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10. wide variation in anti-SSA prevalence across different RA populations.
11. Anti SSA
12.CXCL10
13. serum chemokines
14. relation between RF seropositivity & CXCL10 levels
15. Serum Chemokine
16.3-16%
17. Seropositivity
18. Cxcl10 And Cxcl13
19. Anti- Ssa In Aa
20.Cxcl10
Reading test – Part B: Answer Key
1. Steps to improving interpersonal communication with patients. 2 is associated with various anomalies. 3. Can have a detrimental effect on elderly people. 4. Future course of action. 5. The majority of patients remained hospitalized for 5 days or more 6. The majority of the patients were females.
Reading test – Part C: Answer Key Text 1 – Answer key 7 – 14
7. Affects a higher number of men than women. 8. Arthritis in its final stage. 9. Rebuilding of bone is accelerated. 10. Lower back pain, loss of hearing and discomfort. 11. Correct Answer Is: Pagets disease, is both heritable and inheritable. 12. Increase is indicative of the development of the bone at a rapid speed. 13. Should be taken only during the morning. 14. Correct Answer Is: Surgery can get rid of Pagets disease.
PART C. Text 2 – Answer key 15 – 22 15. Benign and malignant 16. When harmful tumors invade and destroy other healthy tissues of the body. 17. Exocrine gland 18. Exocrine gland 19. Cancerous tissues in the pancreas 20. Genetic mutations 21. Pesticides, dyes and chemicals used for refining metals 22. Pulmonary edema and enlargement of the gallbladder
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Text A: Procedural sedation and analgesia for adults in the emergency department Patients in the emergency department often need to undergo painful, distressing or unpleasant diagnostic and therapeutic procedures as part of their care. Various combinations of analgesic, sedative and anaesthetic agents are commonly used for the procedural sedation of adults in the emergency department.
Although combinations of benzodiazepines and opioids have generally been used for procedural sedation, evidence for the use of other sedatives is emerging and is supported by guidelines based on randomised trials and observational studies. Patients in pain should be provided with analgesia before proceeding to more general sedation. The intravenous route is generally the most predictable and reliable method of administration for most agents.
Local factors, including availability, familiarity, and clinical experience will affect drug choice, as will safety, effectiveness, and cost factors. There may also be cost savings associated with providing sedation in the emergency department for procedures that can be performed safely in either the emergency department or the operating theatre.
Text B: Levels of sedation as described by the American Society of Anesthesiologists Non-dissociative sedation • Minimal sedation and analgesia: essentially mild anxiolysis or pain control. Patients respond normally to verbal commands. Example of appropriate use: changing burns dressings • Moderate sedation and analgesia: patients are sleepy but also aroused by voice or light touch. Example of appropriate use: direct current cardioversion • Deep sedation and analgesia: patients require painful stimuli to evoke a purposeful response. Airway or ventilator support may be needed. Example of appropriate use: major joint reduction • General anesthesia: patient has no purposeful response to even repeated painful stimuli. Airway and ventilator support is usually required. Cardiovascular function may also be impaired. Example of appropriate use: not appropriate for general use in the emergency department except during emergency intubation.
Dissociative sedation: Dissociative sedation is described as a trance-like cataleptic state characterised by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Example of appropriate use: fracture reduction.
Text C: Drug administration: General principles International consensus guidelines recommend that minimal sedation – for example, with 50% nitrous oxide oxygen blend – can be administered by a single physician or nurse practitioner with current life support certification anywhere in the emergency department. Guidelines recommend that for moderate and dissociative sedation using intravenous agents, a physician should be present to administer the sedative, in addition to the practitioner carrying out the procedure. For moderate sedation, resuscitation room facilities are recommended, with continuous cardiac and oxygen saturation monitoring, non-invasive blood-pressure monitoring, and consideration of capnography (monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases). During deep sedation, capnography is recommended, and competent personnel should be present to provide cardiopulmonary rescue in terms of advanced airway management and advanced life support. Text D: Drugs used for procedural sedation and analgesia in adults in the emergency department
Class
Drug
Dosage
Advantages
Cautions
Opioids
Fentanyl Morphine Remifentanil
0.5-1 µg/kg over 2 mins 50-100 µg/kg then 0.8-1 mg/h 0.025-0.1 µg/kg/ min
Short acting analgesic; reversal agent (naloxone) available
Reversal agent (naloxone); prolonged analgesic Ultra-short acting; no solid organ involved in metabolic clearance
May cause apnoea, respiratory depression, bradycardia, dysphoria, muscle rigidity, nausea and vomiting Slow onset and peak effect time; less reliable Difficult to use without an infusion pump
Benzodiazepines
Midazolam
Small doses of
Minimal effect on
No analgesic effect; may
0.02-0.03 mg/kg
respiration; reversal agent
cause hypotension
until clinical effect
(flumazenil)
achieved; repeat
dosing of 0.5-1 mg
with total dose ::;
5mg
Volatile agents
Nitrous oxide
50% nitrous oxide – 50% oxygen mixture
Rapid onset and recovery; cardiovascular and respiratory stability
Acute tolerance may develop; specialised equipment needed
Propofol
Propofol
Infusion of 100
Rapid onset; short-acting;
May cause rapidly
µg/kg/min for 3-5
anticonvulsant properties
deepening sedation, airway
min then reduce
obstruction, hypotension
to-50 µg/kg/min
Phencyclidines
Ketamine
0.2-0.5 mg/kg over 2-3 min
Rapid onset; short-acting; potent analgesic even at low doses; cardiovascular stability
Avoid in patients with history of psychosis; may cause nausea and vomiting
May cause pain on injection, nausea, vomiting; caution when using in patients with seizure disorders/epilepsy – may induce seizures
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 the point at which any necessary pain relief should be given? 2 the benefits and drawbacks of specific classes of drugs? 3 financial considerations when making decisions about sedation? 4 typical procedures carried out under various sedation levels? 5 measures to be taken to ensure a patient’s stability under sedation? 6 reference to research into alternative sedative agents? 7 patients’ levels of sensory awareness when sedated?
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 class of drug is traditionally administered together with opioids for the purpose of procedural sedation? 9 What level of sedation is appropriate for changing burns dressings? 10 What is the only emergency department procedure for which it is appropriate to use general anaesthesia? 11 What procedure may be carried out under dissociative sedation? 12 What class of drugs is unsuitable for patients who have a history of psychosis? 13 What opioid drug should be administered using specific equipment? 14 What is the maximum overall dose of Midazolam which should be given?
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 The majority of sedative drugs are administered via the _______________ 16 General anaesthesia is the one form of sedation under which patients may have reduced_______________ 17 Patients under minimal sedation will react if they are given _______________ 18 Care should be taken when administering Etomidate to patients who are likely to have ______________ 19 It may be helpful to use capnography to keep track of patients _____________ levels during moderate sedation. 20 Fentanyl, Morphine and Midozolam each have a ______________ , which is used to cancel out the effects of the drug.
END OF PART A. THIS QUESTION PAPER WILL BE COLLECTED
Part B. In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6, choose answer (A, B or C) which you think fits best according to the text.
1. The manual states that the wheelchair should not be used A. inside buildings. B. without supervision. C. on any uneven surfaces.
Manual extract: Kuschall ultra-light wheelchair: Intended use: The active wheelchair is propelled manually and should only be used for independent or assisted transport of a disabled patient with mobility difficulties. In the absence of an assistant, it should only be operated by patients who are physically and mentally able to do so safely (e.g., to propel themselves, steer, brake, etc.). Even where restricted to indoor use, the wheelchair is only suitable for use on level ground and accessible terrain. This active wheelchair needs to be prescribed and fit to the individual patient’s specific health condition. Any other or incorrect use could lead hazardous situations to arise.
2. These guidelines contain instructions for staff who A. need to screen patients for MRSA. B. are likely to put patients at risk from MRSA. C. intend to treat patients who are infected with MRSA. MRSA Screening guidelines: It may be necessary to screen staff if there is an outbreak of MRSA within a ward or department. Results will normally be available within three days, although occasionally additional tests need to be done in the laboratory. Staff found to have MRSA will be given advice by the Department of Occupational Health regarding treatment. Even minor skin sepsis or skin diseases such as eczema, psoriasis or dermatitis amongst staff can result in widespread dissemination of staphylococci. If a ward has an MRSA problem, staff with any of these conditions (colonised or infected) must contact Occupational Health promptly, so that they can be screened for MRSA carriage. Small cuts and/or abrasions must always be covered with a waterproof plaster. Staff with infected lesions must not have direct contact with patients and must contact Occupational Health.
3. The main point of the notice is that hospital staff A. need to be aware of the relative risks of various bodily fluids. B. should regard all bodily fluids as potentially infectious. C. must review procedures for handling bodily fluids. Infection prevention: Infection control measures are intended to protect patients, hospital workers and others in the healthcare setting. While infection prevention is most commonly associated with preventing HIV transmission, these procedures also guard against other blood borne pathogens, such as hepatitis Band C, syphilis and Chagas disease. They should be considered standard practice since an outbreak of enteric illness can easily occur in a crowded hospital.
Infection prevention depends upon a system of practices in which all blood and bodily fluids, including cerebrospinal fluid, sputum and semen, are considered to be infectious. All such fluids from all people are treated with the same degree of caution, so no judgement is required about the potential infectivity of a particular specimen. Hand washing, the use of barrier protection such as gloves and aprons, the safe handling and disposal of ‘sharps’ and medical waste and proper disinfection, cleaning and sterilisation are all part of creating a safe hospital.
4. What do nursing staff have to do? A. train the patient how to control their condition with the use of an insulin pump B. determine whether the patient is capable of using an insulin pump appropriately C. evaluate the effectiveness of an insulin pump as a long-term means of treatment. Extract from staff guidelines: Insulin pumps: Many patients with diabetes self-medicate using an insulin pump. If you’re caring for a hospitalised patient with an insulin pump, assess their ability to manage self-care while in the hospital. Patients using pump therapy must possess good diabetes self-management skills. They must also have a willingness to monitor their blood glucose frequently and record blood glucose readings, carbohydrate intake, insulin boluses, and exercise. Besides assessing the patient’s physical and mental status, review and record pump-specific information, such as the pump’s make and model. Also assess the type of insulin being delivered and the date when the infusion site was changed last. Assess the patient’s level of consciousness and cognitive status. If the patient doesn’t seem competent to operate the device, notify the healthcare provider and document your findings.
5. The extract states that abnormalities in babies born to mothers who took salbutamol are A. relatively infrequent. B. clearly unrelated to its use. C. caused by a combination of drugs. Extract from a monograph: Salbutamol Sulphate Inhalation Aerosol: Pregnant women: Salbutamol has been in widespread use for many years in humans without apparent ill consequence. However, there are no adequate and well controlled studies in pregnant women and there is little published evidence of its safety in the early stages of human pregnancy. Administration of any drug to pregnant women should only be considered if the anticipated benefits to the expectant woman are greater than any possible risks to the foetus.
During worldwide marketing experience, rare cases of various congenital anomalies, including cleft palate and limb defects, have been reported in the offspring of patients being treated with salbutamol. Some of the mothers were taking multiple medications during their pregnancies. Because no consistent pattern of defects can be discerned, a relationship with salbutamol use cannot be established.
6. What is the purpose of this extract? A. to present the advantages and disadvantages of particular procedures B. to question the effectiveness of certain ways of removing non-viable tissue C. to explain which methods are appropriate for dealing with which types of wounds Extract from a textbook: debridement: Debridement is the removal of non-viable tissue from the wound bed to encourage wound healing. Sharp debridement is a very quick method, but should only be carried out by a competent practitioner, and may not be appropriate for all patients. Autolytic debridement is often used before other methods of debridement. Products that can be used to facilitate autolytic debridement include hydrogels, hydrocolloids, cadexomer iodine and honey. Hydrosurgery systems combine lavage with sharp debridement and provide a safe and effective technique, which can be used in the ward environment. This has been shown to precisely target damaged and necrotic tissue and is associated with a reduced procedure time. Ultrasonic assisted debridement is a relatively painless method of removing non-viable tissue and has been shown to be effective in reducing bacterial burden, with earlier transition to secondary procedures. However, these last two methods are potentially expensive and equipment may not always be available.
PART C In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the answer (A, B, C or D) which you think fits best according to the text. Text 1: Cardiovascular benefits of exercise
Cardiovascular disease (CVD) is the leading cause of death for both men and women in the United States. According to the American Heart Association (AHA), by the year 2030, the prevalence of cardiovascular disease in the USA is expected to increase by 9.9%, and the prevalence of both heart failure and stroke is expected to increase by approximately 25%. Worldwide, it is projected that CVD will be responsible for over 25 million deaths per year by 2025. And yet, although several risk factors are non-modifiable (age, male gender, race, and family history), the majority of contributing factors are amenable to intervention. These include elevated blood pressure, high cholesterol, smoking, obesity, diet and excess stress. Aspirin taken in low doses among high risk groups is also recommended for its cardiovascular benefits.
One modifiable behaviour with major therapeutic implications for CVD is inactivity. Inactive or sedentary behaviour has been associated with numerous health conditions and a review of several studies has confirmed that prolonged total sedentary time (measured objectively via an accelerometer) has a particularly adverse relationship with cardiovascular risk factors, disease, and mortality outcomes. The cardiovascular effects of leisure time physical activity are compelling and well documented. Adequate physical leisure activities like walking, swimming, cycling, or stair climbing done regularly have been shown to reduce type 2 diabetes, some cancers, falls, fractures, and depression. Improvements in physical function and weight management have also been shown, along with increases in cognitive function, quality of life, and life expectancy.
Several occupational studies have shown adequate physical activity in the workplace also provides benefits. Seat-bound bus drivers in London experienced more coronary heart disease than mobile conductors working on the same buses, as do office-based postal workers compared to their colleagues delivering mail on foot. The AHA recommends that all Americans invest in at least 30 minutes a day of physical activity on most days of the week. In the face of such unambiguous evidence, however, most healthy adults, apparently by choice it must be assumed, remain sedentary.
The cardiovascular beneficial effects of regular exercise for patients with a high risk of coronary disease have also been well documented. Leisure time exercise reduced cardiovascular mortality during a 16-year follow-up study of men in the high risk category. In the Honolulu Heart Study, elderly men walking more than 1.5 miles per day similarly reduced their risk of coronary disease. Such people engaging in regular exercise have also demonstrated other CVD benefits including decreased rate of strokes and improvement in erectile dysfunction. There is also evidence of an up to 3-year increase in lifespan in these groups.
Among patients with experience of heart failure, regular physical activity has also been found to help improve angina-free activity, prevent heart attacks, and result in decreased death rates. It also improves physical endurance in patients with peripheral artery disease. Exercise programs carried out under supervision such as cardiac rehabilitation in patients who have undergone percutaneous coronary interventions or heart valve surgery, who are transplantation candidates or recipients, or who have peripheral arterial disease result in significant short- and long-term CVD benefits.
Since data indicate that cardiovascular disease begins early in life, physical interventions such as regular exercise should be started early for optimum effect. The US Department of Health and Human Services for Young People wisely recommends that high school students achieve a minimum target of 60 minutes of daily exercise. This may be best achieved via a mandated curriculum. Subsequent transition from high school to college is associated with a steep decline in physical activity. Provision of convenient and adequate exercise time as well as free or inexpensive college credits for documented workout periods could potentially enhance participation. Time spent on leisure time physical activity decreases further with entry into the workforce. Free health club memberships and paid supervised exercise time could help promote a continuing exercise regimen. Government sponsored subsidies to employers incorporating such exercise programs can help decrease the anticipated future cardiovascular disease burden in this population.
General physicians can play an important role in counselling patients and promoting exercise. Although barriers such as lack of time and patient non-compliance exist, medical reviews support the effectiveness of physician counselling, both in the short term and long term. The good news is that the percentage of adults engaging in exercise regimes on the advice of US physicians has increased from 22.6% to 32.4% in the last decade. The empowerment of physicians, with training sessions and adequate reimbursement for their services, will further increase this percentage and ensure long-term adherence to such programmes. Given that risk factors for CVD are consistent throughout the world, reducing its burden will not only improve the quality of life, but will increase the lifespan for millions of humans worldwide, not to mention saving billions of health-related dollars.
Text 1: Questions 7-14
7. In the first paragraph, what point does the writer make about CVD? A. Measures to treat CVD have failed to contain its spread. B. There is potential for reducing overall incidence of CVD. C. Effective CVD treatment depends on patient co-operation. D. Genetic factors are likely to play a greater role in controlling CVD.
8. In the second paragraph, what does the writer say about inactivity? A. Its role in the development of CVD varies greatly from person to person. B. Its level of risk lies mainly in the overall amount of time spent inactive. C. Its true impact has only become known with advances in technology. D. Its long-term effects are exacerbated by certain medical conditions.
9. The writer mentions London bus drivers in order to A. demonstrate the value of a certain piece of medical advice. B. stress the need for more research into health and safety issues. C. show how important free-time activities may be to particular groups. D. emphasise the importance of working environment to long-term health.
10. The phrase ‘apparently by choice’ in the third paragraph suggests the writer A. believes that health education has failed the public. B. remains unsure of the motivations of certain people. C. thinks that people resent interference with their lifestyles. D. recognises that the rights of individuals take priority in health issues.
11. In the fourth paragraph, what does the writer suggest about taking up regular exercise? A. Its benefits are most dramatic amongst patients with pre-existing conditions. B. It has more significant effects when combined with other behavioural changes. C. Its value in reducing the risks of CVD is restricted to one particular age group. D. It is always possible for a patient to benefit from making such alterations to lifestyle.
12. The writer says ‘short- and long-term CVD benefits’ derive from A. long distance walking. B. better cardiac procedures. C. organised physical activity. D. treatment of arterial diseases.
13. The writer supports official exercise guidelines for US high school students because A. it is likely to have more than just health benefits for them. B. they are rarely self-motivated in terms of physical activity. C. it is improbable they will take up exercise as they get older. D. they will gain the maximum long-term benefits from such exercise.
14. What does the writer suggest about general physicians promoting exercise? A. Patients are more likely to adopt effective methods under their guidance. B. They are generally seen as positive role models by patients. C. There are insufficient incentives for further development. D. It may not be the best use of their time.
PART C. TEXT 2: POWER OF PLACEBO
Ted Kaptchuk is a Professor of Medicine at Harvard Medical School. For the last 15 years, he and fellow researchers have been studying the placebo effect- something that, before the 1990s, was seen simply as a thorn in medicine’s side. To prove a medicine is effective, pharmaceutical companies must show not only that their drug has the desired effects, but that the effects are significantly greater than those of a placebo control group. However, both groups often show healing results. Kaptchuk’s innovative studies were among the first to study the placebo effect in clinical trials and tease apart its separate components. He identified such variables as patients’ reporting bias (a conscious or unconscious desire to please researchers), patients simply responding to doctors’ attention, the different methods of placebo delivery and symptoms subsiding without treatment – the inevitable trajectory of most chronic ailments.
Kaptchuk’s first randomised clinical drug trial involved 270 participants who were hoping to alleviate severe arm pain such as carpal tunnel syndrome or tendonitis. Half the subjects were instructed to take pain-reducing pills while the other half were told they’d be receiving acupuncture treatment. But just two weeks into the trial, about a third of participants – regardless of whether they’d had pills or acupuncture – started to complain of terrible side effects. They reported things like extreme fatigue and nightmarish levels of pain. Curiously though, these side effects were exactly what the researchers had warned patients about before they started treatment. But more astounding was that the majority of participants – in other words the remaining two-thirds – reported real relief, particularly those in the acupuncture group. This seemed amazing, as no-one had ever proved the superior effect of acupuncture over standard painkillers. But Kaptchuk’s team hadn’t proved it either. The ‘acupuncture’ needles were in fact retractable shams that never pierced the skin and the painkillers were actually pills made of corn starch. This study wasn’t aimed at comparing two treatments. It was deliberately designed to compare two fakes.
Kaptchuk’s needle/pill experiment shows that the methods of placebo administration are as important as the administration itself. It’s a valuable insight for any health professional: patients’ feelings and beliefs matter, and the ways physicians present treatments to patients can significantly affect their health. This is the one finding from placebo research that doctors can apply to their practice immediately. Others such as sham acupuncture, pills or other fake interventions are nowhere near ready for clinical application. Using placebo in this way requires deceit, which falls foul of several major pillars of medical ethics, including patient autonomy and informed consent.
Years of considering this problem led Kaptchuk to his next clinical experiment: what if he simply told people they were taking placebos? This time his team compared two groups of 18S sufferers. One group received no treatment. The other patients were told they’d be taking fake, inert drugs (from bottles labelled ‘placebo pills’) and told also, at some length, that placebos often have healing effects. The study’s results shocked the investigators themselves: even patients who knew they were taking placebos described real improvement, reporting twice as much symptom relief as the no-treatment group. It hints at a possible future in which clinicians cajole the mind into healing itself and the body – without the drugs that can be more of a problem than those they purport to solve.
But to really change minds in mainstream medicine, researchers have to show biological evidence – a feat achieved only in the last decade through imaging technology such as positron emission tomography (PET) scans and functional magnetic resonance imaging (MRI). Kaptchuk’s team has shown with these technologies that placebo treatments affect the areas of the brain that modulate pain reception. ‘It’s those advances in “hard science”‘, said one of Kaptchuk’s researchers, ‘that have given placebo research a legitimacy it never enjoyed before’. This new visibility has encouraged not only research funds but also interest from healthcare organisations and pharmaceutical companies. As private hospitals in the US run by healthcare companies increasingly reward doctors for maintaining patients’ health (rather than for the number of procedures they perform), research like Kaptchuk’s becomes increasingly attractive and the funding follows.
Another biological study showed that patients with a certain variation of a gene linked to the release of dopamine were more likely to respond to sham acupuncture than patients with a different variation – findings that could change the way pharmaceutical companies conduct drug trials. Companies spend millions of dollars and often decades testing drugs; every drug must outperform placebos if it is to be marketed. If drug companies could preselect people who have a low predisposition for placebo response, this could seriously reduce the size, cost and duration of clinical trials, bringing cheaper drugs to the market years earlier than before.
Text 2: Questions 15-22 15. The phrase ‘a thorn in medicine’s side’ highlights the way that the placebo effect A. varies from one trial to another. B. affects certain patients more than others. C. increases when researchers begin to study it. D. complicates the process of testing new drugs.
16. In the first paragraph, it’s suggested that part of the placebo effect in trials is due to A. the way health problems often improve naturally. B. researchers unintentionally amplifying small effects. C. patients’ responses sometimes being misinterpreted. D. doctors treating patients in the control group differently.
17. The results of the trial described in the second paragraph suggest that A. surprising findings are often overturned by further studies. B. simulated acupuncture is just as effective as the real thing. C. patients’ expectations may influence their response to treatment. D. it’s easy to underestimate the negative effect of most treatments.
18. According to the writer, what should health professionals learn from Kaptchuk’s studies? A. The use of placebos is justifiable in some settings. B. The more information patients are given the better. C. Patients value clarity and honesty above clinical skill. D. Dealing with patients’ perceptions can improve outcomes. 19. What is suggested about conventional treatments in the fourth paragraph?
A. Patients would sometimes be better off without them. B. They often relieve symptoms without curing the disease. C. They may not work if patients do not know what they are. D. Insufficient attention is given to developing effective ones.
20. What does the phrase ‘This new visibility’ refer to? A. improvements in the design of placebo studies B. the increasing acceptance of placebo research C. innovations in the technology used in placebo studies D. the willingness of placebo researchers to admit mistakes
21. In the fifth paragraph, it is suggested that Kaptchuk’s research may ultimately benefit from A. the financial success of drug companies. B. a change in the way that doctors are paid. C. the increasing number of patients being treated. D. improved monitoring of patients by healthcare providers.
22. According to the final paragraph, it would be advantageous for companies to be able to use genetic testing to A. understand why some patients don’t respond to a particular drug. B. choose participants for trials who will benefit most from them. C. find out which placebos induce the greatest response. D. exclude certain individuals from their drug trials.
END OF READING TEST. THIS BOOKLET WILL BE COLLECTED
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TEXT A Background: In New York City, the incidence of tuberculosis has more than doubled during the past decade. We examined the incidence of tuberculosis and the acquired immune deficiency syndrome (AIDS) and the rate of death from all cause in a very high-risk group – indigent subject who abuse drugs, alcohol, or both. Methods: In 2009 we began to study prospectively a cohort of welfare applicants and recipients 18 to64 years of age who abused or alcohol. The incidence rate of tuberculosis, AIDS, and death for this group were ascertained through vital records and New York City’s tuberculosis and AIDS registries.
TEXT B: RESULTS. The cohort was followed for eight years. Of the 858 subjects; • tuberculosis developed in 47 (5.5 percent), • 84 (9.8 percent) were given a diagnosis of AIDS, and • 183 (21.3 percent) died. The rates of incidence per 100,000 person- years were • 744 for tuberculosis, • 1323 for AIDS, and., • 2842 for death. In this group of welfare clients, • the rate of newly diagnosed tuberculosis was 14.8 times that of the age matched general population of New York City; • the rate of AIDS-was 10.0 times as high; • the death rate was 5.2 times as high. • no significant difference in the rate of new cases of tuberculosis between subjects with positive skin tests and those with negative skin tests at examination in 2009.
TEXT C. Deaths in the cohort: There were 183 deaths in the cohort during follow-up (21.3 percent) of the subjects, a rate of 2842 deaths per 100,000 person-years, 5.2 times that of the age-matched general population. Causes of death – Table 3
TEXT D: Conclusions • Of the 47 subjects with tuberculosis, 21 (44.7 percent) died before the end of 2017; • 12 (57.1 percent) of those who died also had AIDS. • Of 15 persons with both tuberculosis and AIDS, 12 (80.0 percent) died before the end of 2017 and 8 died before completing anti-TB therapy. • Of the 84 study subjects with AIDS, 68 (81.0 percent) died before the end of 2017.
For each question, 1-7, decide which text (A, B, C or D) the information comes from 1. what was the percentage of deaths caused by diabetes in the study group? 2. what was the rate of incidence per 100,000 person per years for tuberculosis? 3. name the city where the study was conducted? 4. how the incidence rates of diseases and death for the study group were ascertained? 5. how many died before the end of 2017 without completing anti-TB therapy? 6. what was the average age of subjects died due to other causes in the study group? 7. how many years the cohort was followed?
Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts. 8. How many of the study subjects with only AIDS died before the end of 2017? 9. In how many of the study subjects wound was the cause of death? 10. What was the age limits of the study subjects? 11. When did the study begin? 12. What was the total number of deaths in the study group? 13. What was the percentage of deaths caused by respiratory arrest in the study group?
Questions 14-20. Complete each of the sentences, 14-20, with a word or short phrase.
14. The study shows that number of the incidence of tuberculosis in New York City has more than _____________during the past decade. 15. In conclusion, 12 of those who died had both AIDS and ____________ 16. In the cohort during follow-up of the subjects, rate of deaths was 5.2 times that of the _______________ general population. 17. In the group of welfare clients, the rate of ________________ was 10.0 times as high. 18. The study was conducted among _____________ who abuse drugs, alcohol, or both. 19. ___________ subjects died suffering from coronary artery disease. 20. There were ______________ subjects in the study group.
PART B
Incubators for Infant: The general principle is that air is processed before it reaches baby. An electric fan draws room air through a bacterial filter which removes dust and bacteria. The filtered air flows over an electric heating element. The filtered and heated air then passes over a water tank where it is moistened. It then flows on to the incubator canopy. The incubator canopy is slightly pressurized. This allows expired carbon dioxide to pass back into the room via the vent holes and most of the air to be re-circulated. It also prevents unfiltered air entering the system. 1. The extract informs us that the incubators A. is likely to circulate most of the air again. B. may not work correctly in close proximity to some other devices. C. prevents filtered air entering the system.
Nebulizers: A nebulizer is a device used to administer medication in the farm of a mist inhaled into the lungs. Nebulizers are commonly used for treatment of cystic fibrosis, asthma and other respiratory diseases. The reason for using a nebulizer for medicine to be administered directly to the lungs is that small aerosol droplets can penetrate into the narrow branches of the lower airways. Large droplets would be absorbed by the mouth cavity, where the clinical effect would be low. The common technical principle for all nebulizers is to use oxygen, compressed air or ultrasonic power as means to break up medical solutions or suspensions into small aerosol droplets. 2. The notice is giving information about A: ways of checking that a nebulizer has been placed correctly1< B. how the use of nebulizer is authorised. C. why nebulizer is being used.
Oxygen Concentrators: Atmospheric air consists of approximately 80% nitrogen and 20% oxygen. An oxygen concentrator uses air as a source of oxygen by separating these two components. It utilizes the property of zeolite granules to selectively absorb nitrogen from compressed air. Atmospheric air is gathered, filtered and raised to a pressure of 20 pounds per square inch (psi) by a compressor. The compressed air is then introduced into one of the canisters containing zeolite granules where nitrogen is selectively absorbed leaving the residual oxygen available for patient use. After about 20 seconds the supply of compressed air is automatically diverted to the second canister where the process is repeated enabling the output of oxygen to continue uninterrupted. 3. What does this manual tell us about zeolite granules? A. leave residual oxygen for patient use B. selectively absorb nitrogen from air C. absorb only nitrogen from compressed air
Arterial blood pressure: The arterial blood pressure (BP) is connected with the force-, which is exerted by the blood volume on the walls of the arteries. The level of BP is dependent on two factors: the heart minute ejection volume and the elasticity of arterial walls. Other factors affecting BP include: the volume’ and viscosity of the blood, body position and emotional state. The BP at the top of pulse wave (due to the constriction of heart ventricles) is called systolic BP, whereas the respective one during the diastole is called diastolic BP. The difference between systolic and diastolic BP is defined as amplitude or pulse pressure. 4. Which is the main factor behind BP level? A. the heart minute rejection volume B. volume and viscosity of the blood C. elasticity of the arterial wall
Basic Life Support: Basic Life Support means saving lives by maintaining airway, supplying ventilation (rescue breathing by blowing air to the victim’s mouth) and supplying circulation (external cardiac massage – chest compressions) performed without additional equipment. It is the first step in cardio pulmonary resuscitation (CPR) that should be initiated by bystanders and continued until qualified help arrives. Next step is Advanced Life Support (ALS), which is performed by medical services. People with cardiac arrest (CA) need immediate CPR. First aid means BLS that is started by witnesses before the emergency service arrival and is the key action in achieving patient survival. 5. What does this manual tell us about cardio-pulmonary resuscitatio? A. should be initiated by bystanders B. should be initiated immediately only for cardiac arrest C. should be performed by medical services
Types of surgical threads: Materials, which the threads are made of, are divided into absorbable and non- absorbable ones or natural and synthetic sutures. Non-absorbable sutures are applied on the skin and in septic wounds. Absorbable threads, depending on their structure are divided into monofilament, polifilament, braided, plaits, coated and uncoated ones. Time of their absorbing is varied and depends on material properties; it can take from 14 days to 6 months. Absorbing progresses due to enzymatic disintegration and hydrolysis. 6. What does this extract from a handbook tell us about absorbable threads? A. absorbing progresses due to enzymatic integration and hydrolysis7 B. absorbing time is varied and depends on material properties C. are divided into monofilament, polifilament, braided; plaits and uncoated ones
PART C TEXT 1.
Targeting two important risk factors for cardiovascular disease and other major risk factors that can be lowered by modification, treatment or control
Paragraph 1: (ARA) – It’s well known that the prevalence of diabetes is on the rise. According to the Centers for Disease Control and Prevention (CDC), about 23.6 million, or nearly 8 percent of people in the United States, have diabetes, and 1.6 million new cases are diagnosed each year in people aged 20 and older. Type 2 diabetes is the most common form, accounting for about 90 to 95 percent of those diagnosed, and occurs when the body either does not produce enough insulin or does not respond to insulin.
Paragraph 2: But something that many people may not know is that in addition to having diabetes, 70 percent of adult with type 2 diabetes also have high LDL cholesterol (LDL-C), the “bad” cholesterol that can cause build-up in the arteries, greatly increasing their risk for cardiovascular disease. Cholesterol is needed for the body to function normally, but when there is too much LDL-C in the bloodstream, it is deposited in arteries, including those of the heart, which can limit blood flow and lead to heart disease.
Paragraph 3: The American Diabetes Association (ADA) and the American College of Cardiology (ACC) emphasize that it is critical to control both cholesterol and blood sugar levels. The ADA recommends that patients with type 2 diabetes aim for an A1C level which reflects your average blood sugar level for the past two to three months, of less than 7 percent. The National Cholesterol Education Program (NCEP) ATP 111 recommends that patients with type 2 diabetes target an LDL-C goal of less than 100 mg/dL.
Paragraph 4: Treating these two diseases can take a combination of efforts, including a healthy diet and increased exercise. Medications are also sometimes needed. While there are many drugs approved by the U.S. Food and Drug Administration (FDA) to treat type 2 diabetes and others available to lower LDL-C, a drug called Welchol (colesevelam HCI) is the first and only medication approved as an adjunct to diet and exercise to reduce both A1C in adults with type 2 diabetes and LDL-C in adults with elevated cholesterol.t Welchol addresses both of these chronic health conditions with one medication and offers the convenience of two formulations, Welchol tablets and Welchol for Oral Suspension. Welchol can be taken alone or with other cholesterol lowering medications known as statins and can be added to other anti-diabetic medications (metformin, sulfonylureas, or insulin).
Paragraph 5: “For patients with type 2 diabetes and high LDL cholesterol, it is important to manage both conditions,” said Yehuda Handelsman, MD, FACP, FACE, Medical Director of the Metabolic Institute of America in Tarzana, Calif. “Welchol reduces these two risk factors for cardiovascular disease in adults with type 2 diabetes by significantly lowering A1C and LDL-C or ‘bad’ cholesterol, providing a unique therapeutic option.” It is important to note that the affect of Welchol on cardiovascular morbidity and mortality has not been determined.
Paragraph 6: What are the major uncontrollable risk factors for coronary heart disease? The American Heart Association has identified several risk factors for coronary heart disease. Some of them can be modified, treated or controlled, and some can’t. The more risk factors a person has, the greater the chance that he or she will develop heart disease. Also, the greater the level of each risk factor, the greater the risk. For example, a person with a total cholesterol of 300 mg/dL has a greater risk than someone with a total cholesterol of 240 mg/dL, even though all people with a total cholesterol of 240 or higher are considered high risk.
Paragraph 7: Increasing age – About 82% of people who die of coronary heart disease are 65 or older. Male sex (gender) – The lifetime risk of developing CHD after age 40 is 49% for men and 32% for women. The incidence of CHD in women lags behind men I years for total CHD and by 20 years for more serious clinical events such as sudden death.
Paragraph 8: Heredity (including Race)- Children of parents with heart disease are more likely to develop it themselves. African Americans have more severe high blood pressure than Caucasians and a higher risk of heart disease. Heart· disease is also higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans. This is partly due to higher rates of obesity and diabetes. Most people with a strong family history of heart disease have one or more other risk factors. Just as you can’t control your age, sex and race, you can’t control your family history. Therefore, it’s even more important to treat and control any other risk factors you have.
Paragraph 9: Other major risk factors that can be lowered by modification, treatment or control. Tobacco smoke – Smokers’ risk of developing CHD is two to four times that nonsmokers. Smokers who have a heart attack are more likely to die and die suddenly (within an hour) than nonsmokers. Cigarette smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. People who smoke cigars or pipes seem to have a higher risk of death from coronary heart disease (and possibly stroke), but their risk isn’t as great as cigarette smokers’. Constant exposure to other people’s smoke – called environmental tobacco smoke, secondhand smoke or passive smoking – increases the risk of heart disease even for nonsmokers.
Paragraph 10: High blood cholesterol levels – The risk of coronary heart disease rises as blood cholesterol levels increase. When other risk factors (such as high blood pressure and tobacco smoke) are present, this risk increases even more. A person’s cholesterol level is also affected by age, sex, heredity and diet. High blood pressure – High blood pressure increases the heart’s workload, causing the heart to enlarge and weaken over time. It also increases the risk of stroke, heart attack, kidney failure and heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol levels or diabetes, the risk of heart attack or stroke increases several times.
Paragraph 11: Physical inactivity-An inactive lifestyle is a risk factor for coronary heart disease. Regular, moderate-to-vigorous physical activity is important in preventing heart and blood vessel disease. Obesity and overweight – People who have excess body fat – especially if a lot of it is in the waist area – are more likely to develop heart disease and stroke even if they have no other risk factors. Excess weight increases the strain on the heart, raises blood pressure and blood cholesterol and triglyceride levels, and lowers HDL (good) cholesterol levels. It can also make diabetes more likely to develop. Many obese and overweight people have difficulty losing weight. If you can lose as little as 10 to 20 pounds, you can help lower your heart disease risk.
Paragraph 12: Diabetes mellitus – Diabetes seriously increases the risk of developing cardiovascular disease. Even when glucose levels are under control, diabetes greatly increases the risk of heart disease and stroke. From two-thirds to three-quarters people with diabetes die of some form of heart or blood vessel disease.
Paragraph 13: What other factors contribute to heart disease risk? Stress – Individual response to stress may be a contributing factor. Some scientists have noted a relationship between coronary heart disease risk and stress in a person’s life, their health behaviors and socioeconomic status. These factors may affect established risk factors. For example, people under stress may overeat, start smoking or smoke more than they otherwise would.
Paragraph 14: Excessive alcohol intake – Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and other diseases, and produce irregular heartbeats. It also contributes to obesity, alcoholism, suicide and accidents. The risk of heart disease in people who drink moderate amounts of alcohol (an average of one drink for women or two drinks for men per day) is lower than in nondrinkers. One drink is defined as 1-1/2 fluid ounces (fl oz) of 80-proof spirits (such as bourbon, Scotch, vodka, gin, etc.), 1 fl oz of 100- proof spirits, 4 fl oz of wine, or 12 fl oz of beer. It’s not recommended that nondrinkers start using alcohol or that drinkers increase their intake.
Q1. According to paragraph 1 of the article states that a. Diabetes has stabilised b. 1.6 million people aged 20 and older have diabetes c. Type 2 diabetes is the most common d. Type 2 diabetes occurs when there is an over-production of insulin Q2. In addition to having diabetes a. 30% of adult with Type 2 diabetes do not have high counts of low-density lipids b. 70% of adults with Type 2 diabetes do have high counts of low-density lipids c. Too many LDLs in the bloodstream go straight to the heart d. LDLs in the bloodstream cannot hinder blood flow Q3. According to the ADA and the ACC a. Both blood sugar levels and cholesterol levels need to be controlled if diabetes is avoided b. Blood sugar levels need to be controlled if diabetes is to be avoided c. ACA believes less than7% average blood sugar level over a one-month period indicates diabetes risk d. The NCEP does not recommend Type 2 diabetics aim for less than 100 mg/dL of low-density lipids Q4. Welchol, a drug to lower the level of LDLs in the blood a. has not been approved by the U.S. FDA b. Welchol must be taken with other statins c. Welchol should not be added to medications such as metformin, sulfonylureas or insulin. d. Welchol needs to be taken together with a healthy diet and an exercise program to reduce A1C in Type 2 diabetics and LDL-C in adults with elevated cholesterol levels. Q5. Welchol’s effect on cardiovascular morbidity and mortality… a. is supported by the evidence b. has not been positively established c. has been positively established d. none of the above Q6. Some risk factors can be controlled, or lowered; some cannot be controlled: such as advancing age, one’s gender, and one’s genetic inheritance. However, there are some major risk factors that can be lowered by modifying one’s lifestyle – or by medical intervention. Risk factors such as—– a. high blood pressure b. high cholesterol levels c. obesity d. all of the above Q7. The article states that stress a. causes overeating and/or habitual smoking b. does not interact with lifestyle and socioeconomic status c. depends on how one reacts to it d. may depend on how one reacts to it Q8. Alcohol contributes to heart failure and strokes; a. if you drink very less amount b. moderate alcohol intake leads to less risk of heart disease c. but not contribute to high triglycerides d. is not a factor in developing cancer
PART C. TEXT 2. FLUORIDE
Paragraph 1: Globalization has provoked changes in many facets of human life, particularly in diet. Trends in the development of dental caries in population have traditionally followed developmental patterns where, as economies grow and populations have access to a wider variety of food products as a result of more income and trade, the rate of tooth decay begins to increase. As countries become wealthier, there is a trend to greater preference for a more “western” diet, high m carbohydrates and refined sugars. Rapid globalization of many economies has accelerated this process. These dietaries have a substantial impact on diseases such as diabetes and dental caries.
Paragraph 2: The cariogenic potential of diet emerges in areas where fluoride supplementation is inadequate. Dental caries is a global health problem and has a significant negative impact on quality of life, economic productivity, adult and children’s general health and development. Untreated dental caries in pre-school children is associated with poorer quality of life, pain and discomfort, and difficulties in ingesting food that can result in failure to gain weight and impaired cognitive development. Since low-income countries cannot afford dental restorative treatment and in general the poor are most vulnerable to the impacts of illness, they should be afforded a greater degree of protection.
Paragraph 3: By WHO estimates, one third of the world’s population have inadequate access to needed medicines primarily because they cannot afford them. Despite the inclusion of sodium fluoride in the World Health Organization’s Essential Medicines Model List, the global availability and accessibility of fluoride for the prevention of dental caries remains a global problem. The optimal use of fluoride is an essential and basic public health strategy in the prevention and control of dental caries, the most common non communicable disease on the planet. Although a whole range of effective fluoride vehicles are available for fluoride use (drinking water, salt, milk, varnish, etc.), the most widely used method for maintaining a constant low level of fluoride in the oral environment is fluoride toothpaste.
Paragraph 4: More recently, the decline in dental caries amongst school children in Nepal has been attributed to improved access to affordable fluoride toothpaste. For many low-income nations, fluoride toothpaste is probably the only realistic population strategy for the control and prevention of dental caries since cheaper alternatives such as water or salt fluoridation are not feasible due to poor infrastructure and limited financial and technological resources. The use of topical fluoride e.g., in the form of varnish or gels for dental caries prevention is similarly impractical since it relies on repeated applications of fluoride by trained personnel on an individual basis and therefore in terms of cost cannot be considered as part of a population based preventive strategy.
Paragraph 5: The use of fluoride toothpaste is largely dependent upon its socio-cultural integration in personal oral hygiene habits, availability and the ability of individuals to purchase and use it on a regular basis. The price of fluoride toothpaste is believed to be too high in some developing countries and this might impede equitable access. In a survey conducted at a hospital dental clinic in Lagos, Nigeria 32.5% of the respondents reported that the cost of toothpaste influenced their choice of brands and 54% also reported that the taste of toothpastes influenced their choice.
Paragraph 6: Taxes and tariffs on fluoride toothpaste can also significantly contribute to high prices, lower demand and inequity since they target the poor. Toothpastes are u; classified as a’ cosmetic product and as such often highly taxed by governments. For example, various taxes such as excise tax, VAT, local taxes as well as taxation on the ingredients and packaging contribute to 25% of the retail cost of toothpaste in Ne and India, and 50% of the retail price in Burkina Faso. WHO continues to recommend the removal taxes and tariffs on fluoride toothpastes. Any lost revenue can be rest by higher taxes on sugar and high sugar containing foods, which are common risk factors for dental caries, coronary heart disease, diabetes and obesity.
Paragraph 7: The production of toothpaste within a country has the potential to make fluoride toothpaste more affordable than imported products. In Nepal, fluoride toothpaste was limited to expensive imported products. However, due to successful advocacy locally manufactured fluoride toothpaste, the least expensive locally manufactured fluoride toothpaste is now 170 times less costly than the most expensive imported Philippines, local manufacturers are able to satisfy consumer preferences and compete against multinationals by discounting the price of toothpaste by as much as 55% against global brands; and typically receive a 40% profit margin compared to 70% for multinational producers.
Paragraph 8: In view of the current extremely inequitable use of fluoride throughout countries and regions, all efforts to make fluoride and fluoride toothpaste affordable and accessible must be intensified. As a first step to addressing the issue of affordability of fluoride toothpaste in the poorer countries in-depth country studies should be undertaken to analyze the price of toothpaste in the context of the country economies. Q1. Which of the following would be the most appropriate heading for the paragraph 1?
a. High sugar intake and increasing tooth decay b. Globalisation, dietary changes and declining dental health c. Dietary changes in developing nations d. Negative health effects of a western diet Q2. Which of the following is not mentioned as a negative effect of untreated dental caries in pre-school children? a. Decreased mental alertness b. Troubling chewing and swallowing food c. Lower life quality d. Reduced physical development Q3. According to paragraph 3, which of the following statement is correct? a. Dental caries is the most contagious disease on earth. b. Fluoride in drinking water is effective but rarely used c. Fluoride is too expensive for a large proportion of the global population. d. Fluoride toothpaste is widely used by 2/3 of the world’s population. Q4. Fluoride toothpaste is considered the most effective strategy to reduce dental caries in low-income countries because___ a. it is the most affordable. b. topical fluoride is unavailable. c. it does not require expensive infrastructure or training. d. it was effective in Nepal. Q5. Which of the following is closest in meaning to the word impede? a. stop b. prevent c. hinder d. postpone Q6. Regarding the issue of taxation in paragraph 6 which of the following statements is most correct? a. Income tax rates are higher in Burkina Faso than India or Nepal. b. WHO recommends that tax on toothpaste be reduced. c. Governments would like to reduce tax on toothpastes but can’t as it is classified as a cosmetic. d. WHO suggests taxing products with a high sugar content instead of toothpastes. Q7. Which of the following is closest in meaning to the _word advocacy? a. marketing b. demand c. development d. support Q8. Statistics in paragraph 7 indicate that…. a. local products can’t compete with global products and make a profit at the same time.” b. Philippine produced toothpaste is profitable while being less than half the price of global brands. c. in Nepal, fluoride toothpaste is limited to imported products which are very expensive d. toothpaste produced in the Philippines has a higher profit margin than internationally produced toothpaste.
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Would you like to undergo training for OET, PTE, IELTS, Duolingo, Phonetics, or Spoken English with us? Kindly contact us now!
We hope this information has been valuable to you. If so, please consider a monetary donation to Lifestyle Training Centre via UPI. Your support is greatly appreciated.
Would you like to undergo training for OET, PTE, IELTS, Duolingo, Phonetics, or Spoken English with us? Kindly contact us now!
