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TEXT A Background: In New York City, the incidence of tuberculosis has more than doubled during the past decade. We examined the incidence of tuberculosis and the acquired immune deficiency syndrome (AIDS) and the rate of death from all cause in a very high-risk group – indigent subject who abuse drugs, alcohol, or both. Methods: In 2009 we began to study prospectively a cohort of welfare applicants and recipients 18 to64 years of age who abused or alcohol. The incidence rate of tuberculosis, AIDS, and death for this group were ascertained through vital records and New York City’s tuberculosis and AIDS registries.

TEXT B: RESULTS. The cohort was followed for eight years. Of the 858 subjects;
• tuberculosis developed in 47 (5.5 percent),
• 84 (9.8 percent) were given a diagnosis of AIDS, and
• 183 (21.3 percent) died.
The rates of incidence per 100,000 person- years were
• 744 for tuberculosis, • 1323 for AIDS, and., • 2842 for death.
In this group of welfare clients,
• the rate of newly diagnosed tuberculosis was 14.8 times that of the age matched general population of New York City;
• the rate of AIDS-was 10.0 times as high; • the death rate was 5.2 times as high.
• no significant difference in the rate of new cases of tuberculosis between subjects with positive skin tests and those with negative skin tests at examination in 2009.

TEXT C. Deaths in the cohort: There were 183 deaths in the cohort during follow-up (21.3 percent) of the subjects, a rate of 2842 deaths per 100,000 person-years, 5.2 times that of the age-matched general population. Causes of death – Table 3

TEXT D: Conclusions
• Of the 47 subjects with tuberculosis, 21 (44.7 percent) died before the end of 2017;
• 12 (57.1 percent) of those who died also had AIDS.
• Of 15 persons with both tuberculosis and AIDS, 12 (80.0 percent) died before the end of 2017 and 8 died before completing anti-TB therapy.
• Of the 84 study subjects with AIDS, 68 (81.0 percent) died before the end of 2017.

For each question, 1-7, decide which text (A, B, C or D) the information comes from
1. what was the percentage of deaths caused by diabetes in the study group?
2. what was the rate of incidence per 100,000 person per years for tuberculosis?
3. name the city where the study was conducted?
4. how the incidence rates of diseases and death for the study group were ascertained?
5. how many died before the end of 2017 without completing anti-TB therapy?
6. what was the average age of subjects died due to other causes in the study group?
7. how many years the cohort was followed?

Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts.
8. How many of the study subjects with only AIDS died before the end of 2017?
9. In how many of the study subjects wound was the cause of death?
10. What was the age limits of the study subjects?
11. When did the study begin?
12. What was the total number of deaths in the study group?
13. What was the percentage of deaths caused by respiratory arrest in the study group?

Questions 14-20. Complete each of the sentences, 14-20, with a word or short phrase.

14. The study shows that number of the incidence of tuberculosis in New York City has more than _____________during the past decade.
15. In conclusion, 12 of those who died had both AIDS and ____________
16. In the cohort during follow-up of the subjects, rate of deaths was 5.2 times that of the _______________ general population.
17. In the group of welfare clients, the rate of ________________ was 10.0 times as high.
18. The study was conducted among _____________ who abuse drugs, alcohol, or both.
19. ___________ subjects died suffering from coronary artery disease.
20. There were ______________ subjects in the study group.

PART B

Incubators for Infant: The general principle is that air is processed before it reaches baby. An electric fan draws room air through a bacterial filter which removes dust and bacteria. The filtered air flows over an electric heating element. The filtered and heated air then passes over a water tank where it is moistened. It then flows on to the incubator canopy. The incubator canopy is slightly pressurized. This allows expired carbon dioxide to pass back into the room via the vent holes and most of the air to be re-circulated. It also prevents unfiltered air entering the system.
1. The extract informs us that the incubators
A. is likely to circulate most of the air again.
B. may not work correctly in close proximity to some other devices.
C. prevents filtered air entering the system.

Nebulizers: A nebulizer is a device used to administer medication in the farm of a mist inhaled into the lungs. Nebulizers are commonly used for treatment of cystic fibrosis, asthma and other respiratory diseases. The reason for using a nebulizer for medicine to be administered directly to the lungs is that small aerosol droplets can penetrate into the narrow branches of the lower airways. Large droplets would be absorbed by the mouth cavity, where the clinical effect would be low. The common technical principle for all nebulizers is to use oxygen, compressed air or ultrasonic power as means to break up medical solutions or suspensions into small aerosol droplets.
2. The notice is giving information about
A: ways of checking that a nebulizer has been placed correctly1<
B. how the use of nebulizer is authorised.
C. why nebulizer is being used.

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

Arterial blood pressure: The arterial blood pressure (BP) is connected with the force-, which is exerted by the blood volume on the walls of the arteries. The level of BP is dependent on two factors: the heart minute ejection volume and the elasticity of arterial walls. Other factors affecting BP include: the volume’ and viscosity of the blood, body position and emotional state. The BP at the top of pulse wave (due to the constriction of heart ventricles) is called systolic BP, whereas the respective one during the diastole is called diastolic BP. The difference between systolic and diastolic BP is defined as amplitude or pulse pressure.
4. Which is the main factor behind BP level?
A. the heart minute rejection volume
B. volume and viscosity of the blood
C. elasticity of the arterial wall

Basic Life Support: Basic Life Support means saving lives by maintaining airway, supplying ventilation (rescue breathing by blowing air to the victim’s mouth) and supplying circulation (external cardiac massage – chest compressions) performed without additional equipment. It is the first step in cardio­ pulmonary resuscitation (CPR) that should be initiated by bystanders and continued until qualified help arrives. Next step is Advanced Life Support (ALS), which is performed by medical services. People with cardiac arrest (CA) need immediate CPR. First aid means BLS that is started by witnesses before the emergency service arrival and is the key action in achieving patient survival.
5. What does this manual tell us about cardio-pulmonary resuscitatio?
A. should be initiated by bystanders
B. should be initiated immediately only for cardiac arrest
C. should be performed by medical services

Types of surgical threads: Materials, which the threads are made of, are divided into absorbable and non- absorbable ones or natural and synthetic sutures. Non-absorbable sutures are applied on the skin and in septic wounds. Absorbable threads, depending on their structure are divided into monofilament, polifilament, braided, plaits, coated and uncoated ones. Time of their absorbing is varied and depends on material properties; it can take from 14 days to 6 months. Absorbing progresses due to enzymatic disintegration and hydrolysis.
6. What does this extract from a handbook tell us about absorbable threads?
A. absorbing progresses due to enzymatic integration and hydrolysis7
B. absorbing time is varied and depends on material properties
C. are divided into monofilament, polifilament, braided; plaits and uncoated ones

PART C TEXT 1.

Targeting two important risk factors for cardiovascular disease and other major risk factors that can be lowered by modification, treatment or control

Paragraph 1: (ARA) – It’s well known that the prevalence of diabetes is on the rise. According to the Centers for Disease Control and Prevention (CDC), about 23.6 million, or nearly 8 percent of people in the United States, have diabetes, and 1.6 million new cases are diagnosed each year in people aged 20 and older. Type 2 diabetes is the most common form, accounting for about 90 to 95 percent of those diagnosed, and occurs when the body either does not produce enough insulin or does not respond to insulin.

Paragraph 2: But something that many people may not know is that in addition to having diabetes, 70 percent of adult with type 2 diabetes also have high LDL cholesterol (LDL-C), the “bad” cholesterol that can cause build-up in the arteries, greatly increasing their risk for cardiovascular disease. Cholesterol is needed for the body to function normally, but when there is too much LDL-C in the bloodstream, it is deposited in arteries, including those of the heart, which can limit blood flow and lead to heart disease.

Paragraph 3: The American Diabetes Association (ADA) and the American College of Cardiology (ACC) emphasize that it is critical to control both cholesterol and blood sugar levels. The ADA recommends that patients with type 2 diabetes aim for an A1C level which reflects your average blood sugar level for the past two to three months, of less than 7 percent. The National Cholesterol Education Program (NCEP) ATP 111 recommends that patients with type 2 diabetes target an LDL-C goal of less than 100 mg/dL.

Paragraph 4: Treating these two diseases can take a combination of efforts, including a healthy diet and increased exercise. Medications are also sometimes needed. While there are many drugs approved by the U.S. Food and Drug Administration (FDA) to treat type 2 diabetes and others available to lower LDL-C, a drug called Welchol (colesevelam HCI) is the first and only medication approved as an adjunct to diet and exercise to reduce both A1C in adults with type 2 diabetes and LDL-C in adults with elevated cholesterol.t
Welchol addresses both of these chronic health conditions with one medication and offers the convenience of two formulations, Welchol tablets and Welchol for Oral Suspension. Welchol can be taken alone or with other cholesterol lowering medications known as statins and can be added to other anti-diabetic medications (metformin, sulfonylureas, or insulin).

Paragraph 5: “For patients with type 2 diabetes and high LDL cholesterol, it is important to manage both conditions,” said Yehuda Handelsman, MD, FACP, FACE, Medical Director of the Metabolic Institute of America in Tarzana, Calif. “Welchol reduces these two risk factors for cardiovascular disease in adults with type 2 diabetes by significantly lowering A1C and LDL-C or ‘bad’ cholesterol, providing a unique therapeutic option.” It is important to note that the affect of Welchol on cardiovascular morbidity and mortality has not been determined.

Paragraph 6: What are the major uncontrollable risk factors for coronary heart disease? The American Heart Association has identified several risk factors for coronary heart disease. Some of them can be modified, treated or controlled, and some can’t. The more risk factors a person has, the greater the chance that he or she will develop heart disease. Also, the greater the level of each risk factor, the greater the risk. For example, a person with a total cholesterol of 300 mg/dL has a greater risk than someone with a total cholesterol of 240 mg/dL, even though all people with a total cholesterol of 240 or higher are considered high risk.

Paragraph 7: Increasing age – About 82% of people who die of coronary heart disease are 65 or older.
Male sex (gender) – The lifetime risk of developing CHD after age 40 is 49% for men and 32% for women. The incidence of CHD in women lags behind men I years for total CHD and by 20 years for more serious clinical events such as sudden death.

Paragraph 8: Heredity (including Race)- Children of parents with heart disease are more likely to develop it themselves. African Americans have more severe high blood pressure than Caucasians and a higher risk of heart disease. Heart· disease is also higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans. This is partly due to higher rates of obesity and diabetes. Most people with a strong family history of heart disease have one or more other risk factors. Just as you can’t control your age, sex and race, you can’t control your family history. Therefore, it’s even more important to treat and control any other risk factors you have.

Paragraph 9: Other major risk factors that can be lowered by modification, treatment or control. Tobacco smoke – Smokers’ risk of developing CHD is two to four times that nonsmokers. Smokers who have a heart attack are more likely to die and die suddenly (within an hour) than nonsmokers. Cigarette smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. People who smoke cigars or pipes seem to have a higher risk of death from coronary heart disease (and possibly stroke), but their risk isn’t as great as cigarette smokers’. Constant exposure to other people’s smoke – called environmental tobacco smoke, secondhand smoke or passive smoking – increases the risk of heart disease even for nonsmokers.

Paragraph 10: High blood cholesterol levels – The risk of coronary heart disease rises as blood cholesterol levels increase. When other risk factors (such as high blood pressure and tobacco smoke) are present, this risk increases even more. A person’s cholesterol level is also affected by age, sex, heredity and diet.
High blood pressure – High blood pressure increases the heart’s workload, causing the heart to enlarge and weaken over time. It also increases the risk of stroke, heart attack, kidney failure and heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol levels or diabetes, the risk of heart attack or stroke increases several times.

Paragraph 11: Physical inactivity-An inactive lifestyle is a risk factor for coronary heart disease. Regular, moderate-to-vigorous physical activity is important in preventing heart and blood vessel disease.
Obesity and overweight – People who have excess body fat – especially if a lot of it is in the waist area – are more likely to develop heart disease and stroke even if they have no other risk factors. Excess weight increases the strain on the heart, raises blood pressure and blood cholesterol and triglyceride levels, and lowers HDL (good) cholesterol levels. It can also make diabetes more likely to develop. Many obese and overweight people have difficulty losing weight. If you can lose as little as 10 to 20 pounds, you can help lower your heart disease risk.

Paragraph 12: Diabetes mellitus – Diabetes seriously increases the risk of developing cardiovascular disease. Even when glucose levels are under control, diabetes greatly increases the risk of heart disease and stroke. From two-thirds to three-quarters people with diabetes die of some form of heart or blood vessel disease.

Paragraph 13: What other factors contribute to heart disease risk? Stress – Individual response to stress may be a contributing factor. Some scientists have noted a relationship between coronary heart disease risk and stress in a person’s life, their health behaviors and socioeconomic status. These factors may affect established risk factors. For example, people under stress may overeat, start smoking or smoke more than they otherwise would.

Paragraph 14: Excessive alcohol intake – Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and other diseases, and produce irregular heartbeats. It also contributes to obesity, alcoholism, suicide and accidents. The risk of heart disease in people who drink moderate amounts of alcohol (an average of one drink for women or two drinks for men per day) is lower than in nondrinkers. One drink is defined as 1-1/2 fluid ounces (fl oz) of 80-proof spirits (such as bourbon, Scotch, vodka, gin, etc.), 1 fl oz of 100- proof spirits, 4 fl oz of wine, or 12 fl oz of beer. It’s not recommended that nondrinkers start using alcohol or that drinkers increase their intake.

Q1. According to paragraph 1 of the article states that
a. Diabetes has stabilised
b. 1.6 million people aged 20 and older have diabetes
c. Type 2 diabetes is the most common
d. Type 2 diabetes occurs when there is an over-production of insulin
Q2. In addition to having diabetes
a. 30% of adult with Type 2 diabetes do not have high counts of low-density lipids
b. 70% of adults with Type 2 diabetes do have high counts of low-density lipids
c. Too many LDLs in the bloodstream go straight to the heart
d. LDLs in the bloodstream cannot hinder blood flow
Q3. According to the ADA and the ACC
a. Both blood sugar levels and cholesterol levels need to be controlled if diabetes is avoided
b. Blood sugar levels need to be controlled if diabetes is to be avoided
c. ACA believes less than7% average blood sugar level over a one-month period indicates diabetes risk
d. The NCEP does not recommend Type 2 diabetics aim for less than 100 mg/dL of low-density lipids
Q4. Welchol, a drug to lower the level of LDLs in the blood
a. has not been approved by the U.S. FDA
b. Welchol must be taken with other statins
c. Welchol should not be added to medications such as metformin, sulfonylureas or insulin.
d. Welchol needs to be taken together with a healthy diet and an exercise program to reduce A1C in Type 2 diabetics and LDL-C in adults with elevated cholesterol levels.
Q5. Welchol’s effect on cardiovascular morbidity and mortality…
a. is supported by the evidence b. has not been positively established
c. has been positively established d. none of the above
Q6. Some risk factors can be controlled, or lowered; some cannot be controlled: such as advancing age, one’s gender, and one’s genetic inheritance. However, there are some major risk factors that can be lowered by modifying one’s lifestyle – or by medical intervention. Risk factors such as—–
a. high blood pressure b. high cholesterol levels c. obesity d. all of the above
Q7. The article states that stress
a. causes overeating and/or habitual smoking
b. does not interact with lifestyle and socioeconomic status
c. depends on how one reacts to it
d. may depend on how one reacts to it
Q8. Alcohol contributes to heart failure and strokes;
a. if you drink very less amount
b. moderate alcohol intake leads to less risk of heart disease
c. but not contribute to high triglycerides
d. is not a factor in developing cancer

PART C. TEXT 2. FLUORIDE

Paragraph 1: Globalization has provoked changes in many facets of human life, particularly in diet. Trends in the development of dental caries in population have traditionally followed developmental patterns where, as economies grow and populations have access to a wider variety of food products as a result of more income and trade, the rate of tooth decay begins to increase. As countries become wealthier, there is a trend to greater preference for a more “western” diet, high m carbohydrates and refined sugars. Rapid globalization of many economies has accelerated this process. These dietaries have a substantial impact on diseases such as diabetes and dental caries.

Paragraph 2: The cariogenic potential of diet emerges in areas where fluoride supplementation is inadequate. Dental caries is a global health problem and has a significant negative impact on quality of life, economic productivity, adult and children’s general health and development. Untreated dental caries in pre-school children is associated with poorer quality of life, pain and discomfort, and difficulties in ingesting food that can result in failure to gain weight and impaired cognitive development. Since low-income countries cannot afford dental restorative treatment and in general the poor are most vulnerable to the impacts of illness, they should be afforded a greater degree of protection.

Paragraph 3: By WHO estimates, one third of the world’s population have inadequate access to needed medicines primarily because they cannot afford them. Despite the inclusion of sodium fluoride in the World Health Organization’s Essential Medicines Model List, the global availability and accessibility of fluoride for the prevention of dental caries remains a global problem. The optimal use of fluoride is an essential and basic public health strategy in the prevention and control of dental caries, the most common non­ communicable disease on the planet. Although a whole range of effective fluoride vehicles are available for fluoride use (drinking water, salt, milk, varnish, etc.), the most widely used method for maintaining a constant low level of fluoride in the oral environment is fluoride toothpaste.

Paragraph 4: More recently, the decline in dental caries amongst school children in Nepal has been attributed to improved access to affordable fluoride toothpaste. For many low-income nations, fluoride toothpaste is probably the only realistic population strategy for the control and prevention of dental caries since cheaper alternatives such as water or salt fluoridation are not feasible due to poor infrastructure and limited financial and technological resources. The use of topical fluoride e.g., in the form of varnish or gels for dental caries prevention is similarly impractical since it relies on repeated applications of fluoride by trained personnel on an individual basis and therefore in terms of cost cannot be considered as part of a population based preventive strategy.

Paragraph 5: The use of fluoride toothpaste is largely dependent upon its socio-cultural integration in personal oral hygiene habits, availability and the ability of individuals to purchase and use it on a regular basis. The price of fluoride toothpaste is believed to be too high in some developing countries and this might impede equitable access. In a survey conducted at a hospital dental clinic in Lagos, Nigeria 32.5% of the respondents reported that the cost of toothpaste influenced their choice of brands and 54% also reported that the taste of toothpastes influenced their choice.

Paragraph 6: Taxes and tariffs on fluoride toothpaste can also significantly contribute to high prices, lower demand and inequity since they target the poor. Toothpastes are u; classified as a’ cosmetic product and as such often highly taxed by governments. For example, various taxes such as excise tax, VAT, local taxes as well as taxation on the ingredients and packaging contribute to 25% of the retail cost of toothpaste in Ne and India, and 50% of the retail price in Burkina Faso. WHO continues to recommend the removal taxes and tariffs on fluoride toothpastes. Any lost revenue can be rest by higher taxes on sugar and high sugar containing foods, which are common risk factors for dental caries, coronary heart disease, diabetes and obesity.

Paragraph 7: The production of toothpaste within a country has the potential to make fluoride toothpaste more affordable than imported products. In Nepal, fluoride toothpaste was limited to expensive imported products. However, due to successful advocacy locally manufactured fluoride toothpaste, the least expensive locally manufactured fluoride toothpaste is now 170 times less costly than the most expensive imported Philippines, local manufacturers are able to satisfy consumer preferences and compete against multinationals by discounting the price of toothpaste by as much as 55% against global brands; and typically receive a 40% profit margin compared to 70% for multinational producers.

Paragraph 8: In view of the current extremely inequitable use of fluoride throughout countries and regions, all efforts to make fluoride and fluoride toothpaste affordable and accessible must be intensified. As a first step to addressing the issue of affordability of fluoride toothpaste in the poorer countries in-depth country studies should be undertaken to analyze the price of toothpaste in the context of the country economies.
Q1. Which of the following would be the most appropriate heading for the paragraph 1?

a. High sugar intake and increasing tooth decay
b. Globalisation, dietary changes and declining dental health
c. Dietary changes in developing nations
d. Negative health effects of a western diet
Q2. Which of the following is not mentioned as a negative effect of untreated dental caries in pre-school children?
a. Decreased mental alertness b. Troubling chewing and swallowing food
c. Lower life quality d. Reduced physical development
Q3. According to paragraph 3, which of the following statement is correct?
a. Dental caries is the most contagious disease on earth.
b. Fluoride in drinking water is effective but rarely used
c. Fluoride is too expensive for a large proportion of the global population.
d. Fluoride toothpaste is widely used by 2/3 of the world’s population.
Q4. Fluoride toothpaste is considered the most effective strategy to reduce dental caries in low-income countries because___
a. it is the most affordable.
b. topical fluoride is unavailable.
c. it does not require expensive infrastructure or training.
d. it was effective in Nepal.
Q5. Which of the following is closest in meaning to the word impede?
a. stop b. prevent c. hinder d. postpone
Q6. Regarding the issue of taxation in paragraph 6 which of the following statements is most correct?
a. Income tax rates are higher in Burkina Faso than India or Nepal.
b. WHO recommends that tax on toothpaste be reduced.
c. Governments would like to reduce tax on toothpastes but can’t as it is classified as a cosmetic.
d. WHO suggests taxing products with a high sugar content instead of toothpastes.
Q7. Which of the following is closest in meaning to the _word advocacy?
a. marketing b. demand c. development d. support
Q8. Statistics in paragraph 7 indicate that….
a. local products can’t compete with global products and make a profit at the same time.”
b. Philippine produced toothpaste is profitable while being less than half the price of global brands.
c. in Nepal, fluoride toothpaste is limited to imported products which are very expensive
d. toothpaste produced in the Philippines has a higher profit margin than internationally produced toothpaste.

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