TEXT A: The temporomandibular joint (TMJ) is one of the most frequently used joints of the human body. It is used when speaking, chewing, yawning, swallowing and other activities during the day and even in sleep. The frequency of movement is assessed as about 1500-2000 times a day. The term ‘temporomandibular disorder’ (TMD) stands for a number of disorders related to the masticatory muscles or the TMJs and related structures. In the greatest number of cases, the cause of temporomandibular disorder is a disturbance of function in the form of increased muscular tonus and myofascial trigger points. It is essential to start treatment at the stage of mere dysfunction, i.e., at the stage when the changes are still reversible, in order to prevent irreversible structural changes. According to epidemiological statistics, 70% of the randomized population suffers from at least one symptom or sign of TMD, but only one fourth of this number is aware of it and only 5% seeks medical treatment.

TEXT B: Symptoms: Dull aching pain, which varies in strength from mild to severe, is the most common symptom associated with TMJ disorders. The pain is usually felt in the jaw, but can also be felt in the surrounding areas, including the face, ear, and even the teeth. The pain may also radiate to the neck or shoulders, and is usually made worse by chewing and moving your jaw. Other signs and symptoms associated with TMJ disorders include:
• jaw tenderness;
• jaw clicking, or popping, when you open and close your mouth or chew;
• a grating sensation when chewing;
• an uncomfortable or uneven bite; and
• jaw locking (an inability to open or close the mouth completely).
TMJ disorders can be temporary or chronic, but only a small proportion of people develop significant, long-term problems. Women tend to be affected by TMJ disorders more often than men.

TEXTC: Diagnosis and treatment: A dentist can help identify the source of the pain with a thorough exam and appropriate X-rays. However, for some types of pain, the cause is not easily diagnosed. The pain may be related to the facial muscles, the jaw or the TM joint. Some TMJ problems result from arthritis, dislocation or injury. All of these conditions can cause pain and dysfunction. Muscles that move the joints are also subject to injury and disease. Injuries to the jaw, head or neck might cause some TMJ problems. Other factors relating to the way the upper and lower teeth fit together (the bite) may cause some types of TM disorders. Stress and teeth grinding are also considered as possible factors. There are several treatments for TMJ disorders. They may include stress-reducing exercises, wearing a mouth protector to prevent teeth grinding, orthodontic treatment, medication or surgery. Treatment may involve a series of steps beginning with the most conservative options. In many cases, only minor, non-invasive treatment may be needed to help reduce symptoms.

TEXT D: ABSTRACT: Effectiveness of specific physiotherapy in treatment of TMD. The aim of this study was to evaluate the effect of individual specific physiotherapy in the treatment of temporomandibular disorders, its immediate effect and its effect after two months. The research sample was comprised of 23 subjects, 17 women and 6 men, with an average age of 36.5 years. They complained of pain, sound phenomena and restricted mandibular movements. The patients were first examined by a stomatologist who recommended physiotherapy. The effect of treatment was assessed according to the intensity of pain, the occurrence of reflex changes in soft tissues in the region of the masticatory muscles and digastricus muscle, the range of mouth opening and the intensity of sounds produced by mandibular movements. It was found that after treatment pain was significantly reduced (p<0.001) at the temporomandibular joint (from 4.2 points to 0.7 point on the VAS [Visual Analogue Scale]). There were also fewer reflex changes in the muscles and fascias. The range of mouth opening increased significantly (from 37.3 mm to 41.3 mm, p<0.001) and the intensity of sounds was reduced from 100% to 43% (p<0.001). This state was maintained two months later: intensity of pain (p<0.001), mouth opening (p<0.003) and reduction of sound phenomena (p<0.001). Pain was ameliorated, the intensity of sounds reduced, and the range of movement significantly improved after specific physiotherapy.

For each question, 1-7, decide which text (A, B, C or D) the information comes from.
1 frequently found symptom regarding TMJ disorders?
2 improvements noted after treatment?
3 right time to begin the treatment?
4 ratio of patients to the ones who get medical care?
5 gender-wise prevalence of TMJ disorders?
6 how to reduce the symptoms?
7 role of physiotherapy in the treatment?
Questions 8-14. Answer each of the questions, 8-14, with a word or short phrase from one of the texts
8 Which healthcare professional normally does the diagnosis of TMJ disorders?
9 What is the very common symptom exhibited by TMJ disorders?
10 What does ‘VAS’ stand for based on the information given in the texts?
11 What was the average age of the subjects in the research study?
12 What is the term for the inability to open or close the mouth completely?
13 What type of treatment was offered to the subjects in the research study?
14 Where does a patient suffering from TMJ disorders normally sense the pain?
Questions 15-20. Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
15 TMJ is one among the more regularly used in our body.
16 Apart from the pain and sound phenomena, the subjects also complained about .
17 An oral guard is used to avoid .
18 Small, may be required to reduce symptoms of TMJ in most cases.
19 TMJ disorders can be or non-permanent.
20 The aching caused by TMJ disorders may also emanate to the .

PART B. For questions 1-6, choose the answer (A, B or C) which you think fits best according to the text.

1. According to the extract, the nursing facilities require more physicians, who
A. increase the demand of quality long-term care.
B. lead the clinical decision-making for patients after care.
C. can offer care on-site to nursing facility residents.
Nursing Facility Care: Nationwide, nursing facility care is changing to include not only long-term care of frail residents but also complicated and resource-intensive post-hospital care. The population of people receiving care in nursing facilities is more medically complex as patients are discharged ‘sicker and quicker’ from the hospital to skilled nursing facilities and the hospitals focus on decreasing readmission rates. However, the majority of patients are still long term stay patients who themselves have increased in medical complexity and acuity. Both of these imperatives have resulted in an increased need for highly trained and committed health care practitioners willing to provide care on-site to nursing facility residents. Physician involvement in nursing facilities is essential to the delivery of quality long-term care. Attending physicians should lead the clinical decision-making for patients under their care. They can provide a high level of knowledge, skill, and experience needed in caring for a medically complex population in a climate of high public expectations and stringent regulatory requirements

2. Material-mediated pyrogenicity is not assessed using
A. traditional non biocompatibility extraction method.
B. pyrogenicity test equivalent validated method.
C. material-mediated pyrogenicity testing.
Pyrogenicity: Implants as well as sterile devices having direct or indirect contact with the cardiovascular system, the lymphatic system, or cerebrospinal fluid and devices labeled as “non-pyrogenic,” should meet pyrogen limit specifications. Pyrogenicity information is used to help protect patients from the risk of febrile reaction. There are two sources of pyrogens that should be considered when addressing pyrogenicity. The first, material – mediated pyrogens, are chemicals that can leach from a medical device during device use. Pyrogens from bacterial endotoxins can also produce a febrile reaction similar to that mediated by some materials. Material-mediated pyrogenicity testing is not needed if chemical characterization of the device extract and previous information indicate that all patient- contacting components have been adequately assessed for pyrogenicity. Otherwise, we recommend that you assess material-mediated pyrogenicity using traditional biocompatibility extraction methods, using a pyrogenicity test or an equivalent validated method.

3. What is the purpose of the Staffing Reallocation Plan?
A. reallocate RNs from home unit to another unit to provide needed patient care.
B. balance patient census and care needs with RN competencies and availability.
C. flex RNs who match patient census with patient care needs according to their specialty.
Staffing Reallocation Plan: The Staffing Reallocation policy was revised to ensure a consistent system-wide approach that correlates patient census and patient care needs with RN competencies and availability. The newly standardized process may include reallocating RNs from their home unit to another like unit to provide needed patient care. The policy was reviewed and vetted by nurses at all levels of the organization. A standard icon was created in scheduling and productivity system to easily identify RNs who sign- up for additional shifts to support patient care needs. This allows the nursing division to utilize the most cost-effective staffing resources at the appropriate time for the specific patients requiring care. The Clinical Administrators work collaboratively with the Staffing Resources Office and nursing leadership to reallocate and/or flex RN staff matching patient census with patient care needs and the specialty RNs needed to provide care.

4. If a patient request for an assisted death, nurses must
A. explore the reasons and understand them to seem helpful
B. ensure every opportunity to relieve suffering is offered
C. talk to their superior and team for a formal request
Assisted Death: Every question from a patient about assisted death signifies that the patient is, or is worried about, suffering and is an opening for a dialogue with that individual. It is important for us, as nurses, to explore the reasons for the request in order to understand what supports might be helpful, and whether the patient has unmet needs.
Whether or not, a nurse is prepared to be involved in any way in assisting someone to die, they remain a part of the team caring for the patient. Nurses should advocate for their patients, including the pursuit of aggressive symptom management strategies, to ensure every opportunity to relieve suffering is offered. Nurses should also understand the process for medical assistance in dying, and their professional role in the process. Any nurse could be asked by a patient or family member about assisted death. For some, it might be an exploration of options, or simple information seeking. For others, their questions may indicate intent to pursue an assisted death. Please talk to your supervisor and team if a patient would like to proceed with a formal request.

5. The policy document tells us that the potential toxicity of a component is evaluated by
A. testing the component exclusively.
B. testing the exposure separately.
C. adequate assessment of the material.
Inclusion of Multiple Components: For devices that include components with different lengths of contact, we recommend that any extract-based biocompatibility testing be conducted separately. If the components are combined into a single test article, this will dilute the amount of component materials being presented to the test system and may not accurately identify potentially toxic agents that would have been found if the components were tested separately. For example, we recommend testing implants separately from delivery systems or other kit components. For devices or device components that contain multiple materials with differing surface areas or differing exposure to the body, if one or more materials is new, it may also be necessary to test the new material components separately as well, to further understand the potential toxicity of this component. For example, for a catheter-based delivery system that contains a new balloon material, tests of the delivery system separate from the balloon may be necessary to ensure adequate assessment of each of the materials.

6. What is being described in this extract?
A. detailed information about medical records.
B. purpose of medical records in patient care.
C. how to avoid errors in medical records
Medical records: Medical records is a broad term, encompassing a range of data and information storage mediums containing patient information. Whether paper based or electronic, the term “medical records” applies to clinical notes, investigations, letters from other doctors and healthcare providers, photographs and video footage. However, information exchanges (such as correspondence, email and file notes of discussions) between a medical practitioner and their medical indemnity insurer or solicitor should not be stored in the medical record. For this reason, it is recommended that you keep a separate medico-legal file in which to store these documents. Medical records are an integral part of good quality patient care. The primary purpose of the medical record is to facilitate patient care and allow you or another practitioner to continue the management of the patient. Clinical observations, decision making and treatment recommendations or plans should be recorded contemporaneously. This reduces the possibility of an error occurring and is an important risk management tool.

PART C. TEXT 1: GOOD LOOKS

Paragraph 1: Attempts to find out what makes a person physically attractive date back at least to the Ancient Greeks. Plato wrote that the ideal face should have a width two-thirds of its length, and that a nose should be no longer than the distance between the eyes. His theory of ‘golden proportions’, while not necessarily accepted by researchers today, nevertheless represented an attempt to define a fundamental preference for symmetry that scientists say is a highly evolved trait seen in both humans and animals. Human babies, for example, spend more time staring at pictures of symmetric faces than they do at photos of asymmetric ones. In the bird kingdom, female swallows prefer males with longer and more symmetric tails, while female zebra finches mate with males with symmetrically colored leg bands.

Paragraph 2: The rationale behind symmetry preference in both humans and animals is that symmetric individuals have a higher mate-value. Scientists also believe that symmetry is equated with a strong immune system. Thus, beauty is indicative of more robust genes, improving the likelihood that an individual’s offspring will survive_ This evolutionary theory is supported by research showing that standards of attractiveness are similar across cultures. John Manning of the University of Liverpool does not agree entirely, however, and cautions against such over- generalization, especially by Western scientists. Darwin thought that there were few universals of physical beauty because there was much variance in appearance and preference across human groups,’ he says.

Paragraph 3: Research overwhelmingly shows that beauty matters. It pervades society, it affects how people choose partners, and it influences how people are seen and how they see others. One of the chief beneficiaries of this focus on physical attractiveness is the cosmetic medicine and cosmetic surgery industry. Once only for the rich and privileged, cosmetic procedures nowadays are mainstream and affordable. For a fraction of the cost and time required even a decade ago, practitioners these days can remove wrinkles and blemishes, straighten teeth and noses, and sculpt bodies into works of art.

Paragraph 4: In most countries, due to the range of procedures available and of practitioners performing them, from plastic surgeons to cosmetic doctors and dermatologists, statistics for cosmetic surgery are either not collected or not reliable. In the United States, however, statistics released by the American Society for Aesthetic Plastic Surgery show that nearly 11.7 million cosmetic surgical and nonsurgical procedures were performed in 2007. The Aesthetic Society, which has been collecting multi-specialty procedural statistics since 1997, says the overall number of cosmetic procedures in the US has increased 457% since the collection of the statistics first began.

Paragraph 5: It is important to bear in mind that there are potential pitfalls, both physical and emotional, associated with this growing cultural phenomenon. While people have the right to maximize their attractiveness, there is the danger that, for some, cosmetic medicine may become an unhealthy obsession or be mistaken as the answer to life’s problems. Studies spanning four decades have reported that most people undergoing cosmetic interventions are satisfied with the result; however, there is a particular subgroup of people who appear to respond poorly to cosmetic procedures. These are people with the psychiatric condition known as ‘body dysmorphic disorder’ (BDD), which is characterized by a preoccupation with an objectively absent or minimal deformity that causes clinically significant distress or impairment in social, occupational, or other areas of functioning.

Paragraph 6: While few methodologically robust studies have been done, some clinicians and researchers have attempted to evaluate whether improvement in psychosocial wellbeing following cosmetic enhancement can be objectively verified at all. Overall, studies suggest that those patients who were pleased with the outcome showed improvements in ‘self worth’, ‘self esteem ‘, ‘distress and shyness’ and ‘quality of life’. What does appear to be an important factor in assessments of satisfaction is the patient’s expectation of the outcome of the procedure. Research suggests that the more extensive ‘type change’ procedures (e.g., rhinoplasty, breast augmentation) appear to require greater psychological adjustment by the patient than ‘restorative ‘ procedures (e.g., facelift, botulinum toxin A injection).

Paragraph 7: Given the range of possible reactions to cosmetic procedures, it is important for the practitioner to evaluate the patient ‘s motivations for surgery before the procedure is undertaken. First, the individual’s attitude towards the cosmetic problem, and the distress and disability associated with it, should be assessed. Patients should be advised of what the cosmetic outcome is likely to be and fully informed of potential side effects and complications. It is also useful to review past cosmetic interventions, including the number of previous procedures and their cosmetic and psychosocial outcome as perceived by the patient as well as family and friends. The cosmetic specialist should probably be most concerned about people who have had numerous procedures performed by many practitioners, and particularly those who report the outcome of such procedures to have been unsatisfactory.

7. In the first paragraph, babies are mentioned because they
A. prefer faces with symmetric features.
B. have highly evolved symmetric traits.
C. react negatively to asymmetric images.
D. display the same preferences as birds.
8. In the second paragraph, the phrase ‘is equated with’ indicates that symmetry and immunity are
A. linked to each other.
B. equal to each other.
C. dependent on each other.
D. opposite to each other.
9. Which one of the following statements according to John Manning’s opinion, is NOT supported by information given in second paragraph?
A. Western scientists take a Darwinist approach to attractiveness.
B. Darwin’s theories go against some current views of attractiveness.
C. Western scientists tend to take a simplistic view of attractiveness.
D. there is no definitive basis for symmetry’s role in attractiveness.
10. Scientists believe that humans and animals are instinctively attracted by symmetry in potential partners
A. because they want a good-looking mate.
B. in the interests of survival of the species.
C. to strengthen their own immune systems.
D. because symmetrical bodies are noticeable.
11. The cosmetic surgery industry is popular because
A. society is preoccupied with beauty.
B. it is considered an art form.
C. so many people feel unattractive.
D. it promotes wealth and glamour.
12. Aside from the United States, country-specific statistics on cosmetic surgery are unreliable because______
A. the United States dominates the market.
B. of the number of different professions involved.
C. there are too many instances to count.
D. of the rapid increase in demand.
13. In the fifth paragraph, the phrase ‘potential pitfalls’ refers to
A. life’s problems. B. maximum attractiveness. C. unhealthy obsessions. D. dangerous outcomes.
14. Based on the seventh paragraph, the doctor should tell patients about
A. the different attitudes of patients to cosmetic surgery.
B. how distress influences the outcome of surgery.
C. what the result might be and what could go wrong.
D. the success rate of his/her previous procedures.

PART C. TEXT 2: RABBIT CALICIVIRUS DISEASE
David Lord’s family arrived in western New South Wales in 1870. The first rabbit plague came 10 years later. In the 1940s rabbits would flock in thousands to waterholes, kicking up storms of dust. In the 1950s they disappeared, and were thought to be gone. But they came back. Last year Mr. Lord’s property, 40 kilometers west of Broken Hill, had 25,000 warrens and about a million rabbits. Then in early November he found a dead one near his home, and felt pretty sure his problem was solved. Within a week, 600,000 more were dead. Few carcasses were seen above ground but the stench was overpowering as the rabbits just crawled into their burrows and died. The killer is rabbit calicivirus disease (RCD. Transmitted primarily by rabbits themselves, the naturally occurring virus scythes through populations of the European rabbit yet is not known to infect any other species. Proponents of the virus as a biological control say it could save up to $1 billion a year in lost primary production and degraded land, as well as priceless native flora and fauna.

Mr. Lord born in the 1950s, when another imported disease, myxomatosis, killed 99 per cent of the country’s rabbits-calls it “the best thing to happen to inland Australia in 40 years.” But it wasn’t meant to happen now. The virus was not due for release for another two years. Its escape from a South Australian testing station in October severely embarrassed the government and the CSIRO and threatened a nine-year program of testing and hearings to win public support. As the virus is now out, scientists and farmers want to ensure its effectiveness with a controlled release in the next two months. Autumn is believed to be the best time for release as young rabbits, whose underdeveloped immune system makes them less susceptible to the disease, are less common. Yet while the Minister for Primary Industry, John Anderson, said this week that he favored early release, he doubted bureaucratic and legislative approvals could be granted in time. In Western Australia a defense coalition against RCD, including animal rights groups and the fledgling rabbit farming industry, is demanding a public inquiry into the disease. Any virus is hard to sell.

“We recognized years ago that virus-dread, as we call it, would need to be managed,” says Nicholas Newland, the coordinator of the RCD program. Although the CSIRO never guaranteed it could contain the virus on Wardang Island, it had taken great precautions to ensure an escape never happened. The calicivirus – so called because under a microscope its surface resembles a set of inverted chalices –was found in China in 1984. It reached Europe two years later, killing about 64 million farmed rabbits in two months in Italy alone. Scientists here watched with interest. Rabbits had developed some immunity to myxomatosis, and no other control had been as successful. The rabbit count was steadily increasing, to about one-fifth of pre-myxomatosis numbers. In 1991 quarantine authorities allowed the CSIRO to import the virus. At the Animal Health Laboratory in Geelong. scientists injected 28 species with a virus dose 1000 times greater than one lethal to a rabbit. None of these species which included dogs, cats, native mammals and birds, were infected.

Testing moved to Wardang Island in 1994. A direct flight transported the virus, packed into containers so secure that a plane crash would not destroy them. In a scene from science fiction, the quarantine station had an electric fence, double fenced pens and high security shacks that required researchers to change cloths three times before leaving. Rabbits wore radio collar so scientists would know instantly if one had died. Yet the virus escaped-from the shacks to rabbits elsewhere on the island, then across a four-kilometer strait. Researchers blame an insect, perhaps a fly. Once on the mainland, the virus jumped 380 kilometers almost overnight, probably through insects floating on air currents. By Christmas it covered one-third of South Australia. In the Flinders Ranges, where 95 per cent of rabbits are thought to have died, flora such as the bullock bush and mulga tree showed new shoots for the first time in decades, says Ron Sinclair of the Animal and Plant Control Commission. Since Christmas, perhaps because of a hot summer and poor conditions for insects, the spread has slowed.

The first sign of the virus in Victoria appeared only recently with dead rabbits near Castlemaine, Maryborough and Marong. Again, insects on air currents may be responsible. The untimely escape has forced authorities to concertina an approval process of years into months. In December, two American scientists wrote to Australia’s Biological Control Authority and he then Prime Minister, warning that the calicivirus could jump species barriers. Dr. Alvin Smith, professor of veterinary medicine at Oregon State University, wrote that if the virus mutated-and it was far too early to be sure that it wouldn’t or it could endanger livestock and even humans. Australian scientists say there is no evidence the rabbit calicivirus can jump species. Only one virus-feline panleukopaenia, or cat flu-has been documented to have increased its host range (to dogs), says Tony Robinson, a senior CSIRO virologist. He says that after 10 years of contact with diseased rabbits in Europe, no human has been infected.

Nevertheless, the debate has bothered Hugh Wirth. “Two lots of scientists are arguing, so the jury is still out,” says the head of the RSPCA. Yet conservation groups such as the Wildlife Preservation Society favor release. “Calicivirus is a blessing. to all who care for Australia’s plants and animals,” society president Vincent Serventy has written. One thing is sure: the virus will not eradicate all rabbits. “We made that mistake with myxomatosis – apathy crept in,” says lan Lobban, spokesman on rabbit control for the Victorian Farmers’ Federation. In Canberra, CSIRO scientists have already begun to try to engineer a new strain of myxomatosis that causes rabbit sterility. In Europe the rabbit poses a different problem. Worried about the animal’s decline because of calicivirus, Spain is stocking a national park with inoculated rabbits to ensure prey for species such as the lynx and imperial eagle. In its birthplace, the rabbit is struggling. Here it is not wanted, and has thrived. The effects of the Australian and Spanish programs are opposite but the intent is the same: to help to balance an unbalanced world.

15. Australian farmers like David Lord consider the release of the virus to be
A. a dangerous mistake.
B. an embarrassing incident.
C. a fortunate accident.
D. a bureaucratic error.
16. Scientists prefer to release the virus in autumn because
A. there are fewer young rabbits in autumn.
B. rabbits have weaker immune systems in autumn.
C. young rabbits catch the disease more easily in autumn.
D. rabbits are more plentiful in autumn.
17. Official early release of the virus is unlikely because
A. the Minster for Primary Industry supports it.
B. rabbit farmers disagree with animal rights groups.
C. the general public refuses to pay for the program.
D. groups opposing RCD are demanding an inquiry.
18. The number of rabbits in Australia prior to the release of RCD was
A. 20% more than in the period before myxomatosis.
B. 20% less than in the period before myxomatosis.
C. remaining stable.
D. seems to be rising.
19. How did the virus enter Australia?
A. carried by insects.
B. brought by dogs and cats.
C. imported by scientists.
D. found in European rabbits.
20. From the article, we can infer that the virus was being tested on Wardang Island for what reason?
A. to prevent its uncontrolled spread.
B. to eliminate rabbits from the island.
C. to protect the researcher.
D. to keep the tests a secret.
21. Because of the escape of the virus, authorities are trying to:
A. delay the approval process for several months.
B. modify the approval process.
C. speed up the approval process.
D. extend the approval process.
22. Which of the following was not a concern of the American scientists who contacted the Biological Control Authority?
A. that humans could catch the disease.
B. that sheep and cattle could die.
C. that insufficient research had been done before the release.
D. that the virus had already mutated.

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