| Interlocutor: SETTING: HOSPITAL EMERGENCY DEPARTMENT |
| PATIENT: You are very worried about some symptoms you are experiencing. You also suffer from anxiety and feel very agitated and irritated at having to wait to see a medical professional. After 30 minutes, a nurse comes and asks you some questions. TASK: When asked why you have come in, describe your current symptoms (nausea, tightness in chest, dizziness). Express your irritation and agitation at having to wait 30 minutes to be seen. Tell the nurse the symptoms started a month ago, after the death of a friend. Explain that the symptoms come and go but they get worse with each episode. Say that your GP prescribed antidepressants last month. Insist that you don’t need them as you are managing all right. Explain that you only take them when you feel particularly anxious. Explain that you are now feeling a little calmer and agree to take the antidepressants regularly. Ask what will happen next. |
| SETTING: HOSPITAL EMERGENCY DEPARTMENT |
| NURSE: You are a nurse in the Emergency Department and a patient has just arrived in a very agitated state. The patient is worried about some symptoms and is also irritated at having to wait to see a medical professional. TASK: Start the conversation by greeting the patient and asking about the reason for the visit. Apologize for the delay and express understanding of the patient’s concerns. Ask for more details about the symptoms, including when they started and how often they occur. Sympathize with the patient and ask how well he/she is coping with the situation. Find out if he/she is taking any medication. Reassure the patient that the medication is not harmful and will help with the symptoms. Explain that anti-depressants need to be taken regularly and may take up to 4 weeks to be effective. Explain the next steps, which include checking vital signs such as blood pressure, and then seeing the doctor. Reassure the patient that the wait won’t be long. |
All posts by Jomon John
COPD OET ROLE PLAY
| Interlocutor: SETTING: HOME VISIT |
| PATIENT: You have mild COPD, and have been given a home oxygen cylinder to ease your breathlessness after a recent flare-up. Your GP has asked the community nurse to visit you at home to see how you are. TASK: – When asked, explain that overall you feel better and less breathless, but your throat feels a bit dry and sore. – Explain that you have not been getting any headaches or feeling confused. Tell the nurse that the mask feels uncomfortable sometimes and irritates the skin underneath. – Tell the nurse that you will try some moisturizing cream before changing to nasal prongs. – Say that you stopped smoking a year ago. Explain that you have been having some trouble sleeping, so you sometimes take one of your partner’s sleeping pills to help. – Agree to the nurse’s suggestions about sleeping pills. |
| SETTING: HOME VISIT |
| NURSE: You are a community nurse, visiting a patient with mild COPD who recently had a flare-up. Last week, he/she was given an oxygen cylinder for short-burst therapy at home. The patient’s GP has asked you to check on the patient to see how he/she is coping. TASK – Greet the patient and introduce yourself. Find out how he/she is feeling and how he/she is coping with the oxygen therapy. – Reassure the patient that what he/she is feeling is normal. Explain the reason (drying of the mucous membrane in the respiratory tract) and suggest solutions (e.g. keeping hydrated). – Ask about any other side-effects (e.g. headaches, feeling confused). – Sympathise with the patient and suggest that he/she use moisturising cream to help. Find out if he/she knows about the option of nasal prongs rather than a mask. – Check that the patient no longer smokes at all, and ask if he/she has any remaining concerns. – Sympathise with the patient but stress why he/she should avoid sleeping tablets (they cause slow breathing). Suggest alternatives. |
SURVEY ON SKIN LIGHTENING CREAMS OET reading
TEXT A: A British Skin Foundation survey found that fifteen per cent of dermatologists believe lightening creams are ‘completely unsafe’ and four in five feel they are only safe when prescribed by a dermatologist. “Many skin- lightening creams contain illegal compounds that can damage your health,” says Indy Rihal of the British Skin Foundation. “The most common compounds are high-dose steroids.” Although steroids can be useful in treating some skin diseases, such as psoriasis and eczema, this must take place under the supervision of a skin specialist. “Unmonitored use of high-dose steroids can lead to many problems,” says RihaI. If you’ve used a skin-lightening cream and are worried about the effect it has had, see a G P. “Medically approved preparations prescribed by a GP or a dermatologist are not dangerous, within reason,” says Rihal. A cream that you buy over the counter is not necessarily medically approved and could permanently damage your skin.
TEXT B: The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal. Many women of childbearing age from sub-Saharan Africa use topical skin lighteners, some of which present a risk of toxic systemic effects. The goals of this study were to evaluate, in this environment, the frequency of this practice during pregnancy, as well as eventual consequences on pregnancy. Ninety nine women from 6 to 9 months pregnant were randomly selected among those attending a standard maternal centre in Dakar for a prenatal visit. Investigations consisted of questions about the use of skin lighteners, a standard clinical examination, follow-up until delivery and a morning blood sample for plasma cortisol levels. Sixty-eight of the 99 selected women used skin lighteners during their current pregnancy, the main active ingredients being hydroquinone and highly potent steroids (used by 44 and 24 women, respectively). No difference in the main outcomes of pregnancy were found between skin lightener users and the others; however, women using highly potent steroids, when compared with those who did not, had a statistically significant lower plasma cortisol level and a smaller placenta, and presented a higher rate of low-birth-weight infants. Skin lightening is a common practice during pregnancy in Dakar, and the use of steroids may result in consequences in the mother and her child.
TEXT C: Tanning: Biological and Health Effects. Tanning is the skin’s response to ultraviolet (UV) radiation, a type of light exposure. As skin cells are exposed to UV radiation, they produce a brown pigment (melanin) to protect themselves from further UV exposure. This results in a darkening of the skin (tanning), which is the body’s natural defense mechanism and attempt to prevent further damage from UV radiation. Sunlight and artificial tanning methods, such as tanning booths or salons, are sources of UV exposure. Sufficient amounts of UV exposure are known to cause adverse health effects in humans and are a public health concern. Tanning and burning play a role in health effects, including skin cancer. UV radiation damage to DNA in skin cells can result in mutations that promote or cause cancer, and recurring UV exposures may result in aging (wrinkles, loss of elasticity, and sun spots). Other short-term effects on skin are sunburns, fragility, and scarring. Cataracts are a known health effect from UV radiation exposure and eye protection is essential when tanning.
TEXT D: Banned Sunbeds. Unsupervised sunbeds have “no redeeming features”, says Wales’ chief medical officer. Dr Tony Jewell spoke as the facilities are being banned in Wales: laws to clamp down on sunbed use are extended. From Monday, businesses with unstaffed coin-operated sunbeds could be fined £5,000. Welsh cancer charity Tenovus said the ban was important as skin cancer is the most common cancer in 15 to 24-year-olds in the UK, and south Wales has one of the highest incidences in the country. “Skin cancer incidence is very strongly linked to over-exposure to ultra-violet radiation through sunbeds, levels of which can be six times stronger than the Australian midday sun,” said Tenovus head of research Dr Ian Lewis. “Wales alone has 500 cases of malignant melanoma a year, the most dangerous and potentially fatal form of skin cancer, resulting in nearly 100 deaths annually. “The rise in incidence of this type of skin cancer is truly alarming; between 2006 and 2016, Wales saw the rate of malignant melanoma in men and women double.”
In which text can you find information about
1. the contents of skin lightening creams?
2 the risks of over-exposure to UV radiation?
3 the sources of ultra-violet exposure?
4 who use topical skin lighteners?
5 reason for increase in rate of malignant melanoma?
6 the risks of repeated UV exposures?
7 the usual practice during pregnancy?
Questions 8-15. Answer each of the questions, 8-15, with a word or short phrase from one of the texts.
8 Which kind of skin lighteners are used by women in sub-Saharan Africa?
9 What type of sunbeds are subjected to penalties in Wales?
10 How many death cases of malignant melanoma were reported annually in Wales?
11 Which is the common eye disease related to damage from UV radiation exposure?
12 What was the main active ingredient in the skin lighteners used by majority of women in Dakar?
13 What are the most common sources of UV exposure other than sunlight?
14 Which skin cell pigment offers guard against UV exposure?
15 Which type of UV exposures could accelerate the aging processes?
Questions 16-20. Complete each of the sentences, 16-20, with a word or short phrase from one of the texts.
16 are proven to be effective in the treatment of some dermal conditions.
17 The soaring prevalence of is genuinely appalling.
18. Darkening of the skin plays a role in , including skin cancer.
19. Women who used had comparatively small placenta.
20. is vital when the skin is darkened.
PART B. For questions 1-6, choose (A, B or C) which you think fits best according to the text.
1. As explained in the extract, material standards are
A. absolutely helpful to inform a risk assessment.
B. insufficient to find biocompatibility risks.
C. used to find the biocompatibility evaluation.
Medical device standards: Standards specific to a particular device type or material may be helpful to inform a risk assessment; however, the extent to which the standard could be utilized may be dependent on the specificity of the standard and/or the specific material. Ideally, a standard would have sufficient specificity to provide useful information regarding material risks. For example, standards that outline both mechanical and chemical properties of a device type with pass/fail criteria may be particularly informative because of the specificity of such a standard. Standards that address bulk material composition can also be informative as a starting point for incorporating material characterization into a risk assessment. For example, it may be appropriate to use material standards to support the biocompatibility evaluation of stainless steel surgical vascular clamps, as long as any risks associated with manufacturing are appropriately considered and mitigated. Given the effects that manufacturing and processing may have on a polymer as incorporated into the final finished medical device, use of material standards may not be sufficient to identify biocompatibility risks for devices made from polymers.
2. The results of the studies described in the memo may explain why the relationship between
A. enough RN staffing and lower hospital related morbidity.
B. nurse patient ratios interpret gastrointestinal bleeding.
C. RN staffing for post- surgical patients and pulmonary compromise.
Failure To Rescue: The number of patients a Registered Nurse (RN) cares for can directly and indirectly impact patient safety during their hospitalization. “Safety” in this case refers to infection rates, patient falls, hospital-acquired pressure ulcers, and even death. Multiple studies using different methodology and from a variety of disciplines consistently show associations between adequate RN staffing and lower hospital related morbidity, mortality and adverse patient events. RN staffing levels for post- surgical patients have been shown to have an inverse relationship with urinary tract infections, pneumonia, thrombosis and pulmonary compromise; in medical patients, higher nurse patient ratios translated into a reduction in gastrointestinal bleeding, shortened length of stay, and lower rates of ‘failure to rescue’. Failure to rescue is the term used when early warning signs of upper gastrointestinal bleeding, sepsis, deep venous thrombosis, shock or cardiac arrest are not detected and acted upon.
3. What is the most recommended implantation testing?
A. clinically relevant implantation study.
B. in vivo animal study.
C. toxicology implantation study
Implantation: For implantation testing, if there are characteristics of the device geometry that may confound interpretation of this test, it may be acceptable to use device sub-components or coupons instead of the device in its final finished form, with appropriate justification. For example, it may be acceptable to use a coupon instead of a stent, if information is provided to demonstrate that the manufacturing and resulting surface properties are comparable. Instead of a traditional toxicology implantation study in subcutaneous, muscle, or bone tissues, a clinically relevant implantation assessment may be more appropriate for certain implant devices with relatively high safety risks. Clinically relevant implantation studies are critical to determine the systemic and local tissue responses to the implant in a relevant anatomical environment under simulated clinical conditions. In some cases, the toxicity outcomes that would be obtained from a clinically relevant implantation study can be assessed as part of in vivo animal studies that are performed to assess overall device safety.
4. The term ‘mass immunizer’ refers to a
A. Medicare-enrolled provider offering either influenza vaccinations or pneumococcal vaccinations
B. traditional Medicare provider offering neither influenza vaccinations nor pneumococcal vaccinations
C. non-traditional provider offering influenza vaccinations, pneumococcal vaccinations, or both
Mass Immunization Providers: To increase vaccination availability to Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) created the mass immunizer program and simplified the influenza and pneumococcal vaccination claims process by creating roster billing for mass immunizers. CMS defines a ‘mass immunizer’ as a Medicare-enrolled provider offering influenza vaccinations, pneumococcal vaccinations, or both to a group of individuals (e.g., the public, senior center participants, retirement community or retirement housing residents).
A mass immunizer can be either:
• A traditional Medicare provider or supplier, such as a hospital outpatient department; or
• A non-traditional provider that is usually ineligible to enroll in the Medicare Program, such as a supermarket, senior citizen home, public health clinic or an individual practitioner.
5. The guidelines inform us that device materials should not
A. cause any exposure to the body.
B. have benefits that outweigh any potential risks.
C. have any potential risks that outweigh benefits
Evaluation of Local and Systemic Risks: Biological evaluation of medical devices is performed to determine the acceptability of any potential adverse biological response resulting from contact of the component materials of the device with the body. The device materials should not, either directly or through the release of their material constituents: (i) produce adverse local or systemic effects; (ii) be carcinogenic; or (iii) produce adverse reproductive and/or developmental effects, unless it can be determined that the benefits of the use of that material outweigh the risks associated with an adverse biological response. Therefore, evaluation of any new device intended for human use requires information from a systematic analysis to ensure that the benefits provided by the device in its final finished form will outweigh any potential risks produced by device materials over the intended duration and use of the device in or on the exposed tissues. When selecting the appropriate endpoints for biological evaluation of a medical device, one should consider the chemical characteristics of the device materials and the nature, degree, frequency, and duration of exposure to the body.
6. What point does the extract make about designated nursing units?
A. have a team of nurses, mental health technician and behavioral counselor.
B. have specially trained nurses for work exclusively using different strategies.
C. a place where medically stabilized behavioral health patients seeking care are placed.
Behavioral Health Response Plan: A robust Behavioral Health Response Plan has been established to support staff and patients for the growing number of behavioral health patients seeking care. When patients are medically stabilized, up to 11 patients may be cohorted in a specially designed unit to promote patient and staff safety while patients await placement at behavioral health specialized facilities. For patients who require medical treatment, whenever possible they are placed on designated nursing units. Nurses working on these units have received special training and are adept at various communication techniques and strategies. This specialized unit team also consists of a mental health technician and a behavioral counselor.
PART C. TEXT 1: BIRTH CONTROL PILL AND SEXUAL PROBLEMS
In the January issue of The Journal of Sexual Medicine, researchers have published a new investigation measuring sex hormone binding globulin (SHBG) before and after discontinuation of the oral contraceptive pill. The research concluded that women who used the oral contraceptive pill may be exposed to long-term problems from low values of “unbound” testosterone potentially leading to continuing sexual, metabolic, and mental health consequences. Sex hormone binding globulin (SHBG) is the protein that binds testosterone, rendering it unavailable for a woman’s physiologic needs. The study showed that in women with sexual dysfunction, elevated SHBG in “Oral Contraceptive Discontinued-Users” did not decrease to values consistent with those of “Never-Users of Oral Contraceptive”. Thus, as a consequence of the chronic elevation in sex hormone binding globulin levels, pill users may be at risk for long-standing health problems, including sexual dysfunction.
Oral contraceptives have been the preferred method of birth control because of their ease of use and high rate of effectiveness. However, in some women oral contraceptives have ironically been associated with women’s sexual health problems and testosterone hormonal problems. Now there are data that oral contraceptive pills may have lasting adverse effects on the hormone testosterone. The research, in an article entitled: “Impact of Oral Contraceptives on Sex Hormone Binding Globulin and Androgen Levels: A Retrospective Study in Women with Sexual Dysfunction” published in The Journal of Sexual Medicine, involved 124 premenopausal women with sexual health complaints for more than 6 months. Three groups of women were defined: i) 62 “Oral Contraceptive Continued-Users” had been on oral contraceptives for more than 6 months and continued taking them, ii) 39 “Oral Contraceptive Discontinued-Users” had been on oral contraceptives for more than 6 months and discontinued them, and iii) 23 “Never-Users of Oral Contraceptives” had never taken oral contraceptives. SHBG values were compared at baseline (groups i, ii and iii), while on the oral contraceptive (groups i and ii), and well beyond the 7 day half-life of sex hormone binding globulin at 49-120 (mean 80) days and more than 120 (mean 196) days after discontinuation of oral contraceptives (group ii).
The researchers concluded that SHBG values in the “Oral Contraceptive Continued-Users” were 4 times higher than those in the “Never-Users of Oral Contraceptives”. Despite a decrease in SHBG values after discontinuation of oral contraceptive pill use, SHBG levels in “Oral Contraceptive Discontinued-Users” remained elevated when compared to “Never-Users of Oral Contraceptives”. This led to the question of whether prolonged exposure to the synthetic estrogens of oral contraceptives induces gene imprinting and increased gene expression of SHBG in the liver in some women who have used the oral contraceptives. Dr. Claudia Panzer, an endocrinologist in Denver, CO and lead author of the study, noted that “it is important for physicians prescribing oral contraceptives to point out to their patients potential sexual side effects, such as decreased desire, arousal, decreased lubrication and increased sexual pain. Also if women present with these complaints, it is crucial to recognize the link between sexual dysfunction and the oral contraceptive and not to attribute these complaints solely to psychological causes.”
“An interesting observation was that the use of oral contraceptives led to changes in the synthesis of SHBG which were not completely reversible in our time frame of observation. This can lead to lower levels of ‘unbound’ testosterone, which is thought to play a major role in female sexual health. It would be important to conduct long- term studies to see if these increased SHBG changes are permanent,” added Dr. Panzer. Dr. Andre Guay, study co- author and Director of the Center for Sexual Function/Endocrinology in Peabody, MA affirmed that this study is a revelation and that the results have been remarkable. “For years we have known that a subset of women using oral contraceptive agents suffer from decreased sex drive,” states Dr. Guay. “We know that the birth control pill suppresses both ovulation and also the male hormones that the ovaries make in larger amounts during the middle third of the menstrual cycle. SHBG binds the testosterone, therefore, these pills decrease a woman’s male hormone availability by two separate mechanisms. No wonder so many women have had symptoms.”
“This work is the culmination of 7 years of observational research in which we noted in our practice many women with sexual dysfunction who had used the oral contraceptive but whose sexual and hormonal problems persisted despite stopping the birth control pill,” said Dr. Irwin Goldstein, a urologist and senior author of the research. “There are approximately 100 million women worldwide who currently use oral contraceptives, so it is obvious that more extensive research investigations are needed. The oral contraceptive has been around for over 40 years, but no one had previously looked at the long-term effects of SHBG in these women. The larger problem is that there have been limited research efforts in women’s sexual health problems in contrast to investigatory efforts in other areas of women’s health or even in male sexual dysfunction.” To better appreciate the scope of the problem, oral contraceptives were introduced in the USA in 1960 and are currently used for reversible pharmacologic birth control by over 10 million women in the US, including 80% of all American women born since 1945 and, more specifically, 27% of women ages 15-44 and 53% of women age 20-24 years. By providing a potent synthetic estrogen (ethinyl estradiol) and a potent synthetic progesterone (for example, norethindrone), highly effective contraception is achieved by diminishing the levels of FSH and LH, thereby reducing metabolic activity of the ovary including the suppression of ovulation.
Several studies over the last 30 years reported negative effects of oral contraceptives on sexual function, including diminished sexual interest and arousal, suppression of female initiated sexual activity, decreased frequency of sexual intercourse and sexual enjoyment. Androgens such as testosterone are important modulators of sexual function. Oral contraceptives decrease circulating levels of androgens by direct inhibition of androgen production in the ovaries and by a marked increase in the hepatic synthesis of sex hormone binding globulin, the major binding protein for gonadal steroids in the circulation. The combination of these two mechanisms leads to low circulating levels of “unbound” or “free” testosterone.
7. Which statement is the most accurate summary of the method of the study?
A. Levels of SHBG were monitored over a period of time in women who were using the pill.
B. Levels of SHBG were measured in women using pill and women who had stopped using pill, and these were compared to women who had never used pill.
C. Levels of SHBG were compared in women who were using the pill, women who had stopped using the pill, and women who had never used the pill.
D. Medical complications were compared between women using the pill and those who had stopped using the pill.
8. What is the role of SHBG?
A. To prevent sexual dysfunction in human females.
B. To prevent testosterone from being used in the female body.
C. To prevent women from needing to take traditional contraceptive pills.
D. To prevent oncological complications.
9. Which group had the highest level of unbound testosterone?
A. Women with a genetic predisposition for higher testosterone levels.
B. Women who had never taken the pill.
C. Women who had previously taken the pill but since stopped.
D. Women who were taking the pill during the study.
10. Which of the following reasons is given in the study for popularity of oral contraceptive pill?
A. Less interference with sexual routine than other contraceptives.
B. High percentage of contraceptive success.
C. Favorable aesthetic effects on women’s physiques due to reduced testosterone.
D. Low cost.
11. Which is the most accurate description of the study discussed in the article?
A. It involved one hundred and twenty four pre-pubescent girls.
B. It involved 124 premenstrual women who had sexual health issues for 6 months or more.
C. SHBG levels were monitored at different times in three groups of adult women with various status regarding contraceptive pill usage.
D. SHBG levels were compared at regular intervals in each of three groups of women who had different status regarding contraceptive pill usage.
12. Levels of SHBG decreased in women who had stopped using the contraceptive pill
A. due to increased gene expression of SHBG in the livers of these women.
B. in spite of lengthened exposure to artificial estrogen found in pills.
C. because of psychological factors associated with taking the pill.
D. but their levels remained elevated compared to women who had never used pill.
13. Which of the following is an opinion of Dr. Panzer?
A. SHBG levels remained higher in women who discontinued pill use for the duration of the study.
B. The use of oral contraceptives led to changes in SHBG levels which were not reversible within the timeframe of the study.
C. Physicians usually mention the sexual side effects of the pill to their patients.
D. Further studies should determine whether SHBG levels ultimately return to normal over longer periods.
14. Which of the following statements has the same meaning as a statement in the text?
A. The contraceptive pill was invented in the USA in 1960.
B. The pill has been used by over 100 million women globally.
C. Dr. Goldstein monitored women with a history of pill use and sexual dysfunction in his clinic for seven years.
D. Lower levels of unbound testosterone is a result of both higher SHBG and accelerated metabolism in the ovaries.
PART C. TEXT 2: BOVINE SPONGIFORM ENCEPHALOPATHY
Vets at the Ministry of Agriculture have identified a new disease in cows that is causing dairy farmers some consternation. The fatal disease, which they have called bovine spongiform encephalopathy, causes degeneration of the brain. Afflicted cows eventually become uncoordinated and difficult to handle. The first case was reported in 1985. Now there are 92 suspected cases in 53 herds, mostly in the south of England. So far 21 cases in 18 herds have been confirmed. All are Friesian/Holstein dairy animals. Gerald Wells and his colleagues at the Central Veterinary Laboratory in Weybridge, Surrey, describe the symptoms and pathology in the current issue of The Veterinary Record. No one yet knows the cause of the disease but there are some similarities with a group of neurological diseases caused by the so called “unconventional slow viruses”.
This group of progressive diseases includes scrapie in sheep and goats, chronic wasting disease in mule deer and transmissible mink encephalopathy. In humans Kuru and Creutzfeldt-Jakob disease, both fatal neurological diseases, come into the same category. The precise nature of the agents causing this group of diseases is a matter of intense debate but all are infectious. Like scrapie and the other diseases, bovine spongiform encephalopathy is insidious and progressive. A farmer is unlikely to suspect that a cow has the disease until it has almost run its course. Previously healthy animals become highly sensitive to normal stimuli, they grow apprehensive and their movements uncoordinated. In the final stages the cows may be frenzied and unpredictable and have to be slaughtered. At autopsy, Wells and his colleagues found that some areas of the brain were full of holes, giving it a spongy appearance. The pattern of holes shows some similarity with that in the other unconventional encephalopathies.
In all these diseases an important diagnostic feature is the presence of proteinaceous fibrils seen in brain extracts in the electron microscope. No one knows for certain what the fibrils are – whether they are the agents of the disease, a type of subviral particle, as some researchers suggest, or are a product of the disease. The veterinary researchers analyzed the brain tissue from cows that died from the disease and found similar fibrils. Brain tissue from healthy cows did not contain fibrils. At the moment researchers at the Central Veterinary Laboratory are keeping an open mind on the cause of the disease. If it is not a scrapie-like agent it might be something to do with the genetics of Friesian cows. Another suggestion is that contaminated food might be to blame. “It is too early to come to conclusions,” said a spokesman at the Ministry of Agriculture. “It might be caused by toxic products, or food, or it might be genetic.”
According to Richard Kimberlin, of the AFRC/MRC Neuropathogenesis Unit in Edinburgh: “The similarities are enough to make us think that it’s in the scrapie family, but without evidence of transmission it’s impossible to say anything more certain”. Scientists at the Neuropathogenesis Unit will look for evidence of transmission in experiments on mice, while Wells and his colleagues try to transmit the disease in cows. It will take at least two years of experiments before transmission can be proved. What is certain is that the number of reported cases is increasing rapidly. Not all reports will turn out to be bovine spongiform encephalopathy. Farmers and vets might just be getting better at recognizing symptoms. In the past farmers probably got rid of nutty middle-aged cows without thinking too much about it. If the disease turns out to be transmissible then it might spread to other breeds of cows. Many countries ban the import of sheep from areas where scrapie occurs.
In the US, consumer rights groups won a ban on the purchase of meat from scrapie flocks because no one could rule out absolutely the possibility of transmission to humans. If bovine spongiform encephalopathy turns out to be infectious, it could cause problems out of proportion to the number of cases. Vacuoles in the brain prevent the passage of nerve impulses (left). Fibrils in brain tissue resemble those that are diagnostic of scrapie.
15. Bovine spongiform encephalopathy is a disease which is currently found in
A. all dairy cows.
B. some beef cows.
C. beef and dairy cows.
D. Freisian/Holstein dairy cows.
16. When bovine spongiform encephalopathy is confirmed in cows, which of the following symptoms do they not exhibit?
A. chronic wasting.
B. ungainly action.
C. frantic and agitated behavior.
D. sensitivity to usual stimuli.
17. Bovine spongiform encephalopathy is similar to other neurological diseases caused by ‘unconventional slow viruses’, which
A. is transmitted rapidly.
B. develops inconspicuously.
C. is caused by the same agents.
D. can be treated when detected early.
18. Pathology tests conducted on brains of cows which died of bovine spongiform encephalopathy show the presence of
A. fibrils which cause the disease.
B. fibrils which are caused by the disease.
C. fibrils which are also found in other animals infected with unconventional encephalopathies.
D. fibrils similar to those found in healthy cows.
19. Which of the following is not being considered as a cause of bovine spongiform encephalopathy?
A. the intake of contaminated food.
B. a genetic deficiency peculiar to Freisian cows.
C. parasite-produced vacuoles in the brain.
D. exposure to toxic products.
20. Bovine spongiform encephalopathy in cows appears similar to scrapie in sheep because
A. it is transmitted in a similar way.
B. the fibrils in diseased brains are similar.
C. it occurs in animals of a similar age.
D. of the rate at which the disease is transmitted.
21. Vets in Surrey are conducting experiments which will attempt to
A. infect healthy mice with bovine spongiform encephalopathy.
B. infect healthy sheep with bovine spongiform encephalopathy.
C. infect healthy humans through milk from bovine spongiform encephalopathy infected cows.
D. infect healthy cows with bovine spongiform encephalopathy.
22. The purchase of meat from scrapie infected flocks is banned in some countries because
A. the disease may then be transmitted to humans.
B. the disease will then be transmitted to humans.
C. it may lead to the spread of scrapie to other sheep.
D. it will lead to the spread of scrapie to other sheep.
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SURVEY ON SKIN LIGHTENING CREAMS
PART A: QUESTIONS 1-20
1. A
2. D
3. C
4. B
5. D
6. C
7. B
8. topical
9. unstaffed coin-operated
10. 100
11. Cataract
12. hydroquinone
13. artificial tanning methods
14. melanin
15. recurring
16. Steroids
17. malignant melanoma
18. health effects
19. highly potent steroids
20. Eye protection
PART B: QUESTIONS 1-6
1. B insufficient to find biocompatibility risks.
2. B nurse patient ratios interpret gastrointestinal bleeding.
3. A clinically relevant implantation study.
4. C non-traditional provider offering influenza vaccinations, pneumococcal vaccinations, or both
5. C have any potential risks that outweigh benefits.
6. A have a team of nurses, mental health technician and behavioral counselor.
PART C: QUESTIONS 7-14
7. C Levels of SHBG were compared in women who were using the pill, women who had stopped using the pill, and
women who had never used the pill.
8. B To prevent testosterone from being used in the female body.
9. B Women who had never taken the pill.
10. B High percentage of contraceptive success.
11. C SHBG levels were monitored at different times in three groups of adult women with various status regarding
contraceptive pill usage.
12. D but their levels remained elevated compared to women who had never used pill.
13. D Further studies should determine whether SHBG levels ultimately return to normal over longer periods.
14. C Dr. Goldstein monitored women with a history of pill use and sexual dysfunction in his clinic for seven years.
PART C: QUESTIONS 15-22
15. D Freisian/Holstein dairy cows.
16. A chronic wasting.
17. B develops inconspicuously.
18. C fibrils which are also found in other animals infected with unconventional encephalopathies.
19. C parasite-produced vacuoles in the brain.
20. B the fibrils in diseased brains are similar.
21. D infect healthy cows with bovine spongiform encephalopathy.
22. A the disease may then be transmitted to humans.
Rheumatic Heart Disease OET reading
TEXT A:
• People with a history of acute rheumatic fever (ARF) and a diagnosis of rheumatic heart disease (RHD)
• Aboriginal and Torres Strait Islander people (children aged between 5 and 14 are most at risk) and immigrants from developing countries
• Increased cardiac load during pregnancy will exacerbate pre-existing rheumatic valvular heart disease
• Importance of early diagnosis and regular secondary prophylaxis will help prevent deterioration of disease to a point where pregnancy is a risk
• Secondary prophylaxis is safe and should be continued during pregnancy
• Antibiotic prophylaxis to prevent endocarditis if prolonged labour and/or ruptured embranes
• Pre-conception counselling and assessment for all women with known rheumatic valvular disease
What is rheumatic heart disease (RHD)?
• When a person becomes infected by Group A Streptococcus bacterium (GAS), the immune response can cause acute generalised inflammation that affects the heart, joints, brain and skin. This is called acute rheumatic fever (ARF)
• Recurrent ARF can cause permanent damage to the heart valves – most commonly the mitral and aortic valves
• This damage is known as rheumatic heart disease (RHD)
• RHD can be classified as mild, moderate or severe
• In a mild case there will be no clinical evidence of heart failure
• In severe cases there are signs of valvular disease, oedema, angina and syncope
| TEXT-B. Table 1. Classification of rheumatic heart disease | |
| Class | Definition of category |
| HX ARE or no RHD. Priority 4. | • No pathological mitral or aortic regurgitation, but may have minor morphological changes to mitral or aortic valves on echocardiography |
| Mild RHD. Priority 3. | • Mild mitral or aortic regurgitation clinically and on echocardiography, with no clinical evidence of heart failure, and no evidence of cardiac chamber enlargement on echocardiography |
| Moderate RHD. Priority 2. | • Any valve lesion of moderate severity clinically (e.g., mild moderate cardiomegaly and/or mild – moderate heart failure) or on echocardiography • Mild mitral regurgitation together with mild aortic regurgitation clinically or on echocardiography • Mild or moderate mitral or aortic stenosis • Any pulmonary or tricuspid valve lesion co-existing with a left-sided valve lesion |
| severe RHD. Priority 1. | • Any clinically severe valve lesion (e.g., moderate to severe cardiomegaly Or heart failure) on echocardiography • Any impending or previous cardiac valve surgery |
TEXT C: Management
• The fundamental long term goal to manage RHD is to prevent ARF recurrences and therefore prevent the progression of valve disease
• This is achieved by regular delivery of secondary prophylaxis with intramuscular LA Bicillin
• Where adherence to secondary prevention is poor there is greater need for surgical intervention and long term surgical outcomes are poor
Client education and health promotion
• Discuss what RHD is, how it progresses and its association with throat and skin infections
• Recognizing the signs and symptoms of recurrent ARF and of RHD
• The need for timely access to health services and follow up
• Encourage the client to identify barriers to adequate lifestyle modification and medical adherence and to set goals to overcome those barriers based on their capacity and
understanding
• Provide relevant service and educational resources
Social emotional support
• A self- or clinician-rated mood scale can be used to assess for altered moo. Rating scales should be supplemented by a clinical assessment by suitably qualified mental health clinician to make a diagnosis
• Acknowledge any client concerns and reassure them that good adherence to appropriate treatment can improve the symptoms of their condition
Secondary prophylaxis (antibiotics)
• All clients with evidence of RHD and a history of ARF should have secondary antibiotic prophylaxis to control streptococcal infections
• Discuss the effectiveness of Bicillin regimes to prevent recurrence of ARF and minimize RHD
• Consider adverse reactions to medications
Regular physical health and specialist review
• Follow the care plan for RHD, Access to timely specialist physician, paediatric and/or cardiologist services for examination of heart and lungs
• Echocardiography
• Examination of throat, teeth and skin every presentation
• Assessment for shortness of breath, ankle swelling, palpitations or dizziness and chest pain
Dental care
• The risk of infective endocarditis and further heart valve damage increases with poor dental hygiene and oral infections
• 6 – 12 monthly dental care (depending on classification level) is essential for clients with a history of ARF and RHD
• Discuss dental hygiene and oral health at each visit
• Where appropriate, antibiotic prophylaxis are given prior to dental procedures
• A dental assessment and any treatment is required prior to valvular surgery
Recall and review
• Place client on a facility ARF/RHD recall system
• Provide client with the date of the next scheduled Bicillin injection
• Recall client from 21 days after the last injection to ensure that injections are given no more than 28 days apart
• Provide the client and other health services with Bicillin prophylaxis details when client is travelling to different communities
Surgery
• Surgery is determined by the severity of damage to the heart valves (severe RHD)
• Early referral to a cardiologist is required to identify heart failure and consideration for valve repair
• Repair or replacement of damaged heart valves prevents left ventricular dysfunction and severe pulmonary hypertension
• Heart valve replacement risks include stroke and infective endocarditis
TEXT-D: Medications
• Primary prophylaxis involves prompt treatment with antibiotics for treatment of streptococcal infection
• Secondary prophylaxis involves regular administration of Bicillin to prevent recurrent ARF
Secondary prophylaxis
• Decisions to cease secondary prophylaxis should be based on clinical and echocardiographic assessment by a specialist ARF/RHD physician
• All persons with
––ARF or RHD should have prophylaxis for a minimum of 10 years after most recent episode of ARF or until age 21 years (whichever is longer). Clients > 25 years of age who are diagnosed with RHD, without any documented history of prior ARF, should receive prophylaxis until the age of 35 years and then
––no RHD or mild RHD, if clinically assessed by echocardiography can discontinue prophylaxis at this time
––moderate RHD continue prophylaxis until 35 years of age
––severe RHD continue prophylaxis until 40 years of age. Although the risk of recurrence is extremely low in people aged > 40 years, in some cases prophylaxis may be continued beyond the age of 40 years, or even for life e.g. when a client decides they want to reduce even a minimal risk of recurrence
| Table 2. Antibiotic regimens for secondary prevention | |||
| Antibiotic | Dose | Route | Frequency |
| First line | |||
| Benzathine penicillin C (Bicillin) | ≥20 kg 900 mg (1,200,000 U) <20 kg 450 mg (600,000 U) | Deep 1M injection | 28 days |
| Second line | |||
| If 1M route is nol possible or refused • Adhprpncp shoul d bp carefully monitored • Oral secondary prophylaxis is nowhere near as effective as Bicillin | |||
| Phenoxymethylpenicillin (Penicillin V) | 250 mg | Oral | Twice daily |
| Following documented penicillin allergy | |||
| Erythromycin | 250 mg | Oral | Twice daily |
For 1-7, decide which text (A, B, C or D) the information comes from.
1. Classification of RHD
2. Steps to be taken when assessing a patient
3. Providing proper medicines
4. How to determine a patient with RHD
5. High risk groups
6. Giving support to patients
7. Counseling and assessment for women
Questions 8-13. Complete each of the sentences, 8-14, with a word or short phrase from one of the texts.
8. Heart valve substitution dangers include _______________ and infective endocarditic.
9. _______________ to continue, when a client decides they want to reduce even a minimal risk of recurrence over 40 years of age.
10. The prevention of recurring Acute Rheumatic Fever is achieved by regular delivery of secondary prophylaxis with _______________
11. _______________ months of dental care is essential for a patient with history of ARF/ RHD
12. Moderate RHD has been given the _______________ priority
13. No evidence of _______________ can be identified in person identified with mild RHD
Questions 14-20. Answer each of the following questions, 15-20, with a word or short phrase.
14. If IM route is not possible or refused to take medicines, what antibiotic is used to treat?
15. The ultimate aim of RHD is to prevent?
16. If a patient identified with mild rheumatic heart disease while review, what to discontinue
17. Which heart valves will damage, if RHD is attacking again and again?
18. When does a doctor can assess and give the patient Priority 1 of RHD?
19. What should have done prior to Valvular surgery?
20. What involves in Secondary prophylaxis to prevent recurring Acute Rheumatic Fever
PART B. Choose the answer (A, B or C) which you think fits best according to the text.
1. What does this manual extract tell us about?
A. To project I-dopa is not an ideal drug for long term treatment.
B. Treatment is not always ideal for Premature Parkinson’s disease
C. To project that the I-dopa is very effective in removing brain cells
Treatment: Treatment isn’t always needed in the early stages of Parkinson’s disease – mild tremor, for instance, may be inconvenient and cause social embarrassment but otherwise life can go on pretty much as normal. As the disease progresses, it will usually be treated with drugs. Several different drugs are available. These drugs act to increase signally within the dopamin pathways in the basal ganglia.
The best known of these is levodopa, also called l-dopa. When this drug was introduced in the 1960s it was a revolution in the treatment of Parkinson’s disease. It crosses easily from the bloodstream into the brain tissue, where it is converted by surviving brain cells to become dopamine. The symptoms of tremor and rigidity are often dramatically improved. The effect of the drug is not as potent in patients after several years of treatment as fewer remaining brain cells are able to convert the l-dopa to dopamine.
2. Where to use panic door exit devices:
A. Public buildings, visitor rooms
B. Smoke control rooms, schools.
C. Community centers, schools, and hospitals.
EMERGENCY EXIT DOOR PANIC DOORS: In panic situations the safety and rescue possibilities for people in the building are the main concern. In Europe uniform standards for emergency exit door fittings are in application.
Within the meaning of these standards, emergency exit door systems are subdivided in emergency exit devices according to EN 179, and panic door Exit devices according to EN 1125. Emergency exits acc. to EN 179 are designated to buildings to which the general public does not have access and whose visitors understand the function of the emergency doors.
Panic door exit devices acc. to EN 1125 are used in public buildings where the visitors are not familiar with the function of emergency doors, like schools, hospitals, shopping malls. The WICSTYLE door systems offer a comprehensive range of applications, which can also be combined with other functions and design options.
TECHNICAL PERFORMANCE. Profile technology:
• Doors in accordance with EN 179 (emergency Exit devices) or with EN 1125 (panic exit devices)
• Many system options for the emergency application, allowing for a unified door design within the building, irrespective of additional functions
• Single or double leaf possible
• Combination with burglar resistance in classes RC1 and RC2 possible
• Execution in combination with fi re protection in classes T30 and T60 and in combination with smoke control possible (national regulations must be respected)
3. What led for confrontation in resolving patient’s grievances or complaints by many organizations?
A. Lack of uniform rules across the country in dealing with complaints
B. No clear guidelines for channeling patients’ grievances to appropriate
C. Overriding the guidelines lay down by CMHCs.
Responding to complaints and grievances: Requirements for certain providers: Certain entities participating in Medicare and Medicaid are required to have specific grievance policies and procedures.
For example, under the Centers for Medicare and Medicaid Services’ (CMS) Conditions of Participation for Community Mental Health Centers (CMHCs) , CMHCs must inform clients that they have the right to voice grievances. CMHCs must also distribute written information to clients on filing a grievance during the patient’s initial evaluation. Although the Conditions of Participation for CMHCs only apply to a narrow subset of community behavioral health organizations, the standards are similar to expectations related to client rights in many states.
For hospitals, CMS’ Conditions of Participation require more in terms of a specific patient grievance process, including suggested time frames to investigate, resolve and follow-up on grievances. CMS also differentiates between a “complaint” and a “grievance.” While many organizations use these terms interchangeably, the definitions/distinctions laid out by CMS can help to determine the appropriate response when a patient makes a complaint or grievance.
4. The purpose of these notes about a counseling agent is
A. To aid and advice patient’s caretakers at home
B. To consider various aspects while treating a patient
C. Modify himself as patient’s caretaker.
Counseling: a Service to Society: Counselors advise and assist individuals, families, groups and organizations. The American Counseling Association describes counseling as a collaborative effort between counselors and their clients. To be an effective counselor, a trained professional needs to be able to work on numerous levels. For example, counselors help people of all ages identify problems, strengths and goals; work through issues; improve interpersonal and coping skills; address mental health concerns; change behavior and focus on personal growth.
Often, when one person is seeing a counselor, the effect goes beyond what the individual gains. Families and family dynamics are affected when someone who has been grappling with difficult problems begins working with a trained counselor. As the individual client learns what is causing her distress and how to manage it, family members open to evolving may benefit from knowledge, understanding and improvements acquired through counseling sessions. Other beneficiaries include extended family, employers, colleagues and friends, community groups and society.
5. What we understood form the manual extract is
A. Technological progress made product delivery easy to the required.
B. Digital copies made user friendly for the Nurses despite costly
C. Criticism in Manuals will not be the sole criteria in evaluating writer’s works.
Medical device user manuals: Shifting Towards Computerization: Consider the challenges facing technical communicators (i.e., technical writers) who design and produce medical device user manuals: First, their work must address the needs of an especially diverse audience, starting with caregivers and extending to trainers, biomedical engineers, sales personnel, government regulators, and many others. Because of its broad potential audience, the typical medical device user manual must be several documents in one. Second, technical communicators often have only limited resources and time to produce high-quality manuals as their companies speed products to market. Third, a user manual’s primary audience—arguably the nurses, physicians, and technicians who deliver direct care to patients—tend to prefer engaging in hands-on training over reading user manuals. The popularity of the hands-on approach creates a perception of user manuals as perfunctory—a perception that could take the wind out of any technical writer’s sails.
As computer technology grows ever more ubiquitous, a popular trend toward computerizing learning tools is cause for new excitement among technical communicators and allied professionals alike. As more caregivers gain computer access, the practicality of their viewing instructions on a medical device’s computer display, on the Web, or on an interactive CD-ROM, for example, will increase. Such technological progress will enable content developers to think beyond the printed page and embrace alternative delivery mechanisms that may be more compatible with a particular user’s learning style. In addition to the benefits it might afford users, computerization will assist manufacturers in updating content as readily as they install new versions of software into devices. As a result of this emerging multimedia approach, the hard-copy medical device user manual is swiftly evolving toward a system of both print and electronic components.
6. Nursing registration guidelines states that
A. A nurse has to complete her full education in vocational schools
B. To proclaim as a registered Nurse, she has to complete preregistration program study.
C. 5 years full term course completion is the only the criteria for registering as a Nurse.
Registered nurses and registered midwives: If you are applying for registration as a registered nurse and/or a registered midwife, you must provide evidence of the completion of five (5) years*(full-time equivalent) of education taught and assessed in English, in any of the recognised countries.
NOTE: a) The Board will only accept the completion of five (5) years* (full-time equivalent) of:
i) tertiary and secondary education taught and assessed in English; or
ii) tertiary and vocational education taught and assessed in English; or
iii) combined tertiary, secondary and vocational education taught and assessed in English; or
iv) tertiary education taught and assessed in English from one or more of the recognised countries listed in this registration standard.
b) The five (5) years referred to in paragraph a above must include evidence of a minimum of two (2) years full-time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery regulatory body in any of the recognised countries listed in this registration standard.
PART C. TEXT 1. Choose the answer (A, B, C or D)
When health anxiety set my mind (and heart) racing. ” You’re too young to be here.”
I couldn’t agree more. I look around the cardiologist’s waiting room, guessing that I’m the youngest person by at least 20 years. Everyone else is slightly crumpled; soft, wrinkled and grey. But, despite my youthful vigour – well, maybe slightly worn around the edges after 39 years – I did need to be there. You see a month or so prior to my walking into the waiting room, my heart had started doing something weird. Every now and then – roughly every 10 or 20 minutes – it would do an extra big beat, or an odd beat, or something like that. I discovered that it’s hard to listen to your own heart. It’s a bit like a quantum physics problem: the act of observing it changes its behaviour. For a few weeks, I ignored it, thinking it was probably related to the horrible cold I was experiencing.
But it continued. And continued. So I did what all internet-equipped hypochondriacs do, I consulted Dr Google. Being a health journalist whose search history tends to demand the good stuff, I like to think that I found some slightly more authoritative and less hysterical sources than your average search would hand up; but it was still enough to make me decide a trip to the doctor was in order. My GP couldn’t find anything. My blood tests were normal, my ECG healthy, so he sent me to a cardiologist. It wasn’t an urgent referral, so I was faintly reassured that the GP wasn’t worried that I was going to do the clutch-heart-and-drop Hollywood thing just yet. Then I had to wait. It was two weeks between seeing the GP and my cardiology appointment, and for the first time in my life, I experienced something that I have read and written about so often: the anxiety of the so-called ‘worried well’.
This is one of the reasons why, even though we have so many tests for so many diseases, we don’t use them on everyone. Because while a test might pick up one person in a hundred with a medical problem (which may not even have been life-threatening), for the other 99 people in that population, the time between having the test and getting the all-clear is for many a time of great anxiety and stress. For many, that stress will be in the background. We might not even be aware of it, but no matter how bullet-proof we try to convince ourselves that we are, ultimately, we’re all waiting for the bomb with our name on it. It will, on some level, eat away at our psyche.
While there’s no blood test or sliding scale to really quantify that stress, it is real, and it is a cost. During this time I had lunch with a dear friend, who was off to get a lump in her breast checked. Our faces mirrored each other’s unspoken anxiety over our obscenely large midday breakfasts. We talked about the fact that ultimately, everyone has to die of something. I said, “Somehow, I don’t think my ticker and your bosom are it for us,” probably sounding a lot more confident than I felt. Lying in bed at night, I would listen intently for my heart’s occasional mega-thump, trying to glean just a little bit more information from the errant beats that might reassure me this wasn’t atrial fibrillation or a dangerous arrhythmia. Instead, my heartbeat began to sound faster and louder than I had ever noticed before. Even when I tried to ignore it and go to sleep, it pounded in my chest like the war drum of Impending Doom.
Finally, the day comes for my trip to the cardiologist. The night before, I’m plagued with intensely stressful dreams, including one in which I’m due to perform on stage right after Tim Minchin. If that isn’t a hard act to follow, I don’t know what is. I wake up with my guts tight, possessed with a slightly hysterical mania that sees me charging around the house, washing, cleaning, tidying. I get the kids out the door for school earlier than usual, much to their and my confusion at the lack of the usual screaming “HURRY UP!” routine. The cardiologist is running late, so I have nearly an hour in the waiting room watching other patients shuffle in and out of the rooms. My heart flip-flops regularly, reassuring me that I’m not going to be wasting his time.
The nurse beckons me in for my stress test. My chest is decorated with sticky dots, like I’m waiting to be digitally rendered as a female Gollum, and I’m connected to a tangle of electrical leads. Then up onto the treadmill, and my test begins. Oh, the irony. My heart problem has stage fright. The nurse cranks up the treadmill until I’m puffing and sweating under the heavy ECG belt, yet my recalcitrant heart steadfastly refuses to give even a single performance of its aberration. Instead, it defiantly beats strong, solid, and regularly, as if trying to prove that it’s all simply a product of my paranoid imagination.
Even after the test is finished, and I’m cooling off in the waiting room while the doctor reviews the results, my heart beats as reliably as an atomic clock. Despite the absence of anything on the ECG, he diagnoses me as having ventricular ectopic beats. These are occasional misfiring, like an extra heartbeat that happens in the lower chamber of the heart (the ventricle). In otherwise healthy individuals, they are no cause for alarm. In fact, they reassure me that my heart is healthy enough that I could apply for a job with police rescue.
He schedules an echocardiogram to check there’s not some other valve weirdness going on, but by that stage I’m skipping out the door, feeling like a possible death sentence has been lifted and instead I’m contemplating doing a half-marathon for the first time in my life.
7. Why does she heard the words “you’re too young to be here”
A. Because she is not having any problem
B. She is healthy, so, not to come there
C. They think her age is not ideal to have problems
D. It is an restricted area for minors
8. Why the author does compare her increased heartbeat with quantum physics?
A. Probably it was her perception that she had high heartbeat
B. She overwhelmingly responded to the difficult problem in physics
C. Used in the context of her ideas to actions conflicting in her mind.
D. Unable to define a proper form, instead she used.
9. Why she delayed to consult Cardiologist?
A. She thinks it’s unnecessary
B. She was willing consult another GP, instead cardiologist
C. Because it was not an urgent referral
D. Undermined the importance of referral
10. Why she used the words “worried well” in the second paragraph?
A. She is afraid of what going to face, when she meet cardiologist.
B. She is anxious to meet cardiologist
C. It is hard to digest, until she gets positive report
D. Worried to get appointment after two weeks
11. What do you understand from the last sentence in the third paragraph?
A. Stress cannot be in varied from person to person
B. It projects surprisingly at sometimes
C. Stress cannot be hidden at all times
D. Nothing
12. Why does she talk about some quoted words in the fifth paragraph?
A. To regain their confidence
B. To refrain from stress
C. To mobilize themselves to meet doctor regularly
D. To verify that theirs GP have referred correctly
13. The word “Beacons” means
A. Searches B. Signs C. Signals D. Warns
14. Who does the word “they” refers to?
A. Doctors B. Cardiologists C. Nurses D. Patients
PART C. TEXT: 2
News reports about a study from Germany may provide the ultimate excuse for men to dress more casually for work, finding neckties reduce blood supply to the brain.
The study showed that wearing a tie that causes slight discomfort can reduce blood flow to the brain by 7.5 per cent, but the reduction is unlikely to cause any physical symptoms, which generally begin at a reduction of 10 per cent. Past research shows that compression of the jugular vein in the neck reduces blood flow to the brain. In this new study, published recently in the journal Neuroradiology, the researchers tested whether the pressure of a necktie could induce these changes.
They recruited 30 young men aged 21 to 28 years and split them into two groups: those wearing neckties and those without. Using magnetic resonance imaging (MRI), the researchers tested the cerebral blood flow (total blood flow to the brain) using a technique that showed changes to the flow via a colour change. They also tested the blood flow from their jugular vein.
The first MRI took a “baseline” scan, while the participants in both groups had an open collar (and those in the tie-wearing group had a loosened tie). For the second scan, the men’s collars were closed and participants in the tie group tightened their Windsor knot until they felt slight discomfort. A third scan followed, in the same conditions as the baseline scan. All scans lasted 15 minutes.
The authors found that wearing a necktie with a Windsor knot tightened to level of slight discomfort for 15 minutes led to a 7.5 per cent drop in cerebral blood flow, and a 5.7 per cent drop in the 15 minutes after the tie was loosened. The men’s blood flow in the control group — those who weren’t wearing a tie — didn’t change. No change was found in jugular venous flow between the two groups.
The study didn’t go into any detail about the effects, so let’s consider what they might be. The researchers found a reduction in blood flow to the brain of 7.5 per cent, which is unlikely to cause problems for most men. Healthy people are likely to begin experiencing symptoms when blood flow to the brain reduces by about 10 per cent — so, a larger reduction than the study found. Along with an increase in blood pressure at the site, a 10 per cent reduction in blood flow can cause dizziness, light-headedness, headaches and nausea. But even with a 7.5 per cent drop in blood loss to the brain, a person could still experience some temporary dizziness, headaches or nausea.
Compounded with other factors, such as smoking or advanced age, a 7.5 per cent decrease could bring some people over this 10 per cent threshold of blood flow loss, placing extra stress on their already strained bodies and increasing their risk of losing consciousness or developing high-blood pressure. It’s unclear why there was no change to the jugular, but this may be due to the circular nature of the restriction: the pressure is equally distributed across the neck, rather than just the jugular.
Further research is needed to assess the impact of wearing a tie for longer periods and wearing different knots. Any pressure on the neck is slightly discomforting, and men’s style guides advise tightening a necktie to be “tight but not too tight”. Whether this tightness aligns with the participants’ classification of “slight discomfort” is unclear. This study had a sample size of 30 participants, which is relatively small. Most human studies investigating blood pressure and cerebral blood flow have at least 40 to 60 participants.
Another limitation is that the study did not include a discussion about the potential impact of the blood restriction, or the finding that jugular blood flows didn’t change. But overall, the study is simple and well-designed. It adds to a small but growing body of research about the problems with neckties: they can lead to higher rates of infection, as they’re infrequently washed; and they may increase intraocular pressure (blood pressure in the eyes) to the point of increasing the risk of glaucoma.
Perhaps it’s time to get rid of this unwelcome guest from our wardrobe, or restrict it to special occasions.
15. As per the new study report on using neckties by professionals will result in
A. Causing pain to Brian
B. Causes physical changes
C. Will not have major impact on blood supply to brain
D. No relation in causing physical symptoms.
16. How the researchers identified the blood flow change to brain
A. By using a specially designed meter
B. Based on colour
C. With the help of nerves blood flow density
D. Based on samples collected from research
17. The word ‘Baseline’ defines that
A. The first scan was taken as referral mark
B. They considered it as the minimum level to conduct the research
C. It was considered as the highest level to check
D. It was the first stage in process
18. What was the researcher’s conclusion at the end?
A. There was the change of color in blood flow to brain
B. Identified no relation to jugular venous flow
C. Had developed a new technique to check this instead
D. It was a disappointing result for them
19. What will cause, if an aged patient using his necktie continuous for 2-3 hours?
A. May develop additional symptoms to the existing
B. Will develop resistance to blood flow to brain
C. Nothing will happen in prolonged exposure
D. Unable to determine the impacts
20. What was the major limitation in study report?
A. It doesn’t include many other aspects of the study
B. It focuses mainly on analyzing the impact of jugular venous flow.
C. It includes only a small group of people
D. Lack of technical support.
21. What does the word “it” refers to?
A. The study
B. The jugular venous flow
C. Blood flow
D. Infection
22. What does the word “this” refers to?
A. Necktie B. Infection C. Blood pressure D. Research
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Psoriasis OET reading
Text A
Psoriasis is a chronic inflammatory disease of the immune system. It mostly affects the skin and joints, but it may also affect the fingernails, the toenails, the soft tissues of the genitals and the inner side of the mouth. Psoriasis and psoriatic arthritis can be associated with other diseases and conditions, including diabetes, cardiovascular disease and depression.
Psoriasis Facts
• Psoriasis is a serious medical condition.
• Approximately 7.5 million people in the United States have psoriasis and suffer from this medical condition more helplessly.
• Psoriasis can occur at any point of life time but primarily seen in adults. Up to 40 percent of people with psoriasis experience joint inflammation that produces symptoms of arthritis. This condition is called psoriatic arthritis. Psoriatic arthritis patients also experience other arthritis symptoms.
• Psoriasis usually occurs on the scalp, knees, elbows, hands and feet. Approximately 80 percent of those affected with psoriasis have a mild to moderate disease, while 20 percent have moderate to severe psoriasis affecting more than 5 percent of the body surface area.
• Plaque psoriasis is the most common form affecting about 80 to 90 percent of psoriasis, which is characterized by patches of raised, reddish skin covered with silvery-white scales.
Text B Comorbidities Associated with Psoriasis;
• The incidence of Crohn`s disease and ulcerative colitis, two types of inflammatory bowel disease, is 3.8 to 7.5 times greater in psoriasis patients than in the general population.
• Patients with psoriasis also have an increased incidence of lymphoma, heart disease, obesity, type II diabetes and metabolic syndrome. Depression and suicide, smoking and alcohol consumption are also more common in psoriasis patients.
• Psoriasis can have a substantial psychological and emotional impact on patients.
• The prevalence of lugubrious in patients with psoriasis may be as high as 50 percent. Studies have shown that psoriasis patients experience physical and mental disabilities, just like patients with other chronic illnesses such as cancer, arthritis, hypertension, heart disease and diabetes.
Text C Treatment Options for Psoriasis
• Topical treatments are helpful for mild to moderate psoriasis but do not tend to be effective for treating moderate to severe psoriasis.
• Topical treatments include anthralin, coal tar, emollients, salicylic acid, tazarotene, topical corticosteroids and forms of vitamin D. These topical medications can sometimes be used together with other medications.
• Topical corticosteroids are available in many strengths and formulations.
• Psoriasis patients with moderate to severe psoriasis can be treated with traditional systemics, phototherapy or biologic agents.
• In cases of more extensive psoriasis, topical agents may be used in combination with phototherapy, or traditional systemic or biologic medications.
• Phototherapy treatment includes narrowband and broadband ultraviolet B (UVB) and psoralen plus UVA (PUVA).
• Regular systemic treatments include acitretin, cyclosporine and methotrexate. Since biologic therapies, sporadically propounded, target the immune system, it is important to prevent infections during therapy. Patients need to be monitored and evaluated periodically.
Text D The PHAROS EX-308 Excimer Laser
While mild cases of psoriasis can sometimes be treated with specific creams and ointments (Anthralin. Topical retinoids, Calcineurin inhibitors, Coal tar and others are known to be very much effective), many patients do not experience relief with these treatments. For those patients, phototherapy can be a more successful option.
Phototherapy uses UV light to decrease inflammation in areas affected by psoriasis, assisting in clearing the itchy lesions. Laser such as PHAROS EX-308 Excimer Laser allows doctors to administer phototherapy in an especially effective way. This laser allows easy application of highly-concentrated and customized UV light directly to the areas of affected skin, making the treatment as effective as possible without affecting the surrounding skin.
1. More or less like conditions arising in other diseases. Answer .
2. Traditionals procedures. Answer .
3. An effective way of treating. Answer .
4. Facts with respect to new diseases that might arise. Answer .
5. Affect people of all ages. Answer .
6. People have no choice but to endure. Answer .
7. Deal with depression. Answer .
Questions 8-14 Answer each of the questions, 8-14, with a word or short phrase from one of the texts.
8. What phototherapy may entail? Answer .
9. What psoriasis can be connected to? Answer .
10. Which therapy or what is often not suggested? Answer .
11. What is the initial treatment for mild to moderate psoriasis in its beginning stages? Answer .
12. What is the outcome of the research conducted? Answer .
13. What is the advanced treatment option available for the patients? Answer
14. What will the patients with psoriatic arthritis eventually develop? Answer
Questions 15-20 Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
15. Patients show increasing levels of _________________
16. The disease can have _________________ effects on sufferers.
17. Psoriasis can be associated with other diseases such as diabetes, ________________ and depression.
18. _________________ include acitretin, cyclosporine and methotrexate.
19. Phototherapy provides necessary help in wiping out _____________
20. Occurrence of two types of inflammatory bowel disease, is________________ . in psoriasis patients.
PART B. Choose A, B or C
1. Blood cell levels will be low;
A. If there are too many immunoglobulins.
B. If there are too many myeloma cells in the bone marrow.
C. If there are less antibodies.
Tests to Find Multiple Myeloma Blood counts: The complete blood count (CBC) is a test that measures the levels of red cells, white cells, and platelets in the blood. The most common finding is a low red blood cell count (anemia).
Quantitative immunoglobulins: This test measures the blood levels of the different antibodies. There are several different types of antibodies in the blood: IgA, IgD, IgE, IgG, and IgM. The levels of these immunoglobulins are measured to see if any are abnormally high or low. In multiple myeloma, the level of one type may be high while the others are low.
2. What is right about immunoglobulin?
A. Finding a monoclonal immunoglobulin in the blood may be the first step in diagnosing multiple myeloma.
B .Produces different types of proteins.
C .It will not produce all the exact same antibody.
Electrophoresis: The immunoglobulin produced by myeloma cells is abnormal because it is monoclonal. Serum protein electrophoresis (SPEP) is a test that measures the immunoglobulins in the blood and can find a monoclonal immunoglobulin. Then, another test, such as immunofixation or immunoelectrophoresis, is used to determine the exact type of abnormal antibody (IgG or some other type). This abnormal protein is known by several different names, including monoclonal immunoglobulin, M protein, M spike, and paraprotein. Immunoglobulins are made up of protein chains: 2 long (heavy) chains and 2 shorter (light) chains. Sometimes the kidneys excrete pieces of the M protein into the urine. This urine protein, known as Bence Jones protein, is the part of the immunoglobulin called the light chain. The tests used for finding a monoclonal immunoglobulin in urine are called urine protein electrophoresis (UPEP) and urine immunofixation. These are done most often on urine that has been collected over a 24-hour period, not just on a routine urine sample.
3. What is correct about Free Light Chains?
A. Ratio of kappa and lambda is 1:1.
B. Come in handy when it is not possible to diagnose by other methods.
C. Possibly, no differences in ratio arises with differences in light chains.
Free light chains: This test measures the amount of light chains in the blood, being a possible sign of myeloma or light chain amyloidosis. This is most helpful in the rare cases of myeloma in which no M protein is found by SPEP. Since the SPEP measures the levels of intact (whole) immunoglobulins, it cannot measure the amount of light chains.
This test also measures the light chain ratio which is used to see if one type of light chain is more common than the other. Kappa and lambda, in most cases, are present in equal amounts in the blood,. If one kind of light chain is more common than the other, the ratio will be different, which can be a sign of myeloma.
4. The notice deals with;
A. A chromosomal structure testing.
B. FISH and its effectiveness.
C. Appropriateness of the results.
Fluorescent in situ hybridization (FISH) is similar to cytogenetic testing. It uses special fluorescent dyes that only attach to specific parts of chromosomes. FISH can find most chromosome changes (such as translocations and deletions) that can be seen under a microscope in standard cytogenetic tests, as well as some changes too small to be seen with usual cytogenetic testing. FISH can be used to look for specific changes in chromosomes. It can be used on regular blood as well as bone marrow samples. It’s very accurate and because the cells don’t have to grow in a dish first, results are often available within a couple of days.
5. What is right about BUN?
A. Patient may lose his / her memory.
B. Differences in electrolytes.
C. The higher the Cr levels, the greater is the effect on the kidney.
Blood chemistry tests: Levels of blood urea nitrogen (BUN) and creatinine (Cr), albumin, calcium, and other electrolytes will be checked. BUN and Cr levels show how well your kidneys are working. Higher levels mean that kidney function is impaired. This is common in people with myeloma. Albumin is a protein found in the blood. Low levels can be a sign of more advanced myeloma. Calcium levels may be higher in people with advanced myeloma. High calcium levels can cause severe symptoms of ennui, weakness, and confusion. Levels of electrolytes such as sodium and potassium may be affected as well.
6. Bone marrow biopsy;
A. Is painful.
B. Is painless.
C. Helps detect myeloma.
Bone marrow biopsy: In bone marrow aspiration, the back of the pelvic bone is numbed with local anesthetic. Then, a needle is inserted into the bone, and a syringe is used to remove a small amount of liquid bone marrow. This causes a brief sharp pain. Then for the biopsy, a needle is used to remove little amount of bone and marrow, about 1/16- inch across and 1-inch long. Patients may feel some pressure during the biopsy, but it usually isn’t painful. There is some soreness in the biopsy area when the numbing medicine wears off. Most patients can go home immediately after the procedure. A doctor will look at the bone marrow tissue under a microscope to see the appearance, size, and shape of the cells, how the cells are arranged and to determine if there are myeloma cells in the bone marrow and, if so, how many.
PART C. TEXT 1: ALL ABOUT HEMOCHROMATOSIS
Hemochromatosis is the most common form of iron overload disease. Primary hemochromatosis, also called hereditary hemochromatosis, is an inherited disease. Secondary hemochromatosis is caused by anaemia, alcoholism, and other disorders. Juvenile hemochromatosis and neonatal hemochromatosis are two additional forms of the disease. Juvenile hemochromatosis leads to severe iron overload and liver and heart disease in adolescents and young adults between the ages of 15 and 30. The neonatal form causes rapid iron build-up in a baby`s liver that can lead to death.
Hemochromatosis causes the body to absorb and store too much iron. Once it grips on anyone, it will be difficult to free that person from its clutches. The redundant iron builds up in the body`s organs and damages them. Without treatment, the disease can cause the liver, heart, and pancreas to fail. Iron is an essential nutrient found in many foods. The greatest amount is found in red meat and iron-fortified breads and cereals. In the body, iron becomes part of haemoglobin, a molecule in the blood that transports oxygen from the lungs to all body tissues. Healthy people usually take in about 10 percent of the iron contained in the food they eat, which meets normal dietary requirements. People with hemochromatosis absorb up to 30 percent of iron. Over time, they absorb and keep in their body between five to 20 times more iron than the body may be in quest of. Because the body has no natural way to rid itself of the unwanted or superfluous iron, it is stored in body tissues, specifically the liver, heart, and pancreas.
Hereditary hemochromatosis is mainly caused by a drawback, a flaw in a gene called HFE, which helps regulate the amount of iron absorbed from food. The two known mutations of HFE are C282Y and H63D. C282Y is the most important because it is this which can lead to disturbance in taking the helm. In people who inherit C282Y from both parents, the body absorbs too much iron and hemochromatosis can result. Those who inherit the defective gene from only one parent are carriers for the disease but usually do not develop it; however, they still may have a little than orderly iron absorption. Neither juvenile hemochromatosis nor neonatal hemochromatosis are caused by an HFE defect. Juvenile and neonatal hemochromatosis are caused by a mutation in a gene called hemojuvelin.
Hereditary hemochromatosis is one of the most common genetic disorders in the United States. It most often affects Caucasians of Northern European descent, although other ethnic groups are also affected. About five people out of 1,000 – 0.5 percent – of the U.S. Caucasian population carry two copies of the hemochromatosis gene and are susceptible to developing the disease. One out of every 8 to 12 people is a carrier of one abnormal gene. Hemochromatosis is less common in African Americans, Asian Americans, Hispanics/Latinos, and American Indians. Although both men and women can inherit the gene defect, men are more likely than women to be diagnosed with hereditary hemochromatosis at a younger age. On average, men develop symptoms and are diagnosed between 30 to 50 years of age. For women, the average age of diagnosis is about 50.
Joint pain is the most common complaint of people with hemochromatosis. Other common symptoms include debility, abdominal pain and heart problems. However, many people have no symptoms when they are diagnosed. If the disease is not detected and treated early, iron may accumulate in body tissues and eventually lead to serious problems such as arthritis; liver disease (including an enlarged liver); cirrhosis; cancer; liver failure; damage to the pancreas, possibly causing diabetes; brain fog; heart abnormalities, such as irregular heart rhythms or congestive heart failure; impotence; early menopause; abnormal pigmentation of the skin, making it look gray or bronze; thyroid deficiency; damage to the adrenal glands; constant fatigue etc.
7. According to Paragraph 1, hemochromatosis occurs due to;
A. An excess of iron in the blood.
B . A decrease in the quantity of iron in the blood.
C. A genetic disorder. D .Alcoholism
8. In one of the forms of hemochromatosis, which one of the following conditions occurs?
A. Anaemic people are more prone to hemochromatosis
B It can be more fatal as the quantity of the iron increases more and more
C. It can be the result of some genetic disorder but may not lead to death
D. None of this above
9. According to paragraph 2, the patient`s body shows unusual capabilities of;
A. Absorbing iron from food eaten.
B. Storing the iron derived from the food.
C. Absorption and storage of iron.
D. Retaining 20 times more than the iron required.
10. In paragraph 2, which word or phrase may mean the following: To cause someone or something to be free from an unpleasant or harmful thing?
A. Superfluous
B. Free from clutches
C. Rid off
D. Grips on
11. According to paragraph 3, the affected people;
A. May show the presence of defective genes from both the parents.
B. May take defective genes from a single parent.
C. Show capabilities of absorbing and retaining more than the iron required for the body.
D. Show the presence of only C282Y.
12. Which word in the paragraph 3, may mean organizeor manage?
A. Take the helm
B. Orderly
C. Regulate
D. None of the above
13. Paragraph 4 deals more with;
A. Symptoms and diagnosis
B .The risk factors of hemochromatosis
C .Hereditary hemochromatosis
D. How common it is in other countries
14. Which one of the following is considered a major symptom?
A. Arthritis
B. Skin coloration
C. Joint pain
D. Brain fog
PART C. TEXT 2: CHRONIC MYELOGENOUS LEUKEMIA
Leukemia is a type of cancer that starts in the blood or blood-forming tissues. There are many different types of leukemia, and treatment is different for each one. Chronic leukemias develop in a lackadaisical way in comparison with that of acute leukemias, which show great momentum and multiplication celerity. But CL can be just as life threatening. Chronic myelogenous leukemia is commonly referred to as CML. Other names for this type of cancer include chronic myeloid leukemia, chronic myelocytic leukemia, and chronic granulocytic leukemia. This is a cancer of the white blood cells. In CML, blast cells, or immature white blood cells, form and multiply uncontrollably; they crowd out all the other types of necessary blood cells.
CML has different phases of progression. Which phase the disease is in determines the appropriate treatment. The phases are based on the number of blast cells present and include: the chronic phase, the accelerated phase, and the blast crisis phase. The Chronic Phase: This is the earliest stage of CML, and you may have some symptoms or none at all. During this phase, your white blood cells can still fight infections in your body. The Accelerated Phase: In this phase, your red blood cell counts are low, and anemia (not enough iron in your blood) may occur.
Platelet levels are also reduced, which may cause easy bruising or bleeding because platelets help to form blood clots. The amount of blast cells increases. A fairly common complication at this point is a swollen spleen, which may cause stomach pain. The Blast Crisis Phase: A large number of blast cells are present in this advanced phase. Symptoms in this phase are more severe and can be life threatening.
Genetic mutation is known to be the driving factor for this disease. Doctors do not know what implants this initial mutation but it does happen in an unusual way. In humans, there are 23 pairs of chromosomes. In individuals with CML, part of chromosome 9 is switched with a piece of chromosome 22. This makes a short chromosome 22 and a very long chromosome 9. The short chromosome 22 is called the Philadelphia chromosome, and is present in 90 percent of CML patients. Genes from chromosomes 9 and 22 then combine to form a gene, the BCR-ABL gene that enables specific blood cells to multiply uncontrollably, causing CML.
Because CML generally does not cause symptoms in its early stages, the cancer is often detected during a routine blood test. When there are symptoms, they are general and can be symptoms of other health conditions as well. Symptoms may include fatigue, night sweats, fever etc. If tests suggest that you may have cancer, a bone marrow biopsy is performed. This is to get a sample of bone marrow to send to a lab for analysis. Once diagnosed, tests will be done to explore the extent of disease in your body. A complete blood work-up is typically ordered, along with genetic tests done in a laboratory. Imaging tests such as an MRI, ultrasound, and CT scan can also be used to determine the extent of the disease.
Targeted therapies are typically used first in CML treatment. These are drugs that attack a specific part of the cancer cell to kill it. In the case of CML, these drugs block the protein made by the BCR-ABL gene. They may include imatinib, dasatinib, or nilotinib. These are newer therapies that have been very successful; they are truly far from being too perilous. Chemotherapy involves using drugs to kill cancer cells. These drugs are systemic, which means they travel through your entire body via your bloodstream. They can be given intravenously or orally, depending on the specific drug. They are a common cancer treatment with side effects that may be intense, but may not lead to precarious conditions. A bone marrow transplant (also called a blood stem cell transplant) is used when other treatments have failed; this is because those who opt for it go for broke in most of the cases. There is a significant chance of adverse side effects. In this type of transplant, chemotherapy is used to kill the cancerous cells in your bone marrow before healthy donor cells are infused into your blood to replace them. Side effects of this procedure vary widely but can include minor things such as chills and flushing or major complications like anemia, infections, and cataracts.
15. According to paragraph 1, which one of the following statements is true?
A. Chronic leukemia grows at the same speed as that of acute leukemia.
B. Only acute leukemia can be much more fatal than chronic leukemia.
C. Leukemia is a condition in which blood cells start multiplying at a constant speed.
D. .Acute leukemia grows at a rapid speed.
16. Which word in paragraph 1 may suggest the following meaning: slow in movement, showing little energy or enthusiasm?
A. Momentum
B. Lackadaisical
C. Celerity
D .None of the above
17. Paragraph 2 talks more about;
A. Development stages of the leukemia.
B. Different phases of leukemia.
C. Progression of CML.
D. How CML occurs.
18. According to paragraph 4, which one of the following statements is true?
A. The gene that grows out of the fusion of genes from chromosomes 9 and 22 plays a crucial role in multiplication of the blood cells which eventually leads to CML
B. Chromosomes 9 and 22 combine in an unusual way to give birth to BCR – IBL
C. Most of the patients across the globe show the combination of the genes from chromosome 9 and chromosome 22
D. None of the above
19. Paragraph 4 talks more about;
A. CML tests
B. Symptoms of CML
C. The procedure for identification of CML
D. How CML is diagnosed
20. According to paragraph 5, which one of the following statements is correct?
A. A complete blood report will be prescribed at the end of the initial diagnosis
B. An ultrasound should be performed before the blood tests
C. If the reports are suggestive of cancer, then a bone marrow biopsy is performed
D. None of the above
21. Paragraph 6 give notice about;
A The three most common treatment options for CML
B Differences among targeted therapy, chemotherapy and bone marrow transplants
C Why a bone marrow transplant is a better option than chemotherapy
D How targeted therapy is better than the other two treatment options
22. Which word or phrase suggests the following meaning: Risky?
A Perilous
B Go for broke
C Precarious
D None of the above
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PARACETAMOL OVERDOSE: OET reading
TEXT A: Paracetamol: contraindications and interactions
4.4 Special warnings and precautions for use
Where analgesics are used long-term (>3 months) with administration every two days or more frequently, headache may develop or increase. Headache induced by overuse of analgesics (MOH medication-overuse headache) should not be treated by dose increase. In such cases, the use of analgesics should be discontinued in consultation with the doctor.
Care is advised in the administration of paracetamol to patients with alcohol dependency, severe renal or severe hepatic impairment. Other contraindications are: shock and acute inflammation of liver due to hepatitis C virus. The hazards of overdose are greater in those with non-cirrhotic alcoholic liver disease.
4.5 Interaction with other medicinal products and other forms of interaction
• Anticoagulants – the effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol with increased risk of bleeding. Occasional doses have no significant effect.
• Metoclopramide – may increase speed of absorption of paracetamol.
• Domperidone – may increase speed of absorption of paracetamol.
• Colestyramine – may reduce absorption if given within one hour of paracetamol.
• Imatinib–restriction or avoidance of concomitant regular paracetamol use should be taken with imatinib.
A total of 169 drugs (1042 brand and generic names) are known to interact with paracetamol. 14 major drug interactions (e.g., amyl nitrite)
62 moderate drug interactions
93 minor drug interactions
A total of 118 brand names are known to have paracetamol in their formulation, e.g. Lemsip
Text D
Clinical Assessment
• Commonly, patients who have taken a paracetamol overdose are asymptomatic for the first 24 hours or just have nausea and vomiting
• Hepatic necrosis (elevated transaminases, right upper quadrant pain and jaundice) begins to develop after 24 hours and can progress to acute liver failure (ALF)
• Patients may also develop:
• Encephalopathy • Renal failure – usually occurs around day three
• Oliguria • Lactic acidosis
• Hypoglycaemia
History
• Number of tablets, formulation, any concomitant tablets
• Time of overdose
• Suicide risk – was a note left?
• Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the production of the toxin NAPQI, whereas chronic alcoholism may increase it)
Questions 1-20
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 overdose?
7 dealing with paracetamol overdose patients who have not received adequate nutrition?
Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
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. Complete each of the sentences, 14-20, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
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.
PART B. For questions 1-6, choose the answer (A, B or C)
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 followed. Staff should continue to take great care to avoid bedrail entrapment, but be aware that in hospital settings there may be a greater risk of harm to patients who fall out of bed.
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.
PART C. TEXT 1: PATIENT SAFETY. Choose the answer (A, B, C or D)
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 checklist 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
PART C. 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 is 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.
C the way migraine affects older people.
D the value of publicising the research.
22. What does the writer suggest about the brain changes seen in migraine sufferers?
A Some of them may be beneficial.
B They are unlikely to be permanent.
C Some of them make treatment unnecessary.
D They should still be seen as a cause for concern.
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PARACETAMOL OVERDOSE
PART A: QUESTIONS: 1 – 20
1 D
2 C
3 B
4 D
5 A
6 B
7 C
8 headache(s)
9 hepatitis C OR hep C
10 ALF OR acute liver failure
11 renal failure (NOT: renal dysfunction)
12 methionine
13 (activated) charcoal
14 speed of absorption
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)
READING SUB-TEST – ANSWER KEY
PART B: QUESTIONS 1-6
1 C can delegate responsibility for the cupboard keys to another ward.
2 A give a valid reason for conducting it.
3 A help maximise its efficiency.
4 B They enable a patient to receive more of the prescribed medicine.
5 A benefits to patients of using bedrails can outweigh the dangers.
6 A They may be 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 issues.
9 A understands why healthcare employees have to make certain choices.
10 D The information recorded on them does not always reflect reality.
11 D 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 migraine aura
16 B did not result in a definitive conclusion.
17 C the simultaneous occurrence of CSD and aura
18 A migraine could cause a structural change.
19 D the suggestion that infant colic may be linked to migraine
20 A It fails to filter out irrelevant details.
21 B a more positive aspect of the research.
22 B They are unlikely to be permanent.
OPIOID DEPENDENCE OET reading
TEXT A: Identifying opioid dependence
The International Classification of Disease, Tenth Edition [ICD-IO] is a coding system created by the World Health Organization (WHO) to catalogue and name diseases, conditions, signs and symptoms. The ICD-IO includes criteria to identify dependence. According to the ICD-IO, opioid dependence is defined by the presence of three or more of the following features at any one time in the preceding year:
• a strong desire or sense of compulsion to take opioids
• difficulties in controlling opioid use
• a physiological withdrawal state
• tolerance of opioids
• progressive neglect of alternative interests or pleasures because of opioid use
• persisting with opioid use despite clear evidence of overtly harmful consequences.
There are other definitions of opioid dependence or ‘use disorder’ (e.g., the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, [DSM-5]), but the central features are the same. Loss of control over use, continuing use despite harm, craving, compulsive use, physical tolerance and dependence remain key in identifying problems.
TEXT B: WHY NOT JUST PRESCRIBE CODEINE OR ANOTHER OPIOID?
Now that analgesics containing codeine are no longer available OTC (over the counter), patients may request a prescription for codeine. It is important for GPs to explain that there is a lack of evidence demonstrating the long-term analgesic efficacy of codeine in treating chronic non-cancer pain. Long-term use of opioids has not been associated with sustained improvement in function or quality of life, and there are increasing concerns about the risk of harm.
GPs should explain that the risks associated with opioids include tolerance leading to dose escalation, overdose, falls, accidents and death. It should be emphasised that OTC codeine-containing analgesics were only intended for short-term use (one to three days) and that longer-term pain management requires a more detailed assessment of the patient’s medical condition as well as clinical management.
New trials have shown that for acute pain, nonopioid combinations can be as effective as combination analgesics containing opioids such as codeine and oxycodone. If pain isn’t managed with nonopioid medications then consider referring the patient to a pain specialist or pain clinic. Patient resources for pain management are freely available online to all clinicians at websites such as:
• Pain Management Network in NSW – www.aci.health.nsw.gov.au/networks/pain-management
• Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine -www. m.anzca.edu.au
TEXT C
| Medication | Regulatory requirements | Requires off-label use | Strength of evidence | Advantages | Disadvantages | Notes on dosage |
| Buprenorphine- naloxone (sublingual) | Permit before treatment; patient registered as drug dependent in some jurisdictions | Indicated for opioid dependence (off-label for pain) | Multiple well- conducted RCTs demonstrate efficacy and safety | A large evidence base (e.g. Cochrane reviews) shows it is the most effective option for opioid taper16 | More restrictive than other options (regulatory requirements and supervised dosing) Indicated only for opioid dependence, not for chronic pain in the absence of opioid dependence | See sample withdrawal regimen (Box 8) or refer to state and national guidelines |
| Tramadol (oral) | Only those that apply to S4 medications | Yes (indicated for pain not opioid dependence) | Low – a small number of RCTs demonstrate efficacy and safety | A small number of studies examined a one-week tramadol taper, with outcomes comparable with those of other opioid tapers and superior to clonidine | May produce serotonergic side effects, known drug interactions, use with caution in the elderly Use is off label Risk of seizures, even at usual doses Variable metabolism through CYP P450, similar to codeine | 100 to 300 mg sustained- release formulation twice a day for one-week Supervised dosing and daily dispensing may be indicated |
| Buprenorphine (transdermal patch) | Permit before treatment if patient is drug dependent | Yes (indicated for pain not opioid dependence) | None – no RCTs or published cases | Good safety profile | Dose likely to be insufficient for patients with clear evidence of opioid dependence | 5, 10 or 20 mcg weekly patches are available A single patch should be sufficient for taper from oral codeine |
| Symptomatic medications | Only those relating to S4/OTC medications | No (if use is consistent with product indication) | Moderate to high – well- conducted RCTs demonstrate efficacy; however, poorer outcomes than buprenorphine or tramadol15 | Fewer prescribing restrictions Relatively safe in outpatient setting | Shown to be less effective than buprenorphine and tramadol Multiple medications can be confusing Caution using sedative medications in outpatient setting Clonidine can cause severe hypotension | See Table 1 |
TEXT D Preparation for tapering
As soon as a valid indication for tapering of opioid analgesics is established, it is important to have a
conversation with the patient to explain the process and develop a treatment agreement. This agreement
could include:
• time frame for the agreement
• objectives of the taper
• frequency of dose reduction
• requirement for obtaining the prescriptions from a designated clinician
• scheduled appointments for regular review
• anticipated effects of the taper
• consent for urine drug screening
• possible consequences of failure to comply.
Before starting tapering, it needs to be clearly emphasised to the patient that reducing the dose of opioid
analgesia will not necessarily equate to increased pain and that it will, in effect, lead to improved mood
and functioning as well as a reduction in pain intensity. The prescriber should establish a therapeutic
alliance with the patient and develop a shared and specific goal.
PART A -For 1-7, decide which text (A, B, C or D) the information comes from.
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. Answer each of the questions, 8-14, with a word or short phrase from one of the texts.
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
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.
PART B
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.
PART C. 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 stepin 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.
1. 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
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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
PART C. 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 specifi es 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 fi ve 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 defi nition of ADHD was fuelled, at least in part, to broaden the market for medication. In many instances, the evidence proffered to expand the defi nitions 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.
Text 2: Questions 9-16
9. 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.
10. 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
11. 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.
12. In the fourth paragraph, the word ‘They’ refers to
A. syndromes.
B. questions.
C. studies.
D. origins.
13. 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.
14. In the fifth paragraph, it is suggested that drug companies have
A. been overly aggressive in their marketing of ADHD medication.
B. influenced research that led to the reworking of ADHD diagnostic criteria.
C. attempted to change the rules about incentives for doctors who diagnose ADHD.
D. encouraged the APA to rush through changes to the criteria for diagnosing ADHD.
15. In the final paragraph, the word ‘trademark’ refers to
A. a physiological reaction.
B. a substitute medication.
C. a need for research.
D. a common request.
16. In the final paragraph, what does the writer imply about addiction to ADHD medication?
A. It is unlikely to turn into a problem on the scale of that caused by opioid abuse.
B. The effects are more marked in certain sectors of the population.
C. Insufficient attention seems to have been paid to it.
D. The reasons for it are not yet fully understood.
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OPIOID DEPENDENCE
Reading test 2 : Answer Key
Part A – Answer key 1 – 7
1. B
2. A
3. C
4. D
5. A
6. D
7. B
Part A – Answer key 8 – 14
8. pain intensity
9. Buprenorphine-naloxone / Buprenorphine – naloxone / buprenorphine-naloxone / buprenorphine – naloxone / Buprenorphine-naloxone (sublingual) / Buprenorphine – naloxone (sublingual) / buprenorphine-naloxone (sublingual) / buprenorphine – naloxone (sublingual)
10. one to three days / 1 to 3 days / 1-3 days / 1 – 3 days
11. if pain isn’t managed with nonopioid medications / if pain isn’t managed / if pain isn’t managed with non-opioid medications
12. urine drug screening
13. alternative interests or pleasures / alternative interests and pleasures / interests or pleasures / interests and pleasures
14. a single patch / one patch / 1 patch
Part A – Answer key 15 – 20
15. permit
16. poorer outcomes
17. central features / features
18. treatment agreement
19. nonopioid combinations / non-opioid combinations
20. three or more / at least three / 3 or more / at least 3
Reading test – part B – answer key
1. C
2. B
3. B
4. C
5. B
6. A
Reading test – part C – answer key
Text 1 – Answer key 1 – 8
1. B
2. D
3. C
4. A
5. C
6. B
7. A
8. D
PART Text 2: Questions 9-16
9. D
10. C
11. A
12. C
13. C
14. A
15. A
16. B
Can I book OET using a debit card in India?
The short answer is Yes.
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The OET Test, consisting of four sub-tests (Listening, Reading, Writing, and Speaking), is priced at AU$587 (or US$455 for OET on Computer at a venue and OET@Home in the US).
For those opting to book single sub-tests, reduced costs are available for OET on Paper at most venues globally (excluding the USA). Here are the prices, including the AU$7 online booking fee:
- 1 sub-test: AU$315
- 2 sub-tests: AU$415
- 3 sub-tests: AU$515
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