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NF is a rare but serious bacterial infection that affects the tissue beneath the skin, and surrounding muscles and organs (fascia). It is often called the “flesh-eating disease”, although the bacteria that cause it don’t “eat” flesh – they release toxins that damage nearby tissue. NF is caused by bacteria that gain access to the body, often from only a relatively minor injury, such as a small cut. The conditions gets worse very quickly and can be life threatening if it’s not recognised and treated early on. Around a quarter of patients with NF will die of their infection, but this varies with the severity of the infection and the underlying health of the patient. Quite a few different types of bacteria can cause the disease. However, when they cause infection elsewhere, many are only associated with mild disease. These include group A streptococci, a common cause of tonsillitis, and Clostridium perfringens, a cause of food poisoning. The infection can also be spread from person to person, but this is very rare. About 400 cases of NF are diagnosed in Australian hospitals each year, which is similar to the incidence reported in other countries. Anyone can get necrotising fasciitis, including young and otherwise healthy people. It tends to affect older people and those in poor general health
TEXT 2: Contracting necrotising fasciitis
For a person to develop necrotising fasciitis, several factors relating to themselves, the environment and the presence of certain bacteria all have to be present. •Patient factors that increase their risk if exposed to bacteria include: -impaired immunity -obesity -acne or asthma sufferers -chronic diseases such as diabetes, peripheral vascular disease -a breach of the skin such as: – surgical wounds – accidental wounds – intravenous drug use •Environmental factors that increase risk include: -coral cuts in marine environments -contaminated surgical environment or equipment -contamination of intra venous injected substances •Bacteria that can lead to issues include: -Group A streptococci are commonly found in the throat and on the skin and is the most common bacteria to cause NF -Vibrio bacteria are gram-negative bacteria that grow well in salty environments -Aeromonas are Gram-negative, anaerobic bacteria that occur in aquatic environments – Cleansing wounds, keeping wound covered and good hand hygiene are the main ways to prevent necrotising fasciitis
TEXT 3: Symptoms of necrotising fasciitis
The symptoms of NF develop quickly over hours or days. They may not be obvious at first and can be similar to less serious conditions such as flu, gastroenteritis or cellulitis. It might take 3 or 4 days for symptoms to fully appear. Skin becoming red, hot and blistered, together with the patient reporting intense pain in the infected area are the main early symptoms. Patients with NF report pain that is out of proportion to the changes in skin condition. This is a key warning sign. The pain remains intense until the necrosis kills the nerve endings. Other symptoms include: -oedema, or swelling -crackling under the skin -confusion -dehydration -diarrhoea and vomiting -skin swells and changes colour, turning violet -areas of tissue turn black and start to die After 4 or 5 days, septicaemia is likely to develop causing high temperature, dangerously low blood pressure, and they possible loss of consciousness. Without treatment, necrotizing fasciitis is always fatal.
TEXT 4: Treatment and outlook:
NF needs to be treated in hospital, usually in the intensive care unit The main treatments are: •surgery to remove infected tissue which may repeated several times to ensure all the infected tissue is removed, and occasionally it may be necessary to amputate affected limbs •antibiotics, usually several different types, administered intravenously •supportive treatment of blood pressure, fluid levels and organ functions- People usually need to stay in hospital for several weeks. NF can progress very quickly and lead to serious problems such as blood poisoning (sepsis) and organ failure and even with treatment, it is estimated that 1 or 2 in every 5 cases are fatal. People who survive the infection are sometimes left with long-term disability as a result of amputation or the removal of a lot of infected tissue. They may need further surgery to improve the appearance of the affected area and may need ongoing rehabilitation support to help them adapt to their disability.
Questions 1-7 For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more than once. In which text can you find information about
1 What conditions can develop in a person with blood poisoning? _________________ 2 Ways to stop develop necrotising fasciitis? _________________ 3 The prognosis for people with necrotising fasciitis? _________________ 4 The preponderance of necrotising fasciitis diagnosed in Australian hospitals? __________ 5 Underlying issues that can make person more susceptible to developing NF? __________ 6 Operations that can be done to treat necrotising fasciitis? _________________ 7 The timeframe for symptoms of NF to be full blown? _____________
Questions 8-14. Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
8 What types of lesions may let bacteria invade the body? _________________ 9 What type of pain in the infected area do patients experience? _________________ 10 What type of infection is necrotising fasciitis? _________________ 11 Which bacteria is most likely to lead to NF? _________________ 12 Which part of a hospital are people with necrotising fasciitis usually treated? _________________ 13 What might a person cut themselves on in an ocean that could lead to them getting necrotising fasciitis? 14 For every 5 people with necrotising fasciitis, how many are likely to die, even with treatment_______
Questions 15-20 Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
15 People with necrotising fasciitis say their pain is_________________ to what can be seen in the area. 16 Symptoms of NF might be vague at first and more like common conditions such as_________________or cellulitis. 17 People who have conditions such as: _________________obesity and acne or asthma have a greater chance of developing NF if they are exposed to Group A streptococci bacteria. 18 Often multiple antibiotics are_________________to treat NF. 19 NF is more likely to be a problem for_________________and those in poor general health. 20 NF is commonly known as the_________________
PART B TEXT 1:
Know the Difference: Infiltration vs. Extravasation Intravenous infiltration is one of the most common problems that can occur when fluid infuses into the tissues surrounding the venepuncture site. This sometimes happens when the tip of the catheter slips out of the vein or the catheter passes through the wall of the vein. If you are concerned an IV is infiltrated, standard procedures should be followed by, for example, discontinuing the site and relocating the IV. Know the Difference: Infiltration vs. Extravasation An extravasation occurs when there is accidental infiltration of a vesicant or chemotherapeutic drug into the surrounding intravenous site. Vesicants can cause tissue destruction and / or blistering. Irritants can result in pain at the site and along the vein and may cause inflammation. The treatment for extravasation will vary depending on hospital policy. Question 1) What should you do if you think an IV is infiltrated? a) You should terminate the procedure before trying again b) You should change the catheter c) You should irrigate the surrounding intravenous site
TEXT 2 : Arterial Line Placement Arterial line placement is a common procedure in various critical care settings. Intra-arterial blood pressure measurement is more accurate than measurement by non-invasive means, especially in the critically ill. Intra-arterial blood pressure management permits the rapid recognition of changes that is vital for patients on continuous infusions of vasoactive drugs. Overall, arterial line placement is considered a safe procedure, with a rate of major complications that is below 1%. Arterial Line Placement In both adults and children, the most common site of cannulation is the radial artery, primarily because of the superficial nature of the vessel and the ease with which the site can be maintained. Additional advantages of radial artery cannulation include the consistency of the anatomy and the low rate of complications. Question 2) Why is the radial artery usually chosen for cannulation? a) its low profile anatomy is ideal for primary cannulation b) the site can be maintained during other non-invasive manipulations c) it has a shallow position
TEXT 3: Clinically Important Symptoms of PTSD People with clinically important symptoms of PTSD (Post-Traumatic Stress Disorder) refer to those who are assessed as having PTSD on a validated scale, as indicated by baseline scores above clinical threshold, but who do not necessarily have a diagnosis of PTSD. They are typically referred to in studies that have not used a clinical interview to arrive at a formal diagnosis of PTSD and instead have only used self-report measures of PTSD symptoms. Complex PTSD develops in a subset of people with PTSD. It can arise after exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible. The disorder is characterised by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD are met. Question 3) According to this article, people with PTSD a) have a high score on a validated scale, which includes complex PTSD factors b) have experienced prolonged or repetitive symptoms c) have not been examined by qualified clinicians
TEXT 4 How to Assess a Peripheral Intravenous Cannula: Most patients need at least one peripheral intravenous cannula during their hospital stay for intravenous fluids and medications, blood products or nutrition. Complications are common but they can be prevented or minimised by routine assessment. Explanations to patients should be provided, along with education about the treatment. Ensure the patient knows why the treatment is being given, and encourage them to speak up if there are any problems, such as pain, leaking, swelling, etc. The cannula should not be painful. Pain is an early symptom of phlebitis (inflammation of the vein) and could indicate that the cannula is not working well and should be removed. Involving the patient and their family empowers them to voice their concerns, and prompts nurses to address problems and remove Question 4) According to this article, patients experiencing pain at the cannula site should a) tell someone b) ask for medication to stop leaking and/or swelling c) remove the cannula in order to avoid phlebitis (inflammation of the vein)
TEXT 5. Japan Approves New Cell Therapy Trial for Spinal Cord Injury The Japanese government’s health ministry has given the go-ahead for a trial of human induced stem cells to treat spinal cord injury. The treatment will be tested in a handful of patients who suffered nerve damage in sports or traffic accidents. Researchers at Osaka University plan to recruit adults who have sustained recent nerve damage in sports or traffic accidents. The team’s intervention involves removing differentiated cells from patients and ‘reprogramming’ them into neural cells. Clinicians will then inject about two million of these cells into each patient’s site of injury. The approach has been successfully tested in a monkey, which recovered the ability to walk after paralysis. These tests follow researcher carried out at Kyoto University which used cells to treat Parkinson’s disease Question 5) How many people will be involved in the trial? a) around two million b) as many patients as possible c) less than ten
TEXT 6 Steroid Nasal Sprays and Drops A steroid nasal spray usually works well to clear all the nasal symptoms such as itching or sneezing. It works by reducing inflammation in the nose. A steroid nasal spray also tends to ease eye symptoms although it is not clear how this occurs. However, they can take up to several days to build up to the full effect. Steroid nasal sprays should be used each day over the hay fever season to keep symptoms away. However, once symptoms have gone, the amount of steroid spray can often be reduced to a low maintenance dose each day to keep symptoms manageable. Side-effects or problems with steroid nasal sprays are rare. Question 6) How long can a nasal spray be used? a) While symptoms such as itching or sneezing occur and after b) Before and during the time symptoms occur c) Before, during the time symptoms occur and after
PART C TEXT 1 Heat and ice have been used for many years to treat pain and to reduce swelling, and many people have found them effective. More recently, studies have been done to investigate whether heat and ice really make a difference to healing and the results have been inconclusive. In general, when used sensibly, they are safe treatments which make people feel better and have some effect on pain levels and there are few harms associated with their use.
Heat is an effective and safe treatment for most aches and pains. Heat can be applied in the form of a wheat bag, heat pads, deep heat cream, hot water bottle or heat lamp. Heat causes the blood vessels to open wide (dilate). This brings more blood into the area to stimulate healing of damaged tissues. It has a direct soothing effect and helps to relieve pain and spasm. It can also ease stiffness by making the tissues more supple. If heat is applied to the skin, it should not be hot; gentle warmth will be enough. If excessive heat is applied there is a risk of burns and scalds. A towel can be placed between the heat source and the skin for protection. The skin must be checked at regular intervals.
Heat should not be used on a new injury. It will increase bleeding under the skin around the injured area and may make the problem worse. The exception to this is new-onset low back strains. A lot of the pain in this case is caused by muscle spasm rather than tissue damage, so heat is often helpful. A large-scale study suggested that heat treatment had a small helpful effect on how long pain and other symptoms go on for in short-term back pain. This effect was greater when heat treatment was combined with exercise.
Ice has traditionally been used to treat soft tissue injuries where there is swelling. However, there is a growing body of evidence which suggests that applying ice packs to most injuries does not contribute to recovery and may even prolong recovery. This is related to the fact that reducing the temperature at the site of an injury will delay the body’s immune system response. It is the action of the immune system which will heal the injury. In one study, some people who used ice said that it was helpful for managing pain, although this did not translate into a lower use of painkillers. Many people find that ice is helpful when used to manage pain in the short term. It is unlikely that it will have much of a negative effect in the long term when used in this way.
A review of studies into the effectiveness of ice treatment found that most studies were inconclusive and others showed only a small effect. For example, a review of studies using hot and cold therapy for osteoarthritis of the knee found that ice packs reduced swelling and that ice massage improved muscle strength and range of movement. Heat packs had no effect on pain and swelling. No side-effects were reported to either heat or ice. Another study, which looked at a variety of treatments for neck pain, found that neither heat nor cold was effective.
In the later, or rehabilitation, phase of recovery the aim changes to restoring normal function. At this stage the effects of ice can enhance other treatments, such as exercise, by reducing pain and muscle spasm. This then allows better movement. If you are doing exercises as part of your treatment, it can be useful to apply an ice pack before exercise. This is so that after the ice pack is removed the area will still be a little numb. The exercises can also be done with the ice pack in place. This reduces pain and makes movement around the injury more comfortable, although it can also make the muscles being exercised stiffer.
Ice packs can be made from ice cubes in a plastic bag or wet tea towel. A packet of frozen peas is also ideal and can be used very easily. These mould nicely and can go in and out of the freezer. However, frozen vegetables should not be eaten if they have been thawed and re-frozen. Purpose-made cold packs can also be bought from pharmacies. Take care when using ice and cold packs from a deep freeze, as they can cause ice burns quickly if used without care and proper protection.
Ideally, ice should be applied within 5-10 minutes of injury and for 20-30 minutes. This can be repeated every 2-3 hours or so whilst you are awake for the next 24-48 hours. Do not use ice packs on the left shoulder if you have a heart condition. Do not use ice packs around the front or side of the neck. Both heat and ice can be re-applied after an hour if needed.
Questions 7-14 7) What have studies shown about heat and ice treatments? a) Results show heat and ice really make a difference b) Results are uncertain c) Results have not been investigated d) Results show they can cause harm
8) What do we learn about heat in the second paragraph? a) it increases muscle tissue b) it provokes tissue stiffness c) it changes the behaviour of the blood flow d) it can cause muscle spasm
9) What did the study mentioned in the third paragraph find? a) heat made a problem worse b) heat triggered muscle spasms c) heat increased new-onset low back pain d) heat changed the duration of back pain
10) In the fourth paragraph, what have results shown concerning the use of ice? a) Ice could lengthen the time it takes to improve b) Ice stimulates the body’s immune response c) Using ice therapies reduces the need for painkillers d) Ice causes swelling in soft tissue injuries
11) In the fifth paragraph, the review found that a) heat packs had some small side-effects b) ice massage had a positive effect on some muscles c) heat therapy worked best on cases of osteoarthritis of the knee d) heat treatment was more effective than ice treatment
12) In the sixth paragraph, what positive effect of using ice packs is described? a) they eliminate the need for other treatments b) they make some areas less sensitive to pain c) they move the pain to a different area d) they restore normal functions to injured muscles
13) In the seventh paragraph, what does the word ‘these’ refer to? a) frozen peas b) ice cubes c) wet tea towels d) ice packs
14) How long can ice be applied to an injury? a) for five to ten minutes b) no more than half an hour c) for two to three hours d) for 24 to 48 hours
PART C. TEXT 2:
We consider low-dose aspirin so innocuous that we call it baby aspirin. Though we don’t give it to kids anymore, many adults take it every day (at the recommendation of their doctor) to stave off heart attacks and strokes. But just as we now know not to give babies aspirin, expert opinion has shifted on low-dose aspirin for adults, too. Research in the last few years has made it clear that daily aspirin doesn’t help many of the people taking it. If anything, it might hurt them.
New guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) say that aspirin, and even baby aspirin should no longer be prescribed. These principles are largely in line with how other major organizations have begun to view aspirin. The 2016 European guidelines on cardiovascular disease prevention don’t recommend it as a primary method of heart attacks or stroke prevention, and the U.S. Preventive Services Task Force recommends it only for people in their 50’s with elevated cardiovascular disease risk. For the rest of the population, it wasn’t clear whether there was a worthwhile benefit.
Aspirin is an antiplatelet drug, which means it prevents blood from clotting as easily. Forming a blood clot is, of course, a crucial capability—if you couldn’t clot at all, you’d bleed out from small wounds. But clots that form inside your blood vessels can block flow entirely, causing a heart attack when that blood fails to get back to your heart, or a stroke if the clot cuts off blood to part of your brain. In theory, preventing platelets from doing their job means aspirin should help decrease the risk of both of these problems. And that’s true, but only for a select group of people.
The new guidelines note that aspirin is still very much recommended as a secondary treatment, meaning it definitely helps people who have already had a heart attack or stroke. These people are at a significantly higher risk of having another incident, and aspirin can reduce that risk. What physicians are no longer recommending is its widespread use as a primary treatment, for people who have never had a heart attack or stroke before. In other words, if you’ve never had a heart attack, you probably shouldn’t consider it.
So-called baby aspirin may carry a low dose, but patients shouldn’t assume that taking it is harmless. Taking a drug that makes your blood less likely to clot puts you at risk. If you start bleeding in your intestines or your brain, for instance, your platelets are supposed to come to the rescue. If you’re on daily aspirin, that happens less effectively. A 2009 study in The Lancet found that there was a small, but not insignificant increased risk of major bleeds amongst people taking aspirin regularly. A 2016 study found the same thing, as did a 2018 study in The New England Journal of Medicine. Those same risks exist if you’ve had a heart attack already, but the benefits you get from taking aspirin start to outweigh the potential downsides once you’re in this category. That trade-off is what the ACC/AHA cite in their revised recommendations. Once your elevated risk of having a heart attack goes over 10 percent, the guidelines note, it becomes favourable to prescribe aspirin daily. That goes for anyone between 40 and 70. There’s not enough evidence in people younger than 40, and adults over 70 have such elevated risk of bleeding that most wouldn’t do well on daily aspirin regardless of cardiac risk.
The overarching advice for everyone, though, is to discuss with your doctor whether you should take low-dose aspirin before deciding to do so (or deciding to stop). These guidelines note that there are likely to be exceptions, and your physician should be assessing your personal health risks when deciding whether to prescribe daily aspirin. This isn’t actually all that new. Though research from the mid-20th century suggested aspirin would help everyone, these changes to official recommendations are based on many years of modern studies, which the ACC/AHA note are far better designed and more rigorous than anything we’ve had before. If your doctor scoffs and tells you baby aspirin is a great idea for everyone of a certain age, their knowledge is out of date.
Reversals in expert opinion are, unfortunately, inevitable—it’s the scientific process at work. Think of it less as flip-flopping and more as a correction to a formerly mistaken belief. And please talk to your doctor before you prescribe yourself baby aspirin.
Questions 15-22 15) The first paragraph informs us that a) even babies can have aspirin b) the viewpoint of experts has changed regarding aspirin c) aspirin can cause strokes d) aspirin dosage depends on doctors’ recommendations
16) According to the second paragraph, the European guidelines a) continue to recommend the use of aspirin b) harmonize with the American guidelines c) recommend aspirin for people in their 50’s d) say that aspirin should not be prescribed to babies
17) The third paragraph informs us that aspirin a) inhibits blood clotting b) helps to heal small wounds c) decreases the production of platelets d) slows bleeding by stimulating clotting
18) What does the last word of the fourth paragraph refer to? a) primary treatment b) secondary treatment c) aspirin d) the new guidelines
19) The 2009 study published in ‘The Lancet’ found a) that aspirin could be a factor in intestinal bleeding b) risks that were different to the study in ‘The New England Journal of Medicine’ c) daily doses of aspirin were less effective d) that the risk of major bleeds was relevant
20) The revised recommendations in the fifth paragraph are a) people younger than 40 should take aspirin b) people older than 70 can take aspirin to elevate risks c) it’s a good idea for middle aged people to take aspirin if they have a higher risk of heart attack d) anyone with a high risk of heart attack should take aspirin
21) What do we learn in the sixth paragraph about modern studies? a) they are superior to older studies b) they confirm earlier studies about the use of aspirin c) they quickly become out of date d) they reveal data that doctors don’t accept
22) In the last paragraph, what does the writer infer about expert opinion? a) experts shouldn’t keep changing their opinions b) changes in opinion are unavoidable c) opinions need to be corrected d) some opinions are unscientific
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It helps to remind patients that ADHD is not all bad. ADHD is associated with positive attributes such as being more spontaneous and adventurous. Some studies have indicated that people with ADHD may be better equipped for lateral thinking. It has been suggested that explorers or entrepreneurs are more likely to have ADHD. In addition, GPs can reinforce the importance of developing healthy sleep–wake behaviours, obtaining adequate exercise and good nutrition. These are the building blocks on which other treatment is based. For patients who are taking stimulant medication, it is helpful if the GP continues to monitor their blood pressure, given that stimulant medication may cause elevation. Once a patient has been stabilised on medication for ADHD, the psychiatrist may refer the patient back to the GP for ongoing prescribing in line with state-based guidelines. However, in most states and territories, the GP is not granted permission to alter the dose.
Text B: ADHD: Overview:
Contrary to common belief, ADHD is not just a disorder of childhood. At least 40 to 50% of children with ADHD will continue to meet criteria in adulthood, with ADHD affecting about one in 20 adults. ADHD can be masked by many comorbid disorders that GPs are typically good at recognising such as depression, anxiety and substance use. In patients with underlying ADHD, the attentional, hyperactive or organisational problems pre-date the comorbid disorders and are not episodic as the comorbid disorders may be. GPs are encouraged to ask whether the complaints are of recent onset or longstanding. Collateral history can be helpful for developing a timeline of symptoms (e.g. parent or partner interview). Diagnosis of underlying ADHD in these patients will significantly improve their treatment outcomes, general health and quality of life.
Text C: TABLE 2: Medications for attention deficit hyperactivity disorder and typical dosing
Immediate-release methylphenidate
5 to 10 mg in the morning the first day; add a second dose of 5 to 10 mg at lunch time for a week; then add further increments weekly
Total dose typically varies between 10 mg/day and 60 mg/day Doses of more than 80 mg/day are uncommon (maximum recommended dose in the NICE guidelines is 100 mg/day) 11 Transition to longer-acting formulations can occur after a month
Extended-release methylphenidate
18 or 36 mg/day taken once daily in the morning
Increase in 18 mg increments to a maximum of 72 mg/day Adjust dosage at weekly intervals
Long-acting methylphenidate
20 mg/day taken once daily in the morning
At dose wey in Dose usually would not exceed 60 mg/day
Dexamfetamine
2.5 to 5.0mg in the morning the first day; add a second dose of 2.5 to 5.0mg at lunch time for a week; then add further increments weekly
Total dose typically varies between 5 mg/day and 30 mg/day Doses over 40 mg/day are uncommon (maximum recommended dose in the NICE guidelines is 60 mg/day)11
Lisdexamfetamine
30 mg in the morning the first day; increase up to 70 mg according to response
Dose range typically 30 to 70 mg/ day
Atomoxetine
For those weighing less than 70 kg, start at 0.5 mg/kg taken once daily for three days then increase to 1.2 mg/kg once daily in the morning or as evenly divided doses in the morning and late afternoon/early evening. For those weighing more than 70kg, start at 40 mg/day taken once daily for three days then increase to target dose of 80 mga
Target dose 80 mg/day Maximum dose 100 mg
Text D: Treatment of ADHD
It is very important that the dosage of medication is individually optimised. An analogy may be made
with getting the right pair of glasses – you need the right prescription for your particular presentation with not too much correction and not too little. The optimal dose typically requires careful titration by a psychiatrist with ADHD expertise. Multiple follow-up appointments are usually required to maximise the treatment outcome. It is essential that the benefits of treatment outweigh any negative effects. Common side effects of stimulant medication may include:
• appetite suppression
• insomnia
• palpitations and increased heart rate
• feelings of anxiety
• dry mouth and sweating
In which text can you find information about…
1 different types of ADHD medication? __________
2 possible side effects of medication? ___________
3 conditions which may be present alongside ADHD? _____________
4 a doctor’s control over a patient’s medication? ____________
5 positive perspectives on having ADHD? ___________
6 when patients should take their ADHD medicine? _______________
7 figuring out a patient’s optimal dosage of medication? ________________
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both. Your answers should be correctly spelled.
8 What is the maximum recommended dose of Dexamfetamine?
9 What is typically needed to get the best results from ADHD treatment?
10 How can GP’s collect information about their patient’s collateral history?
11 What causes symptoms such as palpitations and anxiety in some patients?
12 What proportion of children with ADHD will carry symptoms into adulthood?
13 What positive personality traits are sometimes associated with ADHD?
14 Which medication has dose recommendations related to patient weight?
Questions 15-20. Complete each of the sentences, 15-20, with a word or short phrase.
Sleep, exercise and nutrition comprise the (15) _______________of further ADHD treatment.
When diagnosing ADHD, it is important to ask if the issues arose recently or are (16) ____________
It is possible to move to (17) ______after one month of immediate-release methylphenidate.
Signs of ADHD can be disguised by (18) _________________ which GPs are more likely to recognise.
GPs should regularly check the (19) _________________ of patients prescribed stimulant medication.
Establishing the ideal dose of ADHD medication needs (20) ________ by an expert psychiatrist.
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1. the risks of feeding a child via a nasogastric tube? 2. calculating the length of tube that will be required for a patient? 3. when alternative forms of feeding may be more appropriate than nasogastric? 4. who to consult over a patient’s liquid food requirements? 5. the outward appearance of the tubes? 6. knowing when it is safe to go ahead with the use of a tube for feeding? 7. how regularly different kinds of tubes need replacing?
Questions 8-15. Answer each of the questions, 8-15, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
8. What type of tube should you use for patients who need nasogastric feeding for an extended period? 9. What should you apply to a feeding tube to make it easier to insert? 10. What should you use to keep the tube in place temporarily? 11. What equipment should you use initially to aspirate a feeding tube? 12. If initial aspiration of the feeding tube is unsuccessful, how long should you wait before trying again? 13. How should you position a patient during a second attempt to obtain aspirate? 14. If aspirate exceeds pH 5.5, where should you take the patient to confirm the position of the tube? 15. What device allows for the delivery of feeds via the small bowel?
Questions 16-20. Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. Each answer may include words, numbers or both. 16. If a feeding tube isn’t straight when you unwrap it, you should it. 17. Patients are more likely to experience long-term feeding via a tube. 18. If you need to give the patient a standard liquid feed, the tube to use is in size. 19. You must take out the feeding tube at once if the patient is coughing badly or is experiencing 20. If a child is receiving ___________ via a feeding tube, you should replace the feed bottle after four hours.
Text A
Paediatric nasogastric tube use Nasogastric is the most common route for enteral feeding. It is particularly useful in the short term, and when it is necessary to avoid a surgical procedure to insert a gastrostomy device. However, in the long term, gastrostomy feeding may be more suitable. Issues associated with paediatric nasogastric tube feeding include: • The procedure for inserting the tube is traumatic for the majority of children. • The tube ls very noticeable. • Patients are likely to pull out the tube making regular re-insertion necessary. • Aspiration, if the tube is incorrectly placed. • Increased risk of gastro-esophageal reflux with prolonged use. • Damage to the skin on the face.
Text B
Inserting the nasogastric tube All tubes must be radio opaque throughout their length and have externally visible markings. 1. Wide bore: – for short-term use only. – should be changed every seven days. – range of sizes for paediatric use is 6 Fr to 10 Fr. 2. Fine bore: – for long-term use. – should be changed every 30 days. In general, tube sizes of 6 Fr are used for standard feeds, and 7-10 Fr for higher density and fibre feeds. Tubes come in a range of lengths, usually 55cm, 75cm or 85cm. Wash and dry hands thoroughly. Place all the equipment needed on a clean tray. • Find the most appropriate position for the child, depending on age and/or ability to co operate. Older children may be able to sit upright with head support. Younger children may sit on a parent’s lap. Infants may be wrapped in a sheet or blanket. • Check the tube is intact then stretch it to remove any shape retained from being packaged. • Measure from the tip of the nose to the bottom of the ear lobe, then from the ear lobe to xiphisternum. The length of tube can be marked with indelible pen or a note taken of the measurement marks on the tube (for neonates: measure from the nose to ear and then to the halfway point between xiphisternum and umbilicus). • Lubricate the end of the tube using a water-based lubricant. • Gently pass the tube into the child’s nostril, advancing·1along the floor of the nasopharynx to the oropharynx. Ask the child to swallow a little water, or offer a younger child their soother, to assist passage of the tube down the oesophagus. Never advance the tube against resistance. • If the child shows signs of breathlessness or severe coughing, • remove the tube immediately. Lightly secure the tube with tape until the position has been checked
Text C
Text D:
Administering feeds/fluid via a feeding tube Feeds are ordered through a referral to the dietitian. When feeding directly into the small bowel, feeds must be delivered continuously via a feeding pump. The small bowel cannot hold large volumes of feed. Feed bottles must be changed every six hours, or every four hours for expressed breast milk. Under no circumstances should the feed be decanted from the container in which it is sent up from the special feeds unit. All feeds should be monitored and recorded hourly using a fluid balance chart. If oral feeding is appropriate, this must also be recorded. The child should be measured and weighed before feeding commences and then twice weekly. The use of this feeding method should be re-assessed, evaluated and recorded daily.
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Question: 29 The chart below shows the percentage of male and female teachers in six different types of educational setting in the UK in 2010. Summarise the information by selecting and reporting the main features, and make comparisons where relevant.
Model answer by Lifestyle Training Centre
The given bar chart illustrates gender wise percentage distribution of male and female teachers among six various kinds of academic settings in the United Kingdom in the year 2010.
Overall, it is evident that the proportion of men increases noticeably as the academic level rises. Conversely, the percentage of women who are employed in lower academic levels are substantially higher, presenting a stark contrast with men.
In Nursery/Pre-school, around 3% of teachers are male and the remaining 97% females. Likewise, primary school consists of around 7% male tutors and 93% female. In secondary school, around 47 % of teachers are male and the remaining 53% female. Interestingly, at college level, the gender wise distribution of teachers are equal: 50% each.
Private training institute consists of around 53% male and 47% female faculties. At university level, around 70% of the faculties are male, while less than half of the strength, 35%, are female.
The pie charts below compare the proportion of energy capacity in gigawatts (GW) in 2015 with the predictions for 2040.Summarise the information by selecting and reporting the main features, and make comparisons where relevant.
Model answer by Lifestyle Training Centre
The provided two pie charts compare the percentage of energy produced in 2015 with the projected figures for 2040, across various sources including fossil fuels, wind, nuclear, solar, and other renewables. The energy capacity is delineated in gigawatts (GW).
Overall, it is evident that fossil fuels and other renewables remain the major energy contributors throughout the given period. Moreover, solar and wind energy are predicted to increase substantially in the future.
The aggregate capacity in 2015 was 6.688 GW, which is expected to almost double to 11.678 GW by 2040. Fossil fuels covered 64% of the energy capacity, which will undergo a considerable downturn to a mere 44% by the year 2040. Other renewables and nuclear, however, are expected to only experience a marginal decline in energy production: the former from 23% in 2015 to 21% by 2040, and the latter from 6% in 2015 to 5% in 2040.
Conversely, both solar and wind energy are estimated to soar remarkably – solar from 2% in 2015 to a staggering 18% by 2040, and wind energy from 5% in 2015 to 12% by 2040.
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