Patient Details: Jim Middleton aged 84 was admitted to your ward following surgery for a left inguinal hernia. His doctor has advised he can be discharged within 48hrs if there are no complications following the surgery. Jim reports some pain on movement but has recovered well from the surgery and is keen to return home.
Name: Jim Middleton. Date of Birth: 3 July 1924
Admitted: 7 July 2008 Planned Discharge Date : 9 July 2008 Diagnosis : Left inguinal hernia
Medical History Hypertension diagnosed 1998 Medication Atacand 4mg daily
Family History: Married 50 years to wife Olga DOB 8.2.32 – one son living in USA
Jim is Second World War veteran – served two years in Borneo -Prison of War 16 months.
Own their own home with large garden which they maintain without assistance. Very independent and proud that they have never applied for a pension or home assistance. Have always managed quite well on their income from a number of investments.
Olga told you she is worried as income from these investments has recently been significantly reduced due to severe stock market falls. She is concerned Jim will not be able to continue to maintain their garden and they will not be able to afford a gardener or any other help at this time.
Transport is also a problem as Olga does not drive. Not close to any reliable public transport so will have to rely on taxis. Olga thinks they may now be eligible to receive a pension and other assistance from the Department of Veteran Affairs but doesn’t know how to find out-doesn’t want to worry Jim.
Olga is in good general health but becoming increasingly deaf – finds phone conversations difficult. She would appreciate a home visit. You agree to enquire on her behalf. Their address is 22 Alexander Street, Belmont, Brisbane 4153 Phone (O 7) 6946 5173
Discharge Plan: Must avoid any heavy lifting. Should not drive for at least six weeks
Light exercise only. May take 2 Panadol six hourly for pain
Appointment made to see surgeon for post operation check at 10am on 11 August
Contact Department of Veterans Affairs re eligibility for pension and home help
WRITING TASK: Using the information in the case notes, write a letter to The Director, Department of Veterans Affairs, GPO Box 777 Brisbane 4001. In your letter, explain why you are writing and the assistance they are seeking.
TASK 31 Read the case notes below and complete the writing task which follows:
You are a nurse with the Blue Skies Home Nursing Centre. You visited this patient at home today for the first time following a referral from the Mater Public Hospital. He was discharged from hospital on 17.3.08.
Medical History: Large lesion successfully removed 14.3.08.
Discharged 17.3.08
Needs assistance with showering and to dress wound prior to removal of sutures at Mater Public Hospital on 24.3.08
Family History: Married aged pensioner. Lives in housing commission home with wife Dorothy also an aged pensioner. No children
18.3.081st Home visit: Showered patient. Wound dressed- healing satisfactory no sign of infection Balance a little shaky- complaining of increased arthritic pains in hands and legs. Currently taking Glucosamine & Chondroitin Supplement recommended by GP. Pain relieved with 2 Panadol 3 times daily. Confused about (why he had operation).Dorothy concerned about future. Tells you she will be 83 in August. Says Henry has not been himself since the surgery. Keeps forgetting things. She finds it difficult to manage the house and garden. Neighbours are helping with shopping. Kitchen and bathroom disordered- trouble finding clean towels- dishes piled in sink, bed unmade.
19.3.08 Henry showered and wound dressed. Still a little unbalanced. Rests most of the day. Does not remember being showered yesterday. House still disorganised, washing piled up in bathroom.
Dorothy says she would be lost without help from neighbours who also appear to be cooking meals for the couple.
Concerns: Provided there are no complications with the wound healing, your role in providing nursing care ends when sutures are removed on 24 March. You consider that Jim and Dorothy need to be assessed for further on-going assistance in managing the house and garden and with shopping and the preparation of cooking.
Plan: Request a home visit by the Aged Care Assessment Team as soon as possible to fully assess their needs and to arrange for appropriate further assistance to be provided.
WRITING TASK: Using the information in the case notes, write a letter to The Director, Aged Care Assessment Team, Brisbane South Region, 78 Masterson St. Acacia Ridge, Brisbane 4110. Explain why you are writing and what types of assistance may be required
TEXT A. An expert group, working for Alzheimer’s Disease International, recently estimated that 24.2 million people live with dementia worldwide (based upon systematic review of prevalence data and expert consensus), with 4.6 million new cases annually (similar to the annual global incidence of non-fatal stroke). • Most people with dementia live in Low- and Middle-Income Countries – 60% in 2017 rising to 71% by 2040. • Numbers will double every twenty years to over 80 million by 2040. • Increases to 2040 will be much sharper in developing (300%) than developed regions (100%). • Growth in Latin America will exceed that in any other world region. Well-designed epidemiological research can generate awareness, inform policy, and encourage service development. However, such evidence is lacking in many world regions, and patchy in others, with few studies and widely varying estimates. There is a particular lack of published epidemiological studies in Latin America with two descriptive studies only, from Brazil and Colombia.
TEXT B. Some Little-Known Facts about Dementia • A Canadian study found that a lifetime of bilingualism has a marked influence on delaying the onset of dementia by an average of four years when compared to monolingual patients (at 75.5 years and 71.4 years old, respectively). • Adult day-care centres provide specialized care for dementia patients, including supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.
TEXT C -The Effect of Aging World Populations on Healthcare: Demographic ageing proceeds apace in all world regions, more rapidly than at first anticipated. The proportion of older people increases as mortality falls and life expectancy increases. Population growth slows as fertility declines to replacement levels. Latin America, China and India are currently experiencing unprecedentedly rapid demographic ageing. In the health transition accompanying demographic ageing, non¬ communicable diseases (NCD) assume a progressively greater significance in low and middle-income countries. NCDs are already the leading cause of death in all world regions apart from sub-Saharan Africa. Of the 35 million deaths in 2017 from NCDs, 80% will have been in low and middle-income countries. This is partly because most of the world ‘s older people live in these regions – 60% now rising to 80% by 2050. However, changing patterns of risk exposure also contribute. Latin America exemplifies the third stage of health transition. As life expectancy improves, and high f at diets, cigarette smoking and sedentary lifestyles become more common, so NCDs have maximum public health salience – more so than in stage 2 regions (China and India) where risk exposure is not yet so elevated, and in stage 4 regions (Europe) where -public health measures have reduced exposure levels. The INTERHEART cross¬ national case-control study suggests that risk factors for myocardial infarction operate equivalently in all world regions, including Latin America and China.
TEXT D. Agitation in Dementia Patients: Agitation often accompanies dementia and often precedes the diagnosis of common age-related disorders of cognition such as Alzheimer’s disease (AD). More than 80% of people who develop AD eventually become agitated or aggressive. Evaluation: It is important to rule out infection and other environmental causes of agitation, such as disease or other bodily discomfort, before initiating any intervention. If no such explanation is found, it is important to support caregivers and educate them about simple strategies such as distraction that may delay the transfer to institutional care (which is often triggered by the onset of agitation). Treatment: There is no FDA-approved treatment for agitation in dementia. Medical treatment may begin with a cholinesterase inhibitor, which appears safer than other alternatives although evidence for its efficacy is mixed. If this does not improve the symptoms, atypical antipsychotics may off er an alternative, although they are effective against agitation only in the short-term while posing a well-documented risk of cerebrovascular events (e.g., stroke). Other possible interventions, such as traditional antipsychotics or antidepressants, are less well studied for this condition.
Part A. TIME: 15 minutes. Questions 1-7: For each question, 1-7, decide which text (A, B, C or D) the information comes from. In which text can you find information about 1. which study found out bilingualism can delay the onset of dementia? 2. why the proportion of older people is increasing? 3. what are the possible interventions ·for agitation in dementia? 4. what does ‘NCD’ stands for? — 5. who provide specialized care for dementia patients? 6. what is the predicted rise in dementia patients in low- and middle-income countries? — 7. How do the risk factors for myocardial infarction operate across the world? — Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts. 8. what does ‘AD’ stand for? 9. Who conducted cross-national case-control study? 10. What is the estimated count of people living with dementia worldwide? 11. Name the region in the world, where NCDs aren’t the leading cause of death. 12. Give two examples for stage 2 regions. 13. Name one stage 4 region. Questions 14-20. Complete each of the sentences, 14-20, with a word or short phrase from one of the texts. 14. There is no ___________ treatment for agitation in dementia. 15. There is a particular lack of published epidemiological studies in ___________ 16. ___________ often accompanies dementia and often precedes the diagnosis of Alzheimer’s disease. 17. The proportion of older people increases as mortality falls and ___________ increases. 18. Medical treatment for agitation in dementia may begin with ___________ 19. More than 80% of people who develop AD eventually become agitated or ___________ 20. ___________ proceeds apace in all world regions.
PART B. For questions 1-6, choose the answer (A, B or C)
Cannulae: A cannula is composed of several parts: the needle, catheter, wings, valve, injection port and Luer-Lok™ cap. Most cannulae also contain a ‘flashback chamber’ giving the practitioner visual confirmation that the cannula has entered the vein. Modern peripheral cannulae are made from polyurethane. This is preferable to older materials such as PVC and Teflon® as the cannulae are more flexible, softer and cause less intimal damage. They are also latex free. 1. What does this manual tell us about modern peripheral cannulae? A. contain a ‘flashback chamber’ B. made from polyurethane C. are more non-flexible
Air embolism: All forms of venous access, but especially central access, may cause air embolism which can have catastrophic consequences. This occurs when. air is aspirated into the vein during the procedure. The air embolus- can translocate to the lung and if the volume is sufficient, it can cause fatal cardiovascular and respiratory collapse. The likelihood may be reduced by keeping the patient in a head down position and ensuring that the vein is open to the external environment for as little time as possible. 2. The notice is giving information about A. ways of checking venous accesses have been placed correctly. B. how to avoid consequences of air embolism. C. steps to minimize the chances of air embolism.
Intraosseous access: The intraosseous (IO) space consists of spongy cancellous epiphyseal bone and the diaphyseal medullary cavity. It houses a vast non-collapsible venous plexus that communicates with the arteries and veins of the systemic circulation via small channels in the surrounding compact cortical bone. Drugs or fluids administered into ·the intraosseous space via a needle or catheter will pass rapidly into the systemic circulation at a rate comparable with central or peripheral venous access. Any drug, fluid or blood product that can be given intravenously can be given via the intraosseous route. 3. What does this extract from a handbook tell us about intraosseous space? A. consists of spongy cancellous epiphyseal bone B. houses a vast collapsible venous plexus C. consists of physeal medullary cavity
Verticalization: The term verticalization means a gradual change in the patient position to the vertical position. The physical load after each mobility restriction must be gradual and smooth. At first, practice sitting, standing beside the bed, and then walk around the bed, then later in the corridor. Patient verticalization is prescribed by a doctor. The doctor sometimes also prescribes to measure the blood pressure and pulse, e.g., before and after walking. 4. The purpose of these notes about verticalization is to A. help maximise its efficiency. B. give guidance- on certain safety procedures. C. recommend a procedure to increase mobility.
Fowler’s position: This position is used in patients with respiratory problems and cardiopulmonary diseases, in the prevention of bronchopneumonia in bedridden patients, after abdominal and thoracic surgery, etc. Patients are put into Fowler’s position during normal daily activities (eating, reading, watching TV, etc.). The sitting or semi¬ sitting position on the bed, when the patient’s head and torso are raised by 15-45° (in relation to the lower limbs) is called Fowler’s position (see Fig. 6.1-3). In the high Fowler’s position, the torso and head are raised at an angle of 45-90°. 5. In Fowler’s position head are raised at an angle of A. >45° B. >45° C. <45°
Thermal gel pads in various sizes: After using a thermo gel pad, the disposable cover is disposed ofor the reusable cover is placed in the dirty laundry bag. The thermal gel pad is soaked in disinfectant solution according to the ward disinfection programme, and is then dried and prepared for the next use. A hot water bottle is a rubber bottle with a plastic stopper, which is filled up to two thirds full with water at 50 to 60 °C while the remaining air is forced out. 6. The guidelines establish) that the healthcare professional should A. the disposable cover is disposed of before using a thermo gel pad _ B. the reusable cover is placed in dirty laundry bag after using a thermo gel pad C. the thermo gel pad is disposed of after using a thermo gel pad
PART C. TEXT 1. Choose the answer (A, B, C or D). ARTHRITIS – A Holistic Approach Can Help
Paragraph 1: Mosby’s Medical and Nursing Dictionary defines arthritis as any inflammatory condition of the joints, characterized by pain and. swelling. The name derives from the Greek word “arthron” which means joint and “itis” which means inflammation. In its various forms arthritis afflicts millions throughout the world from juveniles to the elderly.
Paragraph 2: A 2003-2005 National Health Interview Survey in the United States of America reported 21.6% of adults have self-reported, doctor diagnosed arthritis. In Australia it is estimated that by 2020 one in every five Australians will have arthritis. To date, despite the expenditure of an enormous ·amount of money on research and the considerable efforts of scientists throughout the world, a cure for arthritis has proved elusive.
Paragraph 3: Medical treatments range from simple pain relievers like Paracetamol, which eases pain and if taken as recommended has few side effects, to powerful non-steroidal anti-inflammatory drugs and corticosteroids. Such drugs can provide effective relief from the pain, joint stiffness and inflammation but do not result in a permanent cure. Unlike Paracetamol, these medications taken long term can have serious side effects and they must be regularly and carefully monitored. There may also be contraindications relating to other medical conditions, use during pregnancy or lactation and adverse reactions as a result of allergies.
Paragraph 4: Surgical interventions such as hip and other joint replacements are usually performed to relieve severe pain and loss of function where other non-surgical treatments are unable to bring sufficient relief. Such procedures can be highly effective in enhancing mobility in the majority of cases. The need for hip replacement surgery is becoming increasing common among the elderly as longevity increases. For example, the 2007 Spring Issue Joint News reports “over the last ten years, hip replacement surgery has increased in Australia by 94.1%”.
Paragraph 5: Other non-pharmacological treatments such as physiotherapy, acupuncture, therapeutic massage and aqua aerobics can help to relieve some symptoms. There are also a number of nutritional supplements that may relieve the inflammation, pain and slow degeneration of effected joints. Such supplements are advertised widely and available from chemists, health food outlets, and many supermarkets. However even “natural” products can have side effects or conflict with other medication so always check first with your doctor or pharmacist.
Paragraph 6: In relation of dietary supplements, a number of studies conclude that Fish Oils containing omega-3 fatty acids can help reduce inflammation associated with osteoarthritis and rheumatoid arthritis. Research published in a reputable medical journal also suggests a glucosamine dietary supplement can slow down the deterioration of joints associated with osteoarthritis. As a result, selected hospitals are conducting clinical research trials to determine the validity of the research.
Paragraph 7: While there is no “miracle food” that cures arthritis, general dietary advice recommends a healthy balanced diet rich in foods that contain calcium to reduce the risk of osteoporosis. A wide range of fresh fruit and vegetables, plenty of fluids, preferably water and fresh fruit juices rather than carbonated drinks are recommended. The intake of alcohol should preferably be kept to low level.
Paragraph 8: Dieticians also advise arthritis sufferers to eat f atty fish such as herring, tuna, mackerel, salmon or sardines at least twice a week. There is also anecdotal evidence from people with arthritis that certain foods impact negatively on their condition. Keeping a food diary over a period of a month or more could help individuals identify any particular foods that appear to regularly provoke their arthritic symptoms.
Paragraph 9: It is universally acknowledged that exercise programs which improve the fitness of the heart and lungs, correct poor posture, build muscular strength, increase joint flexibility and improve balance are beneficial to people of all ages and can reduce the pain and stiffness associated with arthritis. The ancient Chinese martial art of Tai Chi, in an appropriately modified style, is a form of exercise which achieves all this and also enhances both mental and physical relaxation.
Paragraph 10: Dr Paul Lam, a family physician who lives in Sydney Australia began to have signs of arthritis after graduating from medical school. He took up Tai Chi and found it improved his arthritis and enabled him to enjoy his chosen and busy lifestyle. He is now a highly respected Tai Chi teacher and practitioner and has created a number of Tai Chi programs to improve people’s health and well-being. Arthritis Foundations and organisations in the Britain, America and Australia, New Zealand support his work. He has travelled the world to train instructors in the Tai Chi for Arthritis Program and produced books, videos and DVDs.
Paragraph 11: The Sun style Tai Chi movements are fluid, gentle and slow and help reduce the pain and stiffness associated with arthritic conditions. The movements incorporate breathing techniques and place an emphasis on posture and on the importance of weight transference which is an essential component of good balance. To ensure smoothness and harmony they require a mental as well as a physical commitment. People who practice these movements regularly, either individually in their homes or with a group in a park or community hall, report many benefits.
Paragraph 12: In many countries there are government funded and other support organizations whose purpose is not only to fund raise for further medical research into a cure for arthritis but also equally to provide comprehensive advice and assistance for people living with arthritis; This can include running education programs and seminars to provide the public with reliable and well researched information and also to providing aids to help in everyday living. These aids range from simple devices to assist in opening jars and cans and to larger equipment to assist with mobility.
Paragraph 13: Ultimately, to live as full a life as possible with an arthritic condition, you need to gain a full understanding of your condition. This can be achieved by working with a medical care team who shares their knowledge, is supportive and recognizes the contributions you can make. The best outcomes require a close partnership between you, your doctor and any health professionals or practitioners involved in your treatment
Paragraph 14: A degree of self-management has proved effective in managing arthritic conditions. This can be achieved in a number of ways. Keep up to date and enquire about the latest research results. Learn about and choose foods that – will ensure you have a healthy well-balanced diet. Always take medicines as directed and do not try any new “natural” supplement or medication without first consulting with your doctor or pharmacist. Undertake an exercise regime such as Tai Chi that is suitable to you and that you can enjoy in the company of others.
Paragraph 15: Until such time as a cure for all forms of arthritis becomes a reality, a holistic approach to the control of arthritis incorporating many of the treatments, therapies and concepts outlined in this article, will help you discover that living with arthritis does not mean you cannot have an enjoyable and fulfilling life.
Q1. Which of the following statements is correct? a. More adults in Australia have arthritis than in the US b. More adults in the· US have arthritis than in Australia c. Over 20 % of Australians have arthritis d. 4 in every hundred people have arthritis Q2. According to the article a cure for arthritis is: a. Much too expensive to justify b. A major focus for Australian scientists c. Hard to find d. Likely within 2 – 3 years Q3. Which of the following statements is not reflected in the article? a. Paracetamol has few side-effects b. Some powerful drugs can provide a permanent cure c. Pregnancy and lactation contraindicate the use of certain drugs d. Powerful non-steroidal anti- inflammatory drugs can provide effective relief from pain, joint stiffness and inflammation. Q4. Which of the following statements is correct? a. In the US hip replacement surgery has increased by 94.1% in the last decade b. Such surgery is unsuitable for the elderly c. Hip replacement surgery usually improves mobility d. Hip replacement surgery is not expensive and is easily accessible Q5. According to the article which one of the following statements is false? a. Glucosamine dietary supplement is clinically proven b. Natural products can have side effects c. A number of nutritional supplements may relieve the inflammation, pain and slow degeneration of effected joints. d. Omega-3 fatty acids can help reduce inflammation Q6. In paragraph 8 the expression anecdotal evidence can best be described as: a. A personal observation b. Scientific investigation c. An old wife’s tale d. None of the above Q7. Which of the following statements appear in the article relating to diet? a. Alcohol in moderc,1tion is beneficial b. Carbonated drinks are recommended c. Arthritis sufferers indicate that some foods adversely affect their condition d. Fatty fish such as herring, tuna, mackerel and sword fish must be eaten twice weekly Q8. In which paragraph can you find a description a style of Tai Chi which is useful for sufferers of arthritis? a. Paragraph 9 b. Paragraph 10 c. Paragraph 11 d. Paragraph 12
PART C. TEXT 2. Choose the answer (A, B, C or D) INFECTIOUS DISEASES AND CLIMATIC INFLUENCES
Paragraph 1: Complex dynamic relationships between humans, pathogens, and the environment lead to the emergence of new diseases and the re-emergence of old ones. Due to concern about the impact of increasing global climate variability and change, many recent studies have focused on relationships between infectious disease and climate.
Paragraph 2: Climate can be an important determinant of vector-borne disease epidemics: geographic and seasonal patterns of infectious disease incidence are often, though not always, driven by climate factors. Mosquito- borne diseases, such as malaria, dengue f ever, and Ross River virus, typically show strong seasonal and geographic patterns, as do some intestine diseases. These patterns are unsurprising, given the influence of climate on pathogen replication, vector and disease., reservoir populations, and human societies. In Sweden, a trend toward milder winters and early spring arrival may be implicated in an increased incidence of tick-borne encephalitis. The recent resurgence of malaria in the East African highlands may be explained by increasing temperatures in that region. However, yet there are relatively few studies showing clear climatic influences on infectious diseases at inter-annual or longer timescales.
Paragraph 3: The semi-regular El Nifio climate cycle, centred on the Pacific Ocean, has an important influence on inter-annual climate patterns in many parts of the world. This makes El Nifio an attractive, albeit imperfect, analogue for the effects of global climate change. In Peru, daily admissions for diarrhoea increased by more than 2-f old during an El Nifio event, compared with expected trends based on the previous five years. There is evidence of a relationship between El Nifio and the timing of cholera epidemics in Peru and Bangladesh; of ciguatera in the Pacific islands; of Ross River virus epidemics in Australia; and of dengue and malaria epidemics in several countries. The onset of meningococcal meningitis in Mali is associated with large-scale atmospheric circulation.
Paragraph 4: These studies were performed mostly at country scale, reflecting the availability of data sources and, perhaps, the geographically local effects of El Nifio on climate. In part because of this geographic “patchiness” of the epidemiological evidence, the identification of climatic factors in infectious disease dynamics, and the relative importance of the different factors, remains controversial. For example, it has been suggested that climate trends are unlikely to contribute to the timing of dengue epidemics in Thailand. However, recent work has shown a strong but transient association between dengue incidence and El Nifio in Thailand. This association may possibly be caused by a “pacemaker-like” effect in which intrinsic disease dynamics interact with climate variations driven by El Nifio to propagate travelling waves of infection.
Paragraph 5: A new study on cutaneous leishmaniasis by Chaves and Pascual also provides fresh evidence of a relationship between climate and vector-borne disease. Chaves and Pascual use a range of mathematical tools to illustrate a clear relationship between climatic variables and the dynamics of cutaneous leishmaniasis, a skin infection transmitted by sandflies. In Costa Rica, cutaneous leishmaniasis displays three-year cycles that coincide with those of El Nifio. Chaves and Pascual use this newly demonstrated association to enhance the forecasting ability of their models and to predict the epidemics of leishmaniasis up to one year ahead. Interestingly, El Nifio was a better predictor of disease than temperature, possibly because this large-scale index integrates numerous environmental processes and so is a more biologically relevant measure than local temperature. As the authors note, the link between El Nifio and epidemics of leishmaniasis might be explained by large-scale climate effects on population susceptibility. Susceptibility, in turn, may be related to lack of specific immunity or poor nutritional status, both of which are plausibly influenced by climate.
Paragraph 6: Chaves and Pascual have identified a robust relationship between climate and disease, with changes over time in average incidence and in cyclic components. The dynamics of cutaneous leishmaniasis evolve coherently with climatic variables including temperature and El Nifio indices, demonstrating a strong association between these variables, particularly after 1996. Long¬ term changes in climate, human demography, and social features of human populations have large effects on the dynamics of epidemics as underlined by the analyses of some large datasets on whooping cough and measles. Another illuminating example is the transient relationship between cholera prevalence and El Nifio oscillations. In Bangladesh, early in the 20th century, cholera and El Nifio appeared unrelated, yet a strong association emerged in 1980- 2001. Transient relationships between climate and infectious disease may be caused by interactions between climate and intrinsic disease mechanisms such as temporary immunity. If population susceptibility is low, even large increases in transmission potential due to climate farcing will not result in a large epidemic.
Paragraph 7: A deeper understanding of infectious disease dynamics is important in order to forecast, and perhaps forestall, the effects of dramatic global social and environmental changes. Conventional statistical methods may f ail to reveal a relationship between climate and health when discontinuous associations are present. Because classical methods quantify average associations over the entire dataset, they may not be adequate to decipher long-term but discontinuous relationships between environmental exposures and human health. On the other hand, relationships between climate and disease could signal problems for disease prediction. Unless all important effects are accounted for, dynamic forecast models may prove to have a limited shelf life.
Q1. According to paragraph 2, which of the following is true? a. The incidence of infectious diseases is rarely caused by climatic factors. b. Seasonal variations and geography always lead to increases in mosquito borne diseases. c. An increase in the rate of tick-borne encephalitis has been caused by milder winters and early arrival spring in Sweden. d. Malaria may have reappeared in East African highlands due to higher temperatures. Q2. Which of the following would be the most appropriate heading for the paragraph 2? a. The link between global warming and disease epidemics. b. The strong relationship between climate and outbreaks of disease. c. The unexpected influence of climate on infectious diseases. d. The need for further research into climate change and infectious diseases. Q3. Which of the following is closest in meaning to the expression relatively few? a. comparatively few b. b. several c. c. quite a few d. d. three Q4. In paragraph 3, which of the fallowing is not true? a. In Peru, the El Nino event led to increased rates of diarrhoea. b. El-Nino has a significant yearly effect on global climate patterns. c. Outbreaks of cholera in Bangladesh and Peru can be linked to El Nino. d. Meningococcal meningitis in Mali is influenced by weather patterns. Q5. The main point the author wishes to raise in paragraph 4 is? a. Despite differing opinions, there is strong current evidence linking climate factors and infectious disease. b. There is insufficient data to determine how significant climatic f actors are on infectious disease. c. The link between climate trends and disease epidemics is still inconclusive. d. There is no connection between climatic trends and dengue fever in Thailand. Q6. According to paragraph 5 which of the following statements is correct? a. Outbreaks of cutaneous leishmaniasis in Costa Rica correspond with El Nino events. b. The mathematical tools used by Chaves and Pascual demonstrate the link between sandflies and cutaneous leishmaniasis. c. Research by Chaves and Pascual will allow for annual prediction of leishmaniasis outbreaks. d. El Nino is an accurate predictor disease due its complexity and biological relevance.
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TEXT A: Changes in gastrointestinal function: The process of aging brings about changes in gastrointestinal function such as increase in gastric pH, deferment in process of expulsion of gastric, decreased motility, and decreased intestinal blood flow. The intake of substances that are actively transported from the intestinal lumen including some sugars, minerals and vitamins may therefore be decreased in elderly patients. Apart from the pathological or surgical alterations in gastrointestinal function such as gastrectomy, pyloric stenosis, pancreatitis, regional enteritis and concurrent administration of other drugs like cholestyramine and antacids may cause changes. Cholestyramine binds and decreases the effectiveness of many drugs including thiazides, anticoagulants, thyroxine, aspirin, PCM, and penicillin, while antacids decrease the efficiency of the process of taking in of drugs such as chlorpromazine, tetracycline, isoniazid. Plasma protein concentrations may also be altered in elderly patients. Plasma albumin concentrations are causing less increase in free concentration of acidic drugs such as naproxen, phenytoin and warfarin. In contrast, the concentration of α1-acid glycoprotein may be increased in the presence of chronic diseases that frequently occur in the elderly population, potentially increasing the binding of drugs such as antidepressants, antipsychotic drugs and β-blockers, which are mainly bound to this protein.
TEXT B: Aging Factor: Body composition, plasma protein binding, and organ blood flow help in determining how effectively the drug is getting into every nook and corner. The total body water and lean body mass decreases, whereas, the body fat as a percentage of body weight increases with aging. The increased body fat is associated with the increase in volume of distribution of fat-soluble drugs such as the benzodiazepines, which leads to a more prolonged drug effect. Thus, it was demonstrated that the elimination half-life of diazepam was prolonged with age despite the fact that systemic clearance was unaltered. Change in organ blood flow with aging may also affect the rate of its efficient movement. In most of the cases, peripheral vascular resistance gets enhanced more and more. The same goes with the enhancement of the heart rate or cardiac output.
TEXT C. Hepatic Blood Flow: Hepatic blood flow and liver mass change in proportion to body weight decrease with aging. The rate of metabolism of many drugs by the cytochrome P450 enzyme system is decreased by 20- 40% with aging. Examples include theophylline, propranolol, nortriptyline, alfentanil, fentanyl, alprazolam, triazolam, diltiazem, verapamil, and levodopa. Many benzodiazepines are metabolized by microsomal enzyme to active metabolites, which are also eliminated by hepatic metabolism. Non-microsomal enzyme pathways may be less affected by age. Example: Ethanol metabolism by alcohol dehydrogenase and isoniazid elimination by acetylation are unchanged in elderly patients. Concurrent drug administration, illness, genetics and environmental factors including smoking may have more significant effects on hepatic drug metabolism than age.
TEXT D. Toxicity In Drugs: Renal blood flow, glomerular filtration rate and tubular function all decline with aging. In addition to physiological decline in renal function, the elderly patient is particularly liable to renal impairment due to dehydration, congestive heart failure, hypotension and urinary retention, or to intrinsic renal involvement, e.g., diabetic nephropathy or pyelonephritis. As lean body mass decrease with aging, the serum creatinine level becomes a poor indicator of (and tends to overestimate) the creatinine clearance in older adults. The Cockroft-Gault formula20 should be used to estimate creatinine clearance in older adults: Creatinine clearance = {140 – age) x weight (kg) / 72 X serum creatinine in mg/dl (For women multiplied by 0.85) Drugs with significant toxicity that have diminished renal excretion with age include allopurinol, aminoglycosides, amantadine, lithium, digoxin, procainamide, chlorpropamide and cimetidine. These agents have reduced clearance, prolonged half-lives and increased steady-state concentrations if dosages are not adjusted for renal function.
PART A – QUESTIONS AND ANSWER SHEET. Questions 1-7. For each question, 1-7, decide which text (A, B, C or D) the information comes from. In which text can you find information about; 1. Substance which is known to decrease absorption. Answer 2. Various factors are known to create an effect on how drug distribution is weakened. Answer _ 3. Belongs to the class of medicines called digitalis glycosides Answer 4. With increase in age, various other health problems increase. Answer 5. Bioavailability and absorption. Answer 6. Drug distribution. Answer 7. Heart will pump less amount of blood through the circulatory system. Answer
QUESTIONS 8-14: Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include words, numbers or both. Your answers should be correctly spelt. 8. What causes delay in gastric emptying? ______________ 9. What can reduce effectiveness of blood thinners? ______________ 10. One of the factors that lead to decrease in body fat is? ______________ 11. How age can have its effect on cardiac output and peripheral vascular resistance? ______________ 12. What is often stamp out by Hepatic metabolism? ______________ 13. What can have major impact on hepatic drug metabolism? ______________ 14. What cimetidine is known to be? ______________ Questions 15-20. Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may include words, numbers or both. Your answers should be correctly spelt. 15. In most of the patients, __________will often get transformed. 16. In most of the adults, the __________ will help signal the pathway for creatinine. 17. With steady increase in __________, there can be increase in volume of distribution of fat- soluble drugs. 18. __________ pathways may not show any kind of change though age increases. 19. Many of these substances, when they are not altered as needed, are recorded to be effective and known to enhance__________ 20. __________is known to be very effective in curtailing down the absorption of drug.
PART B. For questions 1-6, choose the answer (A, B or C). Questions 1-6
1. The risk to the unborn baby may occur; A. During the first half of the pregnancy. B. When baby get primary infection through mother. C. When infected with virus during first pregnancy. CMV Infection: About one out of every 150 babies are born with a congenital CMV infection. However, only about one in five babies with a congenital CMV infection will be sick from the virus or will have long-term health problems. If a woman is newly infected with CMV while pregnant, there is a risk that her unborn baby will also become infected (congenital CMV). Infected babies may, but not always, be born with a disability. Infection during one pregnancy does not increase the risk for subsequent pregnancies. However, if primary infection occurs, consideration should be given to wait for at least 12 months for next pregnancy. Studies conducted in Australia have shown that out of 1,000 live births, about 6 infants will have congenital CMV infection and 1-2 of those 6 infants (about 1 in 1000 infants overall) will have permanent disabilities of varying degree. These can include hearing loss, vision loss, small head size, cerebral palsy, developmental delay or intellectual disability, and in rare cases, death. Sometimes, the virus may be reactivated while a woman is pregnant but reactivation does not usually cause problems to the woman or to the fetus.
2. What is more related to defects? A. SARS Co-V B. MERS Co-V C. Zika Impact of re-emerging infectious diseases: New or re-emerging infectious diseases can have a huge impact on morbidity, mortality, and costs to the affected region, and pose a significant challenge to healthcare and public health systems. Multiple new diseases have been identified during the past twenty years, including severe acute respiratory syndrome coronavirus (SARS Co-V), Middle East respiratory syndrome coronavirus (MERS Co-V), and novel strains of avian and swine influenza. In addition, multiple existing infectious diseases have re-emerged or resurged, causing large outbreaks. Two recent examples include Zika and Ebola. The Zika virus has caused disease in more than 28 countries and is associated with severe natal deformity, such as microcephaly. The 2014 Ebola virus outbreak infected almost 30,000 individuals and resulted in more than 11,000 deaths worldwide.
3. The following manual talks about; A. Digital blood pressure monitoring device. B. Traditional blood pressure monitoring. C. Accurate Blood Pressure Examination. OMRON HEM-907XL Intellisense: Developed for the specific use in the clinical office setting and other health care environments, this device determines blood pressure by oscillometric measurement and displays systolic blood pressure, diastolic blood pressure, and pulse rate using an LCD digital monitor. It has the ability to automatically measure and store up to three sequential readings, and has a “hide” feature that hides measurements during acquisition. The pressure measurement range for this device is 0 to 280 mmHg. The OMRON is calibrated to the mercury manometer for routine quality assurance procedures.
4. What is known to have higher acoustical quality? A. Littmann Cardioscope III B. Littmann Classic II C. A and B Littmann Cardiology III stethoscope: The stethoscopes used for listening to Korotkoff sounds are Littmann Cardioscope III for adults and Littmann Classic II pediatric for children. They have a bell and diaphragm chest piece, and an acoustical rating by the manufacturer of 9 on a scale of 1-10, with a rating of 10 having the best acoustical attributes. The construction uses a single-lumen rubber tubing connection between the ear tubes and the chest piece. The ear tubes can be adjusted to fit the particular user at an anatomically correct angle, and the plastic ear covers come in different sizes allowing the user to match the best ear canal size to achieve an acoustically sealed ear fit. All parts of the stethoscope can be cleaned for use between SPs. The bell of the stethoscope is used to auscultate the Korotkoff sounds for blood pressure measurements.
5. Which word may indicate a plant a sapling? A. Zygote B. Blastocyst C. Poppy Implantation: Implantation takes place, when ovulation and fertilization occur. Implantation occurs in early stage of pregnancy when the fertilized egg (zygote) treks down the fallopian tube to the uterus and ascribes to the epithelium or uterine lining. It takes about 8 to 10 days for the fertilized egg to reaches to the uterus. During this time, it develops into a blastocyst through different stages of transformation instigation as a single cell dividing into 150 cells with an outer layer the trophoblastic, a fluid filled cavity the blastocoel, and a cluster of cells on the interior the inner cell mass. The tiny ball of cells is more or less like poppy generator. It attaches to the epithelium during 4th week of gestation. Once it firmly adheres, this’s called as an embryo. The embryo then again allocates into two parts, which will become the placenta and the fetus. An ultrasound done during the 5 to 6 weeks of gestation period that may show the amniotic sac and yolk sac, which are forming during this time. The amniotic sac is where baby will develop. The yolk sac will later be incorporated in a baby’s digestive tract. This ultrasound approves that implantation has taken place.
6. The given notice gives information about; A. Women who are now more aware of health conditions. B. Industry insights. C. The global gynecology devices market size. The market size was valued at USD 10,984.1 million in 2014. Introduction of minimally invasive procedures such as laparoscopy and high-definition imaging devices such as 3D endoscope is primarily boosting market growth. In addition, rising prevalence of diseases, such as uterine fibrosis and sexually transmitted diseases (STDs), associated with female reproductive organs are anticipated to support market growth during the forecast period. According to the United Nations, the global female population accounted for more than 3.64 billion in 2015. Every woman visits a gynecologist at least once in her lifetime either for pregnancy or other complications related to menstrual cycle. The growing number of patients is likely to drive market growth during the forecast period. Moreover, healthcare agencies are now promoting routine-check-ups for early cancer detection and other gynecological conditions. For example, The American Cancer Society recommends annual breast cancer screening with mammography for women aged between 40 to 44 years. Increase in routine check-ups has helped these devices gain usage rates.
PART C. TEXT 1. For questions 7-22, choose the answer (A, B, C or D). ALL ABOUT FETAL ALCOHOL SPECTRUM DISORDERS:
Fetal Alcohol Spectrum Disorders (FASDs) are an assortment of different conditions that can occur in a person whose mother drank alcohol during pregnancy. These effects can include physical problems and problems with behavior and learning. Often, a person with an FASD has a mix of these problems. FASDs are caused by a woman drinking alcohol during pregnancy when alcohol in the mother’s blood passes to the baby through the umbilical cord. When a woman drinks alcohol, so does her baby. There is no known safe amount of alcohol during pregnancy or when trying to get pregnant.
To curtail down the risks of FASDs, a woman should not drink alcohol while she is pregnant, or when she might get pregnant. This is because a woman could get pregnant and be asymptomatic for up to 4 to 6 weeks. In the United States, nearly half of pregnancies are unplanned. If a woman is drinking alcohol during pregnancy, it is never too late to stop drinking. Because brain growth takes place throughout the pregnancy, the sooner a woman stops drinking, the safer it will be for her and her baby.
FASDs can affect every person in different ways, and can range from mild to severe. It may not be difficult to assess why certain problems occur, however, still they have their own appearance time and pattern. A person with an FASD might have: abnormal facial features, such as a smooth ridge between the nose and upper lip (this ridge is called the philtrum); small head size; shorter-than-average height; low body weight; poor coordination etc.
Different terms are used to describe FASDs, depending on the type of symptoms. (i) Fetal Alcohol Syndrome (FAS): FAS represents the most involved end of the FASD spectrum. Fetal death is the most extreme outcome from drinking alcohol during pregnancy. People with FAS might have abnormal facial features, growth problems, and central nervous system (CNS) problems. People with FAS can have problems with learning, memory, attention span, communication, vision, or hearing. They might have a mix of these problems. People with FAS often have a hard time in school and trouble getting along with others. (ii) Alcohol-Related Neurodevelopmental Disorder (ARND): People with ARND might have intellectual disabilities and problems with behavior and learning. They might do poorly in school and have difficulties with math, memory, attention, judgment, and slow, lethargic behaviour. (iii) Alcohol-Related Birth Defects (ARBD): People with ARBD might have problems with the heart, kidneys, or bones, or with hearing; they might have a combination of these.
Diagnosing FAS can be hard because there is no medical test, like a blood test, for it. And other disorders, such as ADHD (attention-deficit/hyperactivity disorder) and Williams syndrome, have some symptoms like FAS. To diagnose FAS, doctors look for: heteroclite facial features (e.g., smooth ridge between nose and upper lip); lower-than-average height, weight, or both; central nervous system problems (e.g., small head size, problems with attention and hyperactivity, poor coordination); prenatal alcohol exposure; although confirmation is not required to make a diagnosis etc.
FASDs last a lifetime. There is no cure for FASDs, but research shows that early intervention treatment services can improve a child’s development. There are many types of treatment options, including medication to help with some symptoms, behavior and education therapy, parent training, and other alternative approaches. No single treatment is effective for every child. Good treatment plans will include close monitoring, follow-ups, and changes as needed along the way.
7. As per the information given in paragraph 1, FASDs; A. Occur due to alcohol consumption. B. Aren’t known to cause behavioral and learning disabilities. C. Are a collection of diseases, which occur only in women. D. Are a collection of complex, proof-less medical conditions. 8. Paragraph 2 talks more about; A. How to prevent FASDs B. Why FSADs women should not get pregnant? C. What FSADs women should do when pregnant? D. How to protect the baby from FASDs during pregnancy? 9. The most appropriate heading for paragraph 3 is. A. Signs and symptoms B. How FASDs affect babies C. Common features of FASDs D. None of the above 10. According to paragraph 4, what is not true about FAS? A. People affected with the FAS show uneven growth. B. FAS can lead to development of extra facial features. C. People with FAS show poor memory. D. FAS children can have health problems but they may mix well with other children. 11. According to paragraph 4, people with ___________ show low agility levels. A. ARND B. FAS C. ARBD D. ARND and FAS 12. According to paragraph 5, at the time of diagnosis, most doctors look for; A. Effects on facial features B. Height and body weight problems C. Problems with brain functioning D. All of the above 13. According to paragraph 5, when is a diagnosis not required? A. When it is known that the patient’s mother is an alcoholic. B. When the features such as abnormal facial features, low body weight and lower height become obvious. C. When the patient shows all abnormal signs and symptoms of the FAS D. a and c 14. According to paragraph 6, treatment for FASDs is; A. Specific B. Common for all conditions C. Dependent on types of conditions D. Depends on age
PART C. TEXT 2. VALLEY FEVER
Valley fever, also called coccidioidomycosis, is an infection caused by the fungus, Coccidioides. The fungus is known to live in the soil in the south-western United States and parts of Mexico and Central and South America. The fungus was also recently found in south-central Washington. People can get Valley fever by breathing in the microscopic fungal spores from the air, although most people who breathe in the spores don’t get sick. Usually, people who get sick with Valley fever may get better on their own within weeks to months, but some people need antifungal medication. Certain groups of people are at a higher risk of becoming severely ill. It’s difficult to prevent exposure to Coccidioides in areas where it’s common in the environment, but people who are at a higher risk of severe Valley fever should try to avoid breathing in large amounts of dust if they’re in such localities.
Anyone who lives in or travels to the south-western United States (Arizona, California, Nevada, New Mexico, Texas, or Utah), or parts of Mexico or Central or South America can get Valley fever. Valley fever can affect people of any age, but it’s most common in adults aged 60 years and over. Certain groups of people may be at a higher risk of developing the severe forms of Valley fever, such as: people with weakened immune systems, for example, people with HIV/AIDS; people who have had an organ transplant; people who are taking medications such as corticosteroids or TNF-inhibitors; pregnant women; and people who have diabetes.
The fungus that causes Valley fever, Coccidioides, doesn’t have that potential to cross barriers; the transmission is often formidable, a mighty task that could lead to stark failure. However, in extremely rare instances, a wound infection with Coccidioides can spread Valley fever to someone else or the infection can be spread through an organ transplant with an infected organ.
The most common way for someone to get Valley fever is by inhaling Coccidioides spores that are in the air. In extremely rare cases, people can get infected from an organ transplant if the organ donor had Valley fever, inhaling spores from a wound infected with Coccidioides, contact with objects (such as rocks or shoes) that have been contaminated with Coccidioides etc.
Scientists continue to study how weather and climate patterns efficaciously affect the habitat of the fungus that causes Valley fever. Coccidioides is thought to grow expeditiously in soil after heavy rainfall and then disperse into the air most vigorously during hot, dry conditions. For example, hot and dry weather conditions have been shown to parlously correlate with an increase in the number of Valley fever cases in Arizona and in California (but to a lesser extent). The ways in which climate change may be affecting the number of Valley fever infections, as well as the geographic range of Coccidioides, isn’t known yet, but is a subject for further research.
Healthcare providers rely on your medical and travel history, symptoms, physical examinations, and laboratory tests to diagnose Valley fever. The most common way that healthcare providers test for Valley fever is by taking a blood sample and sending it to a laboratory to look for Coccidioides antibodies or antigens. Healthcare providers may do imaging tests such as chest x-rays or CT scans of your lungs to look for Valley fever pneumonia. They may also perform a tissue biopsy, in which a small sample of tissue is taken from the body and examined under a microscope.
Text 2: Questions 15-22
15. According to paragraph 1, the fungus mentioned is a native of. A. US B. Washington C. Mexico D. A and C 16. According to paragraph 1, treatment for valley fever is; A. Required B. Not required C. Required in some specific cases D. Not given 17. The most appropriate heading for paragraph 2 is; A. When Valley fever may affect someone? B. Who gets Valley fever? C. Who can show symptoms of Valley fever? D. Conditions that are common with Valley fever. 18. The most suitable heading for paragraph 3 is; A. Is it contagious? B. How can Valley fever transfer? C. Valley fever is half contagious D. None of the above 19. The most suitable heading for paragraph 4 is; A. Uncommon sources of Valley fever B. Common sources of Valley fever C. How people may get affected with Valley fever D. A and C 20. The most appropriate heading for paragraph 5 is; A. Valley fever agent and its habitat. B. Valley fever and weather. C. How temperature affects Valley fever patients? D. Climate and Valley fever. 21. Which word in paragraph 5 may mean quickly? A. Efficaciously B. Vigorously C. Expeditiously D. B and C 22. The most suitable heading for paragraph 6 is; A. How valley fever is identified? B. Common ways of identifying Valley fever. C. Ways of identifying and treating Valley fever. D. Three common tests for Valley fever.
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In the contemporary era, the escalating demand for energy to power factories, households, and, notably, automobiles has underscored the imperative for renewable energy sources. This essay aims to delve into the advantages and disadvantages of these sustainable energy alternatives in comparison to traditional fossil-based fuels.
On the one hand, renewable energy holds the potential to emerge as our ultimate solution if harnessed effectively. Solar, wind, tidal energy, and other renewable sources stand out prominently, offering far better alternatives to fossil-based fuels. The discernible advantage lies in the marked differences in environmental friendliness and the safeguarding that renewable energy can provide, unlike fossil-based fuels which vent out toxic gasses, which if breathed on a regular basis, could lead to respiratory diseases and more. Moreover, these gases are the primary contributors to the ozone layer’s depletion and global warming. Therefore, renewable energy not only benefits our well-being but also contributes to the health of our planet. Australia is one of the finest examples, embracing wind and solar energy projects, contributing significantly to its electricity generation and concurrently cutting down on air pollution.
On the other hand, renewable energy faces challenges related to reliability, as natural sources like sunlight and wind may not be consistently available. Factors such as precipitation and daylight hours impact successful energy harnessing. For instance, continual rainy or cloudy weather makes electricity production from solar energy close to impossible, and storing it can be costly, highlighting the practical challenges of relying solely on renewables. On the other hand, fossil fuels, like coal, despite environmental concerns, provide a reliable energy source that remains consistently available until fully depleted, exemplifying centuries-long dependence of humanity on such resources.
To conclude, while renewable energy could be the finest alternative to fossil fuel and can be better for our environment and health, it still lacks in the areas of consistency in production, and we cannot yet rely on it solely. However, as technology is evolving, it is possible that the future will offer better alternatives and solutions where we can produce energy without compromise.
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The bar chart and table show information about students from abroad studying in four English-speaking countries in 2004 and 2012. Summarise the information by selecting and reporting the main features, and make comparisons where relevant.
TEXT A. US researchers have found altered sleep patterns among breastfeed infants of mothers who smoke. Julie Mannella from the Monell Chemical Senses Centre in Philadelphia recruited 15 breastfeeding mothers who smoked. Sleep and activity patters in their babies, which were aged between two and six months, were monitored on two occasions over a three-hour period after the children were fed. On both occasions they were allowed to smoke just before they fed their babies. The women were also asked to avoid caffeinated drinks during the study.
TEXT B. Tests on the milk from mothers who had recently smoked confirmed that the babies were receiving a significant increase in nicotine dose, and the team found that the amount of sleep taken during the fallowing three hours by these babies fell from an average of 85 minutes to 53 minutes, a drop of almost 40%. This is probably due to the neuro-stimulatory effects of nicotine, which has been shown to inhibit regions of the brain which are concerned with controlling sleep. It may also, suggests Manella, explain why neonatal nicotine exposure has been linked in the past with long-term behavioural and learning deficits, since these could be the consequence of sleep disturbance. In light of these findings, mothers who smoke might want to consider planning their smoking around their breast feeding. Nicotine levels in milk peak 30-60 minutes after smelting, but take three hours to return to baseline, so this might be feasible.
TEXT C. Cigarette smoke. What is in smoke? Scientific studies show that there can be around 4000 chemicals in cigarette smoke. They can be breathed in by anyone near a smoker. They can also stick to clothes, hair, skin, walls and furniture. Some of these chemicals are: • tar – which has many chemicals in it some of which cause cancer • carbon monoxide – reduces the oxygen in blood – so people can develop heart disease • poisons – including arsenic, ammonia and cyanide.
TEXT D. Passive smoking and respiratory function in very low birth weight children Abstract Aim: To determine if an adverse relationship exists between passive smoking and respiratory function in very low birth weight (VLBW) children at 11years of age. Setting: The Royal Women’s Hospital. Melbourne. Patients: 154 consecutive surviving children of less than 1501 g birth weight born during the 18 months from 1October 2006. Methods: Respiratory function of 120 of the 154 children (77.9%) at 11years of age was measured. Exposure to passive smoking was established by history; no children were known to be actively smoking. The relationships between various respiratory function variables and the estimated number of cigarettes smoked by household members per day were analysed by linear regression Results: Most respiratory function variables reflecting airflow were significantly diminished with increasing exposure to passive smoking. In addition, variables indicative of air-trapping rose significantly with increasing exposure to passive smoking. Conclusions: Passive smoking is associated with adverse respiratory function in surviving VLBW children at 11years of age. Continued exposure to passive smoking, or active smoking, beyond 11years may lead to further deterioration in respiratory function in these children.
Part A. TIME: 15 minutes. Questions 1-7. Choose A, B, C or D. In which text can you find information about 1. how many chemicals are there in cigarette smoke? _____________ 2. which chemical Vs in cigarette smoke cause/s cancer? _____________ 3. when does nicotine levels in breast milk reach at peak? _____________ 4. How does exposure to passive smoking was established in the study? _____________ 5. what happened to respiratory function variables reflecting airflow in the study? _____________ 6. what are the side effects of neonatal nicotine exposure? _____________ 7. what are the poisons in cigarette smoke? _____________ Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts. 8. How much percentage does the sleep drop in the babies who had significant nicotine dose? ________ 9. How much percentage of children at 11years of age was measured for respiratory function? _______ 10. What was the maximum birth weight of babies who were considered for the study? _____________ 11. Which chemical component in cigarette smoke reduces the oxygen in blood? _____________ 12. Who recruited subjects for the study conducted by Monell Chemical Senses Centre? _____________ 13. Which chemical component in cigarette smoke is responsible for heart disease? _____________ Questions 14-20. 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 children are continually exposed to active smoking, it can lead to _________ in respiratory function. 15. Cigarette smoke can be breathed in by anyone near a ___________________ 16. During the study some women were asked to avoid ____________________ 17. ______________________ can also stick to clothes, hair, skin, walls and furniture. 18. Variables indicative of _____________rose significantly with increasing exposure to passive smoking. 19. _____________ of nicotine can inhibit regions of the brain which control sleep. 20. The relationships between respiratory function variables and number of cigarettes smoked per day were analysed by_____________
PART B. Choose the answer (A, B or C) which you think fits best according to the text. B.P.sets: Functioning: The cuff on the arm is inflated until blood flow in the artery is blocked. As the cuff pressure is decreased slowly, the sounds of blood flow starting again can be detected. The cuff pressure at this point marks the high (systolic) pressure of the cycle. When flow is unobstructed and returns to normal, the sounds of blood flow disappear. The cuff pressure at this point marks the low (diastolic) pressure. 1. When should one note the diastolic pressure of patient? A. blood flow is limited to make the sound disappear B. blood flow is normal and the sound disappear C. blood flow is obstructed and the sound disappear
Aspirators: Suction is generated by a pump. This is normally an electrically powered motor, but manually powered versions are also often found. The pump generates a suction that draws air from a bottle. The reduced pressure in this bottle then draws the fluid from the patient via a tube. The fluid remains in the bottle until disposal is possible. A valve prevents fluid from passing into the motor itself. 2. The purpose of bottle in aspirator is to A. deliver suction that draws air B. draw the fluid from the patient C. keep pressure stable if valve prevents fluid
Operating Theatre and Delivery Tables: Where the table has movement, this will be enabled by unlocking a catch or brake to allow positioning. Wheels have brakes on the rim or axle of the wheel, while locks for moving sections will normally be levers on the main table frame. Care should be taken that the user knows which lever applies to the movement required, as injury to the patient or user may otherwise result. The table will be set at the correct height for patient transfer from a trolley then adjusted for best access for the procedure. 3. The email is reminding user that the A. importance of lever for the required movements B. locks of moving wheels are on main table frame C. table should be set at correct height of the patient
Methods of reporting hospital infection: A mass outbreak of a hospital infection, which can result in severe injury or death, must be reported without delay, by telephone, fax or e-mail to the local public health protection authority (usually to the regional hygiene departments). The following cases are subject to the reporting of hospital infections: Severe injury, as a result of hospital infection, A mass outbreak, an infection that led to the death of a patient. 4. The guidelines establish that the healthcare professional should A. report a mass outbreak of hospital infection immediately B. report severe injury, as a result of hospital infection with delay C. report an infection that led to the death of a patient only
Admission and treatment in medical and social care facilities: Hygiene requirements for the admission and treatment of patients at medical inpatient facilities, day care and outpatient care facilities are set out in the operating rules of each healthcare provider, and always take into consideration the nature and scope of activity, and the type of healthcare provided. The receiving healthcare professional at the healthcare facility such as an inpatient facility, day care or social care facility, records anamnesis information that is significant in terms of the potential occurrence of hospital infection, including travel and epidemiological anamnesis, or conducts an examination of the overall health of the individual. 5. This guideline extract says that hygiene requirements are A. determined by the healthcare professional B. implemented by the healthcare provider C. written in the operating rules of the facilities
Treatment of used contagious and surgical linen: The healthcare provider and the laundry contractually agree on a system for classifying and labelling containers according to the content (e.g., in colour or numerical) and the procedure in terms of the quantity, deadlines and handling is documented. Linen is sorted at the place of use but it is not counted. The linen is not to be shaken before placing into the containers in the ward. It is sorted into bags according to the degree of soiling, type of material and colour. 6. The purpose of this email is to A. report on a rise in used contagious and surgical linen in healthcare facility B. explain the background to a change healthcare provider and the laundry contract C. remind staff about procedures for treatment of used contagious and surgical linen _______________________________________________________________________________
PART C. Choose the answer (A, B, C or D) which you think fits best according to the text. PANCREATIC ISLET TRANSPLANTATION Paragraph 1: The pancreas, an organ about the size of a hand, is located behind the lower part of the stomach. It makes insulin and enzymes that help the body digest and use food. Spread all over the pancreas are dusters of cells called the islets of Langerhans. Islets are made up of two types of cells: alpha cells, which make glucagon, a hormone that raises the level of glucose (sugar) in the blood, and beta cells, which make insulin.
Paragraph 2: Islet Functions: Insulin is a hormone that helps the body use glucose energy. If your beta cells do not produce enough insulin, diabetes will develop. In type 1diabetes, the insulin shortage is caused by an autoimmune process in which the body ‘s immune system destroys the beta cells.
Paragraph 3: Islet Transplantation: In an experimental procedure called islet transplantation, islets are taken from a donor pancreas and transferred into another person. Once implanted, the beta cells in these begin to make and release insulin. Researchers hope that; transplantation will help people with type 1 diabetes live without daily injections of insulin.
Paragraph 4. Research Developments: Scientists have made many advances in islet transplantation recent years. Since reporting their findings in the June issue of the New England Journal of Medicine, researchers the University of Alberta in Edmonton, Canada, have continued to use a procedure called the Edmonton protocol to transplant pancreatic islets into people with type 1 diabetes. According to the Immune Tolerance Network (ITN), as of June 2003, about 50 percent of the patients have remained insulin-free up to g 1year after receiving a transplant. Researchers use specialized enzymes to remove islets from the pancreas of a deceased donor. Because the islets are fragile, transplantation occurs soon after they are removed.
Paragraph 5: During the transplant, the surgeon uses ultrasound to guide placement of a small plastic tube (catheter) through the upper abdomen and into the liver. The islets are then injected through the catheter into the liver. The patient will receive a local anesthetic. If a patient cannot tolerate local anesthesia, the surgeon may use general anesthesia and do the transplant through a small incision. Possible risks include bleeding or blood clots. It takes time for the cells to attach to new blood vessels and begin releasing insulin. The doctor will order many tests to check blood glucose levels after the transplant, and insulin may be needed until control is achieved.
Paragraph 6. Transplantation: Benefits, Risks, and Obstacles: The goal of islet transplantation is to infuse enough islets to control the blood glucose level without insulin injections. For an average-size person (70 kg), a typical transplant requires about 1 million islets, extracted from two donor pancreases. Because good control of blood glucose can slow or prevent the progression of complications associated with diabetes, such as nerve or eye damage, a successful transplant may reduce the risk of these complications. But a transplant recipient will need to take immunosuppressive drugs that stop the immune system from rejecting the transplanted islets.
Paragraph 7. Researchers are trying to find new approaches that will allow successful transplantation without the use of immunosuppressant drugs, thus eliminating the side effects that may accompany their long-term use. Rejection is the biggest problem with any transplant. The immune system is programmed to destroy bacteria, viruses, and tissue it recognizes as “foreign,” including transplanted islets. Immunosuppressive drugs are needed to keep the transplanted islets functioning.
Paragraph 8. Immunosuppressive Drugs: The Edmonton protocol uses a combination of immunosuppressive drugs, also called antirejection drugs, including daclixrm (Zenapax), sirolimus (Rapamune), and tacrolimus (Prograf). Dacliximab is given intravenously right after the transplant and then discontinued. Sirolimus and tacrolimus, the two drugs that keep the immune system from destroying the transplanted islets, must be taken for life.
Paragraph 9. These drugs have significant side effects and their long-term effects are still not known. Immediate side effects of immunosuppressive drugs may include mouth sores and gastrointestinal problems, such as stomach upset or diarrhea. Patients may also have increased blood cholesterol levels, decreased white blood cell counts, decreased kidney function, and increased susceptibility to bacterial and viral infections. Taking immunosuppressive, drugs increase the risk of tumors and cancer as well.
Paragraph 10: Researchers do not fully know what long-term effects this procedure may have. Also, although the early results of the Edmonton protocol are very encouraging, more research is needed to answer questions about how long the islets will survive and how often the transplantation procedure will be successful. Before the introduction of the Edmonton Protocol, few islet cell transplants were successful. The new protocol improved greatly on these outcomes, primarily by increasing the number of transplanted cells and modifying the number and dosages of immunosuppressants. Of the 267 transplants performed worldwide “from 1990 to 1999, only 8 percent of the people receiving them were free -of insulin treatments one year after the transplant. The CITR’ s second annual report, published in July 2005, presented data on 138 patients. At six months after patients’ final infusions, 67 percent did not need to take insulin treatments. At one year, 58 percent remained insulin independent. The recipients who still needed insulin treatment after one year experienced an average reduction of 69 percent in their daily insulin needs.
Paragraph 11: A major obstacle to widespread use of islet transplantation will be the shortage of islet cells. The supply available from deceased donors will be enough for only a small percentage of those with type 1diabetes. However, researchers are pursuing avenues for alternative sources such as creating islet cells from other types of cells. New technologies could then be m employed to grow islet cells in the laboratory.
QUESTIONS Q1. The pancreas is A. in the hand B. in the stomach C. above the stomach D. behind the lower part of the stomach Q2. What is the main purpose of insulin? A. Itis a hormone B. to destroy beta cells C. to assist in energy production D. to stimulate the auto immune process Q3. According the article, is islet transplantation common practice? A. Yes, it’s frequently used B. No, it’s still being trialed C. Not stated in the article D. Yes, but only in Canada Q4. What is the Edmonton Protocol? A. A trade agreement B. The journal of Alberta University C. A way to transplant pancreatic islets D. Not stated in the article Q5. What’s the source of the pancreatic islets that are in the transplant operation? A. They are donated by relatives B. They come from people who have recently died C. They are grown in a laboratory D. They come from foetal tissue Q6. Which one of the sentences below is true? A. A local anaesthetic is preferred where possible. B. A general anaesthetic is preferred where possible. C. A general anaesthetic is too risky due to the possibility of blood clots and bleeding. D. An anaesthetic is not necessary if ultrasound is used Q7. How soon after the operation can the patient abandon insulin injections? A. Immediately B. After about two weeks C. When the blood glucose levels are satisfactory D. After the first year Q8. How many islets are required per patient? A. About a million B. 70 kg C. Whatever is available is used D. it depends on the size of the patient
PART C. Choose the answer (A, B, C or D) which you think fits best according to the text. SEASONAL INFLUENZA VACCINATION AND THE HLNL VIRUS
Paragraph 1: As the novel pandemic influenza A (H1N1) virus spread around the world in late spring 2009 with a well-matched pandemic vaccine not immediately available, the question of partial protection afforded by seasonal influenza vaccine arose. Coverage of the seasonal influenza vaccine had reached 30%- 40% in the general population in 2008-09 in the US and Canada, following recent expansion of vaccine recommendations.
Paragraph 2. Unexpected Findings in a Sentinel Surveillance System: The spring 2009 pandemic wave was the perfect opportunity to address the association between seasonal trivalent inactivated influenza vaccine (TIV) and risk of pandemic illness. In an issue of PLoS Medicine, Danuta Skowronski and colleagues report the unexpected results of a series of Canadian epidemiological studies suggesting a counterproductive effect of the vaccine. The findings are based on Canada’s unique near-real-time sentinel system for monitoring influenza vaccine effectiveness. Patients with influenza-like illness who presented to a network of participating physicians were tested for influenza virus by RT-PCR, and information on demographics, clinical outcomes, and vaccine status was collected.
Paragraph 3. In this sentinel system, vaccine effectiveness may be measured by comparing vaccination status among influenza-positive “case” patients with influenza negative “control” patients. This approach has produced accurate measures of vaccine effectiveness for TIV in the past, with estimates of protection in healthy adults higher when the vaccine is well-matched with circulating influenza strains and lower for mismatched seasons. The sentinel system was expanded to continue during April to July 2009, as the H1N1 virus defied influenza seasonality and rapidly became dominant over seasonal influenza viruses in Canada.
Paragraph 4. Additional Analyses and Proposed Biological Mechanisms: The Canadian sentinel study showed that receipt of TIV in the previous season (autumn 2008) appeared to increase the risk of H1N1 illness by 1.03- to 2.74-fold, even after adjustment for the comorbidities of age and geography. The investigators were prudent and conducted multiple sensitivity analyses to attempt to explain their perplexing findings, importantly, TIV remained protective against seasonal influenza viruses circulating in April through May 2009, with an effectiveness estimated at 56%, suggesting that the system had not suddenly become flawed. TIV appeared as a risk factor in people under 50, but not in seniors-although senior estimates were imprecise due to lower rates of pandemic illness in that age group. Interestingly, if vaccine were truly a risk factor in younger adults, seniors may have fared better because their immune response to vaccination is less rigorous.
Paragraph 5. Potential Biases and Findings from Other Countries: The Canadian authors provided a full description of their study population and carefully compared vaccine coverage and prevalence of comorbidities in controls with national or province-level age-specific estimates-the best can do short of a randomized study. In parallel, profound bias in observational studies of vaccine effectiveness does exist, as was amply documented in several cohort studies overestimating the mortality benefits of seasonal influenza vaccination in seniors.
Paragraph 6: Given the uncertainty associated with observational studies, we belie would be premature to conclude that TIV increased the risk of 2009 pandemic illness, especially in light of six other contemporaneous observational studies in civilian populations that have produced highly conflicting results. We note the large spread of vaccine effectiveness estimates in those studies; indeed, four of the studies set in the US an Australia did not show any association whereas two Mexican studies suggested a protective effect of 35%-73%.
Paragraph 7. Policy Implications and a Way Forward: The alleged association between seasonal vaccination and 2009 H1N1 remains an open question, given the conflicting evidence from available research. Canadian health authorities debated whether to postpone seasonal vaccination in the autumn of 2009 until after a second pandemic wave had occurred, but decided to follow normal vaccine recommendations instead because of concern about a resurgence of seasonal influenza viruses during the 2009-10 season.
Paragraph 8: This illustrates the difficulty of making policy decisions in the midst of a public health crisis, when officials must rely on limited and possibly biased evidence from observational data, even in the best possible scenario of a well-established sentinel monitoring system already in place. What happens next? Given the timeliness of the Canadian sentinel system, data on the association between seasonal TIV and risk of H1N1 illness during the autumn 2009 pandemic wave will become available very soon, and will be crucial in confirming or refuting the earlier Canadian results.
Paragraph 9: In addition, evidence may be gained from disease patterns during the autumn 2009 pandemic wave in other countries and from immunological studies characterizing the baseline immunological status of vaccinated and unvaccinated populations. Overall, this perplexing experience in Canada teaches us how to best react to disparate and conflicting studies and can aid in preparing for the next public health crisis. QUESTIONS Q1. The question of partial protection against H1N1 arose _ A. before spring 2009 B. 2. during Spring 2009 C. 3. after spring 2009 D. 4. during 2008-09 Q2. According to Danuta Skowronski—- A. the inactivated influenza vaccine may not be having the desired effects. B. Canada’s near-real-time sentinel system is unique. C. the epidemiological studies were counterproductive D. the inactivated influenza vaccine has proven to be ineffective. Q3. The vaccine achieved higher rates of protection in healthy adults when A. it was supported by physicians. B. the sentinel system was expanded. C. used in the right season. D. it was matched with other current influenza strains. Q4. Which one of the following is closest in meaning to the word prudent? A. Anxious B. 2. cautious C. 3. busy D. 4. confused Q5. The Canadian sentinel study demonstrated that _ A. age and geography had no effect on the vaccine ‘s effectiveness. B. vaccinations on senior citizens is less effective than on younger people C. the vaccination was no longer effective. D. the risk of H1N1 seemed to be higher among people who received the TIV vaccination. Q6. Which of the following sentences best summarises the writers’ opinion regarding the uncertainty associated with observational studies? A. More studies are needed to determine whether TIV increased the risk of the 2009 pandemic illness. B. It is too early to tell whether the risk of catching the 2009 pandemic illness increased due to TIV. C. The Australian and Mexican studies prove that there is no association between TIV and increased risk of catching the 2009 pandemic illness. D. Civilian populations are less at risk of catching the 2009 pandemic illness. Q7. Which one of the following is closest in meaning to the word alleged? A. Reported B. 2. likely C. 3. suspected D. 4. possible Q8. Canadian health authorities did not postpone the Autumn 2009 seasonal vaccination because —– A. of a fear seasonal influenza viruses would reappear in the 2009-10 season. B. there was too much conflicting evidence regarding the effectiveness of the vaccine. C. the sentinel monitoring system was well established. D. observational data may have been biased.
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TEXT A. International flights are suspected of contributing to the formation of DVT in susceptible people, although the research evidence is currently divided. Some airlines prefer to err on the side of caution and offer suggestions to passengers on how to reduce the risk of DVT. Suggestions include: • Wear loose clothes • Avoid cigarettes and alcohol • Move about the cabin whenever possible • Don’t sit with your legs crossed • Perform leg and foot stretches and exercises while seated • Consult with your doctor before travelling
TEXT B. Previous research: Venous thrombosis was first linked to air travel in 1954, and as air travel has become more and more common, many case reports and case series have been published since. Several clinical studies have shown an association between air travel and the risk of venous thrombosis. English researchers proposed, in a paper published in the Lancet, that flying directly increases a person’s risk. The report found that in a series of individuals who died suddenly at Heathrow Airport, death occurred far more often in the arrival than in the departure area. Two similar studies reported that the risk of pulmonary embolism in air travellers increased with the distance travelled. In terms of absolute risk, two studies found similar results: one performed in New Zealand found a frequency of 1% of venous thrombosis in 878 individuals who had travelled by air for at least 10 hours. The other was a German study which found venous thrombotic events in 2.8% of 964 individuals who had travelled for more than 8 hours in an airplane. In contrast, a Dutch study found no link between DVT and long-distance travel of any kind.
TEXT C. Symptoms
• Pain and tenderness in the leg • Pain on extending the foot • Tenderness in calf (the most important sign) • Swelling of the lower leg, ankle and foot • Redness in the leg • Bluish skin discoloration • Increased warmth in the leg
TEXT D. Travel-Related Venous Thrombosis: Results from a Large Population¬ Based Case Control
Study Background: Recent studies have indicated an increased risk of venous thrombosis after air travel. Nevertheless, questions on the magnitude of risk, the underlying mechanism, and modifying factors remain unanswered. Methods: We studied the effect of various modes of transport and duration of travel on the risk of venous thrombosis in a large ongoing case-control study on risk factors for venous thrombosis in an unselected population. We also assessed the combined effect of travel in relation to body mass index, height, and oral contraceptive use. Since March 2015, consecutive patients younger than 70 years of age with a first venous thrombosis have been invited to participate in the study, with their partners serving as matched control individuals. Information has been collected on acquired and genetic risk factors for venous thrombosis. – Results: Of 1,906 patients, 233 had travelled for more than 4 hours in the 8 weeks preceding the event. Travelling in general was found to increase the risk of venous thrombosis. The risk of flying was similar to the risks of traveling by bus or train. The risk was highest in the first week after traveling. Travel by bus, or train led to a high relative risk of thrombosis in individuals with factor V Leiden, in those who had a body mass index of more than 30, those who were more than 190 cm tall, and in those who used oral contraceptives. For air travel these people shorter than 160 cm had an increased risk of thrombosis after air travel as well. Conclusions: The risk of venous thrombosis after travel is moderately increased for all modes of travel. Subgroups exist in which the risk is highly increased.
QUESTIONS 1-7. Choose A, B, C or D. In which text can you find -information about 1. what are the symptoms of DVT? 2. how much risk of DVT is there in the first week after traveling? 3. what is the most important sign of DVT? 4. when did DVT was first linked to air travel? — 5. what are the safe practices to reduce the risk of DYT? 6. which exercises reduce the risk of DVT? — 7. what were the conclusions of the Dutch study on DVT? __
QUESTIONS 8-13. Answer each of the questions, 8-13,”with a word or short phrase from one of the texts. 8. What is the type of skin discolouration seen in DVT patients? 9. What type of clothes reduce the risks of DVT? 10. Which type of flights are more suspected of contributing to the formation of DVT? 11. Name the physical activity which was found to increase the risk of DVT in general? 12. Which type of population was the subject for travel related DVT study? 13. Name the body part/s where tenderness was observed as a symptom of DVT?
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. The risk of flying was similar to the risks of traveling by___________ 15. Recent studies have indicated an increased risk of venous thrombosis after ___________ 16. ___________ of the lower leg, ankle and foot is a symptom of DVT. 17. Several ___________ have shown an association between air travel and the risk of venous thrombosis. 18. ___________in general, was found to increase the risk of venous thrombosis. 19. Venous thrombosis was first linked to air travel in ___________ 20. Some airlines offer ___________ to passengers on how to reduce the risk of DVT.
PART B. Choose the answer (A, B or C) Flowmeter: A flowmeter is an instrument used to measure the flow rate of a liquid or a gas. In healthcare facilities, gas flowmeters are used to deliver oxygen at a controlled rate either directly to patients or through medical devices. Oxygen flowmeters are used on oxygen tanks and oxygen concentrators to measure the amount of oxygen reaching the patient or user. Sometimes bottles are fitted to humidify the oxygen by bubbling it through water. 1. The purpose of bottles that are fitted with flowmeter is to A. humidify the oxygen tanks by bubbling it through water B. humidify the oxygen reaching the patient or user C. dehumidify the gas in the flowmeter
Pulse Oximeters: Non-invasive monitors: The coloured substance in blood, haemoglobin, is carrier of oxygen and the absorption of light by haemoglobin varies with the amount of oxygenation. Two different kinds of light (one visible, one invisible) are directed through the skin from one side of a probe, and the amount transmitted is measured on the other side. The machine converts the ratio of transmission of the two kinds of light into a % oxygenation. Pulse oximeter probes can be mounted on the finger or ear lobe. 2. What does these notes tell us about pulse oximeters? A. levels vary with amount of oxygenation B. converts percent of light into a % oxygenation C. probes can be mounted either on finger or earlobe
Measuring Patient Weight: Measuring patient weight is an important part of monitoring health as well as calculating drug and radiation doses. It is therefore vital that scales continue to operate accurately. They can be used for all ages of patient and therefore vary in the range of weights that are measured. They can be arranged for patients to stand on, or can be set up for weighing wheelchair bound patients. For infants, the patient can be suspended in a sling below the scale or placed in a weighing cot on top of the scale. 3. These notes are reminding staff that the A. importance of precise reading of scales to monitor health of patient B. infants should stand in a weighing cot on top of the scale C. wheelchair bound patients should be suspended in a set up
Breast Examination: Detection of changes in the breast depends on routine medical check-ups, especially by an oncologist, regular breast scanning and mammography, and women’s self-examination. If early detected, a tumor is usually small, and the smaller it is, the less probability of metastases. Early detection considerably improves prognosis in women with breast cancer: Mammography enables detection of breast cancer at least one year ahead of its manifestations. The smallest clinically palpable tumor is about 1cm in size. 4. The purpose of these notes about mammography is to A. help maximise awareness about its efficiency B. give guidance on early detection and prognosis C. decrease probability of metastases
Catheterisation: Regardless of the instrumental examination carried out in the urinary tract, it is obligatory to maintain perfectly sterile conditions, to apply analgesic and sedative drugs in order to alleviate patient’s suffering, and to use gel substances that facilitate the introduction of the instrument into the urinary tract. While introducing instruments into the bladder, it is necessary to remember about overcoming the resistance of the urethral sphincter gently. 5. What must all staff involved in the catheterization process do? A. maintain perfect aseptic conditions B. use non lubricant substances C. inhibit analgesic and sedative drugs
Ophthalmoscopy: Direct ophthalmoscopy is the most common method of examining the eye fundus. It provides a 15x magnified upright image of the retina. Ophthalmoscopy is much easier through a dilated pupil. Tropicamide 1% drops (0.5% for children) are recommended. The pupil mydriasis starts 10 to 20 minutes after installation and lasts for 6-8 hours. There is a small risk of angle closure glaucoma caused by mydriasis in eyes with shallow anterior chambers, particularly in elderly patients. 6. The guidelines establish that the healthcare professional should A. recommend 1% drops of Tropicamide for elderly patients B. recommend 5% drops of Tropicamide for children C. recommend 10% drops of Tropicamide for elderly patients
PART C. TEXT 1. Choose the answer (A, B, C or D) Is ADHD a valid diagnosis in adults?
Paragraph 1: Attention deficit hyperactivity disorder (ADHD) is well established in childhood, with 3.6% of children in the United Kingdom being affected. Most regions have child and adolescent mental health or paediatric services for ADHD. Follow-up studies of children with ADHD find that 15% still have the full diagnosis at 25 years, and a further 50% are in partial remission, with some symptoms associated with clinical and psychosocial impairments persisting.
Paragraph 2: ADHD is a clinical syndrome defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, by high levels of hyperactive, impulsive, and inattentive behaviours in early childhood that persist over time, pervade across situations, and lead to notable impairments. ADHD is thought to result from complex interactions between genetic and environmental factors.
Paragraph 3: Proof of validity. Using the Washington University diagnostic criteria, the National Institute for Health and Clinical Excellence (NICE) reviewed the validity of the system used to diagnose ADHD in children and adults.
Paragraph 4: Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are found to cluster together in both clinical and population samples. Studies in such samples also separate ADHD symptoms from conduct problems and neuro developmental traits. Twin studies show a distinct pattern of genetic and environmental influences on ADHD compared with conduct problems, and overlapping genetic influences between ADHD and neuro developmental disorders such as autism and specific reading difficulties. Disorders that commonly, but not invariably, occur in adults with ADHD include antisocial personality, substance misuse, and depression.
Paragraph 5: Symptoms of ADHD are continuously distributed throughout the population. As with anxiety and depression, most people have symptoms of ADHD at some time. The disorder is diagnosed by the severity and persistence of symptoms, which are associated with high levels of impairment and risk for developing co-occurring disorders. ADHD should not be diagnosed to justify the use of stimulant drugs to enhance performance in the absence of a wider range of impairments- indicating a mental health disorder.
Paragraph 6: ADHD symptoms have been tracked from childhood through adolescence into adult life. They are relatively stable over time with a variable outcome in which around two thirds show persistence of symptoms associated with impairments. Current evidence defines the syndrome as being associated with academic difficulties, impaired family relationships, social difficulties, and conduct problems. Cross sectional and longitudinal follow-up studies of adults with ADHD have reported increased rates of antisocial behaviour, drug misuse, mood and anxiety disorders, unemployment, poor work performance, lower educational performance, traffic violations, crashes, and criminal convictions.
Paragraph 7: Several genetic, environmental, and neurobiological variables distinguish ADHD from non-ADHD cases at group level, but are not sufficiently sensitive or specific to diagnose the syndrome. A family history of ADHD is the strongest predictor-. parents of children with ADHD and off spring of adults with ADHD are at higher risk for the disorder. Heritability is around 76%, and genetic associations, have been identified. Consistently reported associations include structural and functional brain changes, and environmental factors (such as maternal stress during pregnancy and severe early deprivation).
Paragraph 8: The effects of stimulants and atomoxetine on ADHD symptoms in adults are similar to those seen in children. Improvements in ADHD symptoms and measures of global function are greater in most studies than are reported in drug trials of depression. The longest controlled trial of stimulants in adults showed improvements in these response measures over six months. Stimulants may enhance cognitive ability in some people who do not have ADHD, although we are not aware of any placebo-controlled trials of the effects of stimulants on work or study related performance in healthy populations. This should not, however, detract from their specific use to reduce symptoms and associated impairments in adults with ADHD.
Paragraph 9: Psychological treatments in the form of psychoeducation, cognitive behavioural therapy, supportive coaching, or help with organising daily activities are thought to be effective. Further research is needed because the evidence base is not strong enough to recommend the routine use of these treatments in clinical practice. Paragraph 10: Conclusions. ADHD is an established childhood syndrome that often (in around 65% of cases) persists into adult life. NICE guidelines are a milestone in the development of effective clinical services for adults with ADHD. Recognition of ADHD in primary care and referral to secondary or tertiary care specialists will reduce the psychiatric and psychosocial morbidity associated with ADHD in adults.
QUESTIONS Q1. The article reports what proportion of diagnosed children present with ADHD in adulthood? a. Half b. 3.6% c. A quarter d. 15%
Q2. According to the article _ _ a. ADHD is triggered by genetic factors b. ADHD is the result of environmental factors c. both A and B. d. neither A nor B.
Q3. According to the article symptoms _ a. vary across clinical and population samples. b. varies across situational factors. c. need to pervade across time and situations for a diagnosis to be made. d. are not reliably identifiable.
Q4. Which co-occurring disorders does ADHD frequently present with? a. Antisocial personality disorder. b. Substance misuse. c. Depression. d. All of the above.
Q5. According to the article, which one of the following statements about ADHD is FALSE? a. The use of stimulants is justified in the absence of a wider range of impairments. b. Symptoms of ADHD are evenly prevalent throughout the population. c. The criteria for diagnosis measure the severity and persistence of symptoms. d. High levels of impairment and risk for developing co-occurring disorders are related with ADHD.
Q6. Which heading would best describe paragraph 6? a. Symptoms associated with impairments. b. ADHD and outcomes in adulthood. c. Further definition of the syndrome. d. none of the above
Q7. The strongest predictor of ADHD is _ a. Diagnostic and Statistical Manual of Mental Disorders, fourth edition. b. Social and academic impairment. c. Heritability. d. Family environment.
Q8. The effectiveness of atomoxetine on ADHD symptoms is _ a. less than described in drug trials of depression. b. greater when measured over six months. c. reduced in adults with ADHD. d. known to improve measures of global functioning.
PART C. TEXT 2. Choose the answer (A, B, C or D) Risks and Benefits of Hormone Replacement Therapy
Paragraph 1: Several recent large studies have provoked concern amongst both health professionals and the general public regarding the safety of hormone replacement therapy (HRT). This article provides a review of the current literature surrounding the risks and benefits of HRT in postmenopausal women, and how the data can be applied safely in everyday clinical practice.
Paragraph 2: Worldwide, approximately 47 million women will undergo the menopause every year for the next 20 years. The lack of circulating oestrogens which occurs during the transition to menopause presents a variety of symptoms including hot flushes, night sweats, mood disturbance and vaginal atrophy, and these can be distressing in almost 50% of women.
Paragraph 3: For many years, oestrogen alone or in combination with progestogens, otherwise known as hormone replacement therapy (HRT), has been the treatment of choice for control of problematic menopausal symptoms and for the prevention of osteoporosis. However, the use of HRT declined worldwide following the publication of the first data from the Women’s Health Initiative (WHI) trial in 2002.
Paragraph 4: The results led to a surge in media interest surrounding HRT usage, with the revelation that there was an increased risk of breast cancer and, contrary to expectation, coronary heart disease (CHD) in those postmenopausal women taking oestrogen plus progestogen HRT. Following this, both the Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II) and the Million Women Study published results which further reduced enthusiasm for HRT use, showing increased risks of breast cancers and venous thromboembolism (VTE), and the absence of previously suggested cardioprotective effects in HRT users. The resulting fear of CHD and breast cancer in HRT users left many women with menopausal symptoms and few effective treatment options.
Paragraph 5: Continued analysis of data relating to these studies has been aimed at understanding whether or not the risks associated with HRT are, in fact, limited to a subset of women. A recent publication from the International Menopause Society has stated that HRT remains the first-line and most effective treatment for menopausal symptoms. In this article we examine the evidence that has contributed to common perceptions amongst health professionals and women alike, and clarify the balance of risk and benefit to be considered by women using HRT.
Paragraph 6: One of the key messages from the WHI in 2002 was that HRT should not be prescribed to prevent age-related chronic disease, in particular CHD. This was contradictory to previous advice based on observational studies. However, recent subgroup analysis has shown that in healthy individuals using HRT in the early postmenopausal years (age 50-59 years), there was no increased CHD risk and HRT may potentially have a cardioprotective effect.
Paragraph 7: Recent WHI data has suggested that oestrogen-alone HRT in compliant women under 60 years of age delays the progression of atheromatous disease (as assessed by coronary arterial calcification). The Nurses’ Health Study, a large observational study within the USA, demonstrated that the increase in stroke risk appeared to be modest in younger women, with no significant increase if used for less than five years.
Paragraph 8: Hormone replacement therapy is associated with beneficial effects on bone mineral density, prevention of osteoporosis and improvement in osteoarthritic symptoms. The WHI clearly demonstrated that HRT was effective in the prevention of all fractures secondary to osteoporosis. The downturn in HRT prescribing related to the concern regarding vascular and breast cancer risks is expected to cause an increase in fracture risk, and it is predicted that in the USA there will be a possible excess of 243,000 fractures per year in the near future.
Paragraph 9: The WHI results published in 2002 led to a significant decline in patient and clinician confidence in the use of HRT. Further analysis of the data has prompted a re-evaluation of this initial reaction, and recognition that many women may have been ‘denied’ treatment. Now is the time to responsibly restore confidence regarding the benefit of HRT in the treatment of menopausal symptoms when used judiciously. Hormone replacement therapy is undoubtedly effective in the treatment of vasomotor symptoms, and confers protection against osteoporotic fractures.
Paragraph 10: The oncologic risks are relatively well characterised and p9-tients considering HRT should be made aware of these. The cardiovascular risk of HRT in younger women without overt vascular disease is less well defined and further work is required to address this important question. In the interim, decisions regarding HRT use should be made on a case-by-case basis following informed discussion of the balance of risk and benefit. The lowest dose of hormone necessary to alleviate menopausal symptoms should be used, and the prescription reviewed on a regular basis.
QUESTIONS Q1. Which statement is the closest match to the description of the recent studies in Paragraph? a. They demand a prompt review of current HRT practices. b. They have shown that HRT can be used safely in clinical practice. c. They have decreased the confidence of doctors and the public in HRT. d. They have given menopausal women a new confidence to undergo HRT.
Q2. Which statement is the closest match to the description of projected menopause figures in Paragraph 2? a. 47 international women will enter menopause annually for the next 20 years. b. All women are likely to go through menopause if they live long enough. c. 47 million women globally will enter menopause each year for the next 20 years. d. Most women will succumb to menopause if they do not undertake HRT.
Q3. What cause does the article cite for the symptoms of menopause? a. Lack of circulation b. Age c. Low progesterone levels d. Low circulating estrogen levels Q4. What has been the effect of the 2002 WHI study? a. HRT has become less popular. b. HRT has increased in popularity as the treatment of choice for problematic menopause symptoms. c. There has been an increase in combined estrogen and progesterone therapy. d. The women ‘s health initiative has since been established to investigate HRT.
Q5. Why were many women left with menopausal symptoms and no effective treatment? a. They were unable to afford HRT treatments. b. They were concerned about coronary heart disease and breast cancer. c. They were concerned about breast cancer and venous thromboembolism. d. They were concerned about breast cancer and the cardioprotective effects.
Q6. Which of these statements is a TRUE summary of Paragraph S? a. Surveys since WHI have attempted to find out if the WHI results are representative b. Results of past surveys are only valid for a subset of women, whether or not the public is aware of this. c. The present study aims to show that HRT is safer than previously believed. d. Women should ask their doctors to clarify the balance of risks and benefits of HRT
Q7. Which study showed an increased risk of VTE? a. The Nurses’ Health Study b. The Million Women Study c. The Women’s Health Initiative Study d. The WISDOM Study
Q8. Which of the following does the article recommend HRT should NOT be used to treat’? a. Vasomotor symptoms b. Atheromatous disease c. Age-related chronic disease d. Osteoarthritic symptoms
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Read the case notes and complete the writing task which follows Notes Name: Phillip Satchell Age: 73 Marital status: Wife deceased (2007) Family: Two sons in their 40’s in Darwin. First attended community centre: March 2007 Last visit to community centre: Feb 2011 Diagnosis: Multiple sclerosis, Type 2 diabetes, chronic L & R leg ulcers Social/Medical Background: Current: lives alone in public housing in Orange Future: will move to equivalent housing in Maroubra to Î access for MS treatment. Income: aged pension Poor compliance with oral diabetic agents and diabetic diet MS currently stable but frequent relapses 2-3/12 Staphylococcus Aureus infections in leg ulcers; pus ++ Lonely and isolated, but nil mental illness; good relations with sons but rarely see them. They run a pet shop business. Nursing management and progress: Medications: IV antibiotics twice daily and metformin for diabetes three times per day. Twice daily dressings to L & R legs Monitored blood sugar levels, medication compliance and provided education re diabetes. Constantly monitored for signs of MS relapse Discharge plan
Switch to oral antibiotics but continue same diabetic medications and dressings. Please refer to Prince of Wales Diabetic Clinic (medication review + Î education). Via your doctors, facilitate referral to neurologist for MS follow up. Support to link with community services to Î coping and social network. Writing task Using the information in the case notes, write a referral letter to the Community Nurse, Community Health Centre, Maroubra, outlining relevant information and requesting continued community care. In your answer: Expand the relevant notes into complete sentences Do not use note form Use letter format The body of the letter should be approximately 180-200 words.
Sample answer by Lifestyle Training Centre
Community Nurse, Community Health Centre, Maroubra
February 2011
Dear Nurse, Re: Mr Phillip Satchell, aged 73 years.
I am writing to refer Mr Satchell, who requires on going care, particularly for multiple sclerosis, following his relocation to Maroubra. He has been undergoing treatment for MS, Type 2 diabetes, and chronic L & R leg ulcers with us since March 2007.
Though Mr Satchell’s MS is presently stable, it often worsens. He is regularly monitored for signs of MS relapse and now requires finer medical access in Maroubra to treat his condition. With the help of your doctors, kindly refer him to a neurologist for his MS follow up.
Mr Satchell has been suffering from leg ulcers along with Staphylococcus Aureus infections, which happens up two three times a year. Both his legs need to be dressed twice daily. As his medical compliance is poor, he was educated on diabetes and its diet.
Mr Satchell is a widower and his two sons, who live in Darwin, rarely visit him. As he is lonely and isolated, kindly connect him with community services, and help him to increase his social network. He has no mental illness.
Based on the above, please provide Mr Satchell care and assistance on his arrival to Maroubra. His IV antibiotics, twice daily, needs to be switched to oral. He also needs to continue taking metformin for diabetes, three times per day. Kindly refer him to Prince of Wales Diabetic Clinic for medication review and further education. If you have further queries, please do not hesitate to contact me.
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Aging infrastructure poses risks to public safety. What problems can arise from outdated infrastructure, and what measures can governments take to invest in infrastructure renewal and ensure the safety of their citizens?
Sample essay by Lifestyle Training Centre
Antiquated social and economic infrastructure within a nation can undeniably compromise its overall wellbeing, particularly in the context of safety. This essay will expound upon specific instances of these challenges and suggest practical remedies that can be set in motion to bolster them, thereby fostering the upliftment of society and its populace.
Outdated infrastructure can impede a nation in various ways, primarily by constraining its potential for growth if not modernised. This holds true across sectors such as transportation, healthcare, and construction. However, among the multitude of infrastructural aspects, one of the most disregarded necessities in many countries, particularly in developing or underdeveloped nations, is the implementation of road safety protocols and mechanisms. This issue is conspicuous exceptionally in the case of railways, contributing to a myriad of accidents on a daily basis. For instance, over the past year in India alone, it was reported that there were 1,550 railway crossing accidents, resulting in the tragic loss of at least 1,807 lives. This is a substantial and concerning number.
To mitigate the potential threats to a nation arising from faulty or outdated infrastructures, governments should promptly undertake initiatives. Citizens must have access to modernised facilities, especially in critical areas such as medical care and transportation. For instance, addressing railway crossings, notorious for causing injuries, delays, and fatalities, the government should consider constructing overpasses or underpasses. This solution not only eliminates the need for manual gate operators and saves time, but more importantly, prevents numerous accidents and loss of lives. Implementing such improvements is a surefire way to propel a nation forward.
In conclusion, the failure to keep pace with the modernisation of infrastructure within a nation can undoubtedly impede its potential for growth and, most importantly, compromise the safety of its populace. While various areas require attention, prioritising the enhancement of road and transportation infrastructure, especially at railway crossings, would propel a nation forward and ensure the safety of its people.
