women's health initiative has since been established to investigateHRT
19. Why were many women left with menopausal symptoms and no effective
treatment?
A. They were unable to afford HRT treatments.

B. They were concerned about coronary heart disease and breast cancer.
C. They were concerned about breast cancer and venous thromboembolism.
D. They were concerned about breast cancer and the cardio protective effects
20. Which of these statements is a TRUE summary of Paragraph 5?
A. Surveys since WHI have attempted to find out if the WHI results are representative
B. Results of past surveys are only valid for a subset of women, whether or not the
public is aware of this.
C. The present study aims to show that HRT is safer than previously believed.
D. Women should ask their doctors to clarify the balance of risks and benefits of HRT
21. Which study showed an increased risk of VTE?
A. The Nurses Health Study

B. The Million Women Study
Philadelphia recruited 15 breastfeeding mothers who smoked. Sleep and activity
patterns in their babies, which were aged between two and six months, were monitored
on two occasions over a three-hour period after the children were fed. On both
occasions the mothers were asked to abstain from smoking for 12 hours before the
study, but on one of the two occasions they were allowed to smoke just before they fed
babies. The women were also asked to avoid caffeinated drinks during the study.
Text B
Tests on the milk from mothers who had recently smoked confirmed that the babies
were receiving a significant increase in nicotine dose, and the team found that the
amount of sleep taken during the following three hours by these babies fell from an
average of 85 minutes to 53 minutes, a drop of almost 40%. This is probably due to the
neuro-stimulatory effects of nicotine, which has been shown to inhibit regions of the
brain which are concerned with controlling sleep. It may also, suggests Manella,
explain why neonatal nicotine exposure has been linked in the past with long-term
behavioural and learning deficits, since these could be the consequence of sleep
disturbance. In light of these findings, mothers who smoke might want to consider
planning their smoking around their breastfeeding. Nicotine levels in milk peak 30-60
minutes after smelting, but take three hours to return to base line, so this might be
feasible.
Text C
Cigarette smoke
What is in smoke?
Scientific studies show that there can be around 4000 chemicals in cigarette smoke.
They can be breathed in by anyone near a smoker. They can also stick to clothes, hair,
skin, walls and furniture. Some of these chemicals are: tar which has many chemicals
in it some of which cause cancer carbon monoxide reduces the oxygen in blood - so
people can develop heart disease poisons including arsenic, ammonia and cyanide.
Text D
Passive smoking and respiratory function in very low birth weight.

Children Abstract Aim To determine if an adverse relationship exists between
passive smoking and respiratory function in very low birth weight (LBW) children at 11
years of age.
Setting
The Royal Women's Hospital. Melbourne.
Patients
154 consecutive surviving children of less than 1501 g birth weight born during the 18
months from 1 October 2006.
Methods
Respiratory function of 120 of the 154 children (77.9%) at 11 years of age was
measured. Exposure to passive smoking was established by history; no children were
known to be actively smoking. The relationships between various respiratory function
variables and the estimated number of cigarettes smoked by household members per
day were analysed by linear regression.
Results Most respiratory function variables reflecting airflow were significantly
diminished with increasing exposure to passive smoking. In addition, variables
indicative of air-trapping rose significantly with increasing exposure to passive
smoking.
Conclusions
Passive smoking is associated with adverse respiratory function in surviving VLBW
children at 11 years of age. Continued exposure to passive smoking, or active
smoking, beyond 11 years may lead to further deterioration in respiratory function in
these children.
PART A -QUESTIONS
Questions 1-7
1. how many chemicals are there in cigarette smoke?

2. which chemicals in cigarette smoke causes cancer?
3. when does nicotine levels in breast milk reach at peak?
4. How does exposure to passive smoking was established in the study?
5. what happened to respiratory function variables reflecting airflow in the study?
6. what are the side effects of neonatal nicotine exposure?
7. what are the poisons in cigarette smoke?
Questions 8-13
8. How much percentage does the sleep drop in the babies who had significant
nicotine dose?
9. How much percentage of children at 11 years of age was measured for respiratory
function?
10. What was the maximum birth weight of babies who were considered for the study?
11. Which chemical component in cigarette smoke reduces the oxygen in blood?
12. Who recruited subjects for the study conducted by Monell Chemical Senses
Centre?
13. Which chemical component in cigarette smoke is responsible for heart disease?
Questions 14-20
14. If children are continually exposed to active smoking, it can lead to____________
in respiratory function.
15. Cigarette smoke can be breathed in by anyone near a________________
16. During the study some women were asked to avoid__________________
17.________________can also stick to clothes, hair, skin, walls and furniture
18. Variables indicative of __________ rose significantly with increasing exposure to
passive smoking,
19.________________ of nicotine can inhibit regions of the brain which control sleep.
20. The relationships between respiratory function variables and number of cigarettes
smoked per day were analysed by__________
Questions 1-6
1. When should one note the diastolic pressure of patient?
A. blood flow is limited to make the sound disappear

B. blood flow is normal and the sound disappear
C. blood flow is obstructed and the sound disappear
B.P. sets: Functioning

The cuff on the arm is inflated until blood flow in the artery is blocked. As the cuff
pressure is decreased slowly, the sounds of blood flow starting again can be detected.
The cuff pressure at this point marks the high (systolic) pressure of the cycle. When
flow is unobstructed and returns to normal, the sounds of blood flow disappear. The
cuff pressure at this point marks the low (diastolic) pressure.
2. The purpose of bottle in aspirator is to
A. deliver suction that draws air

B. draw the fluid from the patient
C. keep pressure stable if valve prevents fluid
Aspirators
Suction is generated by a pump. This is normally an electrically powered motor, but
manually powered versions are also often found. The pump generates a suction that
draws air from a bottle. The reduced pressure in this bottle then draws the fluid from
the patient via a tube. The fluid remains in the bottle until disposal is possible. A valve
prevents fluid from passing into the motor itself.
3. The email is reminding user that the
A. importance of lever for the required movements

B locks of moving wheels are on main table frame
C. table should be set at correct height of the patient
Operating Theatre and Delivery Tables

Where the table has movement, this will be enabled by unlocking a catch or brake to
allow positioning. Wheels have brakes on the rim or axle of the wheel, while locks for
moving sections will normally be levers on the main table frame. Care should be taken
that the user knows which lever applies to the movement required, as injury to the
patient or user may otherwise result. The table will be set at the correct height for
patient transfer from a trolley then adjusted for best access for the procedure.
A. report a mass outbreak of hospital infection immediately

B. report severe injury, as a result of hospital infection with delay
C. report an infection that led to the death of a patient only
Methods of reporting hospital infection

A mass outbreak of a hospital infection, which can result in severe injury or death,
must be reported without delay, by telephone, fax or e-mail to the local public health
protection authority (usually to the regional hygiene departments). The following cases
are subject to the reporting of hospital infections: Severe injury, as a result of hospital
infection A mass outbreak An infection that led to the death of a patient
5. This guideline extract says that hygiene requirements are
A. determined by the healthcare professional

B. implemented by the healthcare provider
C. written in the operating rules of the facilities
Admission and treatment in medical and social care facilities

Hygiene requirements for the admission and treatment of patients at medical inpatient
facilities, day care and outpatient care facilities are set out in the operating rules of
each healthcare provider, and always take into consideration the nature and scope of
activity, and the type of healthcare provided. The receiving healthcare professional at
the healthcare facility such as an inpatient facility, day care or social care facility,
records anamnesis information that is significant in terms of the potential occurrence of
hospital infection, including travel and epidemiological anamnesis, or conducts an
examination of the overall health of the individual
A. report on a rise in used contagious and surgical linen in healthcare facility

B. explain the background to a change healthcare provider and the laundry contract
C. remind staff about procedures for treatment of used contagious and surgical linen.
Treatment of used contagious and surgical linen

The healthcare provider and the laundry contractually agree on a system for classifying
and labelling containers according to the content (e.g. in colour or numerical) and the
procedure in terms of the quantity, deadlines and handling is documented. Linen is
sorted at the place of use but it is not counted. The linen is not to be shaken before
placing into the containers in the ward. It is sorted into bags according to the degree of
soiling, type of material and colour
Part C -Text 1
Pancreatic Islet Transplantation
The pancreas, an organ about the size of a hand, is located behind the lower part of
the stomach. It makes insulin and enzymes that help the body digest and use food.
Spread all over the pancreas are clusters of cells called the islets of Langerhans. Islets
are made up of two types of cells: alpha cells, which make glucagon, a hormone that
raises the level of glucose (sugar) in the blood, and beta cells, which make insulin
Islet Functions
Insulin is a hormone that helps the body use glucose for energy. If your beta cells do
not produce enough insulin, diabetes will develop. In type 1 diabetes, the insulin
shortage is caused by an autoimmune process in which the body's immune system
destroys the beta cells.
Islet Transplantation
In an experimental procedure called islet transplantation, islets are taken from a donor
pancreas and transferred into another person. Once implanted, the beta cells in these
is begin to make and release insulin. Researchers hope that transplantation will help
people with type 1 diabetes live without daily injections of insulin.
Research Developments
Scientists have made many advances in islet transplantation recent years Since
reporting their findings in the June issue of the New England Journal of Medicine,
researchers the University of Alberta in Edmonton, Canada, have continued to use a
procedure called the Edmonton protocol to transplant pancreatic islets into people with
type 1 diabetes. According to the Immune Tolerance Network (ITN), as of June 2003,
about 50 percent of the patients have remained insulin free up to g 1 year after
receiving a transplant. Researchers use specialized enzymes to remove islets from the
pancreas of a deceased donor. Because the islets are fragile, transplantation occurs
soon after they are removed.
During the transplant, the surgeon uses ultrasound to guide placement of a small
plastic tube (catheter) through the upper abdomen and into the liver. The islets are
then injected through the catheter into the liver. The patient will receive a local
anesthetic. If a patient cannot tolerate local anesthesia, the surgeon may use general
anesthesia and do the transplant through a small incision. Possible risks include
bleeding or blood clots. It takes time for the cells to attach to new blood vessels and
begin releasing insulin. The doctor will order many tests to check blood glucose levels
after the transplant, and insulin may be needed until control is achieved.
Transplantation: Benefits, Risks, and Obstacles

The goal of islet transplantation is to infuse enough islets to control the blood glucose
level without insulin injections. For an average size person (70 kg), a typical transplant
requires about 1 million islets, extracted from two donor pancreases. Because good
control of blood glucose can slow or prevent the progression of complications
associated with diabetes, such as nerve or eye damage, a successful transplant may
reduce the risk of these complications. But a transplant recipient will need to take
immunosuppressive drugs that’s top the immune system from rejecting the
transplanted islets.
Researchers are trying to find new approaches that will allow successful
transplantation without the use of immunosuppressant drugs, thus eliminating the side
effects that may accompany their long-term use. Rejection is the biggest problem with
any transplant. The immune system is programmed to destroy bacteria, viruses, and
tissue it recognizes as "foreign," including transplanted islets. Immunosuppressive
drugs are needed to keep the transplanted islets functioning
Immunosuppressive Drugs
The Edmonton protocol uses a combination of immunosuppressive drugs, also called
anti rejection drugs, including daclizumab (Zenapax), sirolimus(Rapamune), and
tacrolimus (Prograf). Daclizumab is given intravenously right after the transplant and
then discontinued. Sirolimus and tacrolimus, the two drugs that keep the immune
system from destroying the transplanted islets, must be taken for life.
These drugs have significant side effects and their long-term effects are still not known.
Immediate side effects of immunosuppressive drugs may include mouth sores and
gastrointestinal problems, such as stomach upset or diarrhea. Patients may also have
increased blood cholesterol levels, decreased white blood cell counts, decreased
kidney function, and increased susceptibility to bacterial and viral infections. Taking
immunosuppressive drugs increases the risk of tumors and cancer as well
Researchers do not fully know what long-term effects this procedure may have. Also,
although the early results of the Edmonton protocol are very encouraging, more
research is needed to answer questions about how long the islets will survive and how
often the transplantation procedure will be successful. Before the introduction of the
Edmonton Protocol, few islet cell transplants were successful. The new protocol
improved greatly on these outcomes, primarily by increasing the number of
transplanted cells and modifying the number and dosages of immune suppressants. Of
the 267 transplants performed worldwide from 1990 to 1999, only 8 percent of the
people receiving them were free of insulin treatments one year after the transplant. The
CITR's second annual report, published in July 2005, presented data on 138 patients.
At six months after patients' final infusions,67 percent did not need to take insulin
treatments. At one year, 58 percent remained insulin independent. The recipients who
still needed insulin treatment after one year experienced an average reduction of 69
percent in their daily insulin needs.
A major obstacle to widespread use of islet transplantation will be the shortage of islet
cells. The supply available from deceased donors will be enough for only a small
percentage of those with type 1 diabetes. However, researchers are pursuing avenues
for alternative sources, such as creating islet cells from other types of cells. New
technologies could then be m employed to grow islet cells in the laboratory.
7. The pancreas is
A) in the hand
B) in the stomach....
C) above the stomach
D) behind the lower part of the stomach
8. What is the main purpose of insulin?
A) It is a hormone
B) to destroy beta cells
C) to assist in energy production
D) to stimulate the auto immune process
9. According the article, is islet transplantation common practice?
A) Yes, it's frequently used

B) No, it's still being trialed
C) Not stated in the article
D) Yes, but only in Canada
10. What is the Edmonton Protocol?
A) A trade agreement
B) The journal of Alberta University
C) A way to transplant pancreatic islets
D) Not stated in the article
11. What's the source of the pancreatic islets that are in the transplantoperation?
A) They are donated by relatives

B) They come from people who have recently died
C) They are grown in a laboratory
D) They come from foetal tissue
12. Which one of the sentences below is true?
A) A local anaesthetic is preferred where possible.

B) A general anaesthetic is preferred where possible.
C) A general anaesthetic is too risky due to the possibility of blood clots and bleeding
D) An anaesthetic is not necessary if ultrasound is used
13. How soon after the operation can the patient abandon insulin injections?
A) Immediately
B) After about two weeks
C) When the blood glucose levels are satisfactory
D) After the first year
14. How many islets are required per patient?
A) About a million
B) 70 kg
C) Whatever is available is used
D) it depends on the size of the patient.
Part C -Text 2
Seasonal Influenza Vaccination and the H1N1 Virus
As the novel pandemic influenza A (H1N1) virus spread around the world in late spring
2009 with a well-matched pandemic vaccine not immediately available, the question of
partial protection afforded by seasonal influenza vaccine arose. Coverage of the
seasonal influenza vaccine had reached 30%-40% in the general population in 2008-
09 in the US and Canada, following recent expansion of vaccine recommendations.
Unexpected Findings in a Sentinel Surveillance System.

The spring 2009 pandemic wave was the perfect opportunity to address the
association between seasonal trivalent inactivated influenza vaccine (TIV) and risk of
pandemic illness. In an issue of PLoS Medicine, Danuta Skowronski and colleagues
report the unexpected results of a series of Canadian epidemiological studies
suggesting a counterproductive effect of the vaccine. The findings are based on
Canada's unique near-real-time sentinel system for monitoring influenza vaccine
effectiveness. Patients with influenza-like illness who presented to a network of
participating physicians were tested for influenza virus by RT-PCR, and information on
demographics, clinical outcomes, and vaccine status was collected.
In this sentinel system, vaccine effectiveness may be measured by comparing

vaccination status among influenza-positive "case" patients with influenza negative
"control" patients. This approach has produced accurate measures of vaccine
effectiveness for TIV in the past, with estimates of protection in healthy adults higher
when the vaccine is well-matched with circulating influenza strains and lower for
mismatched seasons. The sentinel system was expanded to continue during April to
July 2009, as the H1N1 virus defied influenza seasonality and rapidly became
dominant over seasonal influenza viruses in Canada.
Additional Analyses and Proposed Biological Mechanisms The Canadian sentinel
study showed that receipt of TIV in the previous season (autumn 2008) appeared to
increase the risk of H1N1 illness by 1.03to 2.74-fold, even after adjustment for the
comorbidities of age and geography. The investigators were prudent and conducted
multiple sensitivity analyses to attempt to explain their perplexing findings, importantly,
TIV remained protective against seasonal influenza viruses circulating in April through
May 2009, with an effectiveness estimated at 56%, suggesting that the system had not
suddenly become flawed. TIV appeared as a risk factor in people under 50, but not in
seniors-although senior estimates were imprecise due to lower rates of pandemic
illness in that age group. Interestingly, if vaccine were truly a risk factor in younger
adults, seniors may have fared better because their immune response to vaccination is
less rigorous.
Potential Biases and Findings from Other Countries

The Canadian authors provided a full description of their study population and carefully
compared vaccine coverage and prevalence of comorbidities in controls with national
or province-level age-specific estimates the best can do short of a randomized study.
In parallel, profound bias in observational studies of vaccine effectiveness does exist,
as was amply documented in several cohort studies overestimating the mortality
benefits of seasonal influenza vaccination in seniors
Given the uncertainty associated with observational studies, we belie would be

premature to conclude that TIV increased the risk of 2009 pandemic illness, especially
in light of six other contemporaneous observational studies in civilian populations that
have produced highly conflicting results. We note the large spread of vaccine
effectiveness estimates in those studies: indeed. four of the studies set in the US an
Australia did not show any association whereas two Mexican studies suggested a
protective effect of 35%-73% .
Policy Implications and a Way Forward

The alleged association between seasonal vaccination and 2009 H1N1remains an
open question, given the conflicting evidence from available research. Canadian health
authorities debated whether to postpone seasonal vaccination in the autumn of 2009
until after a second pandemic wave had occurred, but decided to follow normal vaccine
recommendations instead because of concern about a resurgence of seasonal
influenza viruses during the 2009-10 season.
This illustrates the difficulty of making policy decisions in the midst of a

public health crisis, when officials must rely on limited and possibly biased evidence
from observational data, even in the best possible scenario of a well-established
sentinel monitoring system already in place. What happens next? Given the timeliness
of the Canadian sentinel system, data on the association between seasonal TIV and
risk of H1N1 illness during the autumn2009 pandemic wave will become available very
soon, and will be crucial in confirming or refuting the earlier Canadian results
In addition, evidence may be gained from disease patterns during the autumn 2009
pandemic wave in other countries and from immunological studies characterizing the
baseline immunological status of vaccinated and unvaccinated populations. Overall,
this perplexing experience in Canada teaches us how to best react to disparate and
conflicting studies and can aid in preparing for the next public health crisis.
15. The question of partial protection against H1N1 arose
A. before spring 2009

B. during Spring 2009
C. after spring 2009
D. during 2008-09
16. According to Danuta Skowronskia.
A. the inactivated influenza vaccine may not be having the desired effects.
B. Canada's near-real-time sentinel system is unique.
C. the epidemiological studies were counter productive
D. the inactivated influenza vaccine has proven to be ineffective
17. The vaccine achieved higher rates of protection in healthy adults when
A. it was supported by physicians.

B. the sentinel system was expanded
C. used in the right season.
D. it was matched with other current influenza strains.
18. Which one of the following is closest in meaning to the word prudent?
A. anxious
B. Cautious
3. B
4. D
5. D
6. B
7. C
8. almost 40%
9. 77.9%
10. 1500g
11. carbon monoxide
12. Julie Mannella
13. carbon monoxide

14. deterioration
15. smoker
16. caffeinated drinks
17. cigarette smoke
18. air-trapping
19. neuro-stimulatory effects
20. linear regression

1. B
2. B
3. A
4. A
5. C
6. C

7. D
8. C
9. B
10. C
11. B
12. A
13. C
14. D
15. B
16. A
17. D
18. B
19. D
20. B
21. C
22 A
.
PROCEDURES
Counselling Helps patients cope with trauma and loss.
Physical therapies Improve mobility, speech, daily function.
NATURAL METHODS
Herbs Ginkgo biloba and huperzine A
Vitamins Antioxidants help protect brain coils
Text C
Launch of Australia's first dementia and exercise study.
National Ageing Research Institute [NARI] has started recruiting volunteers for an
Australian-first study to assess whether physical activity can improve the memory,
concentration and well being of people with Alzheimer's Disease (AD). The
collaborative study, officially launched at NARI in June, also involves the Universities of
Melbourne, Western Australia and Queensland. Alzheimer's Australia is also
supporting Fitness at the Ageing Brain Study II (known as FABS II). At the launch,
Professor Nicola Lautenschlager, who heads the study, highlighted how her earlier
research had shown that regular exercise improved brain function in older people. The
hope is that a physical activity program will also benefit people with mild to moderate
AD."
Several medications are available to treat AD but this isn't enough to help families deal
with this complex problem. We are pleased to be looking at anon-pharmacological
option," says Professor Lautenschlager. The physical activity program involves a
commitment of 150 minutes a week, which is about 20 minutes daily. Walking is the
most popular physical activity for older people but the program will be tailored to each
person's interests. Before stoning the program, participants will be assessed on
aspects like muscle strength, flexibility, balance and memory function
Text D
Exercise and Alzheimer's disease
(University of Washington study published in Annals of Internal Medicine)
 The study followed 1,740 people aged 65 and older over a six-year period. At the
start of the study none showed signs of dementia.
 After six years, 158 participants had developed dementia, of which 107 had been
diagnosed with Alzheimer's disease.
 People who exercised three or more times a week had a 30% to 40%lower risk of
developing dementia compared with those who exercised fewer than three times
per week.
 Lead researcher Dr. Eric Larson said walking for 15 minutes three times a week
was enough to out the risk
PART A -QUESTIONS
Questions 1-7
1. what is the most effective medications at early stage of AD

2. where did the study by the University of Washington was published?
3. what are the cognitive symptoms of Alzheimer's disease?
4. what does 'NARI' stands for?
5. who was the lead researcher in the University of Washington study?
6. who is supporting FABS II?
7. what are the behavioural and psychiatric symptoms of AD?...
Questions 8-13
8. How many subjects were there in the University of Washington study?

9. What is the most popular physical activity in the physical activity program?
10. Which procedure helps the patients cope with trauma and loss?
11. Who can advise medicines and supportive measures for AD?
12. Which procedures improve the mobility of the patients with AD?
13. what can improve the brain function in older people?
Questions 14-20
14. According to_________ walking for 15 minutes three times a week can minimize
the risk of AD.
15._____________aren't enough to help families deal with the complex problem of A.D
16._____________like Ginkgo biloba, are used for the treatment of AD
17.____________is hoped to benefit people with mild to moderate AD
18._____________contains antioxidants that help to protect the brain coils.
19. At the start of the University of Washington study__________ showed signs of
dementia
20. When one is affected by AD, neurons in the brain are______________
Questions 1-6
1. The manual informs us that the Biopotential Amplifiers
A. record potentials, voltage, and electrical field strengths generated by nerves and
muscles
B. amplify biosignals to make them compatible with devices such as displays or
recorders
C. provide amplification selective to superimposed noise and interference signals
Biopotential Amplifiers
Biosignals are recorded as potentials, voltages, and electrical field strengths generated
by nerves and muscles. The signals need to be amplified to make them compatible
with devices such as displays, recorders, or A/D converters for computerized
equipment. Amplifiers adequate to measure these signals have to satisfy very specific
requirements. They have to provide amplification selective to the physiological signal,
reject superimposed noise and interference signals, and guarantee protection from
damages through voltage and current surges for both patient and electronic
equipment. Amplifiers featuring these specifications are known as biopotential
amplifiers.
2. What does this manual tell us about the programmer?
A. used to provide communications between generator and lead

B. can alter the therapy delivered by the pacemaker
C. retract essential diagnostic data for optimally titrating the therapy
Implantable Cardiac Pacemakers

The modern pacing system is comprised of three distinct components: pulse generator,
lead, and programmer. The pulse generator houses the battery and the circuitry which
generates the stimulus and senses electrical activity. The lead is an insulated wire that
carries the stimulus from the generator to the heart and relays intrinsic cardiac signals
back to the generator. The programmer is a telemetry device used to provide two-way
communications between the generator and the clinician. It can alter the therapy
delivered by the pacemaker and retrieve diagnostic data that are essential for optimally
titrating that therapy
3. What does this extract from a handbook tell us about external defibrillators?
A. used only in the treatment of life-threatening cardiac rhythms

B. used mostly for elective treatment of less threatening rapid rhythms
C. convert excessively fast and ineffective heart rhythms to slower rhythms
External Defibrillators
Defibrillators are devices used to supply a strong electric shock to a patient in an effort
to convert excessively fast and ineffective heart rhythm disorders to slower rhythms
that allow the heart to pump more blood. External defibrillators have been in common
use for many decades for emergency treatment of life-threatening cardiac rhythms as
well as for elective treatment of less threatening rapid rhythms. The most serious
arrhythmia treated by a defibrillator is ventricular fibrillation. Without rapid treatment
using a defibrillator, ventricular fibrillation causes complete loss of cardiac function and
death within minutes.
A. therapeutic uses of showers and baths

B. importance of essential oils in bath therapy
C. when and where the warm wet treatment is used
Thermopositive (warm) wet treatment
The warm wet treatment includes showers and baths, i.e. used therapeutically in
addition to washing. They have an overall effect. They are used in the treatment of
scars, burns, when preheating the body before exercise, when replacing bandages
after surgery, etc. Baths are used on part of or all of the body. Essential oils can be
also used in bath therapy. Warm wet therapy is widely used in balneology.
A. administer oral hygiene several times per day

B. aware of accumulation of mucus in certain patients
C. provide oral care several times per day, if needed
Special oral care

Patients with febrile illnesses, after a stroke, with paralysis of the facial nerve, after
surgery, after injury, or unconscious and dying patients suffer from an accumulation of
mucus in their mouth and coated mucous membrane. A patient can breathe in the
accumulated mucus and the mucous membrane coatings cause bad breath. Defects
on the tongue make sucking and chewing difficult. Oral hygiene must be administered
as required, several times per day
6. The guidelines require those undertaking the preparation of plaster bandages to
A. do attaching quickly, only if you are experienced

B. avoid spilling the plaster during the process
C. soak plaster and the bandage in a 40 °C hot water
Plaster bandages
Plaster bandages are impregnated with plaster. They provide reliable fixation of the
broken bone. It is a hydrophilic bandage which is impregnated with fine plaster. The
bandages are wrapped in moisture-proof packaging; moisture would harden the plaster
and the bandage would be spoiled. Before use, the bandage is soaked in a 40 °C hot
water; the bandage is not moved at this point so as not to spill the plaster. Then it is
removed and gently wrung and then immediately attached. Attaching requires
experience as it must be done quickly the time for moulding the bandage is short (2 3
minutes)

Part C -Text 1
Does Tamiflu really work?

The British Medical Journal (BMJ) was dominated in 2009 by a cluster of articles on
oseltamivir (Tamiflu). Between them the articles conclude that the evidence that
oseltamivir reduces complications in otherwise healthy people with pandemic influenza
is now uncertain and that we need a radical change in the rules on access to trial data.
The use of meta-analysis is governed by the Cochrane review protocol. Cochrane

Reviews investigate the effects of interventions for prevention, treatment and
rehabilitation in a healthcare setting. They are designed to facilitate the choices that
doctors, patients, policy makers and others face in health care. Most Cochrane
Reviews are based on randomized controlled trials, but other types of evidence may
also be taken into account, if appropriate
If the data collected in a review are of sufficient quality and similar enough, they are
summarised statistically in a meta-analysis, which generally provides a better overall
estimate of a clinical effect than the results from individual studies. Reviews aim to be
relatively easy to understand for non-experts (although a certain amount of technical
detail is always necessary). To achieve this, Cochrane Review Groups like to work with
"consumers", for example patients, who also contribute by pointing out issues that are
important for people receiving certain interventions. Additionally, the Cochrane Library
contains glossaries to explain technical terms.
Briefly, in updating their Cochrane review, published in late 2009. Tom Jefferson and
colleagues failed to verify claims, based on an analysis of 10drug company trials, that
oseltamivir reduced the risk of complications in healthy adults with influenza. These
claims have formed a key part of decisions to stockpile the drug and make it widely
available.
Only after questions were put by the BMJ and Channel 4 News has the manufacturer
Roche committed to making "full study reports" available on a password protected site.
Some questions remain about who did what in the Roche trials, how patients were
recruited, and why some neuropsychiatric adverse events were not reported. A
response from Roche was published in the BMJ letters pages and their full point by
point response is published online.
Should the BMJ be publishing the Cochrane review given that a more complete
analysis of the evidence may be possible in the next few months?
Yes, because Cochrane reviews are by their nature interim rather than definitive. They
exist in the present tense, always to be superseded by the next update. They are
based on the best information available to the reviewers at the time they complete their
review. The Cochrane reviewers have told the BMJ that they will update their review to
incorporate eight unpublished Roche trials when they are provided with individual
patient data.
Where does this leave oseltamivir, on which governments around the world have spent
billions of pounds? The papers in last years journal relate only to its use in healthy
adults with influenza. But they say nothing about its use inpatients judged to be at high
risk of complications- pregnant women, children under 5, and those with underlying
medical conditions; and uncertainty over its role in reducing complications in healthy
adults still leaves it as a useful drug for reducing the duration of symptoms. However,
as Peter Doshi points out on this outcome it has yet to be compared in head to head
trials with non-steroidal inflammatory drugs or paracetamol. And given the drug's
known side effects, the risk-benefit profile shifts considerably if we are talking only in
terms of symptom relief.
We don't know yet whether this episode will turn out to be a decisive battle or merely a
skirmish in the fight for greater transparency in drug evaluation. But it is a legitimate
scientific concern that data used to support important health policy strategies are held
only by a commercial organisation and have not been subject to full external scrutiny
and review. It can't be right that the public should have to rely on detective work by
academics and journalists to patch together the evidence for such a widely prescribed
drug. Individual patient data from all trials of drugs should be readily available for
scientific scrutiny
7. A cluster of articles on oseltamivir in the British Medical Journal conclude

A. complication are reduced in healthy people by oseltamivir
B. the efficacy of Tamiflu in now in doubt
C. complications from pandemic influenza are currently uncertain
D. a series of articles supporting Tamiflu
8. Cochrane Reviews are designed to
A. set randomized controlled trials to specific values

B. compile literature meta-analysis
C. peer review articles
D. influence doctors choice of prescription
9. According to the article, which one of the following statements about Tamiflu is
FALSE?
A. The use of randomized controls is suspect

B. The efficacy of Tamiflu is certain
C. Oseltamivir induced complications in healthy people
D. Cochrane reviews are useful when examining the efficacy of Tamiflu
10. According to the article, Cochrane Review Groups
A. like to work for "consumers".

B. are being overhauled
C. use language suitable for expert to expert communication.
D. evaluate a clinical effect better than individual studies.
11. Which would make the best heading for paragraph 4?
A. Analysis of 10 drug company trials

B. The stockpiling of Oseltamivir
C. Risk of complications in healthy adults
D. Tamiflu claims fail verification
12. According to the article, which one of the following statements about Roche is
TRUE?
A. Full study reports were made freely available on the internet

B. Patients were recruited through a double blind trial
C. The identities and roles of researcher in the Roche trials are not fully accounted for
D. Not all neuropsychiatric adverse events were reported
13. Cochrane reviews should

A. use a more complete analysis
B. not be published until final data is available
C. be considered interim rather than definitive advice
D. be superseded by a more reliable method of reporting results
14. Which would make the best heading for paragraph 7?
A. Risk-benefit profile of Tamiflu

B. Studies limited to healthy adults
C. High risk of complications
D. Oseltamivir only for high risk patients
Part C -Text 2
Miracle Jab Makes Fat Mice Thin
After a four-week course of treatment with a protein called ob, the fat simply falls off,
leaving vastly overweight mice slim, active and sensible eaters. If the protein has the
same effect on people, it could be the miracle cure millions have been waiting for that
at least, is the theory. But skeptics warn that too little is known about the way the
human version of the ob protein works to be sure that extra doses would help people
lose weight.
But when the results of the tests were leaked last week, Amgen, the Californian
biotechnology company which owns exclusive rights to develop products based on the
protein, saw an overnight jump in its share price.
Last December, a team led by Jeffrey Friedman and his colleagues at the Howard
Hughes Medical Institute at the Rockefeller University, New York, discovered a gene,
which they called ob. In mice, a defect in this gene makes them grow hugely obese.
Humans have an almost identical gene, suggesting that the product of the gene the ob
protein plays a part in appetite control, The ob protein is a hormone, which Friedman
has dubbed leptin
In April, Amgen, which is based in Thousand Oaks, California, paid the institute $20
million for exclusive rights to develop products based on the discovery. Amgen will
carry out safety tests on the protein in animals next year, and hopes to begin clinical
trials on people within a year.
The excitement began last week when the journal Science published the findings of
three groups which have been working on the protein. The results in obese mice with a
defective gene that prevents them making the protein were dramatic. Mary Ann
Pelleymounter and her colleagues at Amgen gave obese mice shots of the protein
every day for a month. Those on the highest dose lost an average of 22 percent of
their weight.
"Before treatment, these mice overeat, has lower metabolic rates than normal, lower
temperatures, and raised E levels of insulin and glucose in their blood." says
Pelleymounter. "The protein brought all of these back to normal levels," she says
More significantly, in terms of the potential for a human slimming drug, the treatment
also worked on normal mice, which lost what little spare fat they had. They lost
between 3 and 5 percent of their body weight, almost all of it in the form of fat,
according to Pelleymounter. This is important because no one has identified a mutation
in the human ob gene that might lead to obesity, suggesting that whatever the cause
for obesity, the ob protein might still help people lose weight.
Friedman and his team carried out similar experiments. In just one month, their obese
mice shed around half their body fat. In the average obese mouse, fat makes up about
60 percent as much as untreated animals. Their fat is practically melted away, falling to
28 per cent of their body weight after a month. In normal mice, treatment reduced the
amount of fat from an average of 12.22 percent of body weight to a spare 0.67 percent
Friedman and Pelleymounter believe that the protein, which is produced by fat cells,
regulates appetite. "We think it's something like a circulating hormone to tell the brain
there are normal amounts of fat, or too much, in which case the brain turns down your
appetite," says Pelleymounter
The experiments also show that treated mice have an increased metabolic rate,
suggesting that they burn fat more efficiently. Their appetites decrease and they are
less sluggish, becoming as active as normal mice
The third group of researchers from the Swiss Pharmaceuticals company Hoffman-La
Roche, are more skeptical about how significant the ob protein might be in treating
obesity. From their studies, they conclude that the protein is just one of many factors
that control appetite and weight. "This is a very important signal, but it's one of
several." says Arthur Campfield, who led the team
Campfield doubts whether the ob protein alone will have much effect in overweight
humans. His team hopes to unravel the whole signaling system that regulates weight,
and is particularly keen to find the receptor in the brain that responds to the ob
hormone. Hoffman-La Roche, excluded by the Amgen license to deal from developing
products based on the ob protein itself, hopes to develop pills that interfere with
message pathways in appetite control.
Stephen Bloom, professor of endocrinology at London s Hammersmith Hospital,

agrees, "l think the work with ob is a major advance, but we've not got the tablet yet.
That will come when people have made a pill that stimulates the ob receptor in the
brain so it switches off appetite."
Even Pelleymounter at Amgen cautions against over optimism at this stage. "We don't
know whether it would be true that people would lose weight, but you can predict from
mice that it would have some positive effect," she says "However, I don't think obese
people should hold out for this. They should carry on with their exercises and dieting.
15. The first paragraph informs the reader that.
A) A protein treatment has caused mice to lose weight dramatically.

B) A protein treatment for mice cannot be adapted for use in humans.
C) Scientists agree that a new protein treatment will make people lose weight.
D) A scientific method of making obese people slim has been developed.
16. The reader can infer from the second paragraph that
A) The public is skeptical about the possibility of developing a scientific slimming

method
B ) The Californian company, Amgen, is eager to share its new-found
technical knowledge.
C) Several companies will be able to develop products based on the results of the
research.
D ) Many people are confident that a product which guarantees weight loss will sell
very well.
17. Friedman and his colleagues found that a genetic defect in the gene called ob
A ) Causes obesity in mice.

B ) Causes obesity in humans and mice
1. B
2. D
3. A
4. C
5. D
6. C
7. A
8. 1,740
9. walking
10. counselling
11. doctor
12. physical therapies
13. regular exercise
14. Dr. Eric Larson
15. Medications
16. Herbs
17. physical activity program
18. vitamins
19. none
20. progressively destroyed
1. B
2. B
3. C
4. C
5. C
6. B
7. B
8. B
9. B
10. D
11. D
12. A
13. C
14. A
15. A
Glaucoma
Glaucoma
Description
Glaucoma is the name given to a group of eye diseases in which the optic nerve at the
back of the eye is slowly destroyed. In most people this damage is due to an increased
pressure inside the eye a result of blockage of the circulation of aqueous, or its
drainage. In other patients the damage may be caused by poor blood supply to the
vital optic nerve fibers, a weakness in the Structure of the nerve, and/or a problem in
the health of the nerve fibres themselves. Over 146,000 Australians have been
diagnosed with glaucoma. While it is more common as people age, it can occur at any
age. Glaucoma is also far less common in the indigenous population.
Symptoms
Chronic (primary open-angle) glaucoma is the commonest type. It has no symptoms
until eyesight is lost at a later stage.
Prognosis
Damage progresses very slowly and destroys vision gradually, starting with the side
vision. One eye covers for the other, and the person remains unaware of any problem
until a majority of nerve fibres have been damaged, and a large part of vision has been
destroyed. This damage is irreversible.
Treatment
Although there is no cure for glaucoma it can usually be controlled and further loss of
sight either prevented or at least slowed down. Treatments include: Eye drops these
are the most common form of treatment and must be used regularly. Laser (laser
trabeculoplasty) this is performed when eye drops do not stop deterioration in the field
of vision. Surgery (trabeculectomy) - this is performed usually after eye drops and laser
have failed to control the eye pressure. A new channel for the fluid to leave the eye is
created. Treatment can save remaining vision but it does not improve eyesight.
Text B
Table 1: Study of eye pressure and corneal thickness as predictors of Glaucoma.
Intraocular pressure (IOP) Central corneal thickness (CCT) and Glaucoma

correlations.
Central corneal Intraocular Intraocular Predictor of
thickness pressure pressure + Central development of
corneal thickness glaucoma (r2)
thickness of 555 pressure of less Thickness less than .36*

microns or than 21mmHg 555 and pressure
less thickness of pressure of less than 21mmHg
more than 588 more than 22mmHg
microns
-.13*
.38*
.07*
-.49*
power >.05
Text C
Other forms of Glaucoma.

 Low-tension or normal tension glaucoma. Occasionally optic nerve damage can
occur in people with so-called normal eye pressure.
 Acute (angle-closure) glaucoma. Acute glaucoma is when the pressure inside the
eye rapidly increases due to the iris blocking the drain. An attack of acute
glaucoma is often severe. People suffer pain, nausea, blurred vision and redness
of the eye.
 Congenital glaucoma,This is a rare form of glaucoma caused by an abnormal
drainage system. It can exist at birth or develop later.
 Secondary glaucomas, These glaucomas can develop because of other
disorders of the eye such as injuries, cataracts, eye inflammation. The use of
steroids (cortisone) has a tendency to raise eye pressure and therefore
pressures should be checked frequently when steroids are used.
Text D
Overview of Glaucoma Facts

 Glaucoma is the leading cause of irreversible blindness worldwide.
 One in 10 Australians over 80 will develop glaucoma.
 First degree relatives of glaucoma patients have an 8-fold increased risk of
developing the disease.
 At present, 50% of people with glaucoma in Australia are undiagnosed.
 Australian health care cost of glaucoma in 2017 was $342 million.
 The total annual cost of glaucoma in 2017 was $1.9 billion.
 The total cost is expected to increase to $4.3 billion by 2025.
 The dynamic model of the economic impact of glaucoma enables cost
effectiveness comparison of various interventions to inform policy development.
PART A -QUESTIONS
Questions 1-7
1. which is the rare form of glaucoma?

2. what is the leading cause of irreversible blindness in the world?
3. what has the highest value for the predictor of development of glaucoma?
4. which is the most common form of glaucoma??
5. what has the lowest value for the predictor of development of glaucoma?
6. what was the total annual cost of glaucoma in 2017?
7. what is the most common form of treatment for glaucoma?
Questions 8-13
8. Which form of glaucoma can develop due to eye inflammation?

9. What is the predicted total cost of glaucoma in 2025?
10. What is the predictor of development of glaucoma for intraocular pressure more
than 22 mmHg?
11. How many Australians have been diagnosed with glaucoma?
12. What was the Australian health care cost of glaucoma in 2017?
13. what is the current percentage of undiagnosed glaucoma patients in Australia?
Questions 14-20
14. Glaucoma is a group of eye diseases in which the________________ is slowly

destroyed.
15. First degree relatives of glaucoma patients have______________ increased risk of
developing the disease
16.___________can cause pain, nausea, blurred vision and redness of the eye.
17. Steroids such as_____________ has a tendency to raise eye pressure.
18. Glaucoma is far less common in the ___________________.
19. __________________has no symptoms until eyesight is lost at a later stage
20. Laser trabeculoplasty is performed when _________________ don't stop
deterioration in the field of vision.
Questions 1-6
1. What does this extract tell us about parenteral infusion devices?
A. used to provide flow through an intravenous catheter

B. 80% of hospitalized patients receive parenteral infusion devices
C. provide an effective pathway for the delivery of fluid, blood
Parenteral Infusion Devices

Intravenous (IV) and intraarterial access routes provide an effective pathway for the
delivery of fluid, blood, and medications to a patient's vital organs. Consequently, about
80% of hospitalized patients receive infusion therapy. A variety of devices can be used
to provide flow through an intravenous catheter.
An intravenous delivery system typically consists of three major components: (1) fluid
or drug reservoir, (2) catheter system for transferring the fluid or drug from the reservoir
into the vasculature through a venipuncture, and (3) device for regulation and/or
generating flow.
2. The purpose of these notes about Biomedical Lasers is to
A. state the factors that led to the expanding biomedical use of laser technology
B. give valid reasons for the increase in biomedical use of lasers in surgery
C. recommend an alternate for ultraviolet- infrared (UV-IR) radiation in biomedical use
Biomedical Lasers
Three important factors have led to the expanding biomedical use of laser technology,
particularly in surgery. These factors are: (1) the increasing understanding of the
wavelength selective interaction and associated effects of ultraviolet- infrared (UV-IR)
radiation with biologic tissues, including those of acute damage and long-term healing,
(2) the rapidly increasing availability of lasers emitting (essentially monochromatically)
at those wavelengths that are strongly absorbed by molecular species within tissues,
and (3) the availability of both optical fiber and lens technologies as well as of
endoscopic technologies for delivery of the laser radiation to the often remote internal
treatment site
A. the circumstances for prescribing the infant monitor by the doctor

B. why infants shouldn't be discharged from the hospital with infant monitor
C. why infants unidentified with breathing problems need infant monitor...
Infant Monitor
Many infants are being monitored in the home using apnea monitors because they
have been identified with breathing problems. These include newborn premature
babies who have apnea of prematurity, siblings of babies who have died of sudden
infant death syndrome, or infants who have had an apparent life-threatening episode
related to lack of adequate respiration. Rather than keeping infants in the hospital for a
problem that they may soon outgrow, doctors often discharge them from the hospital
with an infant apnea monitor that measures the duration of breathing pauses and heart
rate and sounds an alarm if either parameter crosses limits prescribed by the doctor.
4. What does this extract tell us about post traumatic stress disorder?
A. It is a physiological reaction of the patient to stress.

B. It is only a local response of the patient to stress.
C. It can definitely turn into a post-operative complication.
Postoperative complications
Surgery and anesthesia are stressful events for the patient. The patient handles stress
in accordance with their overall condition, the nature of the surgery and associated
diseases. Post traumatic stress disorder (stress syndrome) can be expected in all
patients following surgery. This is an overall and local response of the organism to
stress and its effort to cope with the strain. It is a physiological reaction of the organism
to stress, which in the worst case scenario can become a pathological or a post-
operative complication.

A. benefits of rinses to patients using suitable solutions.
B. solutions less suitable should not be applied to wounds.
C. epithelizing wounds should be rinsed with antiseptic solution.
Rinses
These are prescribed when redressing necrotic, infected wounds. The rinse, especially
with antiseptic solution for clean, granulating and epithelizing wounds is not
substantiated. The wound rinse helps to clean the wound of early leaching residues,
coatings, necrotic tissue, pus, blood clots, toxins or residues of bacterial biofilm.
Rinsing a colonized chronic wound reduces the existing microbial population.
 Solutions suitable for application to wounds: Prontosan solution, Octenisept,
Dermacin, DebsriEcaSan.
 Less suitable solutions: Betadine, Braunol, saline, Permanganate.
 Solutions not suitable for application to wounds: Chloramine, Presteril,Rivanol,
Jodisol.
6. The purpose of these notes about drains and drainage systems is to
A. help maximize efficiency of healing process.

B. give guidance on certain medical procedures.
C. avoid accumulation of fluid in body cavities.
Drains and drainage systems
Drains are used to drain physiological or pathological fluids from the body.
The use of drains and drainage systems in surgery significantly affects the overall
healing process. The accumulated fluid can endanger the whole body as it has a
mechanical and toxic effect on the surrounding tissue and is a breeding ground for
microorganisms. Drains are used to drain fluids from body cavities, organs, wounds
and surgical wounds (e.g. blood, wound secretion, bile, intestinal contents, pus etc.)
and air (chest drainage).
Part C -Text 1
AIDS deaths blamed on immune therapy
THE DEATHS of three patients during trials of an experimental immune therapy for
people with AIDS have renewed controversy over experiments carried out by the
French scientist Daniel Zagury. The affair has also highlighted shortcomings in the
system of checks and controls over clinical research. The French health minister,
Bruno Durieux, recently announced that an inquiry had cleared Zagury and his team at
the Pierre and Marie Curie University in Paris of alleged irregularities in the way they
conducted tests of a potential vaccine and an experimental immune therapy in patients
at the Saint-Antoine Hospital (This Week, 13 April). But Durieux made no mention of
three deaths which the inquiry had reported.
Following revelations about the circumstances in which the patients died, Durieux has
now announced a new assessment of the tests. to be undertaken by ANRS, the
national agency for AIDS research. Last July, Zagury and his colleagues reported in a
letter to The Lancer (vol 336, p 179) a trial on patients with AIDS or AIDS-related
complex. The patients received a preparation based on proteins from HIV that was
designed to boost their immune systems.
The preparation was made from samples of the patients' own white blood cells, purified
and cultured in the laboratory. The researchers had infected the white blood cells with
a genetically engineered form of the vaccinia virus that had genes from HIV inserted
into its DNA. The vaccinia, or cowpox, virus, had first been inactivated with
formaldehyde, said the researchers. Last week, the Chicago Tribune and Le Monde
alleged that at least two of the deaths were caused by vaccinia disease, a rare
complication of infection with vaccinia virus. Vaccinia is harmless in healthy people and
has been used in its live form as the vaccine against smallpox worldwide. But, in
people whose immune systems are suppressed, the virus can 'occasionally spread
rapidly in the body and kill.
A Paris dermatologist, Jean-Claude Guillaume, said that when he warned Zagury's

team that he was convinced one of their patients had contracted vaccinia disease the
response was that this was not possible" because the vaccinia had been inactivated.
Shortly before his death, the patient had consulted Guillaume about large, rubbery
lesions across his abdomen. Guillaume consulted a colleague, Jean-Claude Roujeau,
about the rare disease. Roujeau told the Chicago Tribune that his tests on the tissue
samples taken from two patients before they died had detected vaccinia virus in their
skin cells.
The Saint-Antoine team's postmortem tests did not reveal vaccinia. Odile Picard, who
is in charge of administering the treatment, says there were three possible causes of
death - vaccinia disease, herpes or a toxic reaction to the procedure used to prepare
white blood cells before injecting them into patients. Zagury, however, insisted that
"nothing allows us to affirm it was vaccinia. It could have been herpes or Kaposi's
sarcoma". The tests are continuing, he says
Luc Montagnier, co-discoverer of HIV, called for an immediate halt to the experiments.
He says that intravenous injections could lead to generalized vaccinia disease. His
team at the Pasteur Institute has already shown in laboratory tests that vaccinia virus
maybe dangerous if the immune system is unable to resist it. The findings at the
Pasteur Institute were apparently unknown to Zagury team, which works with
Montagnier's rival, the researcher Robert Gallo. Gallo's collaboration with Zagury has
been suspended by the National Institutes of Health in the US because of alleged
irregularities.
Zagury and his team have also denied charges that they covered up the deaths, which
are not mentioned in their report in The Lancet. "They were not covered up," Picard
said. "They were accepted [into the trial] on compassionate grounds." The Lancet
report concerns 28 patients. 14 who were treated and 14 controls who were not able to
receive the treatment. Picard says that five other patients were also treated with the
preparation but were not compared with the controls. Their T4 cell counts had fallen
too low to be comparable with the control group, so they were excluded from the study
and not mentioned in its report.
AIDS patients are particularly vulnerable to infection. Furthermore, the French ethics
council had specified that volunteers should be chosen because "their state was so
advanced it excluded treatment with AZT". At least some of the patients were being
treated with AZT at the same time as immune therapy. The council had also asked to
be informed of the results of the trials case by case, but had not been told of the
deaths. The geneticist André Boué, a member of the council, said: "The ethics council
does not have judicial powers; we are not the fraud squad."
The director of the -AIDS research agency ANRS, Jean-Paul Levy, is concerned that
all the controversy may lead to a crisis of public confidence but laid the blame firmly at
the door of the media where "excessive praise is followed by excessive rejection".
Levy, who had still heard nothing, "even informally" from the health ministry the day
after Durieux told parliament that ANRS would assess immune therapy trials, said he
wanted to study the problems "in depth, but not in the atmosphere of a tribunal".
ANRS has a panel of experts in therapeutic trials, which, says Levy, "might seek
international contacts to obtain a broad consensus" on the issues involved. The
research agency's role is to carry out a purely scientific evaluation, not to assess
whether there was a breach of ethical guidelines. according to Levy. "If the government
called on us to examine this case, we could act very quickly," said Philippe Lucas of
the ethics council
7. "Which of the following is FALSE?
A] Zagury experiments have been controversial before.

B] An inquiry found obvious irregularities in Zagury's work.
C] ANRS is to re-evaluate Zagury's tests.
D] Zagury's intention had been to increase patients' immune systems with
proteins.
8. The preparation which the patients received
A) had been accidentally infected with a form of the vaccinia virus.

B) was made from white blood cells which had been manufactured in the laboratory
C) had been stored in formaldehyde.
D) contained laboratory-treated white blood cells which had been taken from them
9. According to the article, vaccinia
A) is potentially lethal for all humans

B) has been used to fight both cowpox and smallpox all around the world.
C) can be dangerous in people who have abnormal immune systems.
D) in none of the above.
10. Jean-Claude Guillaume
A) was also a member of Zagury's team.

B) examined one of the patients who had been referred to him by Zagury's team
C) informed the Chicago Tribune about the results of the tests on the tissue samples.
D) was/did none of the above.
11. Which of the following people does NOT work with Zagury?
A) Odile Picard.
B) Luc Montagnier.
C) Robert Gallo
D) None of the above works with Zagury.
12. It is FALSE that findings at the Pasteur institute
A) were ignored by Zagury's team

B) did not lead to intervention by the National institutes of Health.
C) showed that intravenous injections were not good for patients with weaker immune
systems.
D) led to Zagury's team keeping quiet about the patients who had died.
13. How many people were injected with the preparation in the trial?
A) Fourteen
B) Nineteen
C) Twenty eight
D) Thirty three
14. Which of the following statements best describes the initial condition of the people
who took part in the trial?
A) Fewer than half of them had AIDS

B) Half of them had AIDS
C) Most of them had AIDS
D) All of them had AIDS
Part C -Text 2
Going blind in Australia
Australians are living longer and so face increasing levels of visual impairment. When
we look at the problem of visual impairment and the elderly, there are three main
issues. First, most impaired people retire with relatively "normal" eyesight, with no
more than presbyopia, which is common in most people over 45 years of age. Second,
those with visual impairment do have eye disease and are not merely suffering from
"old age". Third, almost all the major ocular disorders affecting the older population
such as cataract, glaucoma and age-related macular degeneration (AMD), are
progressive and if untreated will cause visual impairment and eventual blindness.
Cataract accounts for nearly half of all blindness and remains the most prevalent cause
of blindness worldwide. In Australia, we do not know how prevalent cataract is, but it
was estimated in 1979 to affect the vision of 43persons per thousand over the age of
64 years. Although some risk factors for cataract have been identified, such as
ultraviolet radiation, cigarette smoking and alcohol consumption, there is no proven
means of preventing the development of most age-related or senile cataract. However
cataract blindness can be delayed or cured if diagnosis is early and therapy, including
surgery, is accessible.
AMD is the leading cause of new cases of blindness in those over 65. In the United
States, it affects 8-1 1% of those aged 65-74, and 20% of those over 75 years. In
Australia, the prevalence of AMD is presently unknown but could be similar to that in
the USA. Unlike cataract, the treatment possibilities for AMD are limited. Glaucoma is
the third major cause of vision loss in the elderly. This insidious disease is often
undetected until optic nerve damage is far advanced. While risk factors for glaucoma,
such as ethnicity and family history, are known, these associations are poorly
understood. With early detection, glaucoma can be controlled medically or surgically.
While older people use a large percentage of eye services, many more may not have
access to, or may underutilise, these services. In the United States 33% of the elderly
in Baltimore had ocular pathology requiring further investigation or intervention. In the
UK, only half the visually impaired in London were known by their doctors to have
visual problems, and 40% of those visually impaired in the city of Canterbury had never
visited an ophthalmologist. The reasons for people under utilising eye care services
are, first, that many elderly people believe that poor vision is inevitable or untreatable.
Second, many of the visually impaired have other chronic disease and may neglect
their eyesight. Third, hospital resources and rehabilitation centres in the community are
limited and finally, social factors play a role.
People in lower socioeconomic groups are more likely to delay seeking treatment; they
also use fewer preventive, early intervention and screening services, and fewer
rehabilitation and after-care services. The poor use more health services, but their use
is episodic, and often involves hospital casualty departments or general medical
services, where eyes are not routinely examined. In addition, the costs of services are
great deterrent for those with lower incomes who are less likely to have private health
insurance. For example, surgery is the most effective means of treatment for cataract,
and timely medical care is required for glaucoma and AMD. However, in December
1991, the proportion of the Australian population covered by private health insurance
was 42%. Less than 38% had supplementary insurance cover. With 46% of category 1
(urgent) patients waiting for more than 30 days for elective eye surgery in the public
system, and 54% of category 2 (semi-urgent) patients waiting for more than three
months, cost appears to be a barrier to appropriate and adequate care.
With the proportion of Australians aged 65 years and older expected to double from the
present 11% to 21% by 2031, the cost to individuals and to society of poor sight will
increase significantly if people do not have access to, or do not use, eye services. To
help contain these costs, general practitioners can actively investigate the vision of all
their older patients, refer them earlier, and teach them self-care practices. In addition,
the government, which is responsible to the taxpayer, must provide everyone with
equal access to eye health care services. This may not be achieved merely by
increasing expenditure - funds need to be directed towards prevention and health
promotion, as well as treatment. Such strategies will make good economic sense if
they stop older people going blind.
15. In paragraph 1, the author suggests that
A. many people have poor eyesight at retirement age.

B. sight problems of the aged are often treatable.
C. cataract and glaucoma are the inevitable results of growing older.
D. few sight problems of the elderly are potentially damaging.
16. According to paragraph 2, cataracts
A. may affect about half the population of Australians aged over 64.
B. may occur in about 4 5% of Australians aged over 64.
C. are directly related to smoking and alcohol consumption in old age
D. are the cause of more than 50% of visual impairments.
17. According to paragraph 3, age-related macular degeneration (AMD)
A. responds well to early treatment.

B. affects 1 in 5 of people aged 65-74.
C. is a new disease which originated in the USA.
D. causes a significant amount of sight loss in the elderly
18. According to paragraph 3, the detection of glaucoma
A. generally occurs too late for treatment to be effective.

B. is strongly associated with ethnic and genetic factors.
C. must occur early to enable effective treatment
D. generally occurs before optic nerve damage is very advanced.
19. Statistics in paragraph 4 indicate that
A. existing eye care services are not fully utilised by the elderly.
B. GPs are generally aware of their patients' sight difficulties
C. most of the elderly in the USA receive adequate eye treatment.
D. only 40% of the visually impaired visit an ophthalmologist.
20. According to paragraph 4, which one of the following statements is true?...
A. Many elderly people believe that eyesight problems cannot be treated effectively.
B. Elderly people with chronic diseases are more likely to have poor eyesight.
C. The facilities for eye treatments are not always readily available.
D. Many elderly people think that deterioration of eyesight is a product of ageing
21. In discussing social factors affecting the use of health services in paragraph 5, the
author points out that
A. wealthier people use health services more often than poorer people.
B. poorer people use health services more regularly than wealthier people.
C. poorer people deliberately avoid having their eye sight examined.
A depressive illness is forcing senior Coalition frontbencher Andrew Robb to take three
months' leave from his shadow cabinet duties. Columnist Laurie Oakes reveals in
today's Herald Sun that Mr. Robb has been diagnosed with a biochemical disorder
known as diurnal variation. Mr. Robb, 58, is going public with his battle lest there be
any misunderstanding why he is temporarily vacating Malcolm Turnbull's front bench.
In an interview with Oakes, Mr. Robb explains he has suffered for as long as he can
remember -without actually knowing his condition had a name. "I thought it was just
that I wasn't good in the mornings," Mr. Robb says" It's like a little black dog has been
visiting me every morning for most of my life." Mr. Robb tells how he wakes up feeling
flat and negative but eventually settles into the positive and confident mindset needed
to tackle politics on the front line. As a youngster, he recalls suffering but telling
nobody. "I can remember as a 12-year old, walking to the station on the way to school
at 7.15 in the morning. I'd see old fellows who had retired and I'd wish I was one of
them." A telephone call to Beyond Blue chairman Jeff Kennett six weeks ago led to Mr.
Robb visiting a psychiatrist who diagnosed the condition. Treatment, however, has
proved more gruelling than Mr. Robb expected. Drugs are sending him into deeper
depression before any benefits emerge, prompting his decision to temporarily move to
the back bench.
Text B
Diagnosis of depression
If you are clinically depressed you would have at least two of the following symptoms
for at least 2 weeks.
 An unusually sad mood that does not go away.
 Loss of enjoyment and interest in activities that used to be enjoyable.
 Tiredness and lack of energy.
As well, people who are depressed often have other symptoms such as:
 Loss of confidence in themselves or poor self-esteem.
 Feeling guilty when they are not at fault.
 Wishing they were dead.
 Difficulty concentrating or making decisions.
 Moving more slowly or, sometimes becoming agitated and unable to settle.
 Having sleeping difficulties or, sometimes, sleeping too much.
 Loss of interest in food or, sometimes eating too much. Changes in eating habits
may lead to either loss of weight or putting on weight.
Text C
Not every person who is depressed has all these symptoms. People who are more
severely depressed will have more symptoms than those who are mildly depressed.
Here is a guide to severity of depression: Mild depression 4 of the 10 symptoms listed
above over the past 2 weeks.
Moderate depression 6 of the 10 symptoms of the past 2 weeks.
Severe depression 8 of the 10 symptoms over the past 2 weeks.
Occasionally, depression is a sign of another illness or is caused by the side effects of
medications. Your doctor will want to check out whether there are any other medical
problems or pills that could be causing your depression.
(WHO, The ICD-10 Classification of Mental and Behavioural Disorders, Geneva.)
Text D
Antidepressant drugs
Occasional sadness or loss of heart are normal, and they usually pass quickly.
However, more severe depression that is accompanied by feelings of despair, lethargy,
loss of sex drive, and often poor appetite may call for medical attention. Such
depression can arise from life stresses such as the death of someone close, an illness,
or sometimes for no apparent cause. Three main types of antidepressant are used to
treat depression: tricyclic antidepressants (TCAs), selective serotonin re-uptake
inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs). These groups of drugs
are equally effective Treatment usually begins with an SSRI.
PART A -QUESTIONS
Questions 1-7
1. How the severity of depression is assessed?

2. what are the symptoms of depression?
3. who is Mr. Andrew Robb?
4. what does TCA' stands for?
5. how can you check whether you're clinically depressed?
6. what are the symptoms of severe depression?
7. what does 'MAOI stands for?
Questions 8-13
8. Which antidepressant is given first in the treatment of depression?

9. Who classified depression on the basis of severity?
10. who diagnosed the condition of Mr. Robb?
11. Which type of depression can arise from stress caused by death of someone
close?
12. How many symptoms are minimum required for a moderate depression?
13. who reported the condition of Mr. Robb?
Questions 14-20
14.___________ or loss of heart are normal and pass quickly.

15. Occasionally, depression is a sign of ________________ effects of medications. or
is caused by the side
16. Changes in_________ may lead to either loss of weight or putting on weight.
17. If you are clinically depressed you would have the symptoms for at least ________
18. The chairman of ____________ Jeff Kennett led Mr. Robb to visit a psychiatrist.
19. Three main types of ____________ used to treat depression are equally effective.
20. _________________ shows four of the ten symptoms over the past two weeks.
Questions 1-6
1. The manual informs us that the tonometer
A. is activated by pulling a button by the patient or the staff

B. display mostly the blood pressure systolic and diastolic values
C. display only the pulse value of the patient immediately
Method of BP measurement using a digital tonometer.

The procedure involves the correct positioning of the cuff on the appropriate place after
previously positioning the disposable circular PVC cuff. This protection cuff helps to
prevent the transmission of infection between patients in the healthcare facility. After
positioning the cuff, the tonometer is activated by pressing a button and the cuff is
automatically inflated. After a while, the display will show the blood pressure systolic
and diastolic values and some types of tonometers also display the pulse value.
2. What must all staff involved in the reprocessing process do?
A. certify their facilities and procedures by a regulatory authority or an accredited

quality system auditor
B. ensure the cleanliness, sterility, safety and functionality of the reprocessed
equipments
C. All of the above.
Single-Use Medical Equipments

Critical and semi-critical medical equipments labeled as single-use must not be
reprocessed and reused unless the reprocessing is done by a licensed reprocessor.
Health care settings that wish to have their single-use medical equipments
reprocessed by a licensed reprocessor should ensure that the reprocessor's facilities
and procedures have been certified by a regulatory authority or an accredited quality
system auditor to ensure the cleanliness, sterility, safety and functionality of the
reprocessed equipments.
A. report on a rise in special cases such as local environmental conditions

B. explain the background to conduct preventive maintenance
C. remind staff about procedures and intervals for preventive maintenance
Preventive maintenance (PM)
PM involves maintenance performed to extend the life of the device and prevent
failure. PM is usually scheduled at specific intervals and includes specific maintenance
activities such as lubrication, cleaning or replacing parts that are expected to wear or
which have a finite life. The procedures and intervals are usually established by the
manufacturer. In special cases the user may change the frequency to accommodate
local environmental conditions
Preventive maintenance is sometimes referred to as planned maintenance or
scheduled maintenance'.
4. The guidelines require those undertaking micro-enema to
A. administer the solution with a Janet rectal syringe

B. administer the other solution with a rectal tube
C. thoroughly shake the contents of the Yal bottle
Micro-enema
This is a form of enema administration, i.e. small liquid volumes in adults 60- 180 ml).
An example of a micro-enema solution used for cleansing the rectum is Yal, which is
already prepared by the manufacturer in a transparent bottle with an attached
applicator. The contents of the bottle must be thoroughly shaken before use and the
sealed end of the applicator cut off. If administering a micro-enema with another
solution, not originally prepared by the manufacturer, rinsing is done with a Janet rectal
syringe and an appropriate sized rectal tube. Other aids are the same as for other
types of enema.
A. should monitor the overall behaviour of the patient.

B. evaluate the strength of the impulse in a particular patient.
C. note internal and external factors influencing the pain
Intensity of pain
The intensity of pain is expressed by the question "How much does it hurt? "It is not
easy to assess pain as it is a subjective symptom. We cannot objectify the intensity of
pain or measure the strength of the impulse in a particular patient. Experiencing pain is
influenced by many internal and external factors. The nursing staff should monitor the
overall behaviour of the patient, especially the quality of sleep, appetite,
communication with other patients, family members, staff etc
A. report on a rise in patient malnutrition complications.

B. explain the background that cause patient malnutrition.
C. remind staff to identify patient malnutrition early.
Patient malnutrition
Poor nutrition brings a number of negative aspects for both treatment and further
patient prognosis. It is reported that the frequency of complications of the disease in
these patients is 27 % higher; the mortality of these patients is12.4% higher,
hospitalization time is 7 - 13 days longer and the cost of treatment is 210% higher.
According to international studies, 40% of hospitalized patients and 40-80 % of
institutionally treated elderly patients are at risk of malnutrition. Patients with
malnutrition should be identified early and provided with a sufficiently nutritional diet.
Part C -Text 1
Pandemic Flu The Bird Flu
What everyone should know about the avian influenza?

A growing number of avian influenza (bird flu) cases are turning up among bird
populations around the world. While the flu has yet to have a large-scale influence on
human lives, the World Health Organization (WHO) and the United States Center for
Disease Control (CDC) warns that it is not a matter of if we will be affected, but when.
The first step you can take is to educate yourself and stay informed. What follows are
questions and answers that will help you to take this first step.
What is the bird flu (avian influenza)?
The bird flu is an infection caused by avian (bird) influenza (flu) virus. These flu viruses
occur naturally among birds. Wild birds worldwide carry the virus in their intestines, but
usually do not get sick from it. However, avian influenza is very contagious among
birds and can make some domesticated birds, including chickens, ducks, and turkeys,
very sick and kill them
How does the bird flu virus differ from seasonal flu viruses that infect humans?
Of the few bird flu viruses that have crossed the species barrier to infection humans,
the most recent virus that you are hearing about in the news has caused the largest
number of reported cases of severe disease and death in humans. In Asia, more than
half of the people infected with the virus have died. Most cases have occurred in
previously healthy children and young adults. However, it is possible that the only
cases currently being reported are those in the most severely ill people and that the full
range of illness caused by the current bird flu virus has not yet been defined. Unlike
seasonal influenza, in which infection usually causes only mild respiratory symptoms in
most people, bird flu infection may follow an unusually aggressive clinical course, with
rapid deterioration and high fatality.
How does the bird flu spread among birds?

Infected birds shed influenza virus in their saliva, nasal secretions, and feces.
Susceptible birds become infected when they have contact with contaminated
secretions or with surfaces that are contaminated with excretions or secretions.
Domesticated birds may become infected with avian influenza virus through direct
contact with infected waterfowl or other infected poultry or through contact with
surfaces (such as dirt or cages) or materials (such as water or feed) that have been
contaminated with the virus.
Do bird flu viruses infect humans?
Bird flu viruses do not usually infect humans, but more than 100 confirmed cases of
human infection with bird flu viruses have occurred since 1997.
What would make the bird flu a 'pandemic flu'?

A pandemic flu' is defined as a global outbreak of disease that occurs when a new
virus appears in the human population and then spreads easily from
person to person. Three conditions must be met for a pandemic to start: 1) anew virus
subtype must emerge; 2) it must infect humans and cause serious illness; and 3) it
must spread easily and continue without interruption among humans. The current bird
flu in Asia and Europe meets the first two conditions: it is a new virus for humans and it
has infected more than 100humans
How do people become infected with bird flu viruses?

Most cases of the bird flu infection in humans have resulted from direct or close
contact with infected poultry (e.g. domesticated chicken, ducks, and turkeys) or
surfaces contaminated with secretions and excretions from infected birds. The spread
of bird flu viruses from an ill person to another person has been reported very rarely,
and transmission has not been observed to continue beyond one person. During an
outbreak of bird flu among poultry, there is a possible risk to people who have direct or
close contact with infected birds or with surfaces that have been contaminated with
secretions and excretions from infected birds.
What are the symptoms of avian influenza in humans?

Symptoms of the bird flu in humans have ranged from typical human flu-like symptoms
(fever, cough, sore throat, and muscle aches) to eye infections, pneumonia, severe
respiratory diseases (such as acute respiratory distress syndrome), and other severe
and life-threatening complications. The symptoms of the bird flu may depend on type of
virus causing the infection.
How is avian influenza detected in humans and treated?
A laboratory test is needed to confirm bird flu in humans. Studies done in laboratories
suggest that the prescription medicines approved for human flu viruses should work in
treating bird infection in humans. However, flu viruses can become resistant to these
drugs, so these medications may not always work. Additional studies are needed to
determine the effectiveness of these medicines.
Does a seasonal flu vaccine protect me from avian influenza?

No. Seasonal flu vaccines do not provide protection against the bird flu However, it is
always a good idea to obtain a vaccine for your well-being.
Should I Wear a surgical mask to prevent exposure to the bird flu?
Currently, wearing a mask is not recommended for routine use (e.g., in public) for
preventing flu virus exposure.
Is there a risk for becoming infected with avian influenza by eating chicken,
turkey, or duck?
There is no evidence that properly cooked poultry or eggs can be a source of infection
for bird flu viruses. The U.S. government carefully controls domestic and imported food
products, and in 2004 issued a ban on importation of poultry from countries affected by
bird flu viruses.
What can I do to help reduce the risk for infection from wild birds in the United
States?
As a general rule, the public should observe wildlife, including wild birds, from a
distance. This protects you from possible exposure to pathogens and minimize
disturbance to the animal. Avoid touching wildlife. If there is contact with wildlife do not
rub eyes, eat, drink, or smoke before washing hands with soap and water. Do not pick
up diseased or dead wildlife. Consumer Services for issues related to poultry flocks or
the Fish and Wildlife Conservation Commission for issues relating to wild birds
Is there a vaccine to protect humans from the bird flu virus?

There currently is no commercially available vaccine to protect humans against the bird
flu virus that is currently being detected in Asia and Europe However, vaccine
development efforts are taking place. Research studies to test a vaccine that will
protect humans against the current bird flu virus began in April 2005, and a series of
clinical trials is under way.
Does CDC recommend travel restrictions to areas with known bird flu
outbreaks?
CDC does not recommend any travel restrictions to affected countries at this time.
However, CDC currently advises that travelers to countries with known outbreaks of
avian influenza avoid poultry farms, contact with animals in live food markets, and any
surfaces that appear to be contaminated with feces from poultry or other animals.
Is there a risk to importing pet birds that come from countries experiencing
outbreaks of the bird flu?
The U.S. government has determined that there is a risk to importing pet birds from
countries experiencing outbreaks of the avian influenza. CDC and the U.S. Department
of Agriculture (USDA) have both taken action to ban the importation of birds from areas
where avian influenza has been documented.
Can a person become infected with the bird flu virus by cleaning a bird feeder?
There is no evidence of the avian influenza having caused disease in birds or people in
the United States. At the present time, the risk of becoming infected with the virus from
bird feeders is low. Generally, perching birds are the type of birds commonly at
feeders. While there are documented cases of avian influenza causing death in such
birds (e.g., house sparrow, Eurasian tree sparrow, house finch), most of the wild birds
that are traditionally associated with bird flu viruses are waterfowl and shore birds.
7. Which of the following statements is NOT true?
A) Wild birds carry the virus in their intestines.

B) Avian influenza is very contagious among birds.
C) Avian flu can make domestic birds very ill and may be fatal.
D) Wild birds often die from Avian flu
A) 50% of the people in Asia infected with bird flu have died
B) Healthy people have been infected
C) Bird flu causes mild respiratory symptoms in most people
D) It's likely that we don't yet know the full range of illnesses caused by the bird flu
virus.
9. How does a bird become infected?
A) Contact with the saliva, nasal secretions or faeces of an infected bird.

B) Contact with surfaces that have been contaminated by excretions or secretions from
infected birds
C) Direct contact with an infected bird.
D) Any of the above.
10. How many confirmed cases of human infection with bird flu viruses have occurred
since 1997?
A) 100+
B) 50
C) Over a thousand.
D) 25
11. Is the current outbreak a 'pandemic?
A) Yes
B) No
C) The information is not given in the text.
D) Not sure
A) Bird flu can be transmitted from bird to bird

B) Bird flu can be transmitted from bird to human.
C) Bird flu can be transmitted from one person to another person.
D) Bird flu can be transmitted from one person to another person and beyond.
13. Which of these are typical symptoms of bird flu in humans?

A) fever, cough, sore throat and muscle aches.
B) vomiting and diarrhoea.
C) insomnia
D) swollen limbs and earache.
14. If you have had a seasonal flu vaccine this year, are you also protected against
bird flu?
A) Yes
B) No
C) Yes, if the virus doesn't mutate.
D) The information is not given in the text.
Part C -Text 2
The Mental Health Risks of Adolescent Cannabis Use
Since the early 1970s, when cannabis first began to be widely used, the proportion of
young people who have used cannabis has steeply increased and the age of first use
has declined. Most cannabis users now start in the mid-to-late teens, an important
period of psychosocial transition when misadventures can have large adverse effects
on a young person's life chances. Dependence is an underappreciated risk of cannabis
use. There has been an increase in the numbers of adults requesting help to stop
using cannabis in many developed countries, including Australia and the Netherlands.
Regular cannabis users develop tolerance to many of the effects of delta-9-
tetrahydrocannabinol, and those seeking help to stop often report withdrawal
symptoms. Withdrawal symptoms have been reported by 80% of male and 60% of
female adolescents seeking treatment for cannabis dependence.
In epidemiological studies in the early 1980s and 1990s, it was found that 4%of the
United States population had met diagnostic criteria for cannabis abuse or dependence
at some time in their lives and this risk is much higher for daily users and persons who
start using at an early age. Only a minority of cannabis-dependent people in surveys
report seeking treatment, but among those who do, fewer than half succeed in
remaining abstinent for as long as a year. Those who use cannabis more often than
weekly in adolescence are more likely to develop dependence, use other illicit drugs,
and develop psychotic symptoms and psychosis.
Surveys of adolescents in the United States over the past 30 years have consistently
shown that almost all adolescents who had tried cocaine and heroin had first used
alcohol, tobacco, and cannabis, in that order; that regular cannabis users are the most
likely to use heroin and cocaine; and that the earlier the age of first cannabis use, the
more likely a young person is to use other illicit drugs. One explanation for this pattern
is that cannabis users obtain the drug from the same black market as other illicit drugs,
there by providing more opportunities to use these drugs.
In most developed countries, the debate about cannabis policy is often simplified to a
choice between two options: to legalize cannabis because its use is harmless, or to
continue to prohibit its use because it is harmful. As a consequence, evidence that
cannabis use causes harm to adolescents is embraced by supporters of cannabis
prohibition and is dismissed as "flawed" by proponents of cannabis legalisation.
A major challenge in providing credible health education to young people about the
risks of cannabis use is in presenting the information in a persuasive way that
accurately reflects the remaining uncertainties about these risks. The question of how
best to provide this information to young people requires research on their views about
these issues and the type of information they find most persuasive. It is clear from US
experience that it is worth trying to change adolescent views about the health risks of
cannabis; a sustained decline in cannabis use during the 1980s was preceded by
increases in the perceived risks of cannabis use among young people.
Cannabis users can become dependent on cannabis. The risk (around 10%) is lower
than that for alcohol, nicotine, and opiates, but the earlier the age a young person
begins to use cannabis, the higher the risk. Regular users of cannabis are more likely
to use heroin, cocaine, or other drugs, but the reasons for this remain unclear. Some of
the relationship is attributable to the fact that young people who become regular
cannabis users are more likely to use other illicit drugs for other reasons, and that they
are in social environments that provide more opportunities to use these drugs.
It is also possible that regular cannabis use produces changes in brain function that
make the use of other drugs more attractive. The most likely explanation of the
association between cannabis and the use of other illicit drugs probably involves a
combination of these factors. As a rule of thumb, adolescents who use cannabis more
than weekly probably increase their risk of experiencing psychotic symptoms and
developing psychosis if they are vulnerable-if they have a family member with a
psychosis or other mental disorder, or have already had unusual psychological
experiences after using cannabis. This vulnerability may prove to be genetically
mediated.
15. In paragraph 1, which of the following statements does not match the information
on cannabis use?
A] The use of cannabis by teenagers has been increasing over the past 40years
B] Cannabis use has adverse effects on young people.
C] Withdrawal symptoms are more common in males.
D] People try cannabis for the first time at a younger age than previously
16. Epidemiological studies in the 1980s & 1990s have found that
A] 4% of the US population currently suffer from cannabis abuse or dependence

B] starting cannabis use at a young age increases the risk of dependence or abuse
C] only a minority of surveys researched treatment options for cannabis dependent
people
D] people who start cannabis use at a young age have high risk of becoming daily
users
17. The main point of paragraph 3 is that
A] alcohol, tobacco and cannabis can lead to the use of heroin and cocaine.
B] most adolescents who have used cocaine or heroin first try alcohol, followed by
tobacco and then cannabis.
C] there is a clear link between habitual cannabis use and the use of heroin and
cannabis.
D] the black market is the main source of illicit drugs.
18. Which of the following would be the most appropriate heading for paragraph 4?
A] Opinion on an effective cannabis policy is divided.

B] Cannabis use is harmful to adolescents and should be prohibited
C] Cannabis use is a serious problem in a majority of developed countries
D] Cannabis use should be legalized
19. The word closest in meaning credible in paragraph 5 is

5. B
6. D
7. D
8. SSRI
9. WHO
10. psychiatrist
11. severe depression
12. 6
13. Laurie Oakes
14. Occasional sadness
15. another illness
16. eating habits
17. 2 weeks
18. Beyond Blue
19. antidepressant
20. Mild depression
1. B
2. C
3. B
4. C
5. A
6. C
7. D
8. C
9. D
10. A
11. B
12. D
13. A
14. B

15. B
16.B
17. C
18. A
19. A
molecular processes, in part due to its ability to inhibit and mimic the actions of
calcium. This impacts on many organs and systems within the body.
 There is an association between blood lead levels of 5 to 10 micrograms per
decilitre and adverse cognitive effects (reduced Intelligence Quotient (IQ) and
academic achievement) and behavioural problems (effects on attention,
impulsivity and hyperactivity) in children. However, it is unclear whether this
association is causal.
 For blood lead levels greater than 10 micrograms per decilitre there are well
established adverse effects on the body's digestive, cardiovascular, renal,
reproductive and neurological functions.
Text C
Testing blood lead levels
 Measurement of blood lead should be considered when symptoms or health
effects associated with lead are present and/or a source of lead exposure is
suspected.
 Testing of asymptomatic children should be conducted based on the individual's
risk profile (eg. life stage, exposure of other household members, local
environment and current health status).
 A blood lead test is considered the most reliable biomarker for general clinical
use. Results tend to reflect more recent exposure but do not necessarily provide
information about stored lead in the body.
 Other types of blood tests (e.g. plasma lead test or erythrocyte protoporphyrin
test ) and tests of bone, teeth, sweat, nails or hair are not recommended for
clinical use.
Management of individuals
 Health practitioners should be aware of the requirements in their state or territory
for notification of blood lead levels to public health authorities.
 Collaboration between primary health practitioners and state and territory
environmental health agencies is recommended to identify and manage
exposure.
 Management approaches are based on individual blood levels and the person's
overall health and social environment. Testing family members, and others
suspected of being exposed to the lead source should be considered as part of
the management plan.
Text D
Investigating the source of exposure.
 The first step to reducing elevated blood lead levels in individuals is to identify
the sources of exposure. A planned, logical process should be followed to
identify lead hazards, and the presence of multiple lead sources should not be
ruled out or overlooked.
 Once the source has been identified, an exposure assessment should be
undertaken to identify the extent and pathways of exposure.
Interventions for reducing elevated blood lead levels.
 Management strategies should focus on breaking the exposure pathway.
Addressing or removing the source of lead is the most effective intervention,
provided it can be successfully applied. This should take place before attempts
are made to change behaviour (e.g. through access restriction and education).
 Substituting lead-containing products with lead-free products will have an
immediate beneficial effect. Remediation of widespread diffuse sources of lead
will require consultation with the local, state or territory health and environmental
protection authorities.
PART A -QUESTIONS
Questions 1-7
1. what are the benefits of investigating the source of lead exposure?

2. what is the first step to reduce the elevated blood lead levels in individuals?
3. what is the most effective intervention for reducing the elevated blood lead levels?
4. what are the factors that determine health effects due to exposure to lead?
5. which blood tests are not recommended for clinical use?
6. what is the basis for testing blood lead levels of asymptomatic children?
7. which body functions are adversely affected by blood lead levels greater than 10
micrograms per decilitre?
Questions 8-13
8. Who should notify public health authorities about blood lead levels?
9. What is the most reliable biomarker to find lead exposure for general clinical use?
10. Who are more adversely affected from lead in the body?
11. Which metal is inhibited and mimicked by lead in the body?
12. what does the blood lead test result reflects?
13. what does 'IQ stands for?
Questions 14-20
14. The average blood lead level in ______________ micrograms per decilitre is
estimated to be less than 5 micrograms per deciliter.
15._____________affects a range of molecular processes.
16. Blood lead levels of 5 to 10 micrograms per decilitre can have adverse
____________ effects and behavioural problems.
17. Tests of bone, teeth, sweat, nails or hair are not recommended for ___________
18. Management approaches are based on ___________ health and social
environment. and the person's overall
19. Testing people who are suspected of being exposed to the lead source
should be considered as part of the ______________
20. A planned, logical process should be followed to identify ______________
Questions 1-6
1. This guideline extract says that when investigating an unexplained failure the
technical personnel
A. should cooperate with electrical power system managing staff in the health-care
organization.
B. should collaborate with staff who manages the electrical equipment in the health-
care organization
Factors affecting equipment failures

When investigating an unexplained failure, environmental factors should be taken into
due consideration. For example, medical devices that require electrical power may be
adversely affected by power issues. Ideally,
Electrical power should have a steady voltage (of the appropriate value); be free of
transient distortions, such as voltage spikes, surges or dropouts; and be reliable, with
only rare loss of power. Technical personnel should collaborate with those responsible
for the electrical power system in the health-care organization to help make the system
function as effectively as possible
2. What does this extract tell us about calibration?
A. medical equipment with therapeutic energy output needs to be calibrated

periodically
B. medical equipment that take measurements needs to be calibrated periodically
Calibration
Some medical equipment, particularly those with therapeutic energy output (e.g.
defibrillators, electrosurgical units, physical therapy stimulators, etc.), needs to be
calibrated periodically. This means that energy levels are to be measured and if there
is a discrepancy from the indicated levels, adjustments must be made until the device
functions within specifications. Devices that take measurements (e.g.
electrocardiographs, laboratory equipment, patient scales, pulmonary function
analysers, etc.) also require periodic calibration to ensure accuracy compared to
known standards.
3. The guidelines establish that the healthcare professional should use
A. common universal descriptive names for devices from a internationally accepted

source
B. specific names for devices from the user manual given by the manufacturer
C. common descriptive nomenclature from the directory of healthcare facility
Common descriptive nomenclature.

Using common universal descriptive names from a single internationally accepted
source is key to comparing inspection procedures, inspection times, failure rates,
service costs and other important maintenance management information from facility to
facility. Although manufacturers have specific names for devices, it is important to store
the common name of the device as listed in the nomenclature system.

A. maximize efficient use of patient care unit resources
B. attend preadmission planning meetings
C. discuss the necessary of bed utilization
Pre Admission Preparation

The clinical staff will conduct preadmission planning for each scheduled
admission of patients. These discussions should address patient schedules and
special needs. Physicians, dentists, and other licensed independent practitioners,
nursing staff, research nurses, and protocol coordinators may participate in these
meetings, which also may involve social workers, nutritionists, pharmacists, and other
members of the multidisciplinary care team. To maximize efficient use of patient-care
unit resources and anticipate the possible need to "board" patients on other units,
meeting participants may discuss bed utilization.
A. staff who should conduct multidisciplinary clinical rounds at least weekly.

B. importance of multidisciplinary clinical rounds in patient management.
C. staff who should use information from multidisciplinary clinical rounds.
Multidisciplinary Patient Care Rounds

All the relevant staff constituting a multidisciplinary team should hold and document
clinical rounds at least weekly during patients' hospitalizations and prior to discharge.
The purpose of these multidisciplinary clinical rounds is to discuss patient data,
progress in the protocol, problems relating to the patient's care, evaluations by
specialists, and recommendations for management. The primary care team can then
use this information to devise treatment plans, prepare patient education, and
formulate recommendations for referring physicians.
6. This guideline extract says that the medical staff
A. will have access to treatment guidelines endorsed by national organizations

B. to practice guidelines in developing recommendations for patient management
C. to develop patient management and treatment guidelines for supportive care of
patients
Patient Management And Treatment Guidelines

Even when the primary treatment is determined by a clinical research protocol,
supportive care for seriously ill patients may benefit from guidelines developed by
institute and center specialists. The medical staff will have access to treatment
guidelines endorsed by national organizations. We encourage investigators and
consultants, when appropriate, to consider practice guidelines in developing their
recommendations for patient management. In addition, we encourage multi-specialty
teams to develop patient management and treatment guidelines for supportive care of
patients in clinical research protocols that are based on clinical trial data and expert
opinions.
Part C -Text 1
The senses of the newborn
Tests for hearing and vision have improved

Shakespeare's description of the infant, "Mewling and puking in the nurse's arms," was
echoed in the attitudes of doctors earlier this century. The newborn baby was thought
to be either drowsy, asleep, or crying, and to experience the world as a "great,
blooming, buzzing confusion." But, we have learnt over the past 30 years that the
healthy newborn baby can discriminate between different sensations from the
environment and responds electively. Within hours of birth the baby will look at the
mother's face, and given the choice newborn babies prefer to look at a card showing
the features of another human being rather than the same features jumbled up or the
features condensed into a large black patch.
The newborn baby spends only 11% of the time awake and alert in the first week of
life, a proportion that rises to 21% in the fourth week. This small traction of
wakefulness hindered the early development of methods of testing senses. When
eliciting responses it is important to record the baby's state of arousal-between deep
sleep at one extreme and crying at the other and Prechtl's group first described five
possible behavioural states. Brazelton extended this work to include items of higher
neurological function, including visual and auditory responses to a bail and rattle, and
his neonatal behavioural assessment scale is a means of scoring interactive
behaviour.
Why do we need to test the senses of the newborn? We want to ensure that the baby
is able to interact with the parents and with the environment and that there is no
impairment to social, emotional, cognitive, and linguistic development. It is often
difficult to prove that early intervention is effective in minimising handicap, but there is
evidence for instance, that deaf children fined with hearing aids in the first six months
of life have better speech than those fitted later. And all parents and most therapists
agree that they would like to know of any handicap as early as possible.
Finding reliable and methods of testing hearing and vision in newborn babies has
proved difficult. They show behavioural responses to sound, blinking and startling to a
sudden clap and stilling" to interesting noise, with alteration in their breathing pattern.
Every mother recognises these responses, but they cannot be used to detect deaf
babies reliably because of the spontaneous random movements that babies make and
possible bias on the part of the observers. The use of a simple rattle to produce head
and eye turning has been described, but the method has not found widespread
acceptance Behavioural responses may be recorded by devices incorporating
microprocessors such as the auditory response cradle (which should eliminate
observer bias). The sensitivity and specificity of this cradle have varied among tri an
sound stimulus has to be very (80-85 dB) to result in a behavioural response by the
baby, so that moderate hearing losses are missed.
The electrophysiological response to sound may be detected by audiometry based on

evoked responses in the brain stun, and this is considerably more sensitive. Simpler
and more portable brain stem screeners have now been developed. Most recently
newborn babies hearing has been tested by using Otoacoustic emissions, a
phenomenon first reported by Kemp in 1978." A click stimulus delivered to normal ear
results in an "echo" sound generated by the cochlea, which can be detected by a
miniature microphone. The method is quicker and less invasive than brain stem
audiometry and can detect even mild hearing losses. Stevens and his colleagues
tested 346 infants at risk and showed that 20 of the 21 surviving infants who gave
negative results to brain stem audiometry also failed on the otoacoustic test.
This work also highlighted a major problem that of validating methods of testing senses
in the newborn baby. This has to be by follow up, checking the outcome with the
testing methods that become possible in the older infant. Steven's group found a poor
correlation between distraction testing of the babies' hearing at 8 months of age and
brain stem audiometry in the newborn, a discrepancy confirmed by others. "We must
now be more cautious in interpreting the results of electrophysiological rests in the
newborn. Babies who give negative results will need retesting several times during the
first year. Though the early fitting of hearing aids is desirable, the degree of hearing
impairment needs to be clearly established, particularly as maturation of the auditory
pathways may be taking place, although delayed
Similar problems and challenges occur in testing vision in newborn babies. Behavioural
responses are familiar to the mother, with the baby blinking to bring light. Babes turn
their heads to a diffuse light but (like turning to sound) this test may not be reliable,
especially in preterm infants. All these responses give a qualitative indication of vision.
Optokinetic nystagmus can be shown when a striped tape or drum is moved in a
temporal to nasal direction across the newborn baby's field of vision and gives a
valuable but crude indication that vision is present. Electrophysiological recording of
the visual evoked potential to a flash gives limited useful information because of great
individual variations and because it relates as much to general cerebral function as to
visual outcome.
Visual evoked potentials to patterns may give a measure of visual function but only
after the age of 2 months. The best method of measuring visual acuity is to use the
preferential looking technique. This is based on the observation of Fantz 30 years ago
that patterned objects are visually interesting to infants. The latest version, called the
acuity card procedure, uses patterned and plain stimuli mounted in pairs on cards, and
these can be used successfully even in the neonatal intensive care unit. Much
fascinating and enjoyable research is being done into the ability of babies to
discriminate and respond to smell, taste, and touch. We should also be glad that at
long last there is widespread acceptance of fact that newborn babies do experience
real pain and need postoperative analgesia like the rest of us.
7. Doctors now know

A) that it is natural for a newborn baby to experience the world as a great blooming
buzzing confusion.
B) that babies are much more responsive to visual and auditory cues in their
surroundings than was previously thought.
C) the newborn babies are slow to develop a response to visual and auditory stimulus,
since they are awake only 11% of tile time.
D) that babies are less able to discriminate between different features of the
environment than was believed in the first half of this century
8. According to research referred to in the article, a baby given a choice

about what to look at is more likely to choose
A) a card showing human facial features.

B) a card showing jumbled human features
C) a card showing a large black patch
D) a black and white photograph of the mother.
9. The senses of the 4-week-old baby can only be tested.
A) 11% of the time.

B) when it is crying.
C) 21% of the time.
D) none of the above.
10. Which of the following statements is true?
A) There is some evidence that early intervention can prevent handicaps.

B) There is much evidence that early intervention can minimize handicaps.
C) There is some evidence that early intervention can minimize handicaps.
D) There is no evidence that early intervention can minimize handicaps.
11. Testing hearing in newborn babies is difficult for all of the following reasons, except
A) Newborn babies show behavioural responses to sound such as blinking and

startling
B) Deaf babies sometimes make movements by chance when interesting noises are
made
C) Observers may be biased in their interpretation of babies' responses.
D) The auditory response cradle does not measure moderate hearing losses.
12. Otoacoustic emissions are
A) sounds delivered to the cochlea.

B) 'echo sounds caused by click stimuli.
C) click stimuli delivered to a normal ear.
D) sounds generated by a miniature microphone.
13. Compared with the use of otoacoustic emissions, brain stem audiometry
A) is quicker
B) can detect even mild hearing loss.
C) is more invasive.
D) is more sensitive.
14. Of the hearing testing methods described in the text
A) brain stem audiometry correlated well with otoacoustic tests.

B) brain stem audiometry correlated well with distraction testing.
C) otoacoustic tests correlated poorly with brain stem audiometry
D) otoacoustic tests correlated well with distraction testing.
Part C -Text 2
Insulin is still a hard act to swallow
Research groups around the world are optimistic that they are making progress
towards developing the drug insulin in a form that can be taken by mouth. Many
diabetics must inject themselves every day with insulin to help control the level of
sugar in their blood. For decades, scientists have been looking for an effective way to
give people insulin by mouth instead. Insulin is an essential hormone for getting
glucose from the bloodstream into body cells, and most people produce it naturally in
the pancreas. People with diabetes mellitus produce either not enough insulin or none
at all. The hormone cannot normally be taken by mouth because insulin molecules are
destroyed by digestive enzymes in the gut. Thus, many diabetics must inject
themselves with insulin daily
Researchers have therefore been aiming to package the hormone in some way so that
it can survive intact in the gut and cross the gut wall into the bloodstream. The current
experiments are all at an early stage. Even if they do lead to an effective treatment, it
may not be suitable for every diabetic Those most likely to benefit are people who find
injections difficult, such as blind people and younger children. This month a team in
Ohio is applying for permission to test its oral insulin on people. The tablet is a gelatin
capsule which contains insulin and a drug similar to aspirin and sodium bicarbonate.
The gelatin has a costing of waterproof plastic that becomes permeable in the gut.
Murray Saffran, who is leading the research at the Medical College of Ohio in Toledo,
says the plastic based on a polymer whose structure contains certain nitrogen-
nitrogen bonds known as azo bonds. In the gut, bacteria break down the azo bonds,
and the plastic becomes permeable to water. Water enters the capsule and causes a
reaction between the aspirin-like drug and the sodium bicarbonate, giving off carbon
dioxide and rupturing the capsule. The researchers believe the aspirin-like drug may
also help the insulin to be absorbed. The insulin is absorbed directly from the gut into
the vein carrying blood to the liver.
Saffran and his colleagues have so far carried out trials of the capsule in rats and most
recently - diabetic dogs. The researchers found that the level of glucose in the animals'
blood fell, on average, from more than 400 to 120milligrams per decilitre after receiving
the capsule. At the same time, the insulin levels in their blood rose, showing they had
absorbed the hormone
Reading Test Version 2 Another group has already staned testing a different insulin
capsule in humans, having first performed animal trials. Hanoch Bar On and his
colleagues at the Hadassah Hospital in Jerusalem have patented their capsule, which
is coated so that it is not destroyed by the stomach acid. Bar-On says the capsule
contains insulin and other ingredients" which help to enhance the hormone's
absorption in the gut and to inhibit the enzymes that destroy it.
So far, the trial in Jerusalem has been small, involving only eight health volunteers. In
future, Bar-on wants to extend the trials to diabetics, but he stresses the need for more
research before he can do so. The success of the tests so far has been limited, but
encouraging, says Bar-On: in three of the eight, the level of sugar in their blood fell
after they took the capsule from100 milligrams per decilitre to between 80 and 85. At
the same time, the insulin level in their blood was seen to rise to a peak then tail off.
For the remaining five people, there was no significant effect from the capsule.
A third project is led by Young Cho at Murdoch University in Perth, Australia, together
with Cortecs, a company in Isle Worth near London. Cho has devised a combination of
insulin and fatty molecules, encapsulated in gelatin. The fatty molecules, which occur
naturally in the gut as a product of the digestion of fat, are easily absorbed from the gut
and carried to the liver. Insulin attached to these molecules can enter the bloodstream.
Cho gave three diabetic men this preparation, in liquid form. In each of the men there
was a "substantial reduction" in the level of blood sugar. Their insulin levels were also
seen to peak and tail off. The team has published this work in The Lancet, and clinical
trials of the capsule are due to start soon at Guy's Hospital, in London.
There are, however, several problems with oral insulin. First, it is relatively inefficient:
several times as much insulin is needed to achieve the same drop in blood sugar that a
specific amount could achieve if injected. This suggests that a significant amount of
insulin is still being destroyed in the gut. Also, the amount of insulin that will be
absorbed is unpredictable and can be disrupted, for example, by illness.
15. According to the article,
A) it is no longer desirable that diabetics should inject themselves with insulin

B) a large number of diabetics no longer want to inject themselves with insulin
C) a viable oral form of insulin has been developed
D) a viable oral form of insulin may soon be developed
16. The major problem with an oral form of insulin has been
A) producing it in sufficient quantities outside the pancreas

B) delivering it undamaged into the bloodstream
C) preventing it from attacking digestive enzymes in the gut
D) its previous inability to cross the gut wall into the bloodstream
17. The capsule which is to be tested in Ohio
A) will also be tested on blind people and younger children

B ) contains a combination of insulin, aspirin and sodium bicarbonate
C) has protection which enables it to overcome the previous problems
D) none of the above
18. The reaction between the capsule and water in the gut
A) is likely to destroy the insulin

B) causes the insulin and the aspirin-like drug to "be taken into the blood stream
C) produces carbon dioxide as a by-product
2. D
3. D
4. B
5. C
6. C
7. B

8. Health practitioners
9. blood lead test
10. children and babies
11. calcium
12. more recent exposure
13. Intelligence Quotient
Part A - Answer key 14– 20

14. Australia
15. Lead toxicity
16. cognitive
17. clinical use
18. individual blood levels
19. management plan
20. lead hazards

1. A
2. C
3. A
4. A
5. B
6. A
7. B
8. A
9. C
10. C
11. A
12. B
13. C
14. A
rate of heart disease in Victoria, with nearly 32 per cent of the population affected by it.
Regional areas of Victoria, including East Gippsland and the Ovens-Murray strict,
showed similarly bad results, whereas Ms Bell said only about 14 per cent of people in
high income areas, close to the city, had experienced heart disease."
These regions are some of the lowest-income areas in Victoria, with a high proportion
of households earning income of less than $350 per week," she said. Ms Bell said
research showed disadvantaged areas had high rates of smoking which needed to be
addressed. She said financial incentives should be considered alongside higher taxes
on cigarettes — both recommendations of a resort recently released by the Federal
Government's preventive health taskforce. A study of more than 800 General Electric
employees in the US found those who were offered rolling payments of up to $750 a
year to quit smoking and remain abstinent were about three times more likely to rant
long-term, compared with use who were not given money.
Text C
Cyber aid to quitting smoking

Battling one's cigarette demons in a virtual world may prove to be an effective way to
help people quit smoking, a research team has found in a preliminary study. Scientists
from Canada's GRAP Occupational Psychology Clinic and the University of Quebec
modified a three-dimensional videogame to create a computer-generated virtual reality
environment as part of an anti-smoking program. Of 91 regular smokers enlisted in the
12-week program, 46 of them crushed computer-simulated cigarettes as part of
psychosocial treatment, while the other 45 grasped a computer-simulated ball. The
group who crushed cigarettes had a "statistically significant reduction in nicotine
addiction" compared with the ball graspers, according to the study in the journal Cyber-
Psychology and Behaviour.
Text D
By the 12th week, abstinence among the cigarette-crushers was 15 per cent,
compared with 2 per cent for the other group. The crushers also stayed in the program
longer and, at a six-month follow-up, 39 per cent of them reported not smoking during
the previous week, compared with 20 per cent of the ball graspers. "It is important to
note that this study increased treatment retention," said Brenda Wieder hold, the
journal's (Cyber-Psychology and Behaviour) editor-in-chief, adding that such treatment
should now be compared to other popular treatments such as the nicotine patch. The
study said about 45 per cent of smokers in the US attempt to quit each year, with
limited success.
PART A -QUESTIONS
Questions 1-7
1. which are the lowest-income areas in Victoria?

2. who created the video game to as part of an anti-smoking program?
3. who are the cigarette-crushers?
4. who is Brenda Wiederhold?
5. why the nicotine patches are causing skin irritation?
6. who proposed the idea to pay Australians to quit smoking?
7. how much smokers in the US attempt to quit each year?
Questions 8-13
8. Who is the editor-in-chief journal Cyber-Psychology and Behaviour?

9. How many regular smokers enlisted in the Canadian Cyber-aid program?
10. Where did the European scientists' published their findings?
11. How many General Electric employees were offered payments to quit smoking?
12. What was the trial subject for the study conducted by European scientists?
13. How many crushed computer-simulated cigarettes?
Questions 14-20
14. Nicotine activates an ion channel in skin cells that unleashes______________ by

the immune system.
15. In Australia, 14 per cent of people in high-income areas had experienced
____________
16. By the 12th week, abstinence among the ball-graspers was ____________
17. In the US, 45 per cent of smokers attempt to quit each year with ____________
18. Previously, nicotine patch irritation was blamed on stimulation of ____________ on

nerve cells.
19._____________stayed in the Cyber aid program longer than the other group.
20. Ms Bell's research showed_______________ had high rates of smoking.
Questions 1-6
1. This guideline extract says that the safety inspections should not
A. be performed to ensure the device is electrically and mechanically safe

B. include checks for radiation safety or dangerous gas or chemical pollutants
C. be the same than planned maintenance and performance Inspections
Safety inspections of medical equipments

These are performed to ensure the device is electrically and mechanically safe. These
inspections may also include checks for radiation safety or dangerous gas or chemical
pollutants. When these inspections are done, the results are compared to country or
regional standards as well as to manufacturer's specifications. The frequency of safety
inspections may be different than planned maintenance and performance inspections,
and are usually based on regulatory requirements.
2. The purpose of this email is to take steps that allow

A. both equipment users and equipment technicians access to operation manuals
B. only the equipment technicians access to operation manuals
C. only the equipment users access to operation manuals
Operation and service manuals

Ideally, the maintenance programme will have an operation (user) manual and a
service manual for each model of medical equipment. The operation manual is
valuable not only for equipment users but also for equipment technicians who need to
understand in detail how the equipment is used in clinical practice. The service manual
is essential for inspection, preventive maintenance, repair, and calibration.
Unfortunately, operation manuals and service manuals are not always available, or
may be in a language not spoken by equipment technicians. Therefore, it is important
to take steps that allow them access to such manuals.
A. use technician efficiently to reduce downtime of equipment and expenses

B. only plan inspection for immobile equipment in a given clinical department
C. schedule inspection of equipment of different types simultaneously
Scheduling maintenance
Efficient use of technician time will reduce downtime of equipment and minimize
overall expenses. The most appropriate method for scheduling maintenance in a
particular health-care facility should be chosen. For inspections, one approach is to
plan for the equipment in a given clinical department to be inspected at the same time.
This works very well for equipment that does not move from the department. Another
approach would be to schedule inspection of equipment of a given type (e.g.
defibrillators) simultaneously.
4. When referring a patient to physician, it is necessary to
A. provide a concise summary of evaluation, treatment, and management

recommendations of the patient
B. provide a form containing discharge instructions, patient's medication list and
contact phone number
C. explain patient's evaluation, treatment, and management recommendations as well
as the follow-ups.
Patient Discharge And Referring Physician Interface
Care teams that may include the attending physician or dentist, fellows, other licensed
independent health-care practitioners, research nurses, and patient care unit nursing
staff will meet with patients at the time of their discharge to explain their evaluation,
treatment, and management recommendations as
well as the follow-up that may be required at the clinical center. The care teams will
provide patients with a form containing discharge instructions, their medication list, and
a contact phone number at the clinical center. Referring physicians will receive a
concise summary of evaluation, treatment, and management recommendations from
the responsible attending physician or other designated licensed independent
practitioner within a week of discharge, or earlier if necessary for appropriate continuity
of care.
5. The purpose of these notes about Quality Assurance is to
A. provide an appropriate opportunity to discuss outcomes of protocol participation

B. review the occurrences and complications of procedures that caused patient harm
C. ensure attendance of patient-care staff and appropriate key staff
Quality Assurance
To review the occurrences and complications of procedures that caused or had the
potential to cause patient harm, the institutes and centers should conduct Quality
Assurance Rounds on a regular basis. These rounds also provide an appropriate
opportunity to discuss especially serious outcomes of protocol participation even when
unassociated with an occurrence or procedural complication. These conferences,
which should be attended by all levels of patient-care staff, will regularly include the
unit nurse manager and other representatives from the nursing staff. When
appropriate, other key staff (e.g., from the Pharmacy or Social Work Department) may
be included.
A. monitor compliance with standardized forms, tools, and methods for transitions of
care
B. use surveys and data collection to find root causes of effective transitions
C. identify patient and caregiver dissatisfaction with ineffective transitions
Evaluation Of Transitions Of Care Measures

Monitor compliance with standardized forms, tools, and methods for transitions of care.
Use surveys and data collection to find root causes of
ineffective transitions and to identify patient and caregiver satisfaction with transitions
and their understanding of the care plan. For example, this three item survey queries
patients about key aspects of a care transition: The hospital staff took my preferences
and those of my family or caregiver into account in deciding what my health care needs
would be when I left the hospital. When I left the hospital, I had a good understanding
of the things I was responsible for in managing my health. When I left the hospital, I
clearly understood the purpose for taking each of my medications
Part C -Text 1
Exercise, fitness and health
Physical inactivity is a substantial risk factor for cardiovascular disease.

Exercise probably works by increasing physical fitness and by modifying other risk
factors. Among other benefits, it lessens the risk of stroke and Osteoporosis and is
associated with a lower all-cause mortality. Moreover, it has psychological effects that
are surely underexploited. A pervasive benefit is the gain in everyday reserve capacity
that is, the ability to do more without fatigue. Nevertheless, there is much debate about
how intense the exercise should be. Some studies show a dose-response relation
between activity and reduction of risk, with a threshold of effect; some suggest that
vigorous aerobic activity is needed and others that frequent moderate exercise is
adequate and indeed safer if ischaemic heart disease might be present. A few surveys
have found a slightly increased risk of heart attack with extreme activity, though further
analysis in one study suggested this applied only to men with hypertension.
A commonly recommended minimum regimen for cardiovascular benefit is thrice

weekly exercise for 20 minutes, brisk enough to produce sweating or hard breathing
(or a heart rate 60-80% of maximum). Indeed, this is what the Allied Dunbar national
survey of fitness among adults in the UK recommends. It conveys a simple popular
message of broad minimum targets for different age groups expressed in terms of
activities of different intensity. The aim is to produce a training effect through exercise
beyond what is customary for an individual.
The main reason why people fail to take exercise is lack of time. Thus an important
message is that exercise can be part of the daily routine walking or cycling to work or
the shops, for instance. Relatively few people in the national fitness survey had walked
continuously for even 1-25 km in the previous month (11-30% depending on age and
sex), and other surveys have also found little walking. Cycling is also beneficial,
however many are put off cycling to work by the danger. Certainly more cycle routes
are needed but even now life years lost through accidents are outweighed by the
estimated life years gained through better health. Employers could encourage people
to make exercise part of the working day by providing showers and changing rooms,
flexible working hours, individual counselling by occupational health or personnel staff,
and sometimes exercise facilities or at least encouragement for exercise groups.
In the promotion of exercise children, women, middle aged men, and older people
need special thought. Lifelong exercise is most likely to be started in childhood, but
children may have little vigorous exercise. Women tend to be much less active than
men and are less fit at all ages. The proportion judged on a treadmill test to be unable
to keep walking at 5 km/h up a slight slope rose with age from 34% to 92% - and over
half of those aged over 54 would not be able to do so even on the level. Women have
particular constraints: young children may prevent even brisk walking. Thus they need
sensitive help from health professionals and women's and children's groups as well as
the media.
A high proportion of men aged 45-54, who have a high risk of coronary heart disease,
were not considered active enough for their health. Promotion of exercise and
individual counselling at work could help. Forty per cent of 6574 year olds had done no
"moderate activity for even 20 minutes in a month. Yet older people especially need
exercise to help them make the most of their reduced physical capacity and counteract
the natural deterioration of age. They respond to endurance training much the same as
do younger people. Doctors particularly should take this challenge more seriously.
People need to be better informed, and much can be done through the media. For
instance, many in the survey were mistaken in thinking that they were active and fit.
Moreover, many gave "not enough energy" and "too old" as reasons for not exercising.
Precautions also need publicity for example, warming up and cooling down gradually,
avoiding vigorous exercise during infections, and (for older people) having a medical
check before starting vigorous activity. Doctors are in a key position. Some general
practitioners have diplomas in sports medicine, and a few are setting up exercise
programmes. As the Royal College of Physicians says, however, all doctors should ask
about exercise when they see patients, especially during routine health checks, and
advise on suitable exercise and local facilities. Their frequent contact with women and
children provides a valuable opportunity. Excluding ischaemic heart disease and also
checking blood pressure before vigorous activity is started are important precautions.
But above all doctors could help to create a cultural change whereby the habit of
exercise becomes integral to daily life.
7. All of the following are mentioned in paragraph 1 as benefits of exercise EXCEPT
A. increase in the capacity to withstand strenuous activity.

B. significant decrease in the risk of osteoporosis.
C. reduction of the risk of heart disease.
D. weight control and decrease in levels of body fat.
8. According to paragraph 2, the recommendations of the report on the national fitness

survey included
A. long, vigorous aerobic sessions for all men, women and children.
B. no more than three, 20 minute exercise sessions per week.
C. avoiding any exercise that brought on hard breathing.
D. different levels of exercise intensity for different age groups
9. According to paragraph 3, one reason many people do not exercise
A. they are unaware of its importance.

B. difficulty in fitting it into their daily routine
C. they are unaware of its long-term health benefits.
D. they live too far from work to walk or cycle
10. Which one of the following is mentioned in paragraph 3 as a way in which

employers can help improve the physical fitness and health of their staff?
A. Making it mandatory for employees to exercise during lunch breaks

B. Providing encouragement and advice from staff within the organisation.
C. Hiring trained sports educators to counsel members of staff about exercise.
D. Setting an example, as individuals, by regularly exercising themselves.
11. According to paragraphs 4 and 5, older men and women need to remain physically
active and fit because
A. they need to counteract the risk of coronary disease.

B. fitness levels decrease rapidly over the age of 54.
C. they need to guard against poor health and inactivity.
D. exercise works against the physical effects of ageing.
12. Which one of the following is NOT mentioned in paragraph 6 as a precaution to be

taken when considering exercise?
A. The need to balance aerobic activity with stretching.

B. The need to warm up before and cool down after exercise.
C. The need to eliminate the risk of ischaemic heart disease before starting.
D. The need to exclude strenuous exercise from the routine during infection.
13. Which one of the following needs in relation to the improvement of national fitness
are NOT mentioned in the article?
A. The need for people to make exercise a regular daily habit.

B. The need to provide information on health and fitness to the community.
C. The need for doctors themselves to improve their own fitness levels.
D. The reed to consult a doctor before starting an exercise program.
14. According to the article, which one of the following is FALSE?
A. It is unsafe for people with high blood pressure to do regular moderate exercise.
B. Experts agree on the importance of both type and intensity of exercise.
C. Men are generally fitter and more active than women.
D. Cycling, though unsafe, is a beneficial form of exercise
Part C -Text 2
Employment records reveal the detail of asbestos danger
About a quarter of the people who worked in an asbestos mine in Western Australia
between 1963 and the closure of the pit in 1986 are already suffering from diseases
related to their exposure to the mineral, or do in the future. This is the estimate of
researchers who say that the mine's employment records have enabled them to carry
out one of the most thorough studies ever of the long-term health effects of exposure
to asbestos fibre. The team, based at the University of Western Australia and the Sir
Charles Gairdner Hospital in Perth, says that it is the only study in which a well defined
group of people has been exposed to a single form of asbestos over a specified period.
Of the 6502 men and 410 women who worked at the mine, almost 2000 have
developed or will develop cancer and other diseases related to asbestos. The
Asbestos Diseases Society of Australia, a group formed to help people exposed to
asbestos, claims that 300 former workers have already died of diseases that are
asbestos-related. The people, mostly migrant labourers from Europe, worked in an
asbestos mine and mill in Wittenoom, a town in the Hamersley Range, about 1600
kilometres north of Perth. Wittenoom, once the home for 4000 people, is now virtually
deserted. The state government cut essential services to the town last year. Blue
asbestos, or crocidolite, was mined there.
The researchers were able to determine how much asbestos the workers were
exposed to by making calculations based on readings of dust that were taken at
various times during the mine's operation. The most extensive exposure to asbestos
occurred in the mill where ore was ground down and the fibre extracted. The Australian
study was published last month in the Medical Journal of Australia. Other records of
exposure to blue asbestos such as those from South Africa have not been as useful to
researchers as the data from Wittenoom, says William Musk, from the University of
Western Australia.
Blue asbestos fibres are very thin, straight and small about 0.1 micrometres in
diameter. As a result, they are more likely to enter the lungs than other types of
asbestos fibres. They are also the least likely to adhere to and be intercepted by the
protective mucus in the airways. Scientists have associated the fibres mined at
Wittenoom with three types of disease: malignant mesothelioma, lung cancer and
asbestosis, a scarring of the lung. Most of the workers were at the mine for only short
periods months, rather than years The diseases may take up to 40 years to develop
The records until 2006 show 94 cases of mesothelioma, 141 lung cancers and 356
cases of asbestosis among the Wittenoom workers. In the general population,
mesothelioma, a cancer of the outer covering of the lung, is rare, occurring at the rate
of less than one per million people each year. The scientists say that exposure to
asbestos can account for about 40 per cent of the cases of lung cancer at Wittenoom;
the remainder were caused by the effects of smoking. Over the next 30 years, there
will be a sevenfold increase in the number of cases of mesothelioma, according to the
researchers estimates. There will be as many as 25 cases of the disease a year by the
year 2030.
The team predicts that between 1997 and 2040, a total of 692 new cases of
mesothelioma will occur. Most will be in the lung (pleural mesothelioma),but some will
be in the abdomen (peritoneal mesothelioma). Cases of lung cancer and asbestos
among the workers will reach a peak by about 2020, with a total of 183 and 482
respectively by the year 2040. The Asbestos Diseases Society claims that the problem
will not be confined to former workers About 6000 of the 14 000 wives and children of
workers at Wittenoom will also suffer from asbestos-related disease, according to the
society. "Forty-one people in their late 30s or 40s who were children at Wittenoom
have died of mesothelioma." according to Robert Vojkovic, the President of the society.
He obtained the statistics from death certificates. The university study only examined
the records of workers.
Last year, after a legal battle lasting 13 years, CSR, the mining company whose
subsidiary, Australian Blue Asbestos, operated the plant, agreed in an-out-of-court
settlement to pay compensation to former miners and residents of Wittenoom. By 5
December, 350 people and their families had received compensation totalling $42
million. The State Government Insurance Commission will share the costs of
compensation based on exposure to asbestos at Wittenoom after 1979. The payments,
part of the largest industrial settlement in Australian history, will range in size between
A$30,000 and A$600,000
However, Western Australia has another problem. The red gorges within the
Hamersley Range, including the Wittenoom Gorge, have become a tourist attraction.
The millions of asbestos tailings that still litter the area are regarded as a health
hazard, especially to children who might be tempted to play on the piles. Camping is
forbidden in the Wittenoom Gorge. The state government is considering burying the
tailings or putting them under the water. Both solutions will be expensive. The asbestos
society is trying to obtain funds from Lang Hancock, the mining magnate who opened
the mine in the late 1950s, and CSR, to help restore Wittenoom Gorge, which it says
could be made into a major tourist attraction. It also wants the town to be relocated
within the gorge.
15. Of all workers in the Western Australian mine, 25%

A) have died since 1986 of mine-related diseases.
B) have already got symptoms of mine-related diseases
C) may suffer from mine-related diseases in the future.
D) have developed mine-related diseases or may do so.
16. Which of the following is not unique to the West Australian study?
A) The mine kept records of all workers.

B) The effects of only one form of asbestos were studied
C) Data were collected during a clear period of time.
D) The group studied was well defined.'
17.The population of Wittenoom is now
A) around 4000 people.

B) extremely small.
C) around 1600 people
D) non-existent.
18. Which of the following is not typical of blue asbestos fibres?
A) The fibres are so small that they enter the lungs easily
B) The fibres easily adhere to protective mucus in the airways.
C) The fibres are usually not intercepted by mucus in the airways.
D) The fibres are less than a micrometre in diameter.
19. Of the three types of diseases associated with asbestos fibres at the Wittenoom
mines
A) mesothelioma is the most frequently occurring type.

B) asbestosis is the most frequently occurring type
C) asbestosis is the least frequently occurring type.
D) lung cancer is the least frequently occurring type.
20. The research team predicts that by the year 2040 there will be a total of 183 cases
of
A) asbestosis.
B ) pleural mesothelioma.
C) lung cancer.
D) peritoneal mesothelioma.
18. special nicotine receptors
19. cigarette-crushers
20. disadvantaged areas
1. C
2. A
3. A
4. A
5. B
6. A
7. D
8. D
9. B
10. B
11. D
12. A
13. C
14. B

15. D
16. A
17. B
18. B
19. B
20. C
21. D
22. A
.
Text B
Cigarette packaging representations
Text C
Effect of Smoking on the Lungs

What does smoking do to my lungs?
It paralyses and can destroy cilia, which line your upper airways and
protect you against infection. It destroys the alveoli, or air sacs, which
absorb oxygen and get rid of carbon dioxide. It destroys lung tissue,
making the lungs less able to function, and irritates the lungs which
creates phlegm and narrows the airways, making it harder to breathe.
How does that affect me?
It makes you short of breath, it makes you cough, it gives you chronic
bronchitis and repeated chest infections, it worsens your asthma and it
can give you lung cancer. That's apart from effects on your heart, fertility,
pregnancy and your children.
But most people who smoke don't get lung cancer.
No. Most people die of other things first, often because they smoked.
If I give up, will my lungs improve?
Yes. Cilia that are paralysed, but not destroyed, can recover. You will have less
asthma and fewer chest infections. The sooner you stop, the better your chances
of improved lung function.
Text D
Passive Smoking: Summary
 In Victoria, it is illegal to smoke in cars carrying children who are under 18
years of age.
 If a person who smokes can’t give up for their own health, perhaps the
health of their partner or children, or other members of their household,
will be a stronger motivation.
 Passive smoking increases the risk of respiratory illness in children, e.g.
asthma, bronchitis and pneumonia.
 People who have never smoked who live with people who do smoke are
at increased risk of a range of tobacco- related diseases, including lung
cancer, heart disease and stroke.
PART A -QUESTIONS
Questions 1-7
1. The effects of passive smoking?

2. The chances of a smoker getting lung cancer?
3. The benefits to the respiratory system of quitting smoking?
4. Ways to get help with quitting smoking?
5. The reduction in lung cancer risk if a smoker quits?
6. Recommended websites or phone numbers for smokers?
7. How smoking leads to particular symptoms?
Questions 8-14
8. How much of the lung cancer risk is avoided by being smoke-free for 10years?
9. What is the phone number for Quitline?
10. What is normally expelled by the alveoli in the lungs?
11. What effect can smoking have on asthma?
12. What type of cancer can be improved by quitting smoking?
13. Which two (2) cardiovascular diseases are associated with passive smoking?
14. In which state is it illegal to smoke in cars carrying children under 18?
Questions 15-20
Cigarette smoke damages the lungs by destroying the (15)__________ that absorb
oxygen.
Eventually, the destruction of lung tissue can render a smoker unable to
(16)__________ normally
Cigarette packets now feature depictions of its health effects, such as (17)________
The effect of previous smoking can be reversed in some ways, as the (18)__________
lining the upper airways can recover from damage.
Passive smoking increases the risk of (19)___________ in children.
The good news is that if people (20)__________ smoking before the age of 40, they
can significantly reduce their cancer risk.
Questions 1-6
1. The treatment guidelines below recommend that
A. All patients receive parathyroid hormone monitoring

B. All patients receive 6-weekly monitoring
C. All patients receive baseline blood tests
Table: Medical Monitoring Guidelines for High Risk Patients on Very Low Energy Diets
Assessment Baseline 6 weeks Completion of

Measures Intensive Phase
Electrolytes/Creatinine Yes If required Yes
Liver function tests Yes If required Yes
Fasting glucose Yes If required Yes
Cholesterol, Yes If required Yes

triglycerides and HDL
Uric acid Yes If required Yes
Full blood count Yes If required Yes
Iron studies Yes If required Yes
Vitamin D Yes If required Yes
Calcium and Yes If required Yes

Parathyroid hormone
(in patients on long
term anticonvulsants)
2. This notice is giving information about
A. The differential management of infants using glucose

B. How to check an infant's blood glucose level
C. The ideal glucose concentration in infants with clinical signs
Management of documented hypoglycemia in breast feeding
infants
A. Infant with no clinical signs

1. Continue breastfeeding (approximately every 1–2 hours) or feed 1–5 mL/kg of
expressed breastmilk or substitute nutrition.
2. Recheck blood glucose concentration before subsequent feedings until the value
is acceptable and stable.
3. Avoid forced feedings (see above).
4. If the glucose level remains low despite feedings, begin intravenous glucose therapy.
5. Breastfeeding may continue during intravenous glucose therapy.
6. Carefully document response to treatment.
B. Infant with clinical signs or plasma glucose levels < 20– 25mg/dL (<1–
1.4mmol/L)
1. Initiate intravenous 10% glucose solution with a minibolus.

2. Do not rely on oral or intragastric feeding to correct extreme or clinically
significant hypoglycemia.
3. The glucose concentration in infants who have had clinical signs should be
maintained at > 45 mg/dL (> 2.5 mmol/L).
4. Adjust intravenous rate by blood glucose concentration.
5. Encourage frequent breastfeeding
6. Monitor glucose concentrations before feedings while weaning off the
intravenous treatment until values stabilize off intravenous fluids.
7. Carefully document response to treatment.
3. This information sheet recommends
A. Regular auditing to ensure pain management program efficacy

B. Indicators to use in pain management program audits
C. At least 50% change as being clinically important
Audit of Pain Management Programs: Methods

It is recommended to conduct an audit of 20 or more sequential patients
undertaking a pain management program. Data collection should include
simple demographic and program data as well as data (pre and post
program with a minimum three month interval between data sets) regarding
changes in:
Healthcare utilisation.
Depression/anxiety/stress.
Pain self-efficacy.
Pain catastrophising.
Percentage change in individual patients has been suggested (rather than
average percentage change across the population audited) as average
percentage change is very sensitive to outliers and small audits may therefore
be significantly influenced by average percentage change.
The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials

(IMMPACT) recommends considering clinical important change (as distinct from
statistically significant change) on the following basis:
Minimal benefit: 10-20 per cent change.
Moderately important benefit: at least 30 per cent change.
Substantially important benefit: at least 50 per cent change
4. This regulatory statement instructs healthcare professionals to
A. Admit all patients to NSW public hospitals within 48 hours

B. Assess all patients in the Emergency Department for VTE
C. Initiate VTE prophylaxis for all patients identified to be at risk
MANDATORY REQUIREMENTS:
• All adult patients admitted to NSW public hospitals must be
assessed for the risk of VTE within 24 hours and regularly as
indicated / appropriate.
• All adult patients discharged home from the Emergency

Department who as a result of acute illness or injury, have
significantly reduced mobility relative to normal state, must be
assessed for risk of VTE.
• Patients identified at risk of VTE are to receive the
pharmacological and / or mechanical prophylaxis most
appropriate to that risk and their clinical condition.
• All health services must comply with the Prevention of VTE
Policy.
• All Public Health Organisations must have processes in
place in compliance with the actions summarised in the VTE
Prevention Framework (Appendix 4.1 of the attachment). A
VTE risk assessment must be completed for all admitted
adult patients and other patients identified at risk, and
decision support tools made available to guide prescription
of prophylaxis appropriate for the patient’s risk level.
5. The advice below can best be applied to a healthcare setting by
A. The inclusion of nurses in governance structures

B. Providing information to patients in their native language
C. Redesigning projects according to advisory group recommendations
Partnerships with consumers can come in many forms. Some examples include:
• working with consumers to check that the health information is easy

to understand.
• using communication strategies and decision support tools that
tailor messages to the consumer.
• including consumers in governance structures to ensure organisational
policies and processes meet the needs of consumers.
• involving consumers in critical friends’ groups to provide advice on safety
and quality projects.
• establishing consumer advisory groups to inform design or redesign projects.
6. The purpose of the document below is to
A. Prevent Medicare claims being paid for public patients

B. Specify when services can be billed to Medicare
C. Ensure healthcare professionals don't falsify claims
Guideline for substantiating claims for diagnostic

imaging and pathology services rendered to emergency
department patients of public hospitals
Public hospitals are funded under an arrangement with the Australian

Government to provide free public hospital services to eligible patients.
This includes diagnostic imaging and pathology services provided to
public hospital emergency department patients. A patient who presents
to a public hospital emergency department should be treated as a public
patient. If that patient is subsequently admitted they may elect to be
treated as a private patient for those admitted services.
For a Medicare claim to be paid for a patient in a public hospital, the

patient must be admitted as a private patient at the time the service
was rendered.
Where a service for a patient in a public hospital has been billed to
Medicare, the hospital or rendering practitioner may be asked to
substantiate these claims.
Documents you may use include:
• the form which the patient (or next of kin, carer or
guardian) - has signed indicating that the patient has
elected to be admitted as a private patient, and
• patient records - that show the patient was admitted

as a private patient at the time the service was
rendered
Part C -Text 1
Scope of Practice for Healthcare Professionals

A "scope of practice" refers to the procedures, actions, and processes
that a healthcare practitioner is allowed to undertake according to their
professional certification. The scope of practice is limited to that which is
legally permitted for a healthcare professional with a certain level of
education and experience, as well as their level of competency. Each
level of jurisdiction has their specific laws, policies and licensing bodies,
which define and regulate scope of practice. Different facilities, such as
hospitals, may have different policies with regards to the clinical
responsibility afforded to a healthcare professional.
There are two types of scope of practice. Core scope of practice refers to
the everyday expectations of a clinician in practice, within that particular unit.
These reflect the clinician's qualifications and training and are considered
to be "usual practice". Advanced scope of practice refers to additional
allowances or responsibilities, and usually specify particular
treatments/procedures or categories of treatments/procedures to be
included in the individual's scope of practice.
Three categories may be useful in identifying a healthcare professional's

scope of practice. The first is education and training – has the person
received formal or on-the-job training and have documentation to prove
this? The second relates to the state or federal government that oversees
the individual’s place of employment – does it allow the skill in question
and not explicitly disallow it? Finally, the particular institution of
employment is also relevant – does it also allow the skill in question and
not explicitly disallow it?
Some examples of how scope of practice differs are useful. All states
and provinces who recognise the licensing of registered respiratory
therapists (RRTs) allow them to carry out extracorporeal membrane
oxygenation (ECMO) support. However, some institutions do not allow this.
In this case, it is within the institution’s rights to refuse to allow RRTs
working there to perform ECMO. Therefore, RRTs working at these
institutions are not allowed to include ECMO as part of their scope of
practice.
Some environments require alterations to be made to a scope of

practice. For example, allied health professionals who work in a rural or
remote area have a broader scope of practice than those who work in
metropolitan areas. They may be required to undertake activities or
procedures that are outside the scope of practice generally accepted for
their profession. This allows them to better meet the needs of communities
in which they work.
Apart from geographical differences, certain significant events may also

result in alterations being made to the scope of practice. For example,
during the 2009 H1N1 influenza pandemic, a number of states expanded
the scope of practice for a number of healthcare professions in order to
increase the number of clinicians eligible to provide vaccinations. This
was a temporary measure that lasted for the duration of the emergency
and was legally permitted. Other states did not employ this measure,
primarily because the capacity of clinicians to vaccinate the public in
these areas was sufficient.
State governments annually review the scope of practice for routine (non-
emergency) activities to make sure they are meeting the population needs.
Changes to scope of practice must be considered with caution, as they can
affect people in both positive and negative ways. Changes may be seen
as a way to protect the public and give broader access to competent
healthcare professionals, but can also result in turf battles between two or
more different professions over the exclusive rights to perform an activity.
Considering this, healthcare professionals must understand their

professional and individual scope of practice. Some tasks, while they
are within the scope of practice for a profession, may not be permitted
under the scope of practice of an individual. This is often an issue for
allied health staff who move from rural or remote areas to metropolitan
areas, where their scope of practice is more limited. Conversely, allied
health staff who formerly worked in a metropolitan area may find
themselves without the skills or experience to meet their scope of practice in
a rural or remote area. In the team environment of the healthcare
system, it is key that each team member can clearly identify and
communicate their professional and individual scope of practice.
7. In the first paragraph, the meaning of the phrase "afforded to" is:
A. The clinical responsibility that is paid for by healthcare professionals.

B. The clinical responsibility that can be afforded by healthcare
professionals.
C. The clinical responsibility that is given to healthcare professionals.
D. The clinical responsibility that is acceptable to healthcare professionals.
8. In the second paragraph, core scope of practice refers to:
A. The clinician's expectations of what their work involves

B. The things that a member of the public can expect from the clinician.
C. The things that the unit can expect from the clinician
D. The qualifications and training of the clinician.
9. All of the following are categories that can be applied to identify scope of
practice except:
A. The formal or on-the-job training received by the healthcare professional

B. The state or federal government's allowance or non-allowance of an
activity.
C. The institution's allowance or non-allowance of an activity
D. A proven history of formal or on-the-job training.
10. The situation for paramedics is similar to that for registered respiratory
therapists because
A. They are both involved in emergency patient care.

B. They both have varying scopes of practice.
C. They can both perform a percutaneous cricothyrotomy.
D. They are both procedures used to help a patient breathe more effectively.
11. According to the fifth paragraph, the benefit of changes to scope of

practice is
A. The communities in which healthcare professionals work can have their

needs met more effectively.
B. The services provided by allied health professionals in rural or remote
areas can be better than those provided in metropolitan areas.
C. Allied health professionals can better serve rural or remote communities.
D. Healthcare professionals can rely more on their judgment when treating
patients, rather than being restricted by their scope of practice.
12. In the sixth paragraph, the author implies that
A. Some states and provinces were better equipped to prevent the spread of
H1N1 influenza in 2009 than others
B. Healthcare professionals should have their scope of practice extended
permanently to provide vaccinations in case of another influenza
pandemic.
C. There was a knee-jerk reaction by some states to contain the spread of
H1N1 influenza in 2009 by expanding their capacity to deliver
vaccinations.
D. In some states, healthcare professionals have been allowed to provide
vaccinations since 2009 to prevent the spread of pandemic influenza.
13. According to the seventh paragraph, the author's opinion on changes to
scope of practice is that:
A. Such changes are necessary to protect the public and provide access to a
broader range of competent healthcare professionals.
B. Such changes can be politically controversial and have an ambiguous
benefit
C. Such changes lead to conflict between two or more healthcare
professions over the exclusive rights to perform an activity
D. Such changes should be reviewed more frequently than they are
currently.
14. The main message of the article is:
A. Scope of practice varies within each profession, so healthcare

professionals should be informed of what their scope of practice is.
B. Scope of practice is dynamic and depends on geographical factors,
individual states or institutions, and significant events
C. Different healthcare professions have different scopes of practice
D. Each member of a healthcare team should be aware of their individual, as
well as professional, scope of practice.
Part C -Text 2
Advanced Dementia
Dementia is a significant cause of morbidity and mortality worldwide. In
2014, approximately 5 million people in the United States had a
diagnosis of Alzheimer's disease, with an estimated 14 million being
affected by 2050. Once diagnosed, patients can survive with the
condition for an average of 3 to 12 years. The majority of this time will
be spent in the most severe stages of the disease. As nursing homes are
the site of death in most cases, these are an important factor to consider
when studying Alzheimer's disease.
At the moment, no cure exists for dementia or the progression of its
disabling symptoms. The Global Deterioration Scale, which ranges from 1
to 7, is used to describe the level of disability in patients with dementia.
Stage 7 characterises advanced dementia: profound memory deficits, a
virtual absence of the ability to verbalise, inability to ambulate
independently or perform activities of daily living, and urinary and fecal
incontinence. These manifestations result in complications such as eating
problems, episodes of fever and pneumonia.
In order to provide an estimate of survival time for patients with dementia,

the Functional Assessment Staging Tool is commonly used. Although
impossible to quantify accurately in 100% of cases, this tool allows a
general prognosis to be made. This is important because a patient's
eligibility for the hospice benefit is assessed based on their projected
survival time as well as history of dementia- related complications. Some
clinicians prefer to use a risk score to predict survival, as this has
slightly better predictive ability. Many consider that the eligibility of
patients for nursing home care should be based on the desire for such
care, rather than prognosis.
The care of patients with advanced dementia revolves around advanced

care planning. This includes educating the patient's family about the
prognosis of the disease and its manifestations, counseling about proxy
decision making, and recording the patient's wishes regarding treatment
through an advanced care directive. Some observational studies have
shown that patients with advanced care directives have better palliative
care outcomes: reduced incidence of tube feeding, fewer hospitalisations
during the final stages, and greater likelihood of enrollment in a hospice.
Decisions about the care of patients should also reflect the goals of such
care. These goals should be agreed upon between the provider, the
primary carers, and ideally, the patient themselves. The goals of
treatment, and therefore the treatment decisions themselves, should be
aligned with the patient's wishes as far as possible. An example of how
treatment preferences may vary is whether the patient would like all
medical interventions deemed necessary, only certain medical
interventions, or comfort measures only. In 90% of proxies interviewed in
prospective studies, the latter was reported to be the primary goal of care.
Out of the most common complications of advanced dementia, eating

problems are the most prevalent. These may include oral dysphagia
("pocketing" of food in the cheek), pharyngeal dysphagia (inability to
swallow, leading to the risk of aspiration), inability to eat independently
and refusal. When eating problems occur, acute causes should always
be considered (e.g. dental pathology). The reversal of such causes
should be guided by the previously agreed goals of care. Chronic or
sustained eating problems are most often managed by hand feeding, tube
feeding, or encouragement of food intake through smaller meals, different
textures or high-calorie supplementation.
Infections are another common clinical problem in patients with advanced

dementia, most commonly relating to the urinary or respiratory tract. In
362 nursing home residents with advanced dementia, the Study of
Pathogen Resistance and Exposure to Antimicrobials in Dementia
(SPREAD) found that two thirds were diagnosed with suspected
infections within a 12 month period. Approximately 50% of patients with
advanced dementia are diagnosed with pneumonia in the last 2 weeks of
life, and such patients experience a high rate of death from this cause.
However, the use of antimicrobials to treat infections has been found to
increase length of survival but also the level of discomfort in patients
with advanced dementia. Therefore, such treatment may not necessarily
align with the patient's preferences or goals of care.
Improving the care of patients with advanced dementia is becoming an
increasingly recognised issue amongst healthcare providers. Studies of
the experiences of patients with advanced dementia have shown that
care which is focused on patient-centred goals and adherence to patient
preferences is most effective in improving outcomes. In order to achieve
this, providers need to be better equipped to engage patients and their
families in advanced care planning, reduce the use of invasive treatments
of limited benefit (such as tube feeding) and better address distressing
clinical symptoms.
15. The Global Deterioration Scale is most useful for providing healthcare
professionals with information about:
A. The patient's ability to recall memories, verbalise, ambulate independently,
attend to activities of daily living and control urine and fecal output.
B. A quantification of the patient's degree of disability.

C. The likelihood of dementia-related complications.
D. The patient's predicted survival time.
16. According to the third paragraph, the main reason for making a general
prognosis about survival time is:
A. To provide family members with some idea of the trajectory of the

disease.
B. To inform decisions that providers must make about treatment.
C. To determine eligibility for nursing home care.
D. To determine eligibility for the government subsidy of hospice care.
17. The best replacement for the word "proxy" in the fourth paragraph would
be:
A. substitute
B. additional
C. carer
D. treatment
18. In the fifth paragraph, the author's main argument is that:
A. Decisions about care should be guided by its goals, which most often
means comfort care rather than medical interventions.
B. Most patients with advanced dementia prefer comfort care to medical
interventions.
C. The goals of care should be agreed upon in consultation with the
provider, the family and the patient themselves.
D. Treatment preferences vary between individual patients with advanced
dementia
19. According to the sixth paragraph, eating problems in advanced dementia
may be caused by:
A. inappropriate eating practices.

B. recent dental procedures.
C. aspiration of food.
D. refusal to eat independently.
20. In the seventh paragraph, the author suggests that:
A. About 50% of people with advanced dementia will suffer from

pneumonia during the last 2 weeks of their life.
B. Infections in people with advanced dementia should not always be
treated.
C. Within a 12 month period, approximately two thirds of nursing home
residents with advanced dementia are suspected to have an infection.
14. Victoria

15. Alveoli
16.Breathe
17. lung cancer
18. Cilia
19. respiratory illnesses
20. Quit

1. C
2. A
3. B
4. C
5. B
6. A

7. C
8. B
9. A
10. B
11. C
12. A
13. B
14. A

15. B
16. D
17. A
18. A
19. A
20. B
21. D
22. B
Text B
Figure: Prevalence of long-term eye conditions, 2011–12
Text C
How Vision Impairment is defined.

Vision impairment is defined as a limitation of one or more functions of the
eye (or visual system).
The most common vision impairments affect:
• The sharpness or clarity of vision (visual acuity)
• The normal range of what you can see (visual fields)
• Colour
Legal blindness in Australia means that someone with vision impairment,

even with glasses or contact lenses, can see an object at 6 metres that
someone without vision impairment could see from 60 metres. This is
called 6/60 vision.
Normal vision is 6/6 vision (or 20/20 in imperial measures).
Text D
Speaking to a Visually Impaired Person

When speaking with a person who is blind or has low vision, be yourself and
act naturally.
You should also consider the following tips:
• Identify yourself - don't assume the person will recognise you by your
voice.
• Speak naturally and clearly. Loss of eyesight does not mean loss of
hearing.
• Continue to use body language. This will affect the tone of your voice
and give a lot of extra information to the person who is vision impaired.
• Use everyday language. Don't avoid words like "see or look or talking
about everyday activities such as watching TV or videos.
• Name the person when introducing yourself or when directing
conversation to them in a group situation.
• In a group situation, introduce the other people present.
• Never leave a conversation with a person without saying so.
• Use accurate and specific language when giving directions. For
example, "the door is on your left", rather than the door is over there".
• Relax and be yourself.
PART A -QUESTIONS
Questions 1-7
1. The definition of vision impairment?

2. How to address someone with visual impairment?
3. The prevalence of visual conditions?
4. Statistics regarding visual impairment globally?
5. The rates of eye conditions in males and females?
6. The language you should use when talking to a blind person?
7. The main causes of vision impairment globally?
Questions 8-14
spelled.
8. How many people in the world have low vision?

9. In which gender is vision impairment most common?
10. How should you act around a person who is visually impaired?
11. What should you do for a visually impaired person in a group situation?
12. What does 6/60 vision mean legally in Australia?
13. What is the definition of normal vision?
14. What is the main cause of moderate and severe vision impairment
globally?
Questions 15-20
Complete each of the sentences, 15- 20, with a word or short phrase from one of the texts.
Each answer may include words, number or both. Your answers should be correctly spelled
 In most cases, vision impairment results in reduced visual acuity,

reduced (15)_________, and/or reduced colour perception.
 When speaking to a visually impaired person, there is no need to
(16)_________ words such as "see" or "look".
 However, you should not assume the person will be able to
(17)________ by your voice.
 It is estimated that 80% of cases of visual impairment can be
(18)_______
 Most of the visually impaired people in the world live in (19)_______.
 In the 0-14 (20)__________, only around 10% of people are diagnosed
with visual impairment.
professionals .
Questions 1-6
1. The most likely outcome of imposing a national scheduling system is
A . Greater caution being used when patients take medication
B. A reduction in deaths related to deliberate medication
overdosing
C . Increased access to medically necessary drugs
Scheduling is a classification system that controls how

medicines and poisons are made available to the public.
Substances are grouped into Schedules according to the level
of regulatory control over their availability required to protect
public health and safety. Some of the Schedules are:
Schedule Pharmacy Medicine
2
Schedule Pharmacist Only Medicine

3
Schedule Prescription Only Medicine OR Prescription Animal Remedy

4
Schedule Caution
5
Schedule Poison
6
Schedule Controlled Drug

8
Schedule Prohibited Substance

9
Schedule Substances of such danger to health as to warrant prohibition of

10 sale, supply and use
2. The point being made below regarding spirometry technique is
A. It can only be performed by health professionals

B. The patient should be comfortable for the procedure
C. Patient effort is an important factor determining accuracy
Conventionally, a spirometer is a device used to measure timed expired

and inspired volumes, and from these we can calculate how effectively
and how quickly the lungs can be emptied and filled.
To measure forced vital capacity (maximum volume of air which can be

forcibly exhaled by a patient), carefully explain the procedure to the patient,
ensuring that he/she is sitting erect with feet firmly on the floor (the most
comfortable position, though standing gives a similar result in adults, but in
children the vital capacity is often greater in the standing position). Apply a
nose clip to the patient's nose (this is recommended but not essential) and
urge the patient to:
• breathe in fully (must be absolutely full).
• seal his/her lips around the mouthpiece.
• immediately blast air out as fast and as far as possible
until the lungs are completely empty.
• breathe in again as forcibly and fully as possible (if inspiratory
curve is required and the spirometer is able to measure
inspiration).
3. The best description of the CHA2DS2 -VASc score would be
A. A patient's history of cardiovascular pathology

B. A score of 9 points in total
C. The likelihood of suffering a stroke
In patients with non-valvular atrial fibrillation, the decision to start warfarin

should be based on the CHADS2, score. This assigns 1 point each for
congestive heart failure, hypertension, age 75 years and older, and diabetes
mellitus, and 2 points for previous ischaemic stroke or transient ischaemic
attack.
5
The CHA2DS2 -VASc score, introduced by the European Society of
Cardiology, provides a more comprehensive assessment of the risk factors
for stroke. It is better at identifying truly low-risk' patients with atrial fibrillation,
and is now preferred over CHADS2.
Score CHA2DS2-VASc Risk Criteria
1 point Congestive heart failure
1 point Hypertension
1 point Age 75 years
1 point Diabetes mellitus
2 points Stroke/transient ischemic attack/thromboembolism
1 point Vascular disease (prior myocardial infarction,

peripheral artery disease or aortic plaque)
1 point Age 65-74 years
1 point Sex category (i.e. female)
9 points Maximum score
4. In patients taking the medication described below
A. The risk of developing secondary leukemia is 1.6%

B. The risk of secondary leukemia outweighs the benefits
C. The risk of developing secondary leukemia increases with time
Secondary acute myelogenous leukemia (AML) has been reported in

multiple sclerosis and cancer patients treated with mitoxantrone. In a cohort
of mitoxantrone treated MS patients followed for varying periods of time, an
elevated leukemia risk of 0.25% (2/802) has been observed. Post marketing
cases of secondary AML have also been reported. In 1774 patients with
breast cancer who received NOVANTRONE concomitantly with other
cytotoxic agents and radiotherapy, the cumulative risk of developing
treatment-related AML, was estimated as 1.1% and 1.6% at 5 and 10 years,
respectively (see WARNINGS section). Secondary acute myelogenous
leukemia (AML) has been reported in cancer patients treated with
anthracyclines. NOVANTRONE is an anthracenedione, a related drug.
5. According to the directive, health professionals should have access to
A. Exposure management packs for addressing sharps injuries

B. New staff orientation and induction programs
C. Immediate and extended management of sharps injuries
Sharps Injury Post-Exposure Management Directive

Health care workers who incur a sharps injury require expedient, timely,
considerate and knowledgeable post exposure management. The basis of
such management must be in accordance with PD2005_311 (HIV, Hepatitis B
and Hepatitis C - Management of Health Care Workers Potentially Exposed),
the key elements of which are:
• rapid assessment of an exposed HCW to ensure
the timely administration of post exposure
prophylaxis (PEP) when appropriate;
• availability of assessment and management over a 24

hour period; and
• the process for reporting and post exposure management being
made known to new staff during orientation and induction
programs.
Exposure management packs should be developed and made ready

for distribution to healthcare workers and source patients in the event
of a sharps injury.
Staff nominated to manage exposed HCWs should receive
specific training in BBV disease processes and counselling.
6. The management of hyperglycemia should be
A. More aggressive in patients diagnosed at a younger age

B. More aggressive in patients with vascular symptoms
C. More aggressive in patients with potentially modifiable features
Part C -Text 1
Progressive Muscular Atrophy

Progressive muscular atrophy (PMA), also known as Duchenne-Aran
muscular atrophy and by various other names, is a rare subtype of motor
neuron disease (MND) that affects only the lower motor neurons. PMA is
thought to account for around 4% of all MND cases. This contrasts with
amyotrophic lateral sclerosis (ALS), the most common form of MND, which
affects both the upper and lower motor neurons, or primary lateral
sclerosis, another rare MND variant, which affects only the upper motor
neurons. The distinction is important because PMA is associated with a
better prognosis than classic ALS.
Due to lower motor neuron degeneration, symptoms of PMA include

atrophy, fasciculations and muscle weakness. Atrophy is the partial or
complete wasting away of part of the body. A fasciculation, or muscle
twitch, is a small, involuntary muscle contraction and relaxation which
may be visible under the skin. Some patients have symptoms only in the
arms or legs (or in some cases, just one of either). These cases are
referred to as "Flail Arm" or "Flail Leg" and are associated with a better
prognosis.
PMA is a diagnosis of exclusion, there is no specific test which can

conclusively establish whether a patient has the condition. Instead, several
other possibilities must be ruled out, such as multifocal motor
neuropathy or spinal muscular atrophy. Tests used in the diagnostic
process include MRI, clinical examination, and EMG. EMG tests in patients
who do have PMA usually show denervation (neuron death) in most
affected body parts, and in some unaffected parts, too.
The importance of correctly recognizing progressive muscular atrophy as

opposed to ALS is important for several reasons. Firstly, the prognosis is a
little better. A recent study found the 5-year survival rate in PMA to be 33%
(vs. 20% in ALS) and the 10-year survival rate to be 12% (vs. 6% in
ALS). Secondly, patients with PMA do not suffer from the cognitive change
identified in certain groups of patients with MND. Thirdly, because PMA
patients do not have UMN signs, they usually do not meet the "World
Federation of Neurology El Escorial Research Criteria" for “Definite” or
“Probable” ALS and so are ineligible to participate in most clinical
research trials such as drugs trials or brain scans. Lastly, because of its
rarity (even compared to ALS) and confusion about the condition, some
insurance policies or local healthcare policies may not recognize PMA as
being the life-changing illness that it is.
An initial diagnosis of PMA could turn out to be slowly progressive ALS

many years later, sometimes even decades after the initial diagnosis. The
occurrence of upper motor neuron symptoms such as brisk reflexes,
spasticity, or a Babinski sign would indicate a progression to ALS. The
correct diagnosis is sometimes made on autopsy.
Since its initial description in 1850, there has been debate in the
scientific literature over whether PMA is a distinct disease with its own
characteristics, or if lies somewhere on a spectrum with ALS, PLS, and
PBP. Jean-Martin Charcot, who first described ALS in 1870, felt that PMA
was a separate condition, with degeneration of the lower motor neurons
the most important lesion. He pointed out that in ALS it was the upper
motor neuron degeneration that was primary, with lower motor neuron
degeneration being secondary. Throughout the course of the late 19th
century, other conditions were discovered which had previously been
thought to be PMA, such as pseudo-hypertrophic paralysis, hereditary
muscular atrophy and progressive myopathy.
The neurologists Joseph Jules Dejerine and William Richard Gowers were
among those who felt that PMA was part of a spectrum of "motor
neurone disease" which included ALS, PMA, and PBP, in part because
it was almost impossible to distinguish the conditions at autopsy. Other
researchers have suggested that PMA is just ALS in an earlier stage of
progression, because although the upper motor neurons appear
unaffected on clinical examination there are in fact detectable pathological
signs of upper motor neuron damage on autopsy. In favour of considering
PMA a separate disease, some patients with PMA live for decades after
diagnosis, which would be unusual in typical ALS.
7. According to the first paragraph, one of the unique features of

progressive muscular atrophy is:
A. It affects only 4% of the population.
B. It has a better prognosis than amyotrophic lateral sclerosis.
C. It is a rare subtype of motor neuron disease.
D. It affects only the lower motor neurons.
8. Lower motor neuron degeneration can lead to:
A. Wasting away of the patient’s arms and legs.

B. Voluntary muscle contraction and relaxation which may be visible
under the skin.
C. Flail arm or leg, which indicates an inferior prognosis.
D. Reduced muscle tone.
9. According to the third paragraph, which of the following is necessary to
diagnose PMA?
A. Proof of denervation in affected body parts.

B. Clinical examination, MRI and EMG tests.
C. Exclusion of multifocal motor neuropathy and spinal muscular atrophy.
10. According to the fourth paragraph, why might some insurance companies
not recognise PMA as a life-changing illness?
A. It is very rare and poorly understood, even compared to ALS.

B. The 5-year and 10-year survival rates are better than for ALS.
C. PMA patients do not experience UMN signs or cognitive change.
D. PMA patients are ineligible to participate in many research studies.
11. All of the following can indicate progression to ALS except:
A. Babinski sign
B. Reduced reflexes
C. Spasticity
D. Upper motor neuron symptoms
12. According to Jean-Martin Charcot:
A. PMA is a result of progressive, secondary ALS.
B. Upper motor neuron lesions are the primary feature of ALS.
C. Several conditions previously thought to be PMA are, in fact, separate
disorders.
D. ALS was first described in 1870.
13. The tone of the author in the last paragraph can best be described as:
A. Critical.
B. Analytical.
C. Speculative.
D. Supportive.
14. The best alternative heading for this article would be:
A. Manifestations of different motor neuron diseases.

B. The history of progressive muscular atrophy.
C. Challenges to diagnosing progressive muscular atrophy.
D. The differences between PMA and ALS.
Part C -Text 2
Cross-cultural Competence
Cross-cultural competence refers to the knowledge, skills, and
affect/motivation that enable individuals to adapt effectively in cross-
cultural environments. Cross-cultural competence is defined here as
an individual capability that contributes to intercultural effectiveness
regardless of the intersection of cultures. Although some aspects of
cognition, behavior, or affect may be particularly relevant in a specific
country or region, evidence suggests that a core set of competencies
enables adaptation to any culture (Hammer, 1987).
Cross-cultural competence is not an end in itself, but is a set of
variables that contribute to intercultural effectiveness. Whereas
previous models have tended to emphasize subjective outcomes, by
focusing primarily on adjustment, outcomes of interest here include
both subjective and objective outcomes. Objective outcomes, such as
job performance, have been addressed in previous research, but to a
lesser degree than the subjective outcomes.
Research indicates that the outcomes are linked, with personal and
interpersonal adjustment linked to work adjustment, which has in turn
been linked with job performance (Shay & Baack, 2006). However,
these relationships are small, and some research has demonstrated
that subjective outcomes can diverge from objective outcomes
(Kealey, 1989), with expatriates sometimes showing relatively poor
adjustment but high effectiveness in their organizational role.
The basic requirements for cross-cultural competence are empathy,

an understanding of other people's behaviors and ways of thinking, and
the ability to express one's own way of thinking. It is a balance,
situatively adapted, among four parts: knowledge (about other cultures
and other people's behaviors), empathy (understanding the feelings and
needs of other people), self-confidence (knowledge of one's own
desires, strengths, weaknesses, and emotional stability) and cultural
identity (knowledge of one's own culture).
In an attempt to offer solutions for developing cross-cultural

competence, Diversity Training University International (DTUI) isolated
four cognitive components: (a) Awareness, (b) Attitude, (c)
Knowledge, and (d) Skills. Awareness is consciousness of one's
personal reactions to people who are different. DTUI added the attitude
component in order to emphasize the difference between training that
increases awareness of cultural bias and beliefs in general and training
that has participants carefully examine their own beliefs and values
about cultural differences.
Social science research indicates that our values and beliefs about
equality may be inconsistent with our behaviors, and we ironically
may be unaware of it. Social psychologist Patricia Devine and her
colleagues, for example, showed in their research that many people
who score low on a prejudice test tend to do things in cross cultural
encounters that exemplify prejudice (e.g. using outdated labels such as
"illegal aliens" or "colored".). This makes the Knowledge component an
important part of cultural competence development. The Skills
component focuses on practicing cross-cultural competence to perfection.
One of these skills is communication - the fundamental tool by which
people interact in organizations. This includes gestures and other non-
verbal communication that tend to vary from culture to culture.
Notice that the set of four components of our cross-cultural

competence definition—awareness, attitude, knowledge, and skills—
represents the key features of each of the popular definitions. The
utility of the definition goes beyond the simple integration of previous
definitions, however. It is the diagnostic and intervention development
benefits that make the approach most appealing.
Regardless of whether our attitude towards cultural differences

matches our behaviors, we can all benefit by improving our cross-
cultural effectiveness. One common goal of diversity professionals, such
as Dr. Hicks from URI, is to create inclusive systems that allow
members to work at maximum productivity levels. This is important,
because cross-cultural competence is becoming increasingly
necessary for work, home, community social lives.

15. According to the second paragraph, the goal of the individual
capability described in the first paragraph is:
A. Cross-cultural competence.
B. Subjective and objective outcomes.
C. Intercultural effectiveness.
D. Improved job performance.
16. An example of the linked outcomes of cross-cultural competence is:

A. Interpersonal adjustment and job performance.
B. Personal adjustment and high organisational effectiveness.
C. Personal adjustment and interpersonal adjustment.
17. In the fourth paragraph, the author argues that cross-cultural

competence is a balance between…
A. Situative adaptation, knowledge, empathy, self-confidence and
cultural identity.
B. Empathy, an understanding of other people's behaviors and ways of
thinking, and the ability to express one's own way of thinking.
C. Having a cultural identity, understanding others, self-confidence and
adequate knowledge.
D. Empathy, an understanding of others, self-expression and good
balance.
18. According to the sixth paragraph:
A. People who score low on prejudice tests usually display prejudice in

cross-cultural situations.
B. We are often unaware when our behaviour is at odds with our
values and beliefs about equality.
C. The Skills component is a fundamental tool by which people
interact in organisations.
D. Non-verbal communication stays relatively consistent from
culture to culture.
19. In the sixth paragraph, the word “exemplify” could best be replaced
with:
A. Demonstrate.
B. Make an example of.
C. Amplify.
D. Exempt.
20. In the seventh paragraph, the author presents the opinion that:
A. The four components of cross-cultural competence are all represented

across its different definitions.
B. The current definition was developed by integrating previous
definitions.
C. The current definition is more useful than previous definitions.
D. Diagnostic and interventional benefits make cross-cultural
competence most appealing.
21. According to the last paragraph:
A. Diversity professionals are aiming at creating more inclusive

systems at work.
B. Diversity professionals are investigating ways to improve our cross-
cultural competence in our work, home and community life.
C. If attitude towards cultural differences matches our behaviours, we
are able to more successfully improve our cross-cultural
effectiveness.
D. Cross-cultural competence isn’t as important now as it was in the past.
22. Overall, the author argues that:
A. Approaching cross-cultural competence as a balance between four

parts is the best way to define it.
B. Cross-cultural competence, defined as an individual capability, is
becoming more important in our daily interactions.
C. Cross-cultural competence is a multi-factorial approach to
improving work performance.
D. Communication is a key part of cross-cultural effectiveness.
END OF READING TEST, THIS BOOKLET WILL BE COLLECTED

7. D
8. A
9. B
10. A
11. B
12. B
13. B
14. C

15. C
16. A
17. C
18. B
19. A
20. C
21. A
22. B
Text B
Diphtheria notification rate and vaccine use, Australia,
1917–2010
Text C
Influenza vaccination in children

Children can begin to be immunised against the flu from six months of
age. Children aged eight years and under require two doses, at least
four weeks apart in the first year they receive the vaccine. One dose of
influenza vaccine is required for subsequent years and for children
aged nine years and over.
All vaccines currently available in Australia must pass stringent safety

testing before being approved for use by the Therapeutic Goods
Administration (TGA).
Specific brands of flu vaccine are registered for use in children. In 2016,
two age-specific flu vaccines will be available – one for children under
three years of age, and another for people aged three years and over:
 FluQuadri Junior for children under three years of age.

 Fluarix Tetra for people aged three years and older.
Text D
NSW CHILDHOOD IMMUNISATION SCHEDULE
PART A -QUESTIONS
Questions 1-7
1. Past rates of diphtheria?
2. What vaccines are given to children in New South Wales?
3. The mechanism of action of vaccines?
4. How vaccines affect the immune system?
5. The introduction of the diphtheria vaccine?
6. How children are vaccinated against the flu?
7. Which diseases are targeted by vaccines?
Questions 8-14
spelled.
8. What is the first vaccine given to a child born in New South Wales?
9. What effect do vaccines have on a child's natural immunity?
10. When was the diphtheria vaccination first used in Australia?
11. Who is FluQuadri Junior given to?
12. How many doses of the flu vaccine are given to children under eight?
13. At what age are children first vaccinated against Meningococcal C?
14. What do vaccines train a baby's immune system to do to bacteria and
viruses?
Questions 15-20
correctly spelled
 In NSW, children are immunised against diseases according to the

(15)_________ released by NSW Health.
 For some children, the last recommended vaccine protects them
against measles,(16)___________ and rubella.
 Vaccines take advantage of the way that a baby's immune system is
designed to experience (17)_________ to new pathogens.
 Children who are over or under (18)__________ receive different
brands of the influenza vaccine.
 Vaccines train the immune system a bit like (19)________ muscles.
 If a baby receives all the vaccines in the schedule simultaneously, a
(20)_________ of its immune cells would be occupied.
professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best
Questions 1-6
1. The main message to workers in the notice below is
A. Workers should be proactive and responsible

B. Workers should notify people whose actions are disagreeable
C. Workers should prepare detailed reports for managers
Workplace Bullying: Roles and Responsibilities of Workers
• Recognise their individual role in developing and maintaining

harmonious workplace relations and promoting a positive and
cooperative workplace culture. Take responsibility for their own
actions in the workplace and, where the actions of others are
disagreeable to them, attempt to settle matters directly with the
other person(s) where appropriate in a respectful and
collaborative manner that reflects the CORE values.
• Raise matters of concern at an early stage and actively participate
in the bullying complaint management process.
• Provide managers with specific information regarding perceived bullying
and be prepared to have their complaint made known to the person they
are making the complaint about, to allow for fair management of the
complaint.
2. The flow chart below would most likely be followed if
A. The patient has symptoms of autonomic dysreflexia
B. The patient is symptomatic with a BP 25mmHg above normal
C. The patient experiences symptoms outside of the hospital setting
3. According to the text, what should clinicians do when prescribing
antibiotics?
A. Discuss the side effects of antibiotics with patients and carers

B. Discuss the antibiotic regime in detail with patients and carers
C. Discuss the purpose of antibiotics with patients and carers
Antimicrobial Stewardship Quality Statement – Taking

antibiotics as prescribed
When a patient is prescribed antibiotics, information about when,

how and for how long to take them, as well as potential side
effects and a review plan, is discussed with the patient and/or
their carer. What the quality statement means:
For patients. If you are prescribed antibiotics, your doctor or nurse

discusses with you and/or your carer about when and how to take
your antibiotics, how long to take them and any potential side
effects. You may need to be seen again to review your progress.
For clinicians. Discuss with the patient and/or their carer the importance
of taking antibiotics as prescribed, how long to take them, any potential
side effects and whether the treatment will need to be reviewed.
For health services. Ensure systems are in place so that clinicians

discuss with patients and/or their carers the need to take antibiotics
as prescribed, how long to take them, any potential side effects
and whether their treatment requires review.
4. The purpose of effective record keeping is
A. To protect the privacy of patient medical records
B. To enhance staff satisfaction within medical practices
C. To maximise the legal accountability of medical practices
Effective record keeping benefits all medical practices. It improves the

efficient day-to-day operation of your practice, helps record and maintain
your patient information and enables transparent reporting.
There are other benefits related to effective record keeping. These include
maintaining the security of confidential clinical files, supporting staff to do
their work more effectively, improving staff retention, and enhanced
business continuity.
Having adequate administrative records will significantly assist if you are

ever asked to participate in an Australian Taxation audit, health provider
compliance audit or for accreditation purposes. It is important to
understand that record keeping obligations differ depending on the
purpose of the records, but their objective is ultimately to maintain the
transparency and integrity that is required of medical practices by
national legislation.
5. For the treatment of warfarin overdose
A. PCC can be used together with fresh frozen plasma

B. PCC can be used with or without vitamin K1
C. FFP does not require Prothrombinex to be added
Warfarin Reversal: Practice Points

For patients with elevated INR (4.5–10.0), no bleeding and no high risk of
bleeding, withholding warfarin with careful subsequent monitoring seems
safe.
Vitamin K1 can be given to reverse the anticoagulant effect of warfarin.
When oral vitamin K1 is used for this purpose, the injectable formulation,
which can be given orally or intravenously, is preferred.
For immediate reversal, prothrombin complex concentrates (PCC) are

preferred over fresh frozen plasma (FFP). Prothrombinex-VF is the only
PCC routinely used for warfarin reversal in Australia and New Zealand.
It contains factors II, IX, X and low levels of factor VII. FFP is not
routinely needed in combination with Prothrombinex-VF. FFP can be
used when Prothrombinex-VF is unavailable. Vitamin K1 is essential
for sustaining the reversal achieved by PCC or FFP.
6. Reducing health care workers' exposure to radiation should mainly

involve
A. Designing work spaces and updating equipment as needed

B. Reducing the exposure time required for a dental X-ray
C. Wearing lead gloves and aprons whenever X-rays are taken
Exposure to ionizing radiation when taking dental X-rays: Control

Strategies
Engineering:
Workplace design to provide distance between worker and source.
Appropriate shielding materials (permanent where possible). Interlock
systems. Equipment designed to minimize scatter. Positioning devices for
patients. Audible signals on machines when exposure is ended.
Replacement of older dental X-ray equipment with newer equipment with
additional safety features.
Administrative:
Worker education. Safe work procedures reduce exposure time
(procedures requiring fewer workers in area, etc.). Scheduling.
Radiation safety program. Exposure monitoring. PPE: Lead gloves,
aprons, etc. as required.
Part C -Text 1
Falls in the Elderly
Falls in older adults are a significant cause of morbidity, mortality and

preventable injury. Nearly one-third of older persons fall each year, and half
of them fall more than once. Due to underlying osteoporosis and reduced
mobility and reflexes, falls often result in hip and other fractures, head
injuries, or even death. In around 75% of hip fractures, recovery is
incomplete and overall health deteriorates. In older women, falls can be
particularly troublesome because osteoporosis (weakening of the bones) is a
widespread issue, increasing the chance of a fracture following a fall. In
Australia, injuries caused by falls are the most common cause of death in
people over 75.
The cause of falling in old age is often multifactorial, and therefore, it requires
a multidisciplinary approach to treat any injuries sustained and to prevent
future falls. Falls include dropping from a standing position, or from exposed
positions such as those on ladders or stepladders. The severity of injury
is generally related to the height of the fall. The state of the ground surface
onto which the victim falls is also important, with harder ones causing more
severe injury.
A fall occurs when a person's centre of mass goes outside of the base of
support. Most research on postural instability has focused on the
anterior/posterior directions, due to the structure of the legs and the
frequency of falls in those directions. However, Maki, Holliday, & Topper
(1994) have stated that sway in the medial/lateral directions can be just as
important: “Results show strong evidence linking deficits in…the control of
m–l stability with an increased risk of falling”. Hence, the consequences of
postural instability have not yet been fully explored.
Vision is integral to the maintenance of a stable posture. Visual acuity,

adaptation to the dark, peripheral vision, contrast sensitivity, and
accommodation, all of which are related to stability, may be affected by
age- related changes. For example, age-related deterioration in peripheral
vision may affect an older person’s ability to use information in the
peripheral visual field for reference. Such narrowing of the visual field also
means that the part of the visual field that is most sensitive to movement is lost.
As a result, postural control may be compromised.
A faller may live comfortably with many risk factors for falling and only
have problems when another factor appears. As such, management is often
tailored to treating the factor that caused the fall, rather than all of the risk
factors a patient has for falling. Falls can be prevented by ensuring that
carpets are tacked down, that objects like electric cords are not in one's path,
that hearing and vision are optimized, dizziness is minimized, alcohol intake
is moderated and that shoes have low heels or rubber soles.
Multifactorial prevention involves addressing both intrinsic and extrinsic

factors. Although further research is needed, preventative measures with
the greatest likelihood of a positive effect include strength and balance
training, home risk assessment, withdrawing psychotropic medication, cardiac
pacing for those with carotid sinus hypersensitivity, and T'ai chi. T'ai chi
exercises have been shown to provide 47% reduction in falls in some studies
but it does not improve measures of postural stability. Assistive technology
can also be applied, although it is mostly reactive in case of a fall.
General practitioners are well placed to identify those at risk of falls and
implement prevention strategies utilising other healthcare professionals as
required. An Enhanced Primary Care plan may facilitate implementing
falls prevention strategies. High risk patients with recurrent, unexplained or
injurious falls should especially be considered for specialist referral and
multidisciplinary intervention. The general practitioner’s role in educating
and supporting patient behaviour change is critical to the uptake of falls
prevention recommendations.
7. In the first paragraph, the author is arguing that
A. Falls are an important public health issue.

B. Fractures are a significant cause of death and disability.
C. Women are particularly vulnerable to fractures.
D. Osteoporosis is a widespread problem.
8. In the second paragraph, “ones” refers to
A. Falls.
B. People.
C. Surfaces.
D. Ladders.
9. According to the third paragraph, the authors opinion on the research is

that:
A. It has mostly focused on anterior/posterior stability.

B. Studies so far have had inadequate scope.
C. There is increasing evidence on stability deficits.
D. Most of it has been poorly conducted.
10. An appropriate heading for the fourth paragraph would be:
A. Vision contributes in various ways to postural stability.

B. The central visual field is an important reference.
C. The mechanisms of visual function.
D. Vision is affected by age-related changes.
11. The word “moderated” in the fifth paragraph could best be replaced with:
A. Monitored.
B. Observed.
C. Controlled.
D. Minimised.
12. What is the author’s view on assistive technology in the sixth paragraph?
A. It is a viable option.
B. It improves reactions.
C. It mainly helps after the fall.
13. According to the last paragraph, the main role of general practitioners in falls
prevention is:
A. Involving other healthcare workers in the patient’s care.

B. Providing referrals to specialists and multidisciplinary teams.
C. Supporting patients through education and behaviour change.
D. Providing at-risk patients with an Enhanced Primary Care Plan.
14. Which of the following would be an appropriate heading for the last
paragraph?
A. The role of the general practitioner in falls prevention.

B. A multidisciplinary approach to falls prevention.
C. The implementation of falls prevention strategies.
D. A holistic approach to high-risk patients.
Part C -Text 2
Physical Inactivity and Heart Disease
Coronary heart disease (CHD) is the most common form of heart disease
in Australia, affecting around 3% of the population. Its two key manifestations
are myocardial infarction and angina. In 2012, CHD was the leading cause of
death in Australia, responsible for 14% of all deaths. Whilst death rates from
CHD are declining, mainly due to reduction in risk factors such as smoking,
high cholesterol and high blood pressure, and improvements in treatment,
CHD still places a significant burden on the Australian healthcare system. It
is estimated that in 2008-09, CHD cost the nation $2.03 billion, including
$1.52 billion in hospital-related costs.
A lack of physical activity has been identified as the fourth leading risk factor
for global mortality, and the principal cause of approximately 30% of the
coronary heart disease burden. Physical inactivity is defined as not meeting
the minimum guidelines of at least 150 minutes of moderate intensity exercise
per week. This characterizes between 60-70% of the Australian population.
However, levels of activity appear to be growing. Regular, moderate to
vigorous physical activity is being widely promoted as a measure for
preventing and managing CHD. It is important to note that a lack of
physical activity is not the same as being sedentary. Many Australians
may meet the minimum guidelines for being physically active, but still spend
excessive amounts of time being sedentary (i.e. sitting). Sedentary behaviour
has been found to contribute to all-cause premature mortality and
cardiovascular disease mortality independently of physical activity levels.
Several studies have found that increased sedentary behavior, measured

through TV viewing time, is associated with an increased risk of type 2
diabetes, acute coronary syndrome, metabolic syndrome and abnormal
glucose tolerance. One proposed mechanism for this is metabolic
dysfunction, characterised by increased plasma triglycerides, decreased
HDL-cholesterol and reduced insulin sensitivity. This has been attributed to
reduced activity of lipoprotein lipase (LPL), an enzyme that facilitates the
uptake of free fatty acids into skeletal muscle and adipose tissue. Reduced
LPL activity has been noted in response to sedentary behaviour. In addition,
sedentary behaviour may affect carbohydrate metabolism through decreased
muscle glucose transporter protein concentration and subsequent glucose
intolerance.
Although the beneficial effect of exercise in the prevention of CHD is

well established, only about 35% of this effect can be attributed to improved
lipid profiles and cholesterol levels, increased insulin sensitivity and blood
pressure control. This means that for about 65% of the effect, the mechanism
by which exercise produces cardiac benefits is unknown.
Several mechanisms for the benefit of exercise have been proposed. Thijssen
et al found that exercise has a direct “vascular conditioning effect” by
stimulating enlargement of arterioles and improvements in endothelial function.
Regular exercise also produces hemodynamic stimuli in vasculature, such as
increased pulse pressure and shear stress. This may enhance vasodilatory
responses to increased cardiac output and reduce ischemia-reperfusion injury
associated with brief periods of ischemia. Also, exercise stimulates
development of collateral vasculature in the heart, increasing perfusion of
the myocardium. Some studies have also shown that exercise may reduce
the levels of circulating pro- inflammatory cytokines and increase
expression of antioxidant and anti- inflammatory mediators in endothelial
cells. This may directly inhibit the development of atherosclerosis and
associated CHD.
A point commonly agreed upon is that the intensity and duration of exercise
are key determinants of whether or not it has a cardio-protective effect. The
dose- response relationship between physical activity and risk of CHD was
quantified in a recent meta-analysis, which found that individuals who met
the minimum US physical activity guidelines for health (150 minutes of
moderate intensity exercise per week) had a 14% lower risk of CHD
compared to those with no leisure-time physical activity. Those who met
the advanced guidelines (300 minutes per week) had a 20% lower risk of
CHD. The effects of physical activity were found to be more beneficial in
women than men.
The beneficial effects of moderate exercise for the prevention of CHD

are strongly supported by the literature. In addition, the minimisation of
sedentary behaviour is an important, independent factor associated with a
reduction in CHD risk. The evidence supporting physical activity is of great
clinical significance to doctors, who should strongly encourage their patients
to follow the Australian government guidelines with regards to minimum
levels of weekly
physical activity, and reduce time spent in sedentary behaviour, as
important health maintenance measures.
15. According to the first paragraph, what is the main impact of CHD?
A. CHD leads to high death rates in the community.

B. CHD leads to high cholesterol and high blood pressure.
C. CHD leads to adverse health in only a minority of people.
D. CHD leads to billions of dollars of associated costs.
16. In the second paragraph, “this” refers to:
A. Physical inactivity.
B. 60-70% of the Australian population.
C. 150 minutes of moderate intensity exercise per week.
D. Levels of activity.
17. Regarding physical activity and sedentary behaviour:
A. The benefits of the former can be offset by the latter.

B. Both are detrimental to health in similar ways.
C. We do not enough of the former and too much of the latter.
D. Increased physical activity can compensate for being sedentary.
18. The main mechanisms for the benefits of exercise for coronary health:
A. Are due to improved lipid profile and cholesterol levels.

B. Are due to increased insulin sensitivity.
C. Are due to better control of blood pressure.
D. Are mostly unknown.
19. The word “collateral” in the fifth paragraph could best be replaced with:
A. Alternate.
B. Corollary.
C. Secondary.
D. Large.
20. The best heading for the sixth paragraph is:
A. Exercise may not always be beneficial to health.

B. The relationship between physical activity and heart health.
C. How to maximise the cardio-protective effect of exercise.
D. Exercise reduces the risk of CHD.
21. The beneficial effects of moderate physical activity:
A. Will reduce the risk of CHD if they meet the minimum guidelines.
16. Mumps
17. Exposure
18. Three years (of age)
19. Exercise strengthens
20. Small fraction

1. A
2. B
3. B
4. C
5. A
6. A

7. A
8. C
9. B
10. A
11. C
12. C
13. C
14. A

15. D
16. A
17. A
18. D
19. C
20. C
21. B
22. C
Reading
Part-C
l&jl:ll
Paragraph 1
Australians are living longer and so face increasing levels of visual impairment. When we look at the problem
of visual impairment and the elderly, there are three main issues. First, most impaired people retire with
relatively "normal" eyesight, with no more than presbyopia, which is common in most people over 45 years
of age. Second, those with visual impairment do have eye disease and are not merely suffering from "old
age". Third, almost all the major ocular disorders affecting the older population, such as cataract, glaucoma
and age-related macular degeneration (AMD), are progressive and if untreated will cause visual impairment
and eventual blindness.
Paragraph 2
Cataract accounts for nearly half of all blindness and remains the most prevalent cause of blindness
worldwide. In Australia, we do not know how prevalent cataract is, but it was estimated in 1979 to affect the
vision of 43 persons per thousand over the age of 64 years. Although some risk factors for cataract have
been identified, such as ultraviolet radiation, cigarette smoking and alcohol consumption, there is no proven
means of preventing the development of most age-related or senile cataract. However cataract blindness
can be delayed or cured if diagnosis is early and therapy, including surgery, is accessible.
Paragraph 3
AMD is the leading cause of new cases of blindness in those over 65. In the United States, it affects
8-11% of those aged 65-7 4, and 20% of those over 75 years. In Australia, the prevalence of AMD is
presently unknown but could be similar to that in the USA. Unlike cataract, the treatment possibilities for
AMD are limited. Glaucoma is the third major cause of vision loss in the elderly. This insidious disease is often
undetected until optic nerve damage is far advanced. While risk factors for glaucoma, such as ethnicity and
family history, are known, these associations are poorly understood. With early detection, glaucoma can be
controlled medically or surgically.
Paragraph 4
While older people use a large percentage of eye services, many more may not have access to, or may
underutilise, these services. In the United States, 33% of the elderly in Baltimore had ocular pathology
requiring further investigation or intervention. In the UK, only half the visually impaired in London were known
by their doctors to have visual problems, and 40% of those visually impaired in the city of Canterbury had
never visited an ophthalmologist. The reasons for people underutilising eye care services are, first, that many
elderly people believe that poor vision is inevitable or untreatable. Second, many of the visually impaired
have other chronic disease and may neglect their eyesight. Third, hospital resources and rehabilitation
centres in the community are limited and, finally, social factors play a role.
Paragraph 5
People in lower socioeconomic groups are more likely to delay seeking treatment; they also use fewer
preventive, early intervention and screening services, and fewer rehabilitation and after-care services. The
poor use more health services, but their use is episodic, and often involves hospital casualty departments
or general medical services, where eyes are not routinely examined. In addition, the costs of services are
a great deterrent for those with lower incomes, who are less likely to have private health insurance. For
example, surgery is the most effective means of treatment for cataract, and timely medical care is required
for glaucoma and AMD. However, in December 1991, the proportion of the Australian population covered
by private health insurance was 42%. Less than 38% had supplementary insurance cover. With 46% of
category 1 (urgent) patients waiting for more than 30 days for elective eye surgery in the public system, and
54% of category 2 (semi-urgent) patients waiting for more than three months, cost appears to be a barrier
to appropriate and adequate care.
Paragraph 6
With the proportion of Australians aged 65 years and older expected to double from the present 11 % to
21% by 2031, the cost to individuals and to society of poor sight will increase significantly if people do not
have access to, or do not use, eye services. To help contain these costs, general practitioners can actively
investigate the vision of all their older patients, refer them earlier, and teach them self-care practices. In
addition, the government, which is responsible to the taxpayer, must provide everyone with equal access
to eye health care services. This may not be achieved merely by increasing expenditure- funds need to be
directed towards prevention and health promotion, as well as treatment. Such strategies will make good
economic sense if they stop older people going blind.
Part B - Text 81: Questions 1-1 0
1 In paragraph 1, the author suggests that ..... .

A many people have poor eyesight at retirement age.
B sight problems of the aged are often treatable.
C cataract and glaucoma are the inevitable results of growing older.
0 few sight problems of the elderly are potentially damaging.
2 According to paragraph 2, cataracts ..... .

A may affect about half the population of Australians aged over 64.
B may occur in about 4-5% of Australians aged over 64.
C are directly related to smoking and alcohol consumption in old age.
0 are the cause of more than 50% of visual impairments.
3 According to paragraph 3, age-related macular degeneration (AMD) ..... .

A responds well to early treatment.
B affects 1 in 5 of people aged 65-74.
C is a new disease which originated in the USA.
0 causes a significant amount of sight loss in the elderly.

QUESTIONS
4 According to paragraph 3, the detection of glaucoma ..... .
A generally occurs too late for treatment to be effective.
8 is strongly associated with ethnic and genetic factors.
C must occur early to enable effective treatment.
D generally occurs before optic neNe damage is very advanced.
5 Statistics in paragraph 4 indicate that ..... .
A existing eye care seNices are not fully utilised by the elderly.
8 GPs are generally aware of their patients' sight difficulties.
C most of the elderly in the USA receive adequate eye treatment.
D only 40% of the visually impaired visit an ophthalmologist.
6 According to paragraph 4, which one of the following statements is NOT true?
A Many elderly people believe that eyesight problems cannot be treated effectively.
8 Elderly people with chronic diseases are more likely to have poor eyesight.
C The facilities for eye treatments are not always readily available.
D Many elderly people think that deterioration of eyesight is a product of ageing.
7 In discussing social factors affecting the use of health services in paragraph 5, the author points
out that ..... .
A wealthier people use health seNices more often than poorer people.
8 poorer people use health seNices more regularly than wealthier people.
C poorer people deliberately avoid having their eye sight examined.
D poorer people have less access to the range of available eye care seNices.
8 According to paragraph 6, in Australia in the year 2031 ..... .
A about one tenth of the country's population will be elderly.
8 about one third of the country's population will be elderly.
C the proportion of people over 65 will be twice the present proportion.
D the number of visually impaired will be twice the present number.
9 According to paragraph 6, the author believes that general practitioners ..... .
A should be more active in investigating patients' possible sight difficulties.
8 should not be required to deal with sight deterioration.
C should not refer patients to specialists until the problems are advanced.
D should seek assistance from eye specialists in detection of problems.

QUESTIONS
10 In paragraph 6, the author suggests that ..... .
A increased government funding will solve the country's eye care problems.
B government services should include prevention and health promotion.
C general practitioners should reduce the cost of treating sight problems in the elderly.
D general practitioners should take full responsibility for treating sight problems.
END OF PART B - TEXT 1
TURN OVER FOR PART B - TEXT 2

IMI:tl
Paragraph 1
Physical inactivity is a substantial risk factor for cardiovascular disease. Exercise probably works by increasing
physical fitness and by modifying other risk factors. Among other benefits, it lessens the risk of stroke and
osteoporosis and is associated with a lower all-cause mortality. Moreover, it has psychological effects that
are surely underexploited. A pervasive benefit is the gain in everyday reserve capacity- that is, the ability
to do more without fatigue. Nevertheless, there is much debate about how intense the exercise should be.
Some studies show a dose-response relation between activity and reduction of risk, with a threshold of
effect; some suggest that vigorous aerobic activity is needed and others that frequent moderate exercise
is adequate - and indeed safer if ischaemic heart disease might be present. A few surveys have found a
slightly increased risk of heart attack with extreme activity, though further analysis in one study suggested
this applied only to men with hypertension.
Paragraph 2
A commonly recommended minimum regimen for cardiovascular benefit is thrice weekly exercise for 20
minutes, brisk enough to produce sweating or hard breathing (or a heart rate 60-80% of maximum). Indeed,
this is what the Allied Dunbar national survey of fitness among adults in the UK recommends. It conveys a
simple popular message of broad minimum targets for different age groups expressed in terms of activities
of different intensity. The aim is to produce a training effect through exercise beyond what is customary for
an individual.
Paragraph 3
The main reason why people fail to take exercise is lack of time. Thus an important message is that exercise
can be part of the daily routine - walking or cycling to work or the shops, for instance. Relatively few people
in the national fitness survey had walked continuously for even 1-25 km in the previous month (11-30%
depending on age and sex), and other surveys have also found little walking. Cycling is also beneficial,
however many are put off cycling to work by the danger. Certainly more cycle routes are needed, but even
now life years lost through accidents are outweighed by the estimated life years gained through better health.
Employers could encourage people to make exercise part of the working day by providing showers and
changing rooms, flexible working hours, individual counselling by occupational health or personnel staff, and
sometimes exercise facilities- or at least encouragement for exercise groups.
Paragraph 4
In the promotion of exercise, children, women, middle aged men, and older people need special thought.
Lifelong exercise is most likely to be started in childhood, but children may have little vigorous exercise.
Women tend to be much less active than men and are less fit at all ages. The proportion judged on a treadmill
test to be unable to keep walking at 5km/h up a slight slope rose with age from 34% to 92%- and over half
of those aged over 54 would not be able to do so even on the level. Women have particular constraints:
young children may prevent even brisk walking. Thus they need sensitive help from health professionals and
women's and children's groups as well as the media.
Paragraph 5
A high proportion of men aged 45-54, who have a high risk of coronary heart disease, were not considered
active enough for their health. Promotion of exercise and individual counselling at work could help. Forty
percent of 65-74 year olds had done no "moderate" activity for" even 20 minutes in a month. Yet older people
especially need exercise to help them make the most of their reduced physical capacity and counteract the
natural deterioration of age. They respond to endurance training much the same as do younger people.
Doctors particularly should take this challenge more seriously.
Paragraph 6
People need to be better informed, and much can be done through the media. For instance, many in the
survey were mistaken in thinking that they were active and fit. Moreover, many gave "not enough energy"
and "too old" as reasons for not exercising. Precautions also need publicity - for example, warming up
and cooling down gradually, avoiding vigorous exercise during infections, and (for older people) having a
medical check before starting vigorous activity. Doctors are in a key position. Some general practitioners
have diplomas in sports medicine, and a few are setting up exercise programmes. As the Royal College of
Physicians says, however, all doctors should ask about exercise when they see patients, especially during
routine health checks, and advise on suitable exercise and local facilities. Their frequent contact with women
and children provides a valuable opportunity. Excluding ischaemic heart disease and also checking blood
pressure before vigorous activity is started are important precautions. But above all doctors could help to
create a cultural change whereby the habit of exercise becomes integral to daily life.
Part B - Text 82: Questions 11-18
11 All of the following are mentioned in paragraph 1 as benefits of exercise EXCEPT ..... .
A increase in the capacity to withstand strenuous activity.
B significant decrease in the risk of osteoporosis.
C reduction of the risk of heart disease.
D weight control and decrease in levels of body fat.
12 According to paragraph 2, the recommendations of the report on the national fitness survey included
A long, vigorous aerobic sessions for all men, women and children.
B no more than three, 20 minute exercise sessions per week.
C avoiding any exercise that brought on hard breathing.
D different levels of exercise intensity for different age groups.
13 According to paragraph 3, one reason many people do not exercise is ..... .
A they are unaware of its importance.
8 difficulty in fitting it into their daily routine.
C they are unaware of its long-term health benefits.
D they live too far from work to walk or cycle.
14 Which one of the following is mentioned in paragraph 3 as a way in which employers can help
improve the physical fitness and health of their staff?
A Making it mandatory for employees to exercise during lunch breaks.
8 Providing encouragement and advice from staff within the organisation.
C Hiring trained sports educators to counsel members of staff about exercise.
0 Setting an example, as individuals, by regularly exercising themselves.

QUESTIONS
15 According to paragraphs 4 and 5, older men and women need to remain physically active and fit
because ..... .
A they need to counteract the risk of coronary disease.
B fitness levels decrease rapidly over the age of 54.
C they need to guard against poor health and inactivity.
D exercise works against the physical effects of ageing.
16 Which one of the following is NOT mentioned in paragraph 6 as a precaution to be taken when
considering exercise?
A The need to balance aerobic activity with stretching.
B The need to warm up before and cool down after exercise.
C The need to eliminate the risk of ischaemic heart disease before starting.
D The need to exclude strenuous exercise from the routine during infection.
17 Which one of the following needs in relation to the improvement of national fitness is NOT mentioned
in the article?
A The need for people to make exercise a regular daily habit.
B The need to provide information on health and fitness to the community.
C The need for doctors themselves to improve their own fitness levels.
D The need to consult a doctor before starting an exercise program.
18 According to the article, which one of the following is FALSE?
A It is unsafe for people with high blood pressure to do regular moderate exercise.
B Experts agree on the importance of both type and intensity of exercise.
C Men are generally fitter and more active than women.
D Cycling, though unsafe, is a beneficial form of exercise.
END OF READING TEST

-- ~ET OCCUPATIONAL ENGLISH TEST
READING ~PART 8 ANSWER SHEET
--- COMPLETION INSTRUCTIONS:
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DATE OF BIRTH:
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DIRECTIONS: Read each question and its suggested answers. When you have decided which answer is correct, fill in the response oval
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OET is owned by Cambridge Boxhill Language Assessment Trust (CBLA), a venture between Cambridge English and Box Hill Institute
OCCUPATIONAL ENGLISH TEST
Reading sub-test
Part B - Answer key
The OET Centre

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Reading Sub-test
Part B - Text 1: Going blind in Australia
Answer Key
Total of 10 questions
1 B sight problems of the aged are often treatable.
2 B may occur in about 4-5% of Australians aged over 64.
3 D causes a significant amount of sight loss in the elderly.
4 c must occur early to enable effective treatment.
5 A existing eye care services are not fully utilised by the elderly.
6 B Elderly people with chronic diseases are more likely to have poor eyesight.
7 D poorer people have less access to the range of available eye care services.
8 c the proportion of people over 65 will be twice the present proportion.
9 A should be more active in investigating patients' possible sight difficulties.
10 B government services should include prevention and health promotion.
END OF KEY
Reading sub-test
Part B - Answer key
The OET Centre


Reading Sub-test
Part B - Text 2: Exercise, fitness and health
Answer Key
11 D weight control and decrease in levels of body fat.
12 D different levels of exercise intensity for different age groups.
13 B difficulty in fitting it into their daily routine.
14 B Providing encouragement and advice from staff within the organisation.
15 D exercise works against the physical effects of ageing.
16 A The need to balance aerobic activity with stretching.
17 c The need for doctors themselves to improve their own fitness levels.
18 B Experts agree on the importance of both type and intensity of exercise.
END OF KEY
Text 81: Animal testing
Paragraph 1
The use of living animals in research and teaching, while first documented around 2000 years ago,
became prominent in the second half of the 19th century as part of the development of the emerging
sciences of physiology and anatomy. In the mid 1900s, the rapid expansion of the pharmaceutical
and chemical industries gave rise to an enormous increase in the use of animals in research. Today it
is a multi-billion dollar industry, involving not only the pharmaceutical and chemical industries, but
also university and government bodies. There is, additionally, a sizeable industry providing support
services in relation to animal research, including animal breeding, food supply and cage manufacture,
among many others.
Paragraph 2
The types of research that animals are subjected to include the traditional forms of physiological
research, which typically involves the study of body function and disease, and psychological
research, which often entails controlling the eating, movement or choices of animals in experimental
contexts. Other more recent forms of research include agricultural research directed towards intensive
farming methods and increasing the efficiency of animals kept for food or food products. The genetic
engineering of species used in agriculture is common amongst sheep and cattle, for example, in an
attempt to increase the production of wool or milk, or to alter the characteristics of the end product
(finer wool, for instance). Safety testing, or toxicology testing, is another common type of research
where medicines, agricultural chemicals and various other chemical products, such as shampoos and
cosmetics, are assessed for safe human use by testing the products on animals.
Paragraph 3
While accurate global figures for animal testing are extremely difficult to obtain, estimates indicate
that anywhere from 50 to 100 million vertebrates are used in experiments every year (although this
figure does not include the many more invertebrates, such as worms and flies, that are employed).
The most commonly used vertebrates are mice, attractive to researchers for their size, low cost, ease
of handling, and fast reproduction rate, as well as the fact that their genetic makeup is comparable to
that ofhuman beings. Other types of vertebrates used in the pursuit of science include fish, chickens,
pigs, monkeys, cats, dogs, sheep and horses.
Paragraph 4
Perhaps one of the most widely-known examples of animals being used for the purposes of scientific
research is Ivan Pavlov's 'conditioned reflex' experiments in the late 19th early 20th centuries. Pavlov
and his researchers were investigating the gastric functions of dogs and the chemical composition of
their saliva under changing conditions, when Pavlov noticed that the animals began salivating before
food was delivered. Pavlov's team then changed the focus of their experiments and embarked on a
series of experiments on conditional reflexes that earned Pavlov the 1904 Nobel Prize in Physiology
and Medicine for his work on the physiology of digestion. What is less well-known about Pavlov's
research is that these experiments included surgically implanting fistulas in animals' stomachs, which
enabled him to study organs and take samples of body fluids from animals while they continued to
function normally. Also, further work on reflex actions involved involuntary reactions to extreme
stress and pain.
2
Paragraph 5
Supporters of animal testing argue that virtually every medical achievement in the 20th century relied on
the use of animals in some way and that alternatives to animal testing, such as computer modelling, are
inadequate and fail to model the complex interactions between molecules, cells, tissues, organs, organisms
and the environment. Opponents argue that such testing is cruel to animals and is poor scientific practice, that
results are an unreliable indicator of the effects in humans, and that it is poorly regulated. They also point
to the fact that many alternatives to using animals have been developed, particularly in the area of toxicity
testing, and that these developments have occurred most rapidly and effectively in countries where the use of
animals is prohibited.
Paragraph 6
Although animal rights groups have made slow headway, there are signs that the issues they are concerned
about are being heard. Most scientists and governments state, publicly at least, that animal testing should cause
as little suffering to animals as possible, and that animal tests should only be yerformed where necessary.
The 'three Rs' of replacement, reduction and refinement are the guiding principles for the use of animals in
research in most countries. They are designed to minimise the use of animals in scientific research by using
other types of research where possible, by reducing the number of animals used in research, and by refining
research techniques to minimise the animals'pain and distress.
Part B -Text B 1 : Questions 1-11

1 According to paragraph 1, research using animals ..... .
A was non-existent before 1850.

8 is most common in the medical industry.
C generates trade for offshoot industries.
D is on the rise.
2 According to paragraph 1, the use of living animals in research and teaching ..... .
A has taken place for at least two millennia.
B rose to prominence around 2,000 years ago.
C emerged in the second half of the 19th century.
D originated in the pharmaceutical and chemical industries.
3 According to paragraph 2, one of the new applications of animal testing is concerned

with ..... .
A combining the traditions of physiological and psychological research.

B finding ways to improve farm animals' productive capacity.
C controlling the eating, movement or choices of animals.
D revisiting the age-old study of body function and disease.
TURN OVER 3
QUESTIONS
4 According to paragraph 3, global figures for animal testing are ..... .
A subsiding.
B elusive.
C confronting.
D extreme.
5 According to paragraph 3, which one of the following statements about mice

is TRUE?
A They are much more popular with researchers than invertebrates.

B They have a genetic make-up which is at odds with that of humans.
C They are very attractive to researchers because of their speed and aptitude.
D They pose fewer constraints than other vertebrates in terms of care and expense.
6 According to paragraph 4, Pavlov's research ..... .
A was unethical at the time.

B involved hurting animals deliberately.
C was conducted solely on dogs.
D did not focus on dogs initially.
7 According to paragraph 4, Pavlov's groundbreaking research into conditional

reflexes ..... .
A was prompted by the observation that dogs salivated when they were hungry.
B came about by accident while he was investigating something else.
C was triggered by his noticing chemical changes in the dogs' saliva.
D led to a larger-scale investigation of the gastric functions of dogs.
8 According to paragraph 5, animal testing proponents argue that ..... .
A many of the alternative methods still rely on the use of animals in some way.
B it was crucial in the 20th century before viable alternatives became available.
C computer modelling requires improvement before it can replace animal testing.
D medical advancement in the 20th century would have been hindered without it.
9 According to paragraph 5, opponents of animal testing argue that ..... .
A countries who prohibit it are developing rapidly.

B its results are unreliable due to poor regulation.
C there are insufficient rules and restrictions.
D it is only justifiable in the area of toxicity testing.
4
QUESTIONS
10 The word headway in paragraph 6 could best be replaced by ..... .
A progress.
8 improvements.
C impact.
D developments.
11 Replacement in the three Rs described in paragraph 6 refers to the

substitution of ..... .
A animal species.
8 research methods.
C painful techniques.
D animal numbers.
END OF PART B- Text 1

5
Text 82: Oral health and systemic disease
Paragraph 1
The relationship between oral health and diabetes (Types 1 and 2) is well known and documented. In the
last decade, however, an increasing body of evidence has given support to the existence of an association
between oral health problems, specifically periodontal disease, and other systemic diseases, such as those
of the cardiovascular system. Adding further layers of complexity to the problem is the lack of awareness
in much of the population of periodontal disease, relative to their knowledge of more observable dental
problems, as well as the decreasing accessibility and affordability of dental treatment in Australia. While
epidemiological studies have confirmed links between periodontal disease and systemic diseases, from
diabetes to autoimmune conditions, osteoporosis, heart attacks and stroke, in the case of the last two the
findings remain cautious and qualified regarding the mechanics or biological rationale of the relationship.
Paragraph 2
Periodontal diseases, the most severe form of which is periodontitis, are inflammatory bacterial infections
that attack and destroy the attachment tissue and suppotiing bone of the jaw. Periodontitis occurs when
gingivitis is untreated or treatment is delayed. Bacteria in plaque that has spread below the gum line release
toxins which irritate the gums. These toxins stimulate a chronic inflammatory response in which the body, in
essence, turns on itself, and the tissues and bone that support the teeth are broken down and destroyed. Gums
separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected. As the
disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Often, this destructive
process only has very mild symptoms. Eventually, however, teeth can become loose and may have to be
removed.
Paragraph 3
The current interest in the relationship between periodontal disease and systemic disease may best be
attributed to a report by Kimma Mattila and his colleagues. In 1989, in Finland, they conducted a case-
control study on patients who had experienced an acute myocardial infarction and compared them to control
subjects selected from the community. A dental examination was performed on all of the subjects studied,
and a dental index was computed. The dental index used was the sum of scores from the number of carious
lesions, missing teeth, and periapical lesions and probing depth measures to indicate periodontitis and the
presence or absence of pericoronitis (a red swelling of the soft tissues that surround the crown of a tooth
which has partially grown in). The researchers reported a highly significant association between poor dental
health, as measured by the dental index, and acute myocardial infarction. The association was independent
of other risk factors for heart attack, such as age, total cholesterol, high-density lipoprotein triglycerides, C
peptide, hypertension, diabetes, and smoking.
Paragraph 4
Since then, researchers have sought to understand the association between oral health, specifically periodontal
disease, and cardiovascular disease (CVD)- the missing link explaining the abnom1ally high blood levels of
some inflammatory markers or endotoxins and the presence of periodontal pathogens in the atherosclerotic
plaques of patients with periodontal disease. Two biological mechanisms have been suggested. One is that
periodontal bacteria may enter the circulatoty system and contribute directly to atheromatous and thrombotic
processes. The other is that systemic factors may alter the immunoflammatoty process involved in both
periodontal disease and CVD. It has also been suggested that some of these illnesses may in tum increase
the incidence and severity of periodontal disease by modifying the body's immune response to the bacteria
involved, in a bi-directional relationship.
6
Paragraph 5
However, not only is 'the jury out' on the actual mechanism of the relationship, it also remains impossible to say
whether treating gum disease can reduce the risk of cardiovascular disease and improve health outcomes for those
who are already sufferers. Additional research is needed to evaluate disease pathogenesis. Should the contributing
mechanisms be identified, however, it will confirm the role of oral health in overall well-being, with some implications
of this being the desirability of closer ties between the medical and the dental professions, and improved public health
education, not to mention greater access to preventive and curative dental treatment. In time, periodontal disease may
be added to other preventable risk factors for CVD, such as smoking, high blood cholesterol, obesity and diabetes.
Part B -Text 82: Questions 12-20

12 According to paragraph 1, oral health problems have recently been linked to ..... .
A periodontal disease.
B heart conditions.
c diabetes.
D economic factors.
13 According to paragraph 1, periodontal disease is unknown to many Australians

because ..... .
A dental treatment is no longer affordable.
B the problem has a high degree of complexity.

C information on dental problems is inaccessible.
D it is not as prominent as other dental issues.
14 The most suitable heading for paragraph 2 is ..... .
A 'Types of periodontal disease'.-

B 'The treatment of gingivitis'.
C 'The body's response to toxins'.
D 'The process of periodontitis'.
15 According to paragraph 3, the 1989 study in Finland ..... .
A prompted further interest in the link between oral health and systemic disease.
B did not take into account a number of important risk factors for heart attacks.
C concluded that people with oral health problems were likely to have heart attacks.
D was not considered significant when it was first reported but is now.
TURN OVER 7
QUESTIONS
16 The research study described in paragraph 3 found that the relationship

between poor dental health and heart attacks was
A inconclusive.
B coincidental.
C evident.
D inconsequential.
17 According to paragraph 3, the dental index was used to ..... .
A indicate whether periodontitis was present.

B assess the overall oral health of patients.
C establish whether pericoronitis was present.
D predict the likelihood of acute myocardial infarction.
18 According to paragraph 4, it has been proposed that ..... .
A cardiovascular disease could actually exacerbate periodontar disease.

B periodontal disease could modify the body's immune response.
C there is a bi-directional relationship between periodontal disease and bacteria.
D systemic factors may contribute directly to atheromatous and thrombotic processes.
19 According to paragraph 5, if the processes by which gum disease contributes

to CVD can be discovered there will be ..... .
A less need for doctors and dentists to work in conjunction.

B a reduced emphasis on other preventable risk factors for CVD.
C a concomitant link between smoking and periodontal disease.
D more support for dental care in the public health system.
20 The expression the jury [is] out in paragraph 5 means that a definitive
conclusion is ..... .
A imminent.
B impossible.
C without empirical basis.
D yet to be attained.
END OF PART B- Text 2
END OF READING TEST
8
Reading sub-test
Part B - Answer key
Animal testing
Sample Test
The OET Centre

©Cambridge Boxhill Language Assessment- Sample Test (2010) ABN 51 988 559 414
Reading Sub-test
Text 81: Animal Testing
Answer Key
1 c generates trade for offshoot industries.
2 A has taken place for at least two millennia.
3 B finding ways to improve farm animals' productive capacity.
4 B elusive.
5 0 They pose fewer constraints than other vertebrates in terms of care and expense.
6 B involved hurting animals deliberately.
7 B came about by accident while he was investigating something else.
8 0 medical advancement in the 20th century would have been hindered without it.
9 c there are insufficient rules and restrictions.
10 A progress.
11 B research methods.
END OF KEY
2
Reading sub-test
Part B - Answer key
Oral health and systemic

disease · ·
Sample Test
The OET Centre

© Cambridge Boxhill Language Assessment - Sample Test (201 0) ABN 51 988 559 414
Reading Sub-test
Text 82: Oral health and systemic disease
Answer Key
12 B heart conditions.
13 D it is not as prominent as other dental issues.
14 D 'The process of periodontitis'.
15 A prompted further interest in the link between oral health and systemic disease.
16 c evident.
17 B assess the overall oral health of patients.
18 A cardiovascular disease could actually exacerbate periodontal disease.
19 D more support for dental care in the public health system.
20 D yet to be attained.
END OF KEY
4
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1@1:11
Euthanasia
Paragraph 1
Over the past few decades, there has been increasing attention paid to medical decisions at the end
of life, and euthanasia, or medically-assisted death, has been the subject of much moral, religious.
philosophical, legal and human rights debate all over the world. At the core of this debate is how to
reconcile the desire of individuals to choose to die with dignity when suffering, and the need, particularly
ofhea1th professionals, to uphold the inherent right to life of every person. Recent surveys in Australia
and elsewhere consistently show that a considerable proportion of health care professionals support
euthanasia under certain conditions. A minority of health care professionals also admit to having practised
euthanasia.
Paragraph 2
The position of international human rights law with respect to voluntary euthanasia is not explicit
or clearly defined. Article 6(1) of the International Covenant on Civil and Political Rights (ICCPR)
provides: 'Every human being has the inherent right to life. This right shall be protected by law. No
one shall be arbitrarily deprived of his life.' The impact of m·ticle 6(1) on voluntary euthanasia raises a
number of questions including the scope of the right to life, the interpretation of 'arbitrary' deprivation
of life, and the definition of life and in particular when life ends. So far these questions remain largely
unanswered.
Paragraph 3
Dealing with death and dying (which includes requests for euthanasia) is an integral part of the practice
of medicine, and medical practitioners frequently have to make decisions that affect the timing of a
patient's death. Determinants of attitudes and practices relating to such decisions include unbearable
pain and suffering, the patient's mental competence, that is, the ability to make decisions for one's self
or to exercise one's right to give or refuse informed consent, and patient requests for euthanasia. As
well as patient factors, there are a number of other considerations that relate to the medical practitioners
themselves such as sex, age, religious and personal beliefs, as well as the area of medicine in which they
specialise.
Paragraph 4
In one of the most detailed surveys of the practice of euthanasia, researchers in Holland found that in 1.8
per cent of all deaths in that country a lethal drug was administered, at the patient's request, to end life.
Also, in 38 per cent of all deaths doctors had taken medical decisions concerning the end of life that may
have shortened the patient's life. The researchers concluded that medical decisions concerning the end
of life were common in tnedical practice and should be the subject of increased research, teaching, and
public debate.
4
Paragraph 5
It is still true to say, however, that most doctors are opposed to euthanasia. Several factors may explain
this. First, in general, death is viewed as a failure in modern medicine; hence the reluctance of medical
professionals to reinforce this perception by accepting euthanasia and physician-assisted suicide.
Secondly, various surveys suggest that doctors would prefer to keep the management of death within
their professional practice (and out of the hands of government regulators) to allow them the flexibility to
respond to the complex realities of differing clinical situations. The regulation of death and dying through
a formal legal process could make it difficult for doctors to respond to the individual needs of the patient
and could also subject doctors to unreasonable and extended legal scrutiny.
Paragraph 6
The opposition of doctors to euthanasia and physician-assisted suicide may also be related to their 'self-
image' and the fact that the contribution of doctors to carrying out requests for euthanasia may have
profound effects on their image in the broader society. Doctors see themselves as the bringers of life,
hope and healing, not as the bringers of death. More hnportantly, the legalisation of euthanasia also raises
the prospect of a complex moral diletnma for those doctors who may be opposed to it on religious or
ethical grounds.
Paragraph 7
The broader community's unease about the legalisation of euthanasia is related to the concerns of some
religious and ethnic groups that, besides violating the ultimate human value, the sanctity of life, such
legislation may render the less privileged and the poor in the community more vulnerable to unethical
practices. However, notwithstanding the concerns of the medical profession and some key groups in
society, the debate about the right of an individual to make a decision about his or her own death is not
going to disappear. Society will ultimately have to resolve the issue by balancing two central human
values: sanctity of life and human dignity.
TURN OVER 5
Questions
1 According to paragraph 1, euthanasia is approved of by ..... .
A most health professionals around the world.

8 only a few health professionals in certain countries.
C mainly Australian health professionals.
D many health professionals in particular circumstances.
2 According to paragraph 2, Article 6(1) of the ICCPR is ......
A ambiguous.
8 arbitrary.
c ·contradictory.
D unconditional.
3 The word 'integral' in paragraph 3 means ......
A accepted.
B central.
C regular.
D general.
4 According to paragraph 3, which one of the following statements is TRUE?
A Medical choices affecting when a patient dies are common.

B Doctors can often choose if and when a patient should die.
C Euthanasia is an everyday occurrence in modern medicine.
D Mental deficiencies can lead patients to request euthanasia.
5 According to paragraph 3, medical decisions about the timing of a patient's death may be influenced by
the ......
A religion of the patient.

B gender of the patient.
C moral position of the doctor.
D prior training of the doctor.
6
Questions
6 According to the survey in paragraph 4, which one of the following statements is TRUE?
A 38% of deaths in Holland were due to euthanasia.

B 1.8% of deaths in Holland were drug related.
C 38% of doctors have shortened patients' lives.
D 1.8% of deaths in Holland were due to euthanasia.
7 Which one of the following statements is NOT supported by information in paragraph 5?
A Deaths are perceived by some as failures in the medical process.

B Physicians are wary of legal involvement in medical decision-making.
C Governments impose restrictive regulations on medical professionals.
D Doctors value the freedom to respond to patients' particular needs.
8 According to paragraph 5, one reason the medical profession is opposed to pro-euthanasia laws may be
that ..... .
A the surveys done of its views are inconclusive.

B doctors dislike government and legal scrutiny.
C doctors want freedom to act according to each situation.
D doctors believe the law will require them to practise euthanasia.
9 According to paragraph 6, many doctors ......
A are only conscious of their own 'self-image'.

B fear a negative perception of their profession.
C wish to be seen as creators not enders of life.
D are pro-euthanasia for complicated reasons.
10 According to paragraph 7, concerns about protecting the poor and vulnerable in society ..... .
A have made some people unsure about supporting euthanasia laws.

B have not been considered by some religious and ethnic groups.
C have not been raised so far in the euthanasia debate.
D will eventually force society to resolve this issue.
END OF PART 8- TEXT 1
TURN OVER FOR PART 8- TEXT 2

7
ltjl:fj
Food additives
Paragraph 1
The use of food additives has increased enormously in the last few decades. As a result, it has been
estimated that today about 75% of the Western diet is made up of various processed foods, each
person consuming an average of3.5-4.5 kilograms of food additives per year. Adverse effects and
conditions which have been attributed to the consumption of food additives include eczema, dermatitis,
irritable bowel syndrome, nausea, vomiting, diarrhoea, rhinitis, bronchospasm, migraine, anaphylaxis,
hyperactivity and other behavioural disorders.
Paragraph 2
There is also now clear evidence that the health of populations in developed nations has deteriorated
considerably during the last few decades. In a recent study which compared the health records of over
5,000 people born in the UK in 1946 with those of their first-born children a generation later, researchers
found among the new generation a substantial increase in hospital admissions of children up to the age of
four, a tripling of instances of asthma, a six-fold increase in both eczema and juvenile diabetes, as well
as a doubling of cases of obesity. The study revealed that the number of children admitted to psychiatric
hospitals also rose sharply, an increase of almost 50% in the number of under 10 year-olds seen by
psychiatric services and a two-thirds increase for children aged between 10 and 14. Admissions of 15
to 19 year-old juveniles to psychiatric hospitals also increased. Though the increase of 21% was not as
sharp, the figures are startling.
Paragraph 3
Crime is presently at the top of the political agenda in many developed nations. When crime statistics
rise, governments and the media tend to place the blame on varied sociopolitical influences such as TV
and film violence, poverty, lack of parental guidance, child abuse, frustration, the prison system, or the
police. In fact, the blame has been attributed to many things, but never to faulty nutrition. Yet, as studies
have increasingly shown, inappropriate nutrition can modify brain function in susceptible individuals and
cause severe mental dysfunction, including manifestations of criminal and violent behaviour. It should
be noted that not all negative behaviour manifestations are nutritional in origin. Sociopolitical influences
do of course play a part, most likely a much greater one. However, inadequate nutrition and subclinical
malnutrition seem to be two of the contributing factors in numerous physical and mental health problems
of today. This could be at least partly rectified by reducing the wide use of non-essential food additives,
which in turn would simply restrict the amount of non-nutritious foods presently on sale, resulting in a
wider uptake of more nutritionally dense foods.
Paragraph 4
The main argument of food manufacturers and government officials for the importance of the use of
preservatives is that without them foods would soon spoil. This argument is indeed quite reasonable.
However, it is interesting to note that of the nearly 4,000 different additives currently in use, over 90%
are used purely for cosmetic reasons and as colouring agents, with preservatives accounting for less than
2% of all additives, by nun1ber or by weight.
8
Paragraph 5
Another justification for the continued approval of the use of additives is based on the argument that
they are present in foods on such a minute scale that they must therefore be completely harmless. This
argument may be acceptable regarding additives with a reversible toxicological action; however, neither
the human nor animal body is able to detoxify additives which have been found to be both mutagenic and
carcinogenic. Therefore, even tiny doses of these additives, when consun1ed continuously, may eventually
result in an irreversible toxic burden. This is quite unacceptable, particularly as the n1ajority of these
questionable agents belong to the food-colouring group.
Paragraph 6
Those against the use of non-essential food additives have voiced a number of recommendations
including the banning of a11 cosmetic agents such as food colourants; clear labellings and warnings on
all foods that include additives with carcinogenic and mutagenic properties; the banning of all food
additives from foods which 1nay be consumed by infants and or young children; stricter laws regarding
TV advertising which encourages children to buy and eat unhealthy junk food; the re-introduction of fi·ee
nutritious school meals, preferably using organic food; the inclusion in education curricula of specific
lectures stressing the prime importance of good nutrition in both physical and mental health; and a law
requiring all foods, drinks or medications currently exempt from declaring additives to be required to do
so in future.
TURN OVER 9
Questions
Part B - Text 82: Questions 11 -1 9
11 The word 'processed' in paragraph 1 means ......
A artificial.
8 unnatural.
c unhealthy.
D altered.
12 According to the UK study in paragraph 2, which one of the following statements is TRUE?
A Fifty percent of children under 10 have had recent psychiatric treatment.

8 There has been an increase in psychiatric disorders in children.
C 10-14 year-olds are at greater risk of mental illness than other groups.
D Twenty-one percent of 15-19 year-olds are in psychiatric hospitals.
13 In the UK study, the group with the greatest increase in psychiatric admissions was aged ..... .
A under 10.
8 10-14.
c 15-19.
D over 19.
14 Which one of the following statements is suport~d by information in paragraph 3?
A Poor diet is most responsible for problem behaviour.

8 Better nutrition would eliminate most negative behaviours.
C Problems in society are both mental and physical in origin.
D Social influences probably affect behaviour more than diet.
15 According to paragraph 3, food additives are ..... .
A unnecessary.
8 used unnecessarily.
C the main cause of nutritional problems.
D not present in nutritionally dense foods.
10
Questions
16 According to paragraph 4, which one of the following statements is FALSE?
A Only a small percentage of additives are preservatives.

B Ninety percent of food additives are colouring agents.
C There are nearly 4,000 additives currently used in food.
D The majority of food additives are non-essential.
17 The word 'minute' in paragraph 5 refers to ......
A the time it takes the body to process additives.

B the length of time the additives remain active.
C the amount of additives present in foods. ·
D the degree of harm caused by additives.
18 According to paragraph 5, ......
A some food additives may have irreversible effects.

B the body will reject food additives eventually.
C food colouring presents no danger to the body.
D there is no safe dosage of any food additives.
19 In paragraph 6, which one of the following is NOT recommended?
A The banning of all food additives.

B Healthy meals provided free at school.
C More informative food-labelling.
D Educating children about good nutrition.
END OF PART 8- TEXT 2
END OF READING TEST
11
Reading sub-test
Part B - Answer key
Euthanasia
Sample Test
The OET Centre

Reading Part B: Text 1
Euthanasia
Answer Key
1 D many health professionals in particular circumstances.
2 A ambiguous
3 8 central
4 A Medical choices affecting when a patient dies are common.
5 c moral position of the doctor.
6 D 1.8% of deaths in Holland were due to euthanasia.
7 c Governments impose restrictive regulations on medical professionals
8 c doctors want freedom to act according to each situation.
9 8 fear a negative perception of their profession.
10 A have made some people unsure about supporting euthanasia laws.
END OF KEY
2
Reading sub-test
Part B - Answer key
Food Additives
Sample Test
The OET Centre

Reading Part B: Text 2
Food Additives
Answer Key
11 0 altered.
12 B There has been an increase in psychiatric disorders in children.
13 B 10-14.
14 0 Social influences probably affect behaviour more than diet.
15 B used unnecessarily.
16 B Ninety percent of food additives are colouring agents.
17 c the amount of additives present in foods.
18 A some food additives may have irreversible effects.
19 A The banning of all food additives.
END OF KEY
4
.
11§31:$1
Sleep apnea
Paragraph 1
Studies have shown that sleep is essential for normal immune system function and to maintain the
ability to fight disease and sickness. Sleep is also essential for normal nervous system function and
the ability to function both physically and mentally. In addition, sleep is vital for learning and for
normal, healthy cell growth. Despite sleep's huge importance to people's lives, scientists and medical
professionals do not fully understand this complicated physiological phenomenon.
Paragraph 2
It is not clear exactly why the body requires sleep, although inadequate sleep, including disorders
such as lack of sleep (e.g., insomnia) or disturbed sleep (e.g., sleep apnea), can have severe
detrimental effects on health. Insomnia is defined as the perception or complaint of inadequate or
poor-quality sleep in the form of difficulty falling asleep, difficulty maintaining sleep, or waking too
early in the morning. Sleep apnea is interrupted breathing during sleep. It usually occurs because of
a mechanical problem in the windpipe, but can also indicate a neurological disorder involving nerve
cells (neurons). There are three distinct forms of sleep apnea- central, obstructive and complex-
with over 80% of cases diagnosed as obstructive sleep apnea, where breathing is interrupted by a
physical block to airflow despite the body's efforts to breathe normally. Central sleep apnea, on the
other hand, is a much rarer condition caused primarily by problems with how the brain controls the
breathing process. In mixed sleep apnea, which accounts for just above 15% of apnea cases, there is a
transition from central to obstructive features during the events themselves.
Paragraph 3
Most patients with sleep apnea lose sleep because every time the windpipe closes, the person has
to wake up enough to contract those muscles and resume breathing. As a result, the sleep cycle can
be interrupted as many as a hundred times a night. In addition, every time the windpipe closes, the
brain is deprived of oxygen. This lack of oxygen can eventually cause problems such as daytime
sleepiness, morning headaches and decreased mental function.
Paragraph 4
Sleep apnea also has a strong association with heart and circulation diseases. While the nature of
the links is not yet fully clear, researchers know that when breathing stops during episodes of apnea,
carbon dioxide levels in the blood increase and oxygen levels drop. This effect may set off a chain of
physical and chemical events that can then increase risk for these conditions.
Paragraph 5
A number of studies have found a strong association between sleep apnea and high blood pressure
(hypertension). For example, a 2000 study followed patients for four years and reported that the
greater the number of nightly apnea episodes they had in year one, the more likely they were to
develop hypertension by the fourth year. A weak but still higher than normal association with high
blood pressure has even been observed in those who snore, wake frequently during the night, or have
mild sleep apnea. The relationship between sleep apnea and hypertension has been thought to be
largely due to obesity, a risk factor common to both conditions. Recent and major studies, however,
are suggesting a higher rate of hypertension in people with sleep apnea reeardless of weight. In those
whose hypertension is resistant to treatment, sleep apnea is likely to be particularly severe.
Paragraph 6
Studies have also reported an association between severe apnea and psychological problems. In
one study, 32% of patients had symptoms of depression. Sleep-related breathing disorders can also
exacerbate nightmares and post-traumatic stress disorder. In fact, in one study, treatment of sleep
apnea eased these complaints. Certainly, daytime sleepiness interferes with quality of life. It is also
possible that severe emotional problems might worsen the apnea. One study investigated the effects
of the antidepressant paroxetine (Paxil) on patients with obstructive sleep apnea and found that
the agent improved breathing during late sleep stages but had little effect on other aspects of the
condition.
Paragraph 7
Because sleep apnea so often includes noisy snoring, the condition can also adversely affect the sleep
quality of a patient's bed partner. Spouses or partners may also suffer from sleeplessness and fatigue.
In some cases, the snoring can even disrupt relationships. Diagnosis and treatment of sleep apnea
in the patient can, of course, help eliminate these problems, and given the amount of time that the
average person spends asleep, it is imperative that work to better understand sleep's functions and
effects continues.
TURN OVER
Questions
1 The word 'phenomenon' in paragraph 1 could best be replaced by ..... .
A result.
8 problem.
C factor.
D activity.
2 Obstructive sleep apnea ..... .
A is mechanical and neurological in origin.

8 accounts for a minority of cases of sleep apnea.
C occurs before central sleep apnea.
D can occur with central sleep apnea.
3 Central sleep apnea accounts for what percentage of sleep apnea sufferers?
A 80%.
8 Roughly 15%.
c 5%.
D Less than 5%.
4 According to paragraph 3, the closure of the windpipe ..... .
A contracts muscles.
8 can happen a hundred times in a night.
C restarts the breathing process.
D also occurs in the daytime.
5 According to paragraph 5, hypertension is considered to be ..... .
A a possible cause of obesity.

8 a more influential factor in sleep apnea than obesity is.
C a cause of sleep apnea rather than of obesity.
D resistant to treatment of sleep apnea.
Questions
6 The phrase 'regardless' of in paragraph 5 means ..... .
A instead of.
8 resulting from.
C and also.
D unrelated to.
7 According to paragraph 6, certain antidepressants may ..... .
A alleviate respiratory problems.

8 have little effect when the patient has sleep apnea.
C interfere with the treatment for sleep apnea.
D aggravate symptoms of sleep apnea.
8 According to information in paragraph 6, which one of the following statements is

TRUE?
A Sleep apnea affects almost a third of depression sufferers.

8 Sleep apnea episodes may be triggered by nightmares.
C Sleep apnea can intensify post-traumatic stress disorder.
D Sleep apnea can sometimes be cured by antidepressants.
9 According to paragraph 7, the partners of those suffering from sleep apnea can ..... .
A also suffer from tiredness.

8 require relationship counselling.
C help to eliminate problems.
D also develop sleep apnea.
END OF PART B- TEXT 1

l(§!jl:tJ
Immunisation and autism
Paragraph 1
Autism is a developmental disorder that commonly affects a child's behaviour, communication and
ability to interact with others. Children are often diagnosed between the ages of 18 months and two
years and the disorder is more common in boys than girls. While the exact cause remains unknown,
recent research suggested a combination of brain development, genetics and environmental factors
(such as diet) may be involved.
Paragraph 2
Controversially, however, links have been made between autism and the measles-mumps-rubella
(MMR) vaccine, which, according to the current Australian Standard Vaccination Schedule, should
be first administered to children at 12 months of age, with a second dose at four years of age. In
1998, researchers at the Royal Free Hospital in London proposed that the measles component of
the vaccination triggers a cascade of events in susceptible children, starting with inflammatory
bowel disease (IBD) and ending in autism. The premise of the theory is that IBD damages the gut
lining to the point where essential vitamins and nutrients cannot be absorbed, possibly leading to
developmental disorders such as autism.
Paragraph 3
Critics of this study argue that the sample was too small and that the methodology was flawed,
pointing out that the sample group was too selective to be significant. All of the children, for
example, were specifically referred to the hospital because of digestive problems. Also, the proposed
association between autism and the MMR vaccination was based only on parental recall.
Paragraph 4
A large number of independent researchers from around the world, using many different techniques
ranging from molecular biology studies to population-based epidemiology, have now shown that
there is no evidence of a link between the MMR vaccine and autism or IBD. Researchers in Japan,
for example, replicated the Royal Free Hospital experiment using similar methodology and could
not find any measles viruses in the intestinal tracts of their subjects, a finding contrary to the London
study, which did. A review by the World Health Organization concluded that current scientific data
do not permit a causal link to be drawn between the measles virus and autism or IBD. An extensive
review published in 2004 by the Institute of Medicine, an independent expert body in the United
States, also concluded that there is no association between the MMR vaccine and the development
of autism.
Paragraph 5
It is true to say that despite these studies, concerns persist within the Australian community, as well
as elsewhere. In the United States, for example, recent court cases have been brought against drug
companies by families with autistic children who attribute the onset of their children's difficulties
to immunisations which contained the substance thimerosal, a preservative substance containing
mercury, which for years was commonly present in MMR vaccines. In 1982, the US Food and Drug
Administration (FDA) called for the removal of thimerosal in over-the-counter products because
of its toxicity, but it continued to be used in immunisations. In 1999, the FDA recognised that the
amount of thimerosal in immunisations exceeded federal safety guidelines set by the Environmental
Protection Agency and asked that drug manufacturers expeditiously eliminate or reduce the use of
the substance. Supporters of the move raise the point that although warnings about eating too much
seafood containing mercury are quite common, there have been no warnings about mercury in
vaccines, and that some symptoms of autism resemble symptoms of mercury poisoning.
Paragraph 6
Again, however, the scientific evidence available to date suggests that thimerosal in vaccines has
never caused any harm. Although a study published by Geier and Geier in 2003 suggested links
between thimerosal in vaccines and the rates of autism and heart disease in the United States, these
findings have been dismissed because of numerous errors in the study's methods. A recent review
published in the journal Pediatrics assessed all the published studies regarding thimerosal and autism,
and concluded that there was no link between thimerosal-containing vaccines and autism spectrum
disorder. In 2008, researchers at the California Department of Public Health looked at autism rates of
children aged 3 to 12 from 1995 to March 2007 who had active cases with the department, or those
who were receiving services from the state for an autism disorder. They found that autism rates in
that state have continued to rise despite the removal of thimerosal from most childhood vaccines.
Paragraph 7
Despite such overwhelming medical evidence and repeated urgings from all levels of government
in Australia, a small percentage of the public remain sceptical and refuse to have their children
immunised with the MMR vaccine. According to the National Centre for Immunisation Research
and Surveillance (NCIRS), approximately 94% of Australian parents get their child vaccinated at
12 months with the MMR vaccine, while approximately 2-3% are concerned about, and sometimes
opposed to, immunisation.
TURN OVER
www.occupationalenglishtest.org 37
Questions
10 According to paragraph 1, current theories on the cause of autism are ..... .
A imprecise.
8 reserved.
C untested.
D unknown.
11 According to paragraph 2, the 1998 Royal Free Hospital study in London ..... .
A was supported by Australian authorities.

8 claimed that the MMR vaccine could cause 180.
C confirmed that autism is caused by the MMR vaccine.
D attributed IBD to damage in the gut lining.
12 According to research carried out by the Royal Free Hospital, which one of the
following statements is TRUE?
A Autism is a complication arising from measles.

8 The MMR vaccine should be administered once only.
C 180 makes children susceptible to autism.
D Absorption of substances into the gut can lead to autism.
13 The London study was NOT questioned in terms of ..... .
A the limited aim of the study.

8 the number of patients in the study.
C the nature of the sample.
D the method of collecting evidence.
14 Which one of the following statements is NOT supported by information in

paragraph 4?
A The London study was replicated by Japanese researchers.

8 There is no causal link between the MMR vaccine and 180.
C Japanese children are immune to measles.
D The Japanese study contradicted the London study.
38 www.occupationalenglishtest.org
Questions
15 Before 1999, the quantity of thimerosal in immunisations ..... .
A was equal to the amount found in much seafood.

8 was high enough to cause mercury poisoning.
C surpassed American safety guidelines.
D was responsible for the onset of autism in some children.
16 According to paragraph 5, thimerosal ..... .
A was removed from MMR vaccines in 1982.

8 was banned by the FDA in 1999.
C may still be used in immunisations.
0 was totally removed from all over-the-counter products in 1999.
17 According to paragraph 6, the link between thimerosal and autism ..... .
A is contradicted by rising rates of autism in California.

8 was recently claimed in a Pediatrics review.
C is more prevalent in children aged 3-12 years.
0 is complicated by rates of heart disease.
18 According to paragraph 7, concerns in Australia about MMR vaccinations have ..... .
A resulted in the removal of thimerosal from vaccinations.

8 dissipated in the light of medical evidence.
C increased in spite of the medical evidence.
0 continued to influence immunisation rates.
19 According to paragraph 7, 2-3°/o of Australian parents ..... .
A refuse to immunise their children.

8 are apprehensive about immunisation.
C immunise their children at 12 months old.
D are under surveillance by the NCIRS.
END OF READING TEST
-- :•~ET OCCUPATIONAL ENGLISH TEST
READING PART B ANSWER SHEET
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OET is owned by Cambridge Boxhill Language Assessment Trust (CBLA}, a venture between Cambridge English and Box Hill Institute
Reading sub-test
Part B - Answer key
Practice test 1
Sleep apnea
The OET Centre

PO Box 16136 Telephone: +613 8656 4000
Collins St West Facsimile: +613 8656 4020
VIC 8007 Australia www.occupationalenglishtest.org
© Cambridge Boxhi/1 Language Assessment ABN 51 988 559 414
w.ocuatinle~h,: nra Ll':l

Reading Sub-test
Part B - Text 1: Sleep apnea
Answer Key
1 D activity.
2 D can occur with central sleep apnea.
3 D Less than 5%.
4 B can happen a hundred times in a night.
5 B a more influential factor in sleep apnea than obesity is.
6 D unrelated to.
7 A alleviate respiratory problems.
8 c Sleep apnea can intensify post-traumatic stress disorder.
9 A also suffer from tiredness.
END OF KEY
Reading sub-test
Part B - Answer key
Practice test 1
Immunisation and autism
The OET Centre

PO Box 16136 Telephone: +613 8656 4000
Reading Sub-test
Part B - Text 2: Immunisation and autism
Answer Key
10 A imprecise.
11 B claimed that the MMR vaccine could cause IBD.
12 c IBD makes children susceptible to autism.
13 A the limited aim of the study.
14 c Japanese children are immune to measles.
15 c surpassed American safety guidelines.
16 c may still be used in immunisations.
17 A is contradicted by rising rates of autism in California.
18 D continued to influence immunisation rates.
19 8 are apprehensive about immunisation.
END OF KEY
11§31:11
Hygiene and public health
Paragraph 1
Hygiene is a set of practices which reduces exposure to bacteria, viruses and parasites through
cleanliness and sterilisation. It is the best preventive measure against infectious diseases and includes
methods such as washing one's hands, particularly before handling food, covering one's face when
sneezing or coughing, and social distancing (avoiding other people when infected). To varying degrees,
personal hygiene is a universal practice, and one that is often dictated by habit and routine. However, the
motivations behind it have been found to be complex, with social, psychological and cultural influences.
Paragraph 2
Hygiene practices have been around since ancient times. For the Greeks and Romans, bathing was
common, but had more to do with spiritual purification and relaxation than cleanliness. During the
Renaissance, on the other hand, hygiene took a step backwards, since a layer of filth was believed to
protect against illness. Indeed, it was not until 1860 that Louis Pasteur made the connection between
germs and disease. Prior to this time, sterilisation was not practiced and personal cleanliness was
maintained purely for religious or aesthetic reasons. As more bacteria were identified, scientists
established ways to immunise against them and to safeguard people from sickness through conscientious
hygiene. By the 20th century, most of the diseases that had afflicted many nations had been eradicated
or were under control. However, in poorer parts of the world, illnesses that can be prevented by good
hygiene still persist. Infectious diseases account for 62% of deaths in Africa, but only 5% in Europe.
Paragraph 3
In countries where many preventable communicable diseases are widespread, personal hygiene is very
important. However, in many cases, it is not practiced properly or consistently. Studies by the London
School of Hygiene and Tropical Medicine in the United Kingdom have looked at hygiene behaviours
in developing countries. In Ghana, for example, 84,000 children die from diarrhoea each year, a disease
easily prevented by vigilant handwashing. The study found that hygiene practices were substandard
and that the strongest incentives had more to do with notions of social acceptance than protection from
disease, as cleanliness was often an indicator of status. While epidemics of diseases, such as cholera,
encouraged more thorough handwashing, .i! was usually short-lived. Since deep-seated habit has been
found to be the key behavioural motivator, the studies proposed a health promotion initiative that
targeted people who were going through a life-changing event, such as giving birth. It is at these times
that people are believed to be more open to incorporating new behaviour into their lives, such as a
different cleaning regime.
Paragraph 4
While an awareness of hygiene and cleanliness is vital for health, individuals prone to obsessive
behaviour have been shown to take this to the extreme. Roughly half the number of people with
Obsessive-Compulsive Disorder (OCD) also have abnormal concerns about contamination. This is
manifested in excessive sanitising and disinfecting of the body and environment. It was originally thought
that this behaviour was motivated by fear of disease and infection, but recent research has reassessed this
view. A study by Vanderbilt University in Tennessee looked into the relationship between disgust and
contamination-related OCD symptoms. Disgust elicits a very different physiological and behavioural
response to fear. The study found strong evidence that disgust plays a large role in contamination-related
avoidance, and suggests that it is a response independent of anxiety and depression. This finding may, in
time, help individuals with compulsive disorders to gain a more balanced view of contamination.
Paragraph 5
Force of habit can be very powerful and routine behaviour difficult to change. Even in the hospitality
industry, where hygiene and cleanliness are of paramount importance, bad habits endure. A study by the
University of Surrey in the UK looked at the motivations behind food hygiene practices of a number
of hospitality workers. The study found that the most influential incentive was the belief that people
in authority - such as a Health Officer or supervisor - required them to carry out safe food-handling
routines. While training and education are useful, they were seldom the sole motivator for food safety.
This exemplifies the problem faced by promoters of hygiene: ingrained habits are difficult to shake, in
all cultures. Researchers have long argued that hygiene promotion should target the poorest nations and
sectors of society. People in these groups are often less receptive to changing their behaviour, and they
are also the most vulnerable to disease.
TURN OVER
Questions
1 According to paragraph 1, personal hygiene is most often a ...... practice.
A complex
B customary
C clean
D cultural
2 According to paragraph 1, which one of the following best defines 'hygiene'?
A 'A socially conditioned habit'.

B 'The avoidance of bacteria'.
C 'A sanitary routine which prevents ill-health'.
D 'A set of rules to follow when ill or infectious'.
3 According to paragraph 2, hygiene-related disease ..... .
A reduced as scientific knowledge increased.

B is a 20th century phenomenon.
C is still unpreventable in some countries.
D has been eradicated by widespread immunisation.
4 The word 'conscientious' in paragraph 2 could best be replaced by ..... .
A hard-working.
B fussy.
C meticulous.
D perfect.
5 The word 'jj;' in line 8 of paragraph 3 refers to ..... .
A an epidemic.
B cholera.
C handwashing.
D none of the above.
Questions
6 According to paragraph 3, ..... .
A reducing death rates from poor hygiene in developing countries is very simple to do.
B disease epidemics are generally effective for changing societal hygiene practices.
C pregnant women in developing countries are most likely to observe hygiene routines.
D life-changing events are considered as good catalysts for effecting other changes.
7 According to paragraph 4, people with Obsessive-Compulsive Disorder (OCD) ..... .
A recognise how important cleanliness is for health.

B will also have an obsession with hygiene practices.
C may not necessarily fear contamination by germs.
D are confused about the causes of their condition.
8 According to paragraph 4, manifestations of disgust ..... .
A may be related to contamination-related OCD.

B are similar to people's reactions to fear of contamination.
C also include anxious and depressive behaviours.
D may indicate disease improvement in a person with OCD.
9 According to the study described in paragraph 5, what was the main reason for hygiene practices
used by hospitality workers?
A They were seen to be required by those in charge.

B Workers were provided with incentives to carry out good hygiene.
C The importance of good hygiene was unknown by workers.
D They are ingrained through training and education.
10 According to paragraph 5, people in poor countries have been considered appropriate targets for
hygiene promotion because they ..... .
A are most likely to obey the hygiene instructions of their supervisors.

B have very low levels of understanding of contamination processes.
C are less amenable to behavioural change despite clearly requiring it.
D have similar unhygienic practices as poor people in rich societies.
TURN OVER FOR PART B- TEXT 2
1[§31:t1
Fructose malabsorption
Paragraph 1
Over the last few decades, there have been conflicting studies about whether the level of sugar intake in
the Western diet has increased significantly. Certainly, on the face of it, with obesity rates soaring across
the Western world, and with surges in lifestyle and diet-related diabetes, it appears that increased sugar
intake is at least highly likely. Moreover, studies have repeatedly found that the modem diet, with its
greater consumption of fruit juices and sugared carbonated drinks, as well as sweetened, processed foods,
offers more opportunities than in the past for the over-consumption of fructose, a natural form of sugar
also present in many commonly-consumed foods, such as fruits, honey, vegetables and wheat.
Recent clinical studies have shown that this increased dietary load of fructose may cause significant
problems for the absorptive capacity of the small intestine, leading to a condition known as Fructose
Malabsorption (FM).
Paragraph 2
If not completely absorbed in the small intestine, fructose can make its way through to the large intestine
where luminal bacteria rapidly ferment it to produce hydrogen, carbon dioxide and short-chain fatty
acids. This rapid gas production can manifest as abdominal bloating, wind, pain, nausea, and may
also lead to diarrhoea or constipation. Symptoms such as these are frequently associated with those of
Irritable Bowel Syndrome (IBS). Furthermore, provocation studies have shown that high fructose loads
administered to FM sufferers have induced symptoms more easily in those who also suffer from IBS than
in those who do not. These results have led to the theory that the reduction or removal of fructose from
the diet may, in tum, reduce the symptoms of IBS. In general, however, IBS treatments rarely address
dietary fructose. One reason for this is that while more than a third of adults with IBS also present with
FM, they are considered to be separate diseases. Another reason is that FM is not specific to IBS patients.
Paragraph 3
A recent study conducted in Australia investigated the hypothesis that a reduction in dietary fructose
would have a positive effect on IBS symptoms in FM patients. One of the major goals of the study was
the formulation of dietary guidelines directed at limiting fructose intake. The study followed 62 patients
with IBS and FM as diagnosed by a hydrogen breath test, a measurement of the presence of hydrogen in
the breath which, in humans, is an indicator that anaerobic bacteria in the colon are producing hydrogen
as a result of being exposed to unabsorbed food, particularly sugars and carbohydrates. At the beginning
of the study, the 62 patients were given basic instruction as to the nature of malabsorption and a list of
problem foods, which included 'foods to avoid', such as honey and large quantities of wheat, as well as
apple, pear, mango and watermelon; foods considered to be 'problematic' if consumed in excess, such as
dried fruit, fruit juice, onion, spring onion, leek, asparagus and artichoke; and a list of 'safe' foods, such
as fresh meats, eggs and nuts. After a median time-frame of 14 months (range 2 to 40 months) of dietary
intervention, a structured telephone interview assessed the patients' adherence to the diet and the longer
term effect on symptoms.
Paragraph 4
Almost eighty per cent of the patients adhered to the diet, following it always or frequently. Those
patients who did not adhere to the diet cited as their main reasons an unwillingness to undertake dietary
recommendations, difficulties accessing specialty wheat-free foods and a dislike of the taste of such
foods. The diet was also more difficult to follow when eating away from home. Adherence to the diet was
associated with marked improvement in all abdominal symptoms with seventy-five per cent of all patients
responding positively. Positive response overall was significantly better in those adherent to the diet than
non-adherent (85% versus 36%), as was improvement in individual symptoms.
Paragraph 5
The study found that although the restriction of certain foods was critical to the success of the diet,
the key to its effectiveness was the emphasis on proposing suitable food alternatives instead of simply
prohibiting problematic foods. Realistic goals, facilitated by intake limitations rather than total bans,
allowed patients a degree of flexibility in their food-choices as opposed to a strict 'fructose-free'
dietary regime. The result of the study was the formulation of a comprehensive diet directed at limiting
fructose intake which, when applied to patients with IBS and FM, revealed that a high level of sustained
adherence was linked to a high rate of improvement in their symptoms.
TURNOVER
Questions
11 According to paragraph 1, argument for increased sugar levels in the Western diet is ..... .
A feasible.
B non-existent.
C doubtful.
D overstated.
12 According to Paragraph 2, which one of the following statements is TRUE?
A FM sufferers also suffer from IBS.

B IBS sufferers also suffer from FM.
C IBS and FM are related diseases.
D IBS and FM are distinct diseases.
A IBS and FM are separate conditions that rarely co-exist.

B FM leads to IBS.
C FM sufferers usually also have IBS.
D FM is rarely treated in IBS sufferers.
14 According to paragraph 3, the patients in the study were interviewed ..... .
A 14 months after commencement of the diet.

B once they had been educated on dietary modification.
C when it was clear that they had adhered to the diet.
D between 2 and 40 months after starting the diet.
15 According to paragraph 3, one purpose of the telephone interview was to check ..... .
A if participants understood the diet instructions.

B if participants followed the diet instructions.
C the long term effects of exposure to fructose.
D how long the participants stayed on the diet.
Questions
A around 80% of the patients in the study always adhered to the diet.
8 some of those who did not stick to the diet improved in their symptoms.
C twenty percent of the patients did not stick to the diet outside of the home.
D those patients who were unable to adhere to the diet did not really want to.
17 According to paragraph 4, reduction in fructose intake ..... .
A was reported to be an enjoyable food experience by most participants.

8 could be a means of alleviating symptoms of Fructose Malabsorption.
C is necessary for relief of abdominal symptoms in 188 and FM patients.
D produced at least some negative effects in those who adhered to the diet.
18 According to paragraph 4, reasons given by participants for non-adherence to the diet did NOT
include ..... .
A affordability.
8 flavour.
C attitude.
D impracticality.
19 According to paragraph 5, the study resulted in a ...... dietary plan.
A strict
8 limited
C thorough
D simple
20 According to paragraph 5, dietary modification recommended by the study's researchers

involved ..... .
A eliminating fructose from the patient's diet.

8 letting patients eat whatever they felt comfortable with.
C allowing patients to over-indulge occasionally.
D substituting symptoms-producing foods.
END OF READING TEST

-- ~ET OCCUPATIONAL ENGLISH TEST
READING PART 8 ANSWER SHEET
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Reading sub-test
Part B - Answer key
Practice test 2
Hygiene and public health
The OET Centre

PO Box 16136 Telephone: +613 8656 4000

Reading Sub-test
Part B - Text 1: Hygiene and public health
Answer Key
1 B customary
2 c 'A sanitary routine which prevents ill-health'.
3 A reduced as scientific knowledge increased.
4 c meticulous.
5 c handwashing.
6 D life-changing events are considered as good catalysts for effecting other changes.
7 c may not necessarily fear contamination by germs.
8 A may be related to contamination-related OCD.
9 A They were seen to be required by those in charge.
10 c are less amenable to behavioural change despite clearly requiring it.
END OF KEY
Reading sub-test
Part B - Answer key
Practice test 2
Fructose malabsorption
The OET Centre

PO Box 16136 Telephone: +613 8656 4000

Reading Sub-test
Part B - Text 2: Fructose malabsorption
Answer Key
11 A feasible.
12 D IBS and FM are distinct diseases.
13 D FM is rarely treated in 18S sufferers.
14 D between 2 and 40 months after starting the diet.
15 8 if participants followed the diet instructions.
16 8 some of those who did not stick to the diet improved in their symptoms.
17 8 could be a means of alleviating symptoms of Fructose Malabsorption.
18 A afford ability.
19 c thorough
20 D substituting symptoms-producing foods.
END OF KEY
l[fii:ll
Hypochondria
Paragraph 1
Although people often joke about hypochondria, experts say it is a real disorder that puts strain on the
medical system and affects an estimated four to six per cent of primary care patients. While it is widely
believed that hypochondriacs are malingerers, research suggests they may be more finely tuned to their
bodies than other people are. The problem is that they repeatedly misread symptoms, regardless of how
benign they might be, and tend to believe they suffer from diseases where diagnosis is often difficult.
Paragraph 2
Because hypochondriacs are reluctant to acknowledge the possible role of psychosocial factors in
causing their symptoms, they often provoke strong antipathy on the part of physicians, who find them
exceptionally frustrating to treat. As many doctors do not really know how to handle the situation, and
in the increasingly litigious setting of the GP surgery, they may grant approval for unnecessary tests to
help put both themselves and their patients at ease. Evidence suggests, however, that this is a reasonably
pointless exercise and usually only serves to exacerbate the concerns of the already anxious patient. It
also puts a strain on an already overburdened medical system.
Paragraph 3
There are several treatment options for hypochondriasis. According to Dr A. J. Barsky from the Brigham
and Women's Hospital (BWH) in Boston, Massachusetts, while hypochondriasis is regarded as a
psychiatric disorder, from the perspective of patients, their problems are a medical concern, so referring
them directly to a psychiatrist is likely to be interpreted as an outright dismissal of their symptoms, and
can lead to a lack of trust. They may, however, be more receptive to seeing a mental health professional
if it is recommended for the general emotional distress they are experiencing about their perceived health
problems.
Paragraph 4
Other doctors prefer pharmacotherapy or treatment with medications. Around two-thirds of people
diagnosed with hypochondriasis have a coexisting psychiatric disorder such as major depression, panic
disorder or obsessive-compulsive disorder, and studies show that treating these accompanying problems
with appropriate pharmacological options, for example through using antidepressants, can often alleviate
the symptoms of hypochondriasis at the same time.
Paragraph 5
Recent research involving drug-free therapeutic treatments combined with appropriate care by GPs
points to potentially significant advances in the treatment of hypochondriasis. Cognitive behavioural
therapy (CBT) is one option. When treating hypochondriasis, the aim is to help people not to read
so much into their symptoms. In an experimental, six-session CBT program, researchers from BWH
compared two groups of patients suffering from hypochondria. The primary care physicians assigned to
the 102 patients receiving the therapy also received a special letter outlining treatment and management
recommendations. A control group of 80 patients, followed for the same period of time, did not undergo
the CBT therapy and their doctors did not receive the letter. After one year, the group undergoing therapy
showed a significant improvement in symptoms compared to the patients who received the usual medical
care. They reported feeling better, with fewer symptoms and less anxiety about their health. They were
also found to have improved social functioning and improved functioning in their daily activities, such as
doing errands and working around the house.
Paragraph 6
Another, more recent, drug-free approach to treatment uses the unlikely stimulus of sound. Dr Michael
Cavanagh and Professor John Franklin of Macquarie University, Sydney, undertook a controlled clinical
trial of what they describe as 'attention training', a technique originally developed at the Manchester
Royal Infirmary. Imagine a tap dripping while you are trying to sleep at night. Pay attention to the
dripping and it is sure to get louder. As the sound is amplified, echoing throughout the hollows of your
mind, your anxiety increases. In this case it is sound that is the bugbear, but in hypochondriasis it is
bodily sensations. 'What happens in health anxiety is that people become so locked on their symptoms
that they actually can't shift their attention onto anything else. They don't tune into other sorts of
evidence or ways of thinking about what's happening to them,' says Franklin. The idea with attention
training is to shift patients' attention away from the sensations that they are preoccupied with. Patients
participate in sessions during which they listen to a complex array of sounds mixed together. They are
required to discriminate between each sound, and then swap their attention from one to the next.
Paragraph 7
In this very small but promising trial, the 21 participants showed significant reductions in the time they
spent worrying about and checking on their health, their need for reassurance, and the severity of their
conviction that they were ill. A follow-up 18 months later revealed that, in most cases, these benefits had
been retained. Clearly, part of the success of this treatment is having someone affirm, without judgement,
the participant's anxiety about their health. Some patients come to accept that they may be suffering from
a psychological condition.
TURN OVER
Questions
1 In paragraph 1, 'malingerers' are people who are ......
A insensitive to their symptoms.

8 amusing.
C seriously ill.
D pretending to be ill.
2 According to paragraph 2, hypochondriacs are frustrating to treat because they ..... .
A dismiss their symptoms as medical.

8 are litigious.
C exacerbate their concerns.
D reject a psychosocial diagnosis.
3 In paragraph 2, what is said to be 'pointless'?
A Not knowing how to handle the situation.

8 Approving tests.
C The threat of litigation.
D Putting patients at ease.
4 According to Dr Barsky in paragraph 3, which of the following is TRUE?
A Hypochondriacs rarely see psychiatrists for emotional distress.

8 Psychiatrists dismiss hypochondriacs' symptoms.
c Psychiatrists tend to misinterpret hypochondriacs' concerns.
D Hypochondriacs feel let down when referred to psychiatrists.
5 According to paragraph 4, treating hypochondriacs with medications ..... .
A can create accompanying problems.

8 is an alternative to pharmacotherapy.
C frequently reduces the symptoms of hypochondria.
D may worsen coexisting psychiatric disorders.
Questions
6 According to paragraph 5, the BWH study ..... .
A found that the control group had improved social functioning.

S demonstrated that drug-free treatments have promise.
C provided all participating physicians with information on CST.
D revealed that appropriate care by GPs is preferable to CST.
7 According to paragraph 6, attention training ..... .
A does not tune hypochondriacs into other ways of thinking.

S causes hypochondriacs to become locked on their symptoms.
C amplifies the anxiety felt by hypochondriacs.
D diverts hypochondriacs' attention away from their symptoms.
8 According to paragraph 6, in the Macquarie University trial, ..... .
A researchers initially thought sound was unlikely to work as a stimulus.

S patients listened to a variety of sounds.
C methods were adapted from military training techniques.
D a dripping tap was used because of the way it echoes in the mind.
9 According to paragraph 7, after the Macquarie University trial had finished, the
participants ..... .
A showed reduced symptoms of hypochondria.

S had the same need for reassurance.
C had a stronger conviction that they were ill.
D expressed a greater anxiety about their symptoms.
10 According to the WHOLE text, which of the following is NOT a belief of hypochondriacs?
A Other people misinterpret their symptoms.

S Doctors are unsympathetic.
C They have a psychological problem.
D They have symptoms of a serious disease.
END OF PART B- TEXT 1
TURN OVER FOR PART B- TEXT 2
li§31:t1
Gender assignment
Paragraph 1
Boy or girl? This is one of the first questions new parents are asked. But sometimes it is not so clear,
with about one in 4,500 Australian children born without a clearly identifiable sex. Doctors and parents
face huge dilemmas when they have to make the choice - boy or girl. Hermaphroditism - also known as
intersexuality - is characterised by ambiguities of the external sex organs and the internal reproductive
system, resulting from any of a wide variety of genetic and hormonal irregularities. Every individual
affected is unique. Sometimes an intersexual child or adult can look quite unambiguous sexually,
although internally sex anatomy is mixed.
Paragraph 2
At the core of the intersex debate is 'normalising' surgery on babies and very young children. While it
is widely accepted that it is important, socially and psychologically, for children to have a clear gender
identity, there is some disagreement about what determines whether someone feels male, female, or a bit
of both.
Paragraph 3
Until recently, the dominant medical system for treating intersex assumed gender was all a matter of
nurture, not nature. John Money, an influential psychologist at John Hopkins University, claimed that
a child could be turned into either gender as long as the parents believed in the assigned gender. As
a consequence, doctors made a decision about what gender a child was and then scheduled intensive
'normalising' surgeries to try to make the child appear clearly female or male.
Paragraph 4
Money used a case known as 'John/Joan' to prove this system worked. An eight-month-old boy (John)
suffered an accident during circumcision and Money recommended that the child be made into a girl
(Joan). While for years Money claimed the sex reassignment was successful, it is now known that the
child was never happy as a girl and eventually switched back to being a male. Nevertheless, the John/
Joan case stood as the precedent upon which thousands of sex reassignments were performed.
Paragraph 5
The main challenge to Money's claims has come from Dr Milton Diamond, Professor of Anatomy and
Reproductive Biology at the University of Hawaii. Diamond used evidence from biology, psychology,
psychiatry, anthropology and endocrinology to argue that gender identity is hardwired into the brain
virtually from conception. For Diamond, John/Joan's case is evidence that gender identity is largely
inborn, and that while rearing may play a role in helping to shape it, nature is by far the stronger of the
two forces.
Paragraph 6
This conclusion is supported by child psychiatrist Bill Reiner, who has been following the lives of six
genetic males who suffered injuries in infancy and were subsequently raised as girls. Two years into his
study, all six are closer to males than to females in both attitudes and behaviour. Two have spontaneously
(without being told of their XY male chromosome status) switched back to being boys. While more
studies are needed, few researchers today dispute the mounting evidence of a strong inborn bias for
gender identity. Indeed, modem neurobiological research is leading scientists toward the conclusion that
the most important sex organ is the brain.
Paragraph 7
Since physicians currently have no way of being sure in which direction, male or female, the infant's
gender identity has differentiated, some surgeons and intersex patient advocacy groups have called for
a moratorium on paediatric surgery. Putting off the surgeries until at least puberty allows the child to
have input on the decision, and it seems to provide for better outcomes as well as for the possibility that
surgical techniques and outcome data will improve in the interim.
Paragraph 8
However, in some cases there are medical reasons for early surgery. Women who have XY material in
their reproductive systems have an approximately 30 per cent risk of malignancy by the time they are
about 30 years of age. If there is a tumour, it develops into a terminal cancer. Furthermore, some doctors
believe that surgery might be more successful if it is done in children rather than at a later age, because
the patient is smaller.
Paragraph 9
However, most practitioners acknowledge that there are a number of risks. Children who have had early
surgery spend their childhood having follow-up examinations and this can have a profound effect on their
attitude towards sex. Furthermore, some surgeries require that parents provide follow-up care that they
may find very troubling. A tradition of secrecy means most parents are totally unprepared to make these
decisions. There are also cultural and religious differences in the way this issue is dealt with.
Paragraph 10
For intersex babies, doctors and parents need to work together to try to decide what gender a child is
likely to feel, given the child's anatomy and physiology, what doctors know from scientific studies of
outcomes in similar cases, and how the parents perceive that child's gender. Whatever is decided, the
parents and child will need substantial and continuous professional and peer support.
Questions
Part 8 - Text 82: Questions 11-19 ·
11 The word 'assigned' in paragraph 3 means ......
A obvious.
B dominant.
C given.
D uncertain.
12 According to paragraph 4, the John/Joan case ..... .
A was very influential in the field of sex reassignment.

B proved that sex reassignment can be successful.
C is an example of sex reassignment due to hermaphroditism.
D proved that intersex children can never be happy.
13 According to paragraph 6, in Reiner's study, the subjects who reverted to the male sex provide
evidence of ..... .
A a desire to conform to group attitudes and behaviour.

B how neurobiological research can influence such decisions.
C the importance of knowing individual chromosome make-up.
D the primacy of hardwired gender identity.
14 According to paragraph 7, some intersex patient advocacy groups ..... .
A argue that surgery is less successful on younger children.

B do not trust doctors' judgements of children's gender identity.
C want surgery on young children to be halted.
D believe puberty is the only time children can decide their own sex.
15 According to paragraph 8, which one of the following arguments supports paediatric surgery?
A Parents' judgements on the child's likely sexual identity.

B Greater likelihood of success on less mature patients.
C Potential for good monitoring and follow-up examinations.
D Sexual identity is already decided before birth.
Questions
16 According to paragraph 9, which of the following is given as a reason parents have difficulty in
dealing with gender assignment?
A Intersexuality tends not to be discussed.

8 Religions do not acknowledge the issue.
C Cultural differences vary widely.
D They have insufficient medical expertise.
17 Match the heading, 'Arguments supporting paediatric surgery' with the paragraph it suits best.
A Paragraph 2
8 Paragraph 3
C Paragraph 7
D Paragraph 8
18 Match the heading, 'Arguments supporting delayed surgery' with the paragraph it suits best.
A Paragraph 4
8 Paragraph 5
C Paragraph 7
D Paragraph 8
19 The article as a WHOLE ..... .
A rejects paediatric surgery in all cases.

8 cautions that early surgery is often inappropriate.
C strongly supports paediatric surgery.
D recommends that doctors consider cultural differences.

END OF READING TEST
-- :•~ET OCCUPATIONAL ENGLISH TEST
READING PART B ANSWER SHEET
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OET is owned by Cambridge Boxhill Language Assessment Trust (CBLA), a venture between Cambridge English and Box Hill institute
Reading sub-test
Part B - Answer key
Practice test 3
Hypochondria
The OET Centre

PO Box 16136 Telephone: +613 8656 4000

Reading Sub-test
Part B - Text 1: Hypochondria
Answer Key
1 D pretending to be ill.
2 D reject a psychosocial diagnosis.
3 B Approving tests.
4 D Hypochondriacs feel let down when referred to psychiatrists.
5 c frequently reduces the symptoms of hypochondria.
6 8 demonstrated that drug-free treatments have promise.
7 D diverts hypochondriacs' attention away from their symptoms.
8 B patients listened to a variety of sounds.
9 A showed reduced symptoms of hypochondria.
10 c They have a psychological problem.
END OF KEY
Reading sub-test
Part B - Answer key
Practice test 3
Gender assignment
The OET Centre

PO Box 16136 Telephone: +613 8656 4000

Reading Sub-test
Part B - Text 2: Gender assignment
Answer Key
11 c given.
12 A was very influential in the field of sex reassignment.
13 D the primacy of hardwired gender identity.
14 c want surgery on young children to be halted.
15 8 Greater likelihood of success on less mature patients.
16 A Intersexuality tends not to be discussed.
17 D Paragraph 8
18 c Paragraph 7
19 8 cautions that early surgery is often inappropriate.
END OF KEY
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OET 2.

Use the lower end of dose range in patients ≥70 years.

Fractures, dislocations and sprains: Questions

1 procedures for delivering pain relief?

2 the procedure to follow when splinting a fractured

4 the terms used to describe different types of

6 what to look for when checking an injury?

7 how fractures can be caused?

8. What should be used to elevate a patient’s fractured leg?

10. Which parts of a limb may need extra padding?

11 What should be used to treat a patient who suffers respiratory depression?

12 What should be used to cover a freshly applied plaster backslab?

13 What analgesic should be given to a patient who is allergic to morphine?

14 What condition might a patient have if severe pain persists after

splinting, elevation and repeated analgesia?

15. Falling on an outstretched hand is a typical cause of a of the elbow

16. Upper limb fractures should be elevated by means of a______________.

17.Make sure the patient isn’t wearing any on the

18. Check to see whether swollen limbs are or

19. In a plaster backslab, there is a layer of closest to the skin.

20. Patients aged and over shouldn’t be

READING SUB-TEST : PART B

1. The manual informs us that the Blood Pressure Monitor

A is likely to interfere with the operation of other medical equipment.

B may not work correctly in close proximity to some other devices.

C should be considered safe to use in all hospital environments

Instruction Manual: Digital Automatic Blood Pressure Monitor

Electromagnetic Compatibility (EMC)

2. The notice is giving information about

A ways of checking that an NG tube has been placed correctly.

B how the use of NG feeding tubes is authorised.

which staff should perform NG tube placement.

3. What must all staff involved in the transfusion process do?

A check that their existing training is still valid

B attend a course to learn about new procedures

C read a document that explains changes in policy

'Right Patient, Right Blood' Assessments

4. The guidelines establish that the healthcare professional should

A aim to make patients fully aware of their right to a chaperone.

respect the wishes of the patient above all else.

A patient may specifically request a chaperone or in certain circumstances may nominate

5. The guidelines require those undertaking a clinical medication review to

A involve the patient in their decisions.

B consider the cost of any change in treatments.

Annual medication review

It also states that GP practices are expected to

• minimise waste in prescribing and avoid ineffective treatments.

• engage effectively in the prevention of ill health.

6. The purpose of this email is to

A report on a rise in post-surgical complications.

B explain the background to a change in patient care.

To: All staff

Subject: Advisory Email: Safe use of opioids

the incidence of respiratory depression among post-surgical patients to an average

0.5% – thus for every 5,000

surgical patients, 25 will experience respiratory depression. Failure to recognise

respiratory depression and institute timely intervention can lead to cardiopulmonary

arrest, resulting in brain injury or

death. A retrospective multi-centre study of 14,720 cardiopulmonary arrest cases showed

is therefore recommended that post-operative patients now have continuous monitoring,

instead of spot checks, of both oxygenation and ventilation.

READING SUB-TEST : PART C

Part C -Text 1: Questions 7-14