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Reading Part B Tamiflu and ADHD

Reading Sub-test B
Time allowed : 45 minutes
There are two reading passages in this test. After each passage you will find 10 questions or
unfinished statements about the passage, each with four suggested answers or ways of finishing.
You must choose the one which you think fits best, i.e., the best answer. For each question, 1-20,
indicate on your answer sheet the letter A, B, C or D against the number of the question.
Answer all questions. Marks will not be deducted for incorrect answers.
You must complete your answer sheet within the 45 minutes allowed for this sub-test.

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Reading Part B Tamiflu and ADHD

Test 1

Title: Does Tamiflu really work?

Paragraph 1
The British Medical Journal (BMJ) was dominated in 2009 by a cluster of articles on oseltamivir
(Tamiflu) Between them the articles conclude that the evidence that oseltamivir reduces
complications in otherwise healthy people with pandemic influenza is now uncertain and that we
need a radical change in the rules on access to trial data.
Paragraph 2
The use of meta-analysis is governed by the Cochrane review protocol. Cochrane Reviews
investigate the effects of interventions for prevention, treatment and rehabilitation in a
healthcare setting. They are designed to facilitate the choices that doctors, patients, policy
makers and others face in health care. Most Cochrane Reviews are based on randomized
controlled trials, but other types of evidence may also be taken into account, if appropriate.
Paragraph 3
If the data collected in a review are of sufficient quality and similar enough, they are
summarised statistically in a meta-analysis, which generally provides a better overall estimate of
a clinical effect than the results from individual studies. Reviews aim to be relatively easy to
understand for non-experts (although a certain amount of technical detail is always necessary).
To achieve this, Cochrane Review Groups like to work with "consumers", for example patients,
who also contribute by pointing out issues that are important for people receiving certain
interventions. Additionally, the Cochrane Library contains glossaries to explain technical terms
Paragraph 4
Briefly, in updating their Cochrane review, published in late 2009. Tom Jefferson and colleagues
failed to verify claims, based on an analysis of 10 drug company trials, that oseltamivir reduced
the risk of complications in healthy adults with influenza. These claims have formed a key part
of decisions to stockpile the drug and make it widely available.
Paragraph 5
Only after questions were put by the BMJ and Channel 4 News has the manufacturer Roche
committed to making "full study reports" available on a password protected site. Some
questions remain about who did what in the Roche trials, how patients were recruited, and why
some neuropsychiatric adverse events were not reported. A response from Roche was
published in the BMJ letters pages and their full point by point response is published online.

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Reading Part B Tamiflu and ADHD

Paragraph 6
Should the BMJ be publishing the Cochrane review given that a more complete analysis of the
evidence may be possible in the next few months? Yes, because Cochrane reviews are by their
nature interim rather than definitive. They exist in the present tense, always to be superseded
by the next update. They are based on the best information available to the reviewers at the
time they complete their review. The Cochrane reviewers have told the BMJ that they will
update their review to incorporate eight unpublished Roche trials when they are provided with
individual patient data.
Paragraph 7
Where does this leave oseltamivir, on which governments around the world have spent billions
of pounds? The papers in last years journal relate only to its use in healthy adults with influenza.
But they say nothing about its use in patients judged to be at high risk of complications
pregnant women, children under 5, and those with underlying medical conditions; and
uncertainty over its role in reducing complications in healthy adults still leaves it as a useful drug
for reducing the duration of symptoms. However, as Peter Doshi points out on this outcome it
has yet to be compared in head to head trials with non-steroidal inflammatory drugs or
paracetamol. And given the drugs known side effects, the risk-benefit profile shifts considerably
if we are talking only in terms of symptom relief.
Paragraph 8
We dont know yet whether this episode will turn out to be a decisive battle or merely a skirmish
in the fight for greater transparency in drug evaluation. But it is a legitimate scientific concern
that data used to support important health policy strategies are held only by a commercial
organisation and have not been subject to full external scrutiny and review. It cant be right that
the public should have to rely on detective work by academics and journalists to patch together
the evidence for such a widely prescribed drug. Individual patient data from all trials of drugs
should be readily available for scientific scrutiny.

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Reading Part B Tamiflu and ADHD

Questions: Tamiflu

1 A cluster of articles on oseltamivir in the British Medical Journal conclude ......

A
B
C
D

complication are reduced in healthy people by oseltamivir

the efficacy of Tamiflu in now in doubt
complications from pandemic influenza are currently uncertain
a series of articles supporting Tamiflu

2 Cochrane Reviews are designed to ......

A
B
C
D

set randomized controlled trials to specific vaues

compile literature meta-analysis
peer review articles
influence doctors choice of prescription

3 According to the article, which one of the following statements about Tamiflu is FALSE?
A
B
C
D

The use of randomized controls is suspect

The efficacy of Tamiflu is certain
Oseltamivir induces complications in healthy people
Cochrane reviews are useful when examining the efficacy of Tamiflu

4 According to the article, Cochrane Review Groups ...

A
B
C
D

like to work for "consumers".

are being overhauled.
use language suitable for expert to expert communication.
evaluate a clinical effect better than individual studies.

5 Which would make the best heading for paragraph 4?

A
B
C
D

Analysis of 10 drug company trials

The stockpiling of Oseltamivir
Risk of complications in healthy adults
Tamiflu claims fail verification

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Reading Part B Tamiflu and ADHD

6 According to the article, which one of the following statements about Roche is TRUE?
A
B
C
D

Full study reports were made freely available on the internet

Patients were recruited through a double blind trial
The identities and roles of researcher in the Roche trials are not fully accounted for
Not all neuropsychiatric adverse events were reported

7 Cochrane reviews should ..

A
B
C
D

use a more complete analysis

not be published until final data is available
be considered interim rather than definitive advice
be superseded by a more reliable method of reporting results

8 Which would make the best heading for paragraph 7?

A
B
C
D

Risk-benefit profile of Tamiflu

Studies limited to healthy adults
High risk of complications
Oseltamivir only for high risk patients

9 Which one of the following is given as THE LEAST CERTAIN application of oseltamivir?
A
B
C
D

All of the below

Healthy adults with influenza
Patients judged to be at high risk of complications
In terms of symptom relief

10 From the article, it can be inferred that ...

A
B
C
D

Ressearch on Tamiflu needs to be re-evaluated and more transparent

There is no need to stockpile Tamiflu
The studies by Roche may have been falsified
The effectiveness of Tamiflu in healthy adults is validated

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Reading Part B Tamiflu and ADHD

TEST 2
Title: Is ADHD a valid diagnosis in adults?

Paragraph 1
Attention deficit hyperactivity disorder (ADHD) is well established in childhood, with 3.6% of children in
the United Kingdom being affected. Most regions have child and adolescent mental health or paediatric
services for ADHD. Follow-up studies of children with ADHD find that 15% still have the full diagnosis at 25
years, and a further 50% are in partial remission, with some symptoms associated with clinical and
psychosocial impairments persisting.
Paragraph 2
ADHD is a clinical syndrome defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition, by high levels of hyperactive, impulsive, and inattentive behaviours in early childhood that persist
over time, pervade across situations, and lead to notable impairments. ADHD is thought to result from
complex interactions between genetic and environmental factors.
Paragraph 3
Proof of validity. Using the Washington University diagnostic criteria, the National Institute for Health and
Clinical Excellence (NICE) reviewed the validity of the system used to diagnose ADHD in children and
adults.
Paragraph 4
Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are found to cluster
together in both clinical and population samples. Studies in such samples also separate ADHD symptoms
from conduct problems and neurodevelopmental traits. Twin studies show a distinct pattern of genetic
and environmental influences on ADHD compared with conduct problems, and overlapping genetic
influences between ADHD and neurodevelopmental disorders such as autism and specific reading
difficulties. Disorders that commonly, but not invariably, occur in adults with ADHD include antisocial
personality, substance misuse, and depression.
Paragraph 5
Symptoms of ADHD are continuously distributed throughout the population. As with anxiety and
depression, most people have symptoms of ADHD at some time. The disorder is diagnosed by the severity
and persistence of symptoms, which are associated with high levels of impairment and risk for developing
co-occurring disorders. ADHD should not be diagnosed to justify the use of stimulant drugs to enhance
performance in the absence of a wider range of impairments indicating a mental health disorder.

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Reading Part B Tamiflu and ADHD

Paragraph 6
ADHD symptoms have been tracked from childhood through adolescence into adult life. They are
relatively stable over time with a variable outcome in which around two thirds show persistence of
symptoms associated with impairments. Current evidence defines the syndrome as being associated with
academic difficulties, impaired family relationships, social difficulties, and conduct problems. Cross
sectional and longitudinal follow-up studies of adults with ADHD have reported increased rates of
antisocial behaviour, drug misuse, mood and anxiety disorders, unemployment, poor work performance,
lower educational performance, traffic violations, crashes, and criminal convictions.
Paragraph 7
Several genetic, environmental, and neurobiological variables distinguish ADHD from non-ADHD cases at
group level, but are not sufficiently sensitive or specific to diagnose the syndrome. A family history of
ADHD is the strongest predictorparents of children with ADHD and offspring of adults with ADHD are at
higher risk for the disorder. Heritability is around 76%, and genetic associations have been identified.
Consistently reported associations include structural and functional brain changes, and environmental
factors (such as maternal stress during pregnancy and severe early deprivation).
Paragraph 8
The effects of stimulants and atomoxetine on ADHD symptoms in adults are similar to those seen in
children. Improvements in ADHD symptoms and measures of global function are greater in most studies
than are reported in drug trials of depression. The longest controlled trial of stimulants in adults showed
improvements in these response measures over six months. Stimulants may enhance cognitive ability in
some people who do not have ADHD, although we are not aware of any placebo controlled trials of the
effects of stimulants on work or study related performance in healthy populations. This should not,
however, detract from their specific use to reduce symptoms and associated impairments in adults with
ADHD.
Paragraph 9
Psychological treatments in the form of psychoeducation, cognitive behavioural therapy, supportive
coaching, or help with organising daily activities are thought to be effective. Further research is needed
because the evidence base is not strong enough to recommend the routine use of these treatments in
clinical practice.
Paragraph 10
Conclusions. ADHD is an established childhood syndrome that often (in around 65% of cases) persists into
adult life. NICE guidelines are a milestone in the development of effective clinical services for adults with
ADHD. Recognition of ADHD in primary care and referral to secondary or tertiary care specialists will
reduce the psychiatric and psychosocial morbidity associated with ADHD in adults.

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Reading Part B Tamiflu and ADHD

Questions: ADHD

11

The article reports what proportion of diagnosed children present with ADHD in
adulthood?
A
B
C
D

Half
3.6%
A quarter
15%

12 According to the article

A
B
C
D

ADHD is triggered by genetic factors

ADHD is the result of environmental factors
both A and B.
neither A nor B.

13 According to the article symptoms

A
B
C
D

vary across clinical and population samples.

varies across situational factors.
need to pervade across time and situations for a diagnosis to be made.
are not reliably identifiable.

14 Which co-occurring disorders does ADHD frequently present with?

A
B
C
D

Antisocial personality disorder.

Substance misuse.
Depression.
All of the above.

15 According to the article, which one of the following statements about ADHD is FALSE?
A
B
C
D

The use of stimulants is justified in the absence of a wider range of impairments.

Symptoms of ADHD are evenly prevalent throughout the population.
The criteria for diagnosis measure the severity and persistence of symptoms.
High levels of impairment and risk for developing co-occurring disorders are
related with ADHD.

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Reading Part B Tamiflu and ADHD

16 Which heading would best describe paragraph 6?

A
B
C
D

Symptoms associated with impairments.

ADHD and outcomes in adulthood.
Further definition of the syndrome.
none of the above

17 The strongest predictor of ADHD is ..

A
B
C
D

Diagnostic and Statistical Manual of Mental Disorders, fourth edition.

Social and academic impairment.
Heritability.
Family environment.

18 The effectiveness of atomoxetine on ADHD symptoms is .

A
B
C
D

less than described in drug trials of depression.

greater when measured over six months.
reduced in adults with ADHD.
known to improve measures of global functioning.

19 Which heading would best describe paragraph 9?

A
B
C
D

Recommendations.
Use of alternative treatments.
Programs thought to be effective.
Psychological treatments.

20 It can be inferred from the article the author believes, ......

A
B
C
D

ADHD is a non-persistent syndrome.

The majority of children with ADHD will go on to display symptoms in adulthood.
Psychological treatments should replace drug treatment.
There is a need to develop clinical services for adults with ADHD.

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Reading Part B Tamiflu and ADHD

Answers

Tamiflu

ADHD

11

12

13

14

15

16

17

18

19

10

20

10