PART A

TEXT 1:

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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