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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