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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