TEXT A: An ultrasound scan, also referred to as sonography, uses high frequency sound waves to create an image of some part of the inside of the body, such as the stomach or muscles, by bouncing sound energy off tissue and translating the returning sound information into a visual representation. The word “ultrasound”, in physics, refers to all sound with a frequency humans cannot hear; in diagnostic ultrasound this is usually between 2 and 10 MHz. Higher frequencies provide better quality images, but are more readily absorbed by the skin and other tissue, so they cannot penetrate as deeply as lower frequencies. Lower frequencies can penetrate deeper, but the image quality is inferior. Obstetric ultrasound is performed routinely in most U.S. medical communities at about 20 weeks of gestation. Benefits include accurate dating, placental location, the diagnosis of multiple gestation or congenital abnormalities and the possible detection of maternal health risks.

TEXT B: Abstract: Implementing a obstetric ultrasound training program in rural Africa
Objective: To evaluate the feasibility and sustainability of basic obstetric ultrasound training in rural Africa. Methods: An 8-week training course, led by UK-based sonographers, was supported by training videos and followed by 10 months of remotely supported scanning in Mandimba, Mozambique. Data were collected using an Android tablet and the EpiCollect web application.
Results: The study group included 1744 pregnant women: 804 scanned by trainees under direct supervision and 940 scanned by trainees alone. Ultrasound identified 36 (2.1%) twin pregnancies, 230 (13.2%) breech presentations, 83 (4.8%) transverse presentations, and 22 (1.3%) cases of placenta previa. The detection rates for the above features were similar in the 2 groups. A subgroup of 230 (13.2%) women had a follow-up scan and 62 (3.6%) were referred to a doctor; 21 of these women required cesarean delivery.
Conclusion: Ultrasound training in a rural setting supported remotely is feasible and sustainable. It can help local healthcare workers to screen their prenatal populations for obstetric and neonatal risks, and therefore has the potential to improve outcomes at delivery and provide site specific epidemiologic data that can be used to develop new healthcare provision strategies.

TEXT C: The Role of Obstetric Ultrasound in Low Resource Settings
Poor maternal and child health (MCH) outcomes are a global, yet highly preventable problem. Evidence informs that the developing world accounts for the majority of the maternal mortality burden. Half a million women died of complications related to pregnancy in 2005, half of these in Africa and another third in South East Asia. Infant mortality is closely related and the trend is similar. About 3.1 million babies died before 28 days of age with 99% of these deaths occurring in middle- and low-income countries. Maternal mortality is the health indicator that shows the widest gap between rich and poor, both between and within countries. In Africa the maternal mortality ratio is 620 per 100,000 live births compared to 14 per 100,000 live births in developed countries. Within countries there are also disparities between urban and rural populations, with rural areas suffering worse outcomes. The potential to reduce maternal and neonatal deaths through the use of ultrasound is significant and addresses two of the millennium development goals (MDGs) including (i) MDG 4 which aims to reduce child mortality and (ii) MDG 5 which aims to improve maternal health. Improving the level of obstetric care is critical to address MCH outcomes and to accelerate progress toward achieving MDG 4 and 5 targets.

TEXT D: “Entertainment” Ultrasound Examinations
It has been proposed that natural-appearing 3-D ultrasound images of the fetus could improve parent fetal bonding. Given the recognized importance of maternal-child bonding immediately postpartum, it seems reasonable that extending this bonding experience into the fetal period could be beneficial. However, a psychological benefit of viewing fetal photos has not been proven, and obtaining such images largely remains in the realm of “entertainment”. In some countries, parents are able to enter a photography studio with ultrasound facilities and leave with pictures suitable for framing: no physician involvement is needed for this event. The use of ultrasound for non-diagnostic purposes has been condemned by the American Institute of Ultrasound in Medicine and the American College of Obstetricians and Gynecologists. Concerns that were raised in their policy statements include possible adverse bio-effects of ultrasound energy, the possibility that an examination could give false reassurance to women, and the fact that abnormalities may be detected in settings where personnel are not prepared to discuss and provide follow-up for concerning findings.
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. alternative name for professionals who do ultrasound scan?
2. benefits of obstetric ultrasound scan?
3. benefits of three-dimensional ultrasound images?
4. places which recorded high maternal mortality?
5. who condemned non-diagnostic uses of ultrasound?
6 who conducted the study in rural Africa?
7 differences among countries regarding maternal mortality?

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 is the maximum frequency limit of diagnostic ultrasound?
9. What does ‘MDG’ stand for based on the information given in the texts?
10. How many participants were there in the study conducted in rural Africa?
11. What type of frequencies travel more into human body?
12. Which millennium development goal aim to reduce maternal mortality?
13. What is the alternate term for ultrasound scan?
14. What is the maternal mortality ratio in comparison with live births in developed nations?
15. How many transverse presentations were identified in the study conducted in rural Africa?

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. in a hinterland backdrop, which is assisted remotely is very practical.
17. The adverse bio-effects of ultrasound energy is a major brought up by the American Institute of Ultrasound in Medicine.
18. Advancements in is vital to eliminate the adverse outcomes of MCH globally.
19. can penetrate through skin and provide superior image quality.
20. The significance of is identified as essential, soon after the fetal period.

PART B. For questions 1-6, choose the answer (A, B or C)

1. This extract informs us that multidisciplinary care is
A. essential to tackle the increasing complexness of the residents care needs.
B. enhancing the resident’s quality of life to meet the needs of residents.
C. providing an integrated team approach by addressing the problems.
Multidisciplinary Care: Given the increasing complexity of the resident’s care needs combined with the call for a palliative approach to care delivery suggests that the adoption of a multi-disciplinary team approach to care planning and delivery is required. Multidisciplinary care is the vehicle for providing an integrated team approach to the provision of health care and this occurs when medical, nursing and allied health professionals consider all treatment options, including all of the potential benefits and disadvantages of treatment decisions, personal preferences of the resident and collaboratively develop an individual care plan that best meets the needs of each resident and their family. There is compelling evidence to suggest that a multi-disciplinary approach to care helps to enhance the resident’s quality of life by addressing the problems that are of most concern to the residents are addressed, reduces ambiguity around treatment and the goals of care, ensures that care decisions are based on best evidence-based practice.

2. What is being described in this section of the guidelines?
A. changes in protocols.
B. best practice protocols.
C. exceptions to the protocols.
Protected Health Information: Employees access our office via main entrance or employee entrance. Main entrance is locked after hours and is unlocked each morning at 8:00. The Office Manager has the key to both entrances and is responsible for unlocking main entrance each AM. Employee entrance is accessed only via key. Employees or service personal may gain entrance through the employee entrance by knocking on the door. All patients’ protected health information (PHI) regardless of its form, mechanism of transmission, or storage is to be kept confidential. Only individuals with a business need to know are allowed to view, read, or discuss any part of a patient’s PHI. An employee who violates this confidentiality policy will be subject to sanctions up to immediate termination. All employees are required to verify in writing that they have read and will comply with our policy regarding confidentiality of all forms of PHI. Employees whose job functions require access to our computer system will be given a secure, unique password to access the system.

3. The carcinogenicity potential should be assessed for
A. all medical devices with direct human contact.
B. reviewing the carcinogenicity of novel materials.
C. all medical devices with lasting human contact.
Carcinogenicity: Carcinogenicity potential should be evaluated for devices with permanent contact. This includes devices in contact with breached or compromised surfaces, as well as externally communicating and implanted devices. If novel materials are used to manufacture devices in contact with breached or compromised surfaces, externally communicating devices, or implant devices, we also recommend a review of the carcinogenicity literature. In the absence of experimentally derived carcinogenicity information, structure activity relationship modeling for these materials may be needed regardless of the duration of contact, to better understand the carcinogenicity potential for these materials. Because there are carcinogens that are not genotoxins and carcinogenesis is multifactorial, the assessment of carcinogenicity should not rely solely on genotoxicity information.

4. According to the extract, the best way to address the biocompatibility of a device is through
A. clinical testing
B. clinical studies
C. clinical experience
Clinical experience: Clinical experience should be considered in the overall benefit-risk profile for the device where the totality of the data available for the device may inform whether more testing is needed, or if any testing is needed at all. For example, clinical experience may be useful to mitigate problematic findings in an in vitro biocompatibility. In other cases, testing to address long-term biocompatibility endpoints may not be necessary if the patient’s life expectancy in the intended use population is limited. Generally, clinical studies are not sufficiently sensitive to identify biocompatibility concerns. Clinical or sub-clinical symptoms that result from the presence of a non- biocompatible material may not be identifiable, or may result in symptoms that are indistinguishable from the disease state such that the clinical data may not be informative to the biocompatibility evaluation. For example, blood vessel occlusion at the site of an implanted stent could be indicative of a toxic response to the stent materials or be related to damage to the stent during implantation.

5. Which is not an alternate term for a medical committee?
A. drug and medicine committee.
B. pharmacy and therapeutics committee.
C. medicine and therapeutics committee.
Drugs in Hospital: A hospital exists to provide diagnostic and curative services to patients. Pharmaceuticals are an integral part of patient care. Appropriate use of medicines in the hospital is a multidisciplinary responsibility shared by physicians, nurses, pharmacists, administrators, support personnel, and patients. A medical committee, sometimes called the drug and therapeutics committee, pharmacy and therapeutics committee, or the medicine and therapeutics committee, is responsible for approving policies and procedures and monitoring practices to promote safe and effective medicine use. The pharmacy department, under the direction of a qualified pharmacist, should be responsible for controlling the distribution of medicines and promoting their safe use. This task is challenging because medicines are prescribed by physicians, administered by nurses, and stored throughout the hospital. The control of narcotics is of particular concern in the hospital setting and requires a systematic approach for the prevention and detection of abuse.

6. What point does the extract make about known genotoxins?
A. can assume a positive result for the devices containing genotoxic materials.
B. cannot absolutely negate the negative results for other device components.
C. overall benefit-risk determined by device indication and human exposure.
Genotoxicity: Genotoxicity testing may be waived if chemical characterization of device extracts and literature references indicate that all components have been adequately tested for genotoxicity. Genotoxicity testing may not be informative for devices containing materials already known to be genotoxic assumed to be due to the known genotoxin. Thus, a second genotoxin from another source may be overlooked. If genotoxicity testing is performed, a negative result should be interpreted as a negative for the other device components or interaction products, but does not necessarily negate the risk of the known genotoxin. Chemical characterization may be needed to demonstrate to what extent the genotoxin is released from the device. For known genotoxins, the overall benefit-risk determination will depend on the device indication and human exposure. Genotoxicity testing is requested when the genotoxicity profile has not been adequately established.

PART C. TEXT 1: EYE DAMAGES IN DIVERS Choose (A, B, C or D)

An investigation of the circulation of blood in the eyes of divers has produced the strongest evidence yet that tissue damage is caused by diving is more common and more severe than previously thought. Researchers from Moorefield’s Eye Hospital in London and Maurice Cross of the Diving Diseases Research Centre in Plymouth examined the retinas of 80 divers of varying experience. The researchers found evidence of damage in nearly half the divers. Although the damage tended to increase with diving experience some of the divers developed it within two years of diving. The study is the first evidence of damage to the eye tissue in amateur divers and it suggests for the first time that a career in diving almost inevitably leads to damage of the 26 professional divers studied all had abnormal retinas. None of the divers taking part in the study had visual problems as a result of their damaged retinas but Bird said that he “would not be surprised to find divers whose damage has progressed far enough to affect their vision”.

Evidence has mounted during recent years to show that exposure to pressure during diving subtly damages the central nervous system. Doctors believe that the damage is due to obstruction in the flow of blood through the tissues. People who take up diving as a sport know they are at risk of getting “the bends” or an air embolism, but if they follow the correct procedures the risk is very low. All professional divers know they also run the risk of bone necrosis. About 5 per cent of them develop small dead patches in their bones. Active professional divers have the bones of their thighs and upper arms x-rayed as part of their annual medical examination. Doctors have been concerned that if diving caused dead patches to appear on bones, other tissues may be suffering a similar fate. Their concern increased in the early 2000s, when detailed neurological examinations and tests of the memory and reactions of experienced professional divers suggested that some of them might have slight damage to the brain and spinal cord.

Then, in 2006, nuclear magnetic resonance imaging revealed small areas of damage in the brains of apparently healthy North Sea divers. The following year Ian Calder, a pathologist at the London Hospital in the city’s East End, published the results of a postmortem study of eleven professional divers. Seven of them had areas of damage in the spinal cord that had not been detected while the divers were alive. The samples were too small for researchers in the studies to draw conclusions as to how common such damage might be. The fact that few divers are currently complaining of neurological symptoms does not mean that they will not experience problems later in life. There is a great deal of extra capacity in the nervous system of young people that begins to diminish in middle age. Most people who have dived deeper than 50 meters are still relatively young. Deeper diving did not become common until the mid-1970s when drilling for offshore oil began in the deeper water of the North Sea. Over the same period recreational diving became more popular and the amateur divers began to go deeper.

In order to determine the size of the problem, the researchers needed a method of looking for the damage in a large sample of divers that did not involve surgery. The damage which occurs in the tissue of both the bones and the nerves of divers is similar. Minute areas of tissue had died, probably because they had been starved of blood, suggesting that capillaries that supplied blood to the areas had been blocked. The bone necrosis of divers closely resembles that seen in victims of sickle-cell anemia whose capillaries are temporarily blocked during a sickle-cell “crisis” when their red blood cells become too rigid to pass through. Sickle-cell disease damages the retina which doctors can see using the technique known as retinal angiography. The process involves injecting Fluorescein dye into the blood stream and photographing the back of the eye through the pupil. The technique can provide a detailed photograph of the two vascular systems supplying blood to their retina without causing too much discomfort to the patient.

The researchers used retinal angiography to assess the tissue damage in divers. The abnormalities that they detected in the angiograms of divers were very similar to those seen in sickle-cell disease. There was clear evidence of obstruction to the capillaries. The researchers suggested three mechanisms to explain how diving causes this obstruction. When divers come back to the surface air bubbles sometimes form in their veins and their lungs. If bubbles also form in the arteries, they would block the capillaries. Bubbles forming in the lungs trigger changes in the body’s clotting mechanism which could result in minute clots becoming trapped in the capillaries.
The third suggestion is that the mechanism might also be similar to that of sickle-cell disease. The pressure that divers experience at 30 meters causes their white blood cells to become rigid just as red blood cells do during a sickle-cell crisis. The researchers hope that clues to the cause of the obstruction will come from investigations into the individual differences between divers. Some of the divers studied had relatively little damage even though they had been diving for many years and done a great deal of deep diving. On the other hand, a few inexperienced divers had quite extensive damage.

7. According to the article,
A. low blood pressure can cause eye problems in divers.
B. diving is becoming more and more dangerous.
C. eyes can be severely harmed as a result of diving.
D. many divers experience approximately 50% vision loss.
8. The study suggests that
A. divers should have at least two years of experience..
B. experienced divers can avoid the risk of eye damage.
C. professional divers are more careful than amateur divers.
D. none of the above.
9. Damage to the retina is caused by
A. obstructions to blood circulation.
B. loss of pigment in the epithelium.
C. pressure on the central nervous system.
D. all of the above.
10. Approximately 5 per cent of professional divers
A. develop bone necrosis.
B. have annual bone x-rays.
C. get the ‘bends’.
D. are nervous when diving.
11. All of the following were used by doctors to examine the health of practicing divers except
A. nuclear magnetic resonance imaging.
B. post-mortem examinations.
C. memory tests and reaction tests.
D. neurological examinations.
12. Which of the following statements is true according to the article?
A. Small dead patches always develop in divers’ bones.
B. Brain damage is common among North Sea divers.
C. Neurological problems may not be immediately apparent.
D. Spinal cord damage in divers is easily detected.
13. Which of the following is not true according to the article?
A. Sickle-cell anemia is a common disease among divers.
B. Neurological and bone tissue damage are similar.
C. Tissue damage of diver’s results from blockage of blood.
D. Researchers avoided the use of surgery in their investigations.
14. Retinal angiography
A. involves the injection of fluoroscein dye into the pupil.
B. provides graphic information about blood supply to retinas.
C. causes considerable discomfort to the patient.
D. none of the above.



PART C. TEXT 2: PLUMBISM

Paragraph 1: Plumbism is the technical term for lead poisoning, which represent a diseased condition, produced by the absorption of lead, common among workers in this metal or in its compounds, as among painters, typesetters, etc. Lead is a metal which is toxic to humans when ingested or inhaled. When lead enters the bloodstream, whether the route of entry is the lungs or the gastrointestinal tract, it is distributed to the tissues and organs of the body, including the brain, liver and kidneys. In the long term, lead is stored in the teeth and bones. Although it is excreted gradually (mostly in the urine, but also in feces, sweat, hair and nails), repeated exposure and absorption results in an accumulation of lead in the body. Cumulative doses of lead over time can result in chronic lead poisoning, while acute lead toxicity may be observed in cases of short-term, high-dose exposures.

Paragraph 2: A naturally occurring element, lead may be dispersed by natural processes such as erosion, volcanic eruptions and forest fires. Overwhelmingly, however, hazardous human exposure to lead is due to its release into the environment through industrial processes, and to the widespread use of lead-containing products, most notoriously petrol, paints, and plumbing and building materials. Many everyday household items including adhesives, batteries, ceramics, glassware and children’s toys may also contain lead, particularly if manufactured in the twentieth century. Other items that have traditionally contained lead include bullets and radiation shields. Industrial sources of lead contamination of soil, water and air include mining and smelting of lead and lead- containing ore, car manufacture and combustion of large quantities of fuels such as coal in the generation of electricity. The leading cause of lead poisoning among adults is occupational exposure, particularly for those working in the industries previously mentioned.

Paragraph 3: To alleviate the incidence of environmental exposure due to contact with building materials and other products containing lead, industry guidelines and government legislation have been introduced in many countries: drinking water is no longer prone to lead contamination where alternatives to lead pipes and lead-soldered fittings, roofs and water tanks are required in new houses; maximum allowable lead content in domestic paint is now specified in a growing number of jurisdictions; and the last two decades or so have seen leaded petrol banned in most countries around the world. However, exposure to lead particles is still a significant health risk due to the lingering contamination of soil and dust from past fuel emissions, from continuing industrial exposure, and from contact with older lead-based products still in use.

Paragraph 4: Even small quantities of lead taken into the body are considered hazardous to human health. Adverse systemic effects can extend to the neurological, cardiovascular, gastrointestinal and renal. Damage caused by lead poisoning is known to be irreversible in some cases, such as severe neuro-behavioral impairment resulting from acute intoxication. However, health outcomes are influenced by the timing, duration and amount of exposure (or dosage), and by how much accumulation has occurred. Among the available biological markers of lead dose, blood lead levels provide a more accurate measure if there has been recent exposure to lead, while levels of lead in bone, measuring stored lead, are more accurate indicators of accumulation.

Paragraph 5: Among the most vulnerable to lead exposure and its effects are children under the age of six. Where lead is present in soil, dust, paint or toys, young children are at an increased risk of ingesting lead, as they may touch lead- based or contaminated materials with their fingers and mouths. A child’s body is also more susceptible to lead absorption -it has been estimated that a child’s body can absorb 50% of lead particles on exposure compared with only 10% for an adult’s. The likely health effects for young children are even more dire considering the vulnerability of the developing brain to permanent disadvantage as a result of the neurotoxicity of lead. Intelligence quota (IQ) deficit has been linked to neuro-toxic effects in children with lead blood levels as low as five micrograms per deciliter (5µg/dL). Less research has been conducted on the effects of lead exposure during prenatal development but, because lead is able to cross the blood brain barrier and the placenta, the risk of significant harm to the brain and to the developing fetus is a key concern. One study in Mexico led researchers to conclude that fetal neurodevelopment is adversely affected by lead exposure and particularly so during the first trimester of pregnancy.

Paragraph 6: Studies suggest that chronic lead toxicity in individuals could change behavior and cognitive function and even trigger psychosocial disturbances that contribute to aggressive behavior. One study observed a significant decline in rates of violent crime throughout the 1990s in the United States, a country where the use of leaded petrol was phased out during the 1970s. The researchers hypothesized that this change in crime rate is attributable to a reduction of childhood exposure to lead in the decades prior to the 1990s. Studies like this one, which documents an association between childhood lead exposure and criminal behavior in adults, are supported by findings that some adolescent criminals have blood lead levels quadrupling the average among teenagers. Despite these alarming health effects, the World Health Organization has described lead poisoning as a completely preventable disease.

15. Based on the first paragraph, lead
A. is excreted completely from the human body.
B. accumulates mainly in the lungs and intestines.
C. can be taken into the body through the skin.
D. moves about the body via blood circulation.
16. Which is the most likely source of lead poisoning in humans?
A. Exposure in the workplace.
B. A contaminated water supply.
C. Common household items.
D. Medical imaging procedures.
17. Legislation in many countries has resulted in
A. lead pipes being replaced in all housing.
B. petrol being produced without added lead.
C. the use of leaded paint being made illegal.
D. drinking water being guaranteed lead free.
18. The third paragraph describes
A. measures taken to reduce levels of lead in the environment.
B. the elimination of lead contamination in some countries.
C. twenty years of legislation restricting the use of lead.
D. difficulties in removing lead from construction sites.
19. The effects of lead in a person’s body
A. are not easy to observe.
B. cannot be reversed.
C. sometimes cause death.
D. depend on several factors.
20. The preferred method for measuring lead levels in the body depends on
A. how old the person is.
B. how sick the person is.
C. how intense the exposure was.
D. how long ago the exposure was.
21. Young children are at greater risk of lead poisoning than adults due to
A. the continuing presence of lead in children’s toys.
B. their more frequent exposure to contaminated materials.
C. a higher capacity for lead absorption into their bodies.
D. the increased retention of lead in developing brains.
22. In sixth paragraph research links a fall in incidents of violent crime to
A. environmental changes during the 1990s.
B. reduced exposure to lead in the workplace.
C. behavioral changes from lead poisoning.
D. the widespread use of unleaded petrol.

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Obstetric Ultrasound

PART A: QUESTIONS 1-20

1.         B

2.         A

3.         D

4.         C

5.         D

6.         B

7.         C

8. 10 MHz

9. millennium development goals

10. 1744

11. lower frequencies

12. MDG 5

13. sonography

14. 620 per 100,000

15. 83

16. Ultrasound training

17. concern

18. obstetric care

19. Higher frequencies 20. maternal-child bonding

PART B: QUESTIONS 1-6

1. A essential to tackle the increasing complexness of the residents care needs,

2. B best practice protocols.

3. C all medical devices with lasting human contact.

4. C clinical experience

5. A drug and medicine committee.

6. C overall benefit-risk determined by device indication and human exposure.

PART C: QUESTIONS 7-14

7. C

8. D

9. A

10. A

11. D

12. C

13. B

14. B

PART C: QUESTIONS 15-22

15. D moves about the body via blood circulation.

16. A Exposure in the workplace.

17. D drinking water being guaranteed lead free.

18. A measures taken to reduce levels of lead in the environment.

19. D depend on several factors.

20. D how long ago the exposure was.

21. B their more frequent exposure to contaminated materials.

22. D the widespread use of unleaded petrol.