TEST-8

Gallstones
PART A
TEXT 1
Gallstones (Cholelithiasis) are hardened deposits of digestive fluid that can form in
the gallbladder. The stones can be the size of a grain of sand or a golf ball. Gallstones
do not cause problems in approximately 70% of cases. Problems occur if a stone, or
stones, becomes trapped in the cystic duct or the common bile duct tract that carries
the digestive fluids from the gallbladder to the bowel. There are no single causes of
gallstones but they are more common in women, overweight people and those with
a family history of gallstones.
Biliary colic is a sudden, intense abdominal pain and fever that usually lasts between
one and five hours. It occurs when a stone moves into the cystic duct (neck of the
gallbladder) leading to obstruction.
Cholangitis (inflammation of the bile ducts) occurs when a bile duct becomes blocked
by a gallstone and the bile becomes infected. This causes pain, fever, jaundice and
rigors.
Cholecystitis (inflammation of the gallbladder) is a common complication from
gallstones. It can cause persistent pain, fever, nausea and vomiting.
Jaundice develops if a gallstone blocks a bile duct leading to the bowel. This means
trapped bile enters the person’s bloodstream instead of the digestive system.
Jaundice is painless but can cause itchiness. Bile pigments cause the persons skin and
eyes to turn yellow and their urine may also turn orange or brown.

TEXT 2
Clinical assessment
• Take a thorough family history
• Ask about lifestyle activities including exercise, diet and recent weight loss

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 Take symptom history including:
1.
• onset of symptoms
• a link between symptoms and eating
presence of a fever?
• severity and duration of symptoms
• any symptom relievers or antagonists
• Perform abdominal examination including Murphy’s test Diagnostic tests include:
• plain abdominal x-ray
• ultrasound scan – the most common diagnostic test for gallstones
• endoscopy
• magnetic resonance imaging (MRI)
• cholangiography
• CT Scan
• endoscopic retrograde cholangiopancreatography (ERCP) –
conclusive test if diagnosis unclear in other tests and can include removal of
gallstones during the procedure
• Blood tests may be performed to check:
• Liver function
•
• For infection

TEXT 3
Treatment for gallstones
Active monitoring for asymptomatic patients
Simple analgesia for biliary colic
- continue indefinitely if episodes mild and/or infrequent
- Surgical options are the preferred choice of treatment
Laparoscopic cholecystectomy (lap.choly) carried out to:
- remove the gallbladder and any stones in the cystic duct
- remove any stones seen in the bile ducts
Open abdominal surgery to remove gallbladder (cholecystectomy) if patient is:
- in last three months of pregnancy
- extremely overweight

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 - has atypical gallbladder or bile duct physiology
Non-surgical treatment options
Medication to dissolve calcium free gallstones
- rarely effective
- significant side effects
A well balanced diet
- to ease, not cure, symptoms
Lithotripsy
- rarely used for gallstones, but still widely used for kidney stones
- soundwaves that shatter the gallstones.
- suitable for people with small and soft stones
ERCP
- Can be used for diagnosis
- if stones are found, the bile duct is widened with a small incision or an electrically
heated wire
- stones are removed or left to pass naturally

TEXT 4
Ways to prevent gallstones
•Avoid eating too many foods with a high saturated fat content such as:
−meat pies
−sausages and fatty cuts of meat
−butter, ghee and lard
−cream
−hard cheeses
−cakes and biscuits
−food containing coconut or palm oil
•Drinking small amounts of alcohol may also help reduce risk of gallstones
•Gradual weight loss if obese
- there's evidence that low-calorie, rapid-weight-loss diets can disrupt the bile
Ways to prevent gallstones
•Avoid eating too many foods with a high saturated fat content such as:
−meat pies
−sausages and fatty cuts of meat
−butter, ghee and lard
−cream
−hard cheeses

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 −cakes and biscuits
−food containing coconut or palm oil
•Drinking small amounts of alcohol may also help reduce risk of gallstones
•Gradual weight loss if obese
- there's evidence that low-calorie, rapid-weight-loss diets can disrupt the
bile chemistry and increase the risk of developing gallstoneschemistry and
increase the risk of developing gallstones

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 How gallstones are confirmed?___________________

2 The signs a person has jaundice?___________________

3 What type of food to avoid to prevent gallstones? ___________________

4 The surgical options available for ladies with gallstones in their third
trimester?___________________

5 Biliary colic? ____________________

6 Pharmaceutical options for managing gallstones? ___________________

7 Key evidence that suggests gallstones that can be captured when taking the
patients history? ___________________

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 type of cheese should be avoided to reduce the risk of developing
gallstones? ____________________

9 What test is usually carried out to check for gall stones? ____________________

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10 If a person has cholecystitis, what past of their body is affected?
____________________

11 The gallbladder and what else might be removed during a laparoscopic

cholecystectomy? ____________________

12 Diets that are low calorie, leading to what, should be avoided?

____________________

13 A blood test may be taken from a person suspected of having gallstones to check
the functioning of which organ? ____________________

14 Which non-surgical treatment is now mostly used to treat kidney stones?

____________________

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 In approximately____________________of cases, people with gallstones are
asymptomatic

16 Low intake of____________________can keep the risk of developing gallstones

low.

17 During surgery, if gallstones are found, the bile duct is expanded with a minor cut
or an____________________

18 A person may appear yellow if a gallstone occludes

a____________________connecting to the bowel.

19 During the clinical assessment of a patient presenting with possible gallstones, an

abdominal examination is carried out including____________________

20 Cholelithiasis are solid lumps of____________________that can grow in the

gallbladder.

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 PART B
TEXT 1
Focus: wound/infection control. New solutions for wound healing

Treating skin tissue damaged by burns and other trauma, diabetes or vascular
disease is a major challenge and a burden on healthcare systems. Several advanced
skin graft treatments exist but they are costly, come with risks such as host rejection,
excessive scarring and potentially disease transmission, and are limited to treating
shallow wounds where formation of blood vessels is less important. The emergence
of 3D printing tools and techniques, biofabrication of tissue materials from
biologically compatible materials offers the possibility of not only reducing
availability and cost of treatment issues, but also the prospect of treating deep
wounds comprising several tissue layers. The layered fabrication method could also
accommodate the use of wound healing proteins, stem cells and anti-inflammatory
drugs during the printing process, as well as creating more complex tissue structures
that could eventually include vascular networks that facilitate oxygen and nutrient
exchange to hair follicles and sweat glands. Even though the biological complexities
of human skin are relatively well understood, appropriate repair mechanisms are
scarce and often costly.

Question
1) In this article what might eventually be made on a 3D printer?
a) Skin with its various layers, components and blood supply
b) Skin including nerve cells, stem cells and sweat follicles
c) Skin, with muscles, tendon and blood vessels

TEXT 2
Therapeutic Objectives in the Elderly

When treatments are very likely to achieve benefits and very unlikely to have adverse effects,
decisions are relatively easy. However, assessing the relative importance of these quality of life
factors to each patient is important when treatments may have discordant effects. For
example, aggressive cancer therapy may prolong life but have severe adverse effects (e.g.,

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chronic nausea and vomiting, mouth ulcers) that greatly reduce quality of life. In this case, the
patient’s preference for quality vs duration of life and tolerance for risk and uncertainty help
guide the decision whether to attempt cure, prolongation of life, or palliation. The patient’s
perspective on quality of life may also affect treatment decisions when different treatments
(e.g., surgical vs drug treatment of severe angina or osteoarthritis) may have different
efficacies, toxicities, or both. Practitioners can help patients understand the expected
consequences of various treatments, enabling patients to make more informed decisions.

Questions 1-6
2) What three options are generally available for discussion when a person
is faced with making a decision about what treatment pathway to take
for their illness?
a) Modifying their lifestyle to deal with the illness, accepting that they cannot be
cured, taking all treatment options available.
b) Managing the side effects of treatment, consider declining treatment, revising
their expectations of whether they will be cured
c) Extending life-expectancy, treating the symptoms to lessen their effect,
remedying the condition

TEXT 3
Treatment or management of chronic kidney disease

Early CKD is usually asymptomatic and must be actively sought to be recognised.

Kidney function is measured by the glomerular filtration rate (GFR), which is the
amount of blood the kidneys clear of waste products in one minute. As GFR cannot
be measured directly, current practice is to estimate GFR (eGFR) by applying a
formula that includes age, gender and creatinine levels in the blood. Kidney function
can also be tested by measuring the levels of albuminuria (type of protein) in the
urine, but this testing requires follow-up, as CKD is diagnosed where albuminuria is
seen to be persistent in the urine for at least three months.

General practitioners (GPs) are the usual source of initial assessment and diagnosis
of CKD and have a variety of options available for treating the condition, including
the ordering of imaging and pathology tests, prescribing of medications and, where
necessary, referral to a specialist. Best practice management of CKD utilises a

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collaborative effort, involving at least the individual and their GP, but also including
practice nurses and/or allied health professionals as appropriate.

Questions 1-6
3) Why does a urine test to check for Chronic Kidney Disease have to be
followed up on?
a) The urine test has to be compared with the blood test results so a formula can
be applied to confirm CKD
b) The urine is tested for a protein that has to be present for 90 days to confirm
CKD.
c) The urine test has to be repeated to ensure the results are accurate before
CKD can be confirmed.

TEXT 4
Position Statement on Medicinal Cannabis

It is the position of the NSW Nurses and Midwives’ Association that:

Access to cannabis for therapeutic purposes should be supported where patients, in

consultation with their treating health professionals, receive some benefit or
symptoms are alleviated. Clinical trials should be conducted to develop the evidence
base. Approved pharmaceutical cannabis products should be accessible and
affordable. A legal framework must be established so that patients or their carers
who are in possession of cannabis for personal, therapeutic purposes should have a
complete legal defence from arrest or prosecution. A legal framework must be
established so that approved cannabis products can be developed and sold for the
purposes of therapeutic use. Cannabis misuse should be approached primarily as a
health issue rather than a criminal issue and we support an appropriate harm-
reduction response.

Questions 1-6

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4) What is the NSW Nurses and Midwives Association stance regarding
carers found in possession of cannabis?
a) Carers should be protected from legal action against them
b) Carers should be arrested and prosecuted
c) Carers should be referred to health professionals

TEXT 5
Memo to all staff re: Mandatory FONT requirements bulletin

Completion of all components of the FONT program is mandatory for all NSW Health
maternity clinicians (including Obstetricians, General Practitioner Obstetricians,
Trainees in Obstetric Medicine, Registered Midwives and midwifery students).

This is to occur in three yearly cycles and will consist of:

• 16 hours to complete the online K2MS Perinatal Training Programs (once

every three years) which includes:
o Fetal Monitoring Training System (including 15 Cardiotocograph (CTG)
‘Training Simulator’ cases)
o Maternity Crisis Management Training System
• 2½ hours to complete two (2) K2MS - Fetal Monitoring Training System
‘Training Simulator’ CTG case studies (every year within the cycle where the
entire Fetal Monitoring Training System is not completed)

• 16 hours to complete both face-to-face education sessions (once every three

years)

o Fetal Welfare Assessment (‘F’)

o Obstetric emergencies and Neonatal resuscitation Training (ONT’).

Chief Executives of Local Health Districts – are responsible for:

• Supporting:

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 o FONT Facilitators to provide the face-to-face sessions
o Maternity clinicians to complete the mandatory FONT requirements

• Monitoring FONT completion compliance.

Information relating to the granting of Recognition of Prior Learning (RPL) will be

available in the FONT Curriculum. The changes outlined in this Information Bulletin
will be incorporated into relevant NSW Ministry of Health Policy Directives during
2013.

Questions 1-6
5) How much cardiotocograph training is must be completed to complete
the FONT programme?
a) Two face to face training sessions and fifteen case studies every three years
b) Sixteen hours online training every three years and two and half hours
annually
c) Two case studies and fifteen simulator cases every three years

TEXT 6
Choice of meter for the individual with diabetes

The choice of a blood glucose meter for the person with diabetes will depend on a
variety of factors including ease of use, size and portability, type of strip (e.g.
canister, individual foil-wrapped strip or strip-free), amount of blood required,
suitability for alternate site testing and other additional features such as memory
and download capability, alarms and back lights. Individuals with sight or dexterity
problems will need a meter that accommodates these issues. Many people with type
1 diabetes use more than one blood glucose meter, and may require a meter to
measure blood ketone levels, a smart meter that assists in insulin bolus calculations
or a meter that relays blood glucose levels to their insulin pump. Capillary blood
samples are best taken from the side of the finger, but avoiding close proximity to
the nail bed, particularly when blood glucose levels are changing rapidly. Some blood
glucose meters allow the measurement of glucose levels from small samples of blood
from the forearm and other sites.

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Questions 1-6
1) Where is the best place to take blood from to monitor blood glucose
levels?
a) Near the nail bed
b) The side of the finger
c) The forearm

PART C
TEXT 1
Cancer, of course, is not new. Throughout the ages societies have defined and dealt
with it variously. Ancient Greeks employed the term to describe tumors: mass,
burden. It is an apt translation of what cancer does inside of our bodies. In Emperor
of All Maladies Siddhartha Mukherjee travels to the root of onkos.

Nek is an Indo-European term that represents an active form of “load.” It means to

carry, to move the burden from one place to the next, to bear something across a
long distance and bring it to a new place. It is an image that captures not just the
cancer cell’s capacity to travel—metastasis—but also Atossa’s journey, the long arc
of scientific discovery—and embedded in that journey, the animus, so inextricably
human, to outwit, to outlive and survive.As Atul Gawande recently expressed in
conversation with musician Andrew Bird—Bird asked the doctor how cancer forms,
given a severe bout his wife had recently undergone—we all grow cancer cells every
day. Fortunately, our bodies are designed to not let them metastasize. Then a
mutant gets through, our body under attack.

Certain cancers are genetic—my testicular cancer two years ago is one such case,
given a childhood condition that predisposed me to it. Yet many are environmental.
More importantly, where genetics and environment meet is either a breeding
ground or defense system for cancer. Cigarettes have always been the former, like
letting streptococcal bacteria loose in a sauna.

A recent study published in Science reminds us just how dangerous cigarettes are. It
turns out that hundreds of DNA cells are in danger of mutation in what scientists
believe is impactful enough to leave an “archaeological record.Smoking a pack a day
leads to the following number of potential mutations every single year 150 in the

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lungs; 97 in the larynx or voice box; 23 in the mouth; 18 in the bladder; six in the
liver. Each mutation increases the risk of cells becoming cancerous.

Every cigarette contains at least 60 carcinogens, which is why six million people die
because of cigarette-related (and thus avoidable) cancers every year. Tobacco has
been implicated in 17 types of cancer. While the researchers remind us that smoking
is “mechanistically complex,” and there are multiple factors when considering
cancer, they conclude: Although we cannot exclude roles for covariate behaviors of
smokers or differences in the biology of cancers arising in smokers compared with
nonsmokers, smoking itself is most plausibly the cause of these differences.

Forty-five percent of American adults puffed tobacco 60 years ago. This is partly the
result of the hundreds of millions of dollars manufacturers were pouring into
advertising. The 1955 introduction of the Marlboro Man increased sales by whopping
5,000 percent over eight months. Peak consumption hit in the early sixties, with sales
of nearly $5 billion in America alone.

It’s been a long, slow withdrawal. In 1956, Richard Doll and Bradford Hill began
questioning the role of cigarettes in lung cancer. Today we view the Mad Men-esque
nonchalance of lighting up as a romantic throwback to a better time. Yet since
January 1, 1971, cigarette ads have been banned on television. That decade marked
a profound turn in our understanding of just how dangerous cigarettes are.

Still, addictions persist. While Utah is just over 12 percent smokers, and California in
second at 15 percent, Kentucky leads the charge with 30.2 percent of its population.
West Virginia and Mississippi follow closely behind. That means over 1.3 million
people still smoke in Kentucky. Even though that state doubles the percentage of
California smokers, around 5.8 million people still light up on the west coast.

Mukherjee, whose brilliant book on cancer is lucid and frightening, has spent a lot of
time in cancer wards around the world. In one passage he describes a fraction of the
devastation: “An ebullient, immaculately dressed young advertising executive who
first started smoking to calm his nerves had to have his jawbone sliced off to remove
an invasive tongue cancer. A grandmother who taught her grandchildren to smoke
and then shared cigarettes with them was diagnosed with esophageal cancer. A
priest with terminal lung cancer swore that smoking was the only vice that he had
never been able to overcome. He then describes that even while going through this,
many patients refuse to surrender their vice: “I could smell the acrid whiff of tobacco
on their clothes as they signed the consent forms for chemotherapy.

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Questions 7-14

7) What point does the writer make about the term the Ancient Greeks
used for cancer?
a) That it is a suitable translation that reflects the way in which cancer behaves
b) That it is an appropriate description of the outcomes of cancer.
c) That it describes precisely the root of the disease.
d) That the word cannot describe the disease properly.

8) How does the author describe cancer in terms of its Indo-European

implication?
a) As a carrier
b) As a load
c) As a journey
d) As a discovery

9) Which of the following can be a cause of cancer?

a) Environment
b) Breeding
c) Childhood conditions
d) Streptococcal bacteria

10) What does “the former” refer to in third Paragraph?

a) Genetics
b) Environment
c) A Breeding ground
d) A Defense system

11) Why do cigarettes cause cancer?

a) They can cause mutations in DNA cells.

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 b) They cause mutations in the organs of the body.
c) They turn cells into cancerous tissues.
d) They increase the risk for lung, larynx, mouth, bladder, and liver cancer.

12) When considering cancer, scientists

a) Are not sure that it is caused by smoking because cancers are complex
b) Are sure that smoking causes cancer
c) Believe that smoking is the most likely cause for cancer in smokers as opposed
to nonsmokers
d) Believe that smoking is the most likely cause for differences that are visible in
the cancers that occur in smokers compared to nonsmokers
13) What happened in the seventies?
a) New ways of advertising
b) A different attitude towards smokers
c) A Decrease in sales of cigarettes
d) People began to view cigarettes as a health hazard

14) What does Mukherjee say about smokers who got cancer?
a) He is worried about them.
b) He is disgusted by them.
c) He was disgusted by the smell of tobacco on their clothes.
d) He knows that many of them haven’t quit smoking.

TEXT 2
According to the National Institutes of Health, we spend about 26 years of our life
asleep, one-third of the total. The latest research states that between 6.4 and 7.5
hours of sleep per night is ideal for most people. But some need more and others
less. A contingent out there, mostly women, who do surprisingly well on just six
hours.There is even some data to suggest that a slim minority, around three percent
of the population, thrive on just three hours sleep per night, with no ill effects. Of
course, most people need much more. Even though in general, Americans are getting
far less sleep today than in the past.

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Cutting out needful rest could damage your health, long-term. A recent study
showed that sleep is essential to clearing the brain of toxins that build up over the
course of the day. It also helps in memory formation and allows other organs to
repair themselves. Our professional lives and our natural cycles don’t always mesh.
Often, they are at odds. What if you are insanely busy, like ten times the norm? Say
you are going to medical school, earning your PhD, or are trying to get a business off
the ground. There may not be enough hours in the day for what you have to do. One
thing you can do is rearrange your sleep cycle to give yourself more time.

Paleoanthropologists espouse that our ancestors probably didn’t sleep for seven
hours at a clip, as it would make them easy prey. Instead, they probably slept at
different periods throughout the day and night, and you can too.What we consider a
“normal” sleep cycle is called monophasic. This is sleeping for one long period
throughout the night. In some Southern European and Latin American countries, the
style is biphasic. They sleep five to six hours per night, with a 60-90 minute siesta
during midday. There is a historical precedent too. Before the advent of artificial
light, most people slept in two chunks each night of four hours each, with an hour of
wakefulness in-between. That’s also a biphasic system.

Then there is polyphasic sleep. This is sleeping for different periods and amounts of
time throughout the day. Certain paragons of history slept this way including
Leonardo Da Vinci, Nikola Tesla, Franz Kafka, Winston Churchill, and Thomas Edison,
among others. The idea gained popularity in the 1970’s and 80’s among the scientific
community. Buckminster Fuller, a famous American inventor, architect, and
philosopher of the 1900’s, championed this kind of slumber. So what’s the science
behind this radical system? Unfortunately, no long-term research has been
conducted, yet. One 2007 study, published in the Journal of Sleep Research, found
that most animals sleep on a polyphasic schedule, rather getting their sleep all at
once. This also begs the question, how much sleep does the human brain need to
function properly? The answer is unknown.

Sleep is broken into three cycles. There is light sleep, deep sleep, and rapid eye
movement (REM) sleep. The last one is considered the most important and restful of
phases. We don’t stay in any one phase for long. Instead, we cycle through these
constantly throughout the night. So with polyphasic sleep, the idea is to experience
these three phases in shorter amounts of time, and wake up rested.

We don't know the exact purpose of these phases. Sleep is still something of a
mystery. Without a good understanding, it’s difficult to quantify the impact a
polyphasic schedule has. One question is whether such a schedule allows for enough

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REM sleep. Polyphasic practitioners say they are able to enter the REM phase
quickly, more so than with a monophasic style. Jost, for example, claimed he could
enter REM sleep immediately. This quick entry into the REM state is known as
“repartitioning.” The deprivation of sleep may help the body enter REM quickly, as
an adaptation.

Questions 15-22
15) In first paragraph, the author
a) Introduces the phases of sleep
b) Introduces general facts about sleep
c) Discusses the amount of time people sleep.
d) Discusses the period of time when people sleep.

16) The author uses the word “contingent” in the first Paragraph to refer to
the women as:
a) An exception
b) A group
c) Resilient.
d) Brave.

17) What does the author imply when he/she says that our professional
lives and natural cycles are at odds?
a) That they are in congruence.
b) That they are in conflict.
c) That they correspond to one another.
d) That they cannot be compared.

18) What does the author suggest about our ancestors?

a) That they had monophasic sleep.
b) That they didn’t sleep for 7 hours.
c) That they didn’t have monophasic sleep.
d) That they had biphasic sleep.

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19) What is a siesta?
a) A long afternoon sleep.
b) A 60-90 minute afternoon sleep.
c) A 60-90 minute sleep which follows a regular 5-6 hour sleep.
d) Part of the biphasic sleeping schedule in Latin America.

20) What do scientists suggest about sleep in fourth paragraph?

a) That in order to be successful you need to have polyphasic sleep.
b) They can’t explain why many animals have polyphasic sleep.
c) They have no answers about what proper sleep is as no studies have been
carried out
d) They have no specific answers about the amount of sleep we require?

21) What does the author say about the way we sleep in fifth paragraph?
a) That we all experience polyphasic sleep.
b) That we all sleep in cycles.
c) We cycle when we go to sleep
d) That polyphasic sleep makes us feel rested.

22) Why are some scientists skeptical about the success of polyphasic
sleep?
a) Because they believe that it does not allow for enough REM sleep.
b) Because they believe that it allows people to enter the REM phase more
quickly
c) They suspect that it may not allow for enough REM sleep.
d) They don’t believe that the repartitioning phase can be achieved.

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TEST-9
Overweight and Obesity
PART A
TEXT 1
Overweight and obesity are defined as abnormal or excessive fat accumulation that
may impair health. Originally this was found to be an issue in western societies, but
obesity levels are now rising in Africa and Asian states. Worldwide, obesity has nearly
tripled since 1975. In 2016, more than 1.9 billion adults were overweight. Of these
over 650 million were obese. 39% of adults were overweight in 2016, and 13% were
obese. Worryingly, in 2016, over 340 million children and adolescents aged 5-19
were overweight or obese. Becoming overweight or obese is entirely preventable.
This means conditions linked to being overweight and obese are also preventable or
at least deferred from causing problems.
Body mass index(BMI) is a simple index of weight-for-height that is commonly used
to classify overweight and obesity in adults. It is defined as a person's weight in
kilograms divided by the square of his height in meters (kg/m2). The World Health
Organisation defines adults as overweight if their BMI greater than or equal to 25;
and obese if their BMI is greater than or equal to 30.
Waist circumference measurement is increasingly used as a measure of obesity. BMI
can be misleading. A highly muscular athlete or someone of non-European ethnicity
can present with a raised BMI but this does not reflect their body fat levels and their
lack of health risks.However, people with very large waists – generally, 94cm (37in)
or more in men and 80cm (about 31.5in) or more in women – are more likely to
develop obesity-related health problems.
Significant health, social and economic impacts are linked to people being
overweight or obese Being overweight or obese increases the risk of suffering from a
range of health conditions, including coronary heart disease, Type 2 diabetes, some
cancers, knee and hip problems, and sleep apnoea. In 2008, the total annual cost of
obesity to Australia, including health system costs, loss of productivity costs and
careers’ costs, was estimated at around $58 billion.
Eating too much and moving too little causes is an imbalance between calorie intake
and calorie expenditure. For this reason, overweight and obesity are generally
considered to be the individual persons ‘fault’ and they need to solve the issue.

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TEXT 2
Medical checks
Take a thorough history is essential to eliminate contributing factors of:
- family history of diabetes, heart conditions and obesity
- an underactive thyroid gland
- Cushing's syndrome
-Polycystic ovary syndrome (PCOS)
medicines for:
-epilepsy
-diabetes
-depression
-schizophrenia
-corticosteroids
-recent smoking cessation
-chronic mobility limiting pain or injury

TEXT 3
Managing overweight and obesity
Treatment focuses on strategies to bring about the lifestyle changes of:
-Eating a healthy balanced diet
-Increasing activity levels
Cognitive behaviour therapy may be offered to help a person change their lifestyle
‘green prescriptions’ can increase opportunities to exercise
Medication – Orlistat is the only prescription medication
Surgical options include:

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-lap band surgery: an adjustable ring is put around the top part of the stomach to
create a very small pouch that increases the time food remains in the top part of the
stomach
-regastric bypass: a small stomach pouch created by stapling is joined directly to the
small intestine after some of the intestine has been removed. Food bypasses most of
the stomach and fewer calories are absorbed
-gastric sleeve surgery: most of the stomach is removed, including the part that
makes a hormone which makes you feel hungry.

TEXT 4
Individual or societal responsibility?

· Social, political and economic factors help to create and maintain an overweight
and obese population.

· Daily activity to burn calories is reducing due to:

- an increasingly sedentary nature of many forms of work

- changing modes of transportation

- policy decisions that promote car use and do not ensure adequate open, safe
streets

- increasing urbanisation

· Increased intake of food of high calorie, low nutritional value, i.e. foods that are
high sugar, high fat, high salt, low fibre is due to:

- convenient, fitting into ‘time poor’ family lives where both parents work,

- heavily marketed

- widely available in supermarkets, fast food outlets, petrol stations, cafes, etc.

· Political impact low due to:

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- food producers arguing for ‘personal choice’ and resisting political change

- companies being largely unregulated, or at best self-regulated, on the amount of

sugar, salt and fat they can include

- reluctance to impose change on large companies who generate significant

employment and tax income through their productions

- lack of legislation to reduce number of eating and fast food outlets

· Economic impacts on obesity include:

- low cost, low nutritional value foods are frequently available in low socio-economic
areas

- the food industry are massive contributors to a country’s business, through direct
employment and purchasing supplies locally

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 Surgical options to manage obesity? __________________

2 The political impact on obesity? __________________

3 The lifestyle changes that obesity management focusses on? __________________

4 Why the aily activity needed to burn calories is reducing __________________

5 Waist circumference measurement? __________________

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6 The medications that might contribute to the risk of
obesity? __________________

7 What eating too much and moving too little does? __________________

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 factors help to create and maintain an overweight and obese
population__________________

9 What type of prescriptions can increase opportunities to exercise?

__________________

10 In 2016, how many children and adolescents aged 5-19 were overweight or
obese__________________

11 What is found in high levels, in food that is of high calorie but low nutritional
value__________________

12 What change has happened to many forms of work that makes it difficult for
people to burn calories? __________________

13 Stopping what activity can lead to a person becoming overweight or obese?

__________________

14 An adult with a BMI greater than or equal to 25, is considered to be

what__________________

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.

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15 A__________________involves a small stomach pouch being created by stapling
and then directly joining it to the small intestine after some of the intestine has been
removed.

16 Overweight and obesity are defined as abnormal or __________________that

may impair health.

17 Food producers argue for__________________and resist political change.

18 Being overweight or obese increases the risk of suffering from a range of health
conditions, including coronary heart disease__________________and some cancers

19 A(n) __________________gland can lead to being overweight or obese.

20 Orlistat is the only__________________available to help manage obesity.

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 PART B
TEXT 1
Memo to public health workers: A reminder about the safe and correct use of
condoms

A batch of Durex Real Feel condoms was recently recalled internationally because of
their tendency to burst before their expiry date. This has prompted a reminder about
the safe use of condoms, including making sure you're aware of the expiry date.

As a product ages, it has a higher potential to fail, so it is important to always check

the use-by date before using a condom and make sure you know how to use a
condom correctly. Taking the right precautions will help manage the spread of
disease and reduce the likelihood of unwanted consequences, such as pregnancy.

Durex Real Feel condoms from batch 1000432443 (expiry January 2021) should not
be used. No other condoms are affected by this issue.

Question
1) What guidance do staff need give to their patients to limit the chance of
condoms failing?
a) Open the packaging to see if the condom has burst
b) Check the condom expiry date and put one on correctly
c) Discard the condom if it is a Durex Real Feel

TEXT 2
Directive: compliance is mandatory – Introduction

SA Health is responsible for ensuring Local Health Networks provide comprehensive,

timely and high quality health services in South Australian (SA) public hospitals.
Approximately 46,000 elective surgery procedures are performed each year in South
Australian (SA) metropolitan public hospitals and approximately 16,000 elective
surgery procedures in country hospitals. Patients requiring elective surgery have
been assessed by a medical practitioner or authorised delegate as needing surgery
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for a medical condition, but for which admission can be delayed for at least 24 hours.
These patients are placed on a booking list and treated according to the clinical
urgency category assigned by the treating medical practitioner. SA Health Elective Surgery
Policy Framework and Associated Procedural Guidelines (Policy Framework) has been developed to
provide a consistent, structured approach to support the provision of elective surgery within SA Health
public hospitals

Question
2) What is the purpose of the SA Health Elective Surgery Policy Framework
and Associated Procedural Guidelines?
a) To ensure all patients have an operation within 24 hours of being referred for
publicly funded surgery
b) To make sure GPs know the process for referring patients for publicly funded
surgery
c) To ensure all patients in SA get equal access to the publicly funded operation
they need

TEXT 3
Women at lower risk of caesarean section when they're induced

For most women, labour naturally starts between weeks 37 and 42 of pregnancy.
When a woman is induced, doctors break her waters and make the uterus contract
more strongly to bring on labour deliberately. There's a variety of reasons why a
woman might be induced in this way including that the baby is overdue, that the
baby doesn't seem to be growing well, or that the mother has a health condition that
can make labour trickier, like high blood pressure. But the women in the study didn't
have any of those problems, and none had given birth before. The researchers
wanted to see whether inducing labour was better than waiting in women who
didn't otherwise need to be induced for health reasons. Half of the pregnant women
were randomly sorted into a group that would be induced at 39 weeks, while the
other half would instead go through "expectant management", where they simply
waited for labour to come. The researchers found that women who had a labour
induction were 15 per cent less likely to need a caesarean delivery.

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Question
3) What was the selection criteria for women to be included in this research
project?
a) 42 weeks pregnant and baby has stopped growing
b) No problems and a first time mum
c) A first time mum whose waters had broken

TEXT 4
Drug categories of concern in the elderly: anti-coagulants

Age may increase sensitivity to the anticoagulant effect of warfarin. Careful dosing and routine
monitoring can largely overcome the increased risk of bleeding in elderly patients taking
warfarin. Also, because drug interactions with warfarin are common, closer monitoring is
necessary when new drugs are added or old ones are stopped; computerized drug interaction
programs should be consulted if patients take multiple drugs. Patients should also be
monitored for warfarin interactions with food, alcohol, and OTC drugs and supplements. The
newer anticoagulants (dabigatran, rivaroxaban, apixaban) may be easier to dose and have
fewer drug-drug interactions and food-drug interactions than warfarin, but still increase the risk
of bleeding in elderly patients, particularly those with impaired renal function.

Questions 1-6
4) From this article, what is the most important role of health professionals
when they are caring for an elderly person taking anti-coagulants?
a) Ongoing and regular reviews
b) Frequently checking for bleeding
c) Prescribing anticoagulants other than warfarin

TEXT 5
Musculoskeletal conditions

There are more than 150 forms of arthritis and musculoskeletal conditions, but the
more common conditions include:

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Osteoarthritis: a degenerative joint condition affecting the weight-bearing joints
such as the hips, knees and ankles and well as the hands and spine.

Rheumatoid arthritis: an autoimmune disease where the body’s immune system

attacks its own tissues, and thus differs from osteoarthritis which is characterised by
wear and tear of joints. It is more severe than osteoarthritis and while not only
confined to the joints, the hand joints are the most commonly affected.

Osteoporosis: a largely preventable condition whereby there is a progressive loss of

bone density and decrease in the strength of the skeleton, such that even a minor
bump or accident can cause serious fractures. Often people are not aware they have
osteoporosis because the condition lacks obvious symptoms. The condition is much
more common in females than in males.

Questions 1-6
5) Which of these conditions is most associated with wear and tear?
a) The practically avoidably condition
b) An auto immune condition
c) The deteriorating joint condition

TEXT 6
Pressure injuries are not inevitable

Some aged care providers suggest anyone can use available risk assessment tools to
identify and rate a person’s potential for pressure injury and implement treatment.
However, while such tools may assist decision making, they cannot be relied on in
isolation of knowledge and clinical assessment conclusions. This is precisely where
the importance of having the right skills mix in aged care comes into play. Research
commissioned by the ANMF in 2016, in conjunction with Flinders University and the
University of South Australia, provides evidence that a skills mix of registered nurses
– 30%, enrolled nurse – 20% and personal care workers – 50%, is the minimum
requirement “to ensure safe residential and restorative care” (Willis et al. 2016).
Registered nurses are equipped with the knowledge, backed by an evidence base, to
undertake a comprehensive assessment of potential for pressure injury and

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commence appropriate preventative measures, and/or, to institute required wound
management systems for established pressure injuries.

Questions 1-6
6) What do the researchers identify as the lowest safe ratio of staff in an
aged care setting?
a) Just under a third RNs, half personal care workers and the rest ENs
b) Mostly personal care workers and an equal split of ENs and RNs
c) Fifty percent are personal care workers with thirty percent ENs and 20% RNs.

PART C
TEXT 1
Have you ever experienced déjà vu? If so, you are among the 60-70% of the
population who has. The majority of those who report déjà vu are between the ages
15 and 25.

Though some radical notions have in the past been connected to this strange feeling,
such as déjà vu being a momentarily aligning with a past life or another you in a
parallel universe, scientists now believe it has a neurological basis.

Unfortunately, the feeling is here one minute and gone the next, making it difficult to
study. Even so, there are quite a few theories on what causes it. One traditional
hypothesis, posited by psychiatrists, is mismatched brain signals. For a second it feels
as though we are transported to a moment in the past and we mistake it for the
present. This may be why it has been associated with the idea of reincarnation.

Another theory is that déjà vu is our brain trying to piece together a situation on
limited information. A third states that it is a misfiring in the parts of the brain that
recall memory and decipher sensory input. Sensory information, rather than taking
the proper channels, leaks out of the short-term memory and into the long-term
one. In this way, current experiences seem to be connected to the past. Some
studies even suggest that familiar geometric shapes give us a sense of knowing
something about a place that is, in reality, totally unfamiliar to us.

Since we are completely aware of everything that’s going on when we experience

déjà vu, this suggests that every part of the brain need not participate for the

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sensation to take place. Psychologist Anne M. Cleary at Colorado State University, in
a study in 2008, found that déjà vu followed patterns we associate with memory,
specifically recognition memory“. This is the kind that gets us to understand that we
are confronting something that we have seen or experienced before. If you have
ever recognized a landmark, a friend from across the room, or a song on the stereo,
you have experienced recognition memory.”

Familiarity-based recognition is associated with recognition memory. Here, we have

that feeling of familiarity, but we can’t quite place where we’ve seen this person,
place, or thing. For instance, you recognize someone across the street, but can’t
remember their name or where you know them from. Prof. Cleary conducted several
studies which found that déjà vu is a form of familiarity-based recognition. Her work
suggests that our memory stores items in fragments. When there is a certain overlap
between old and new experiences, we have strong feelings about the connection,
which we interpret as déjà vu.

Recent studies looking at epileptic patients made impressive breakthroughs in our

understanding of the phenomenon. Epileptics with certain intractable conditions
require electrodes to be placed inside their brains in order to locate the source of
their seizures. During this procedure, some neurologists have had patients
experience déjà vu. They soon discovered that the phenomenon takes place in the
medial temporal lobe, which is responsible for memory. The electrodes are usually
placed within the rhinal cortex—the most important piece of which is the
hippocampus, the structure responsible for long-term memory formation. French
scientists have found that firing current into this cortex can trigger an episode of déjà
vu.

The French study, published in the journal Clinical Neurophysiology, measured EEG
wave patterns from patients with epilepsy who experienced déjà vu through
electrical stimulation. The areas of the brain they examined included the amygdala,
which is responsible for emotion and the hippocampus. Researchers found that
electrical patterns, emanating from rhinal cortices and the amygdala or the
hippocampus, caused déjà vu to occur. These neuroscientists believe that some sort
of electrical phenomenon in the medial temporal lobe activates the memory in such
a way that it causes déjà vu to occur.

Stranger still, scientists in the UK have actually found patients who experience
“chronic déjà vu.” In this case, experts identified four senior citizens who encounter
the feeling on a consistent basis. What is the impact of such a phenomenon? It made
them feel as if they were clairvoyant. All four refused to go to the doctor, believing

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they already knew what the physician would say, and avoided watching the news,
thinking they already knew the outcome. That’s because each time they took part in
either activity that was the result they came to.

Questions 7-14
7) What does the first paragraph infer about déjà vu?
a) Only young people get déjà vu
b) As the people get older, their déjà vu episodes will stop
c) Some people may never get déjà vu
d) None of the above

8) In the second paragraph, which of the following is new information

about déjà vu?
a) It is a demonstration of a parallel existence of some experience from the past
in the present
b) It demonstrates the existence of a being in another parallel world
c) Neuroscientists may be able to offer an explanation
d) It has given rise to some extreme interpretations

9) In the third paragraph, the feeling of déjà vu is described as:

a) Fleeting
b) Quick
c) Difficult
d) Unreal

10) What is the author talking about in the fourth paragraph?

a) Parapsychological explanations for déjà vu.
b) Scientific theories about déjà vu.
c) Sensory theories about déjà vu.
d) Brain theories about déjà vu.
11) Which example of recognition memory does the Psychologist Anne M.
Cleary not mention?

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 a) Recognizing a landmark.
b) Recognizing a friend from across the room.
c) Recognizing a song.
d) Recognizing patterns that we associate with memory.

12) How does déjà vu come into existence according to Prof. Cleary in the
sixth paragraph?
a) When we experience recognition memory.
b) When we experience familiarity-based recognition.
c) When there is overlap between old and new experiences.
d) When we connect old and new experiences.

13) In the seventh paragraph, scientists have discovered that:

a) Transmitting current into the rhinal cortex of epileptic patients may produce
déjà vu.
b) Transmitting current into the rhinal cortex of epileptic patients produces déjà
vu
c) Current that is transmitted into the brain of epileptic patients produces déjà
vu.
d) Epileptic patients experience déjà vu when they are subjected to electrode
treatment.

14) In paragraph 9, chronic déjà vu

a) turns people into fortune tellers
b) cannot be cured by doctors
c) only affects the elderly
d) affects its sufferers' decisions

TEXT 2
Imagine healing the body without drugs or surgery, each of which can have nasty
side effects. Instead, a physician uses the body’s own building blocks to heal you.

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Instead of returning again and again, or having to take medication continually, one
shot does it all. These are the promises of gene therapy.

The concept is easy to grasp. Genes control proteins that in turn control all of our
body’s functions. When a faulty gene, usually due to a mutation, malfunctions and
causes disease, all that would have to be done is to “knock out” or replace the faulty
gene. Once the correct protein enters the system, the disease is finished. It is,
however, the replacement process that is complicated.

One problem is exactly how to deliver a gene to a patient’s DNA. To do that,

scientists create a custom virus that infects a target cell, yet flies under the immune
system’s radar. By doing so, the virus leaves its own genetic material inside the cell.
That cell begins to reproduce, carrying the gene with it, and spreading it throughout
the body.

Gene therapies are not currently approved by the FDA. Dozens of clinical trials are
ongoing, however. This cutting-edge therapy is approved to treat one particular
disorder in Europe—lipoprotein lipase deficiency, where the patient cannot break
down fat. Another use will soon be approved, to treat combined immune deficiency,
or the “bubble boy” disease.

Other conditions it is expected to someday treat include heart disease, diabetes,

some forms of cancer, muscular dystrophy, immune disorders, genetic disorders,
AIDS, hemophilia, and certain blindness-causing conditions. With AIDS, gene therapy
will be used in a different way. The HIV virus camouflages itself from the immune
system. Gene therapy can make its presence known, allowing it to be recognized and
destroyed.

The things researchers look at when evaluating a new therapy is its safety profile,
how effective it is, and what a proper dosage may look like. Just like any therapy,
things can go wrong. For instance, altered viruses could change back into their
original form, causing infection. Sometimes the wrong cell is approached by the
virus. Or the virus places the gene in the wrong place within a cell’s DNA. In this last
case, healthy cells may become damaged or cause illness, even develop into a tumor.

There have been stumbling blocks along the way. Keep in mind that all clinical trials
are monitored by the FDA and the National Institutes of Health (NIH). Even so, gene
therapy almost went bust in 1999 when a volunteer, 19-year-old Jesse Gelsinger,
died during testing. The Arizona teen’s immune system reacted violently as a result
of the treatment. Gene therapy lost its innocence and many young, promising

174
scientists decided to put their efforts elsewhere, setting the field back. A year after
that, during a French trial, some participants developed leukemia.

After these incidents, dozens of clinical trials ceased and funding was pulled.
Researchers learned a lot from these disturbing tragedies, and put stringent safety
controls in place. They have since discovered how to deliver genes using viruses in a
safe and effective manner, that doesn’t set off the immune system.

Researchers have also implemented guidelines that help monitor patients and
administer to side effects. A few successes then brought gene therapy back from the
brink. In 2008, some blind subjects reported improvements in vision. Shortly after, in
another experiment, 80% of “bubble boy” children regained immune system
function.

The efficacy of gene therapy today is not constant throughout, but varies from one
condition to the next. A recent study using the therapy to treat muscular dystrophy
saw impressive results. A 2013 study was even more dramatic, where a small clutch
of patients with leukemia were cured. Other studies on hemophilia and one cause of
blindness, retinitis pigmentosa, have also seen remarkable results.

There have been other trials however that have not been so encouraging. One for
congestive heart failure ended in “disappointing” results, and another for Parkinson’s
ended in what researchers called a “mixed bag.” One problem that must be
overcome, the immune system sometimes does recognize and take out the viral
messenger

Questions 15-22
15) Which of these can be attributed to gene therapy in the process of
healing?
a) Using drugs
b) Performing surgery
c) Taking medication continually
d) Using the body’s building blocks

16) How are genes delivered to a patient’s DNA?

a) Through viruses that manage to escape the body’s immune system.

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 b) By creating a custom virus that carries the necessary genetic material and
leaves it in the target cell.
c) By using a virus that carries the necessary genetic material and leaves it in the
target cell in the body.
d) Through cells that reproduce, carry the gene, and spread it throughout the
body.

17) Which of these diseases is eligible for gene treatment?

a) A disease in which the patient cannot break down fat.
b) The “bubble boy” disease.
c) Muscular dystrophy.
d) Blindness-causing conditions.

18) Which of the following poses a danger to the gene treatment therapy?
a) Proper dosage of therapy
b) Its effectiveness.
c) Controlling and predicting virus’ efficiency.
d) Cell damage.
19) What is the author referring to when he says that “there have been
stumbling blocks along the way”?
a) The obstacles the researchers faced during clinical trials
b) The obstacles created by the FDA and the National Institutes of Health (NIH).
c) The fact that some patients died during the clinical trial.
d) The fact that some patients developed leukemia during the clinical trial.

20) What did these incidents contribute to?

a) Discovering how to use viruses to deliver genes.
b) Finding safer methods and following protocols for monitoring patients
c) Finding a way to improve sight in blind people.
d) Finding a way to treat “bubble boy” disease.

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21) What does the author imply about gene therapy in tenth paragraph?
a) That all diseases can be treated with equal success.
b) That not all diseases can be treated with equal success.
c) That the leukemia treatment is more successful than the treatment for
hemophilia.
d) Some diseases can be completely cured.

22) What is the author describing in the final paragraph?

a) Failures of gene therapy.
b) Disappointing results that gene therapy produced for Parkinson’s disease.
c) The mixed results that gene therapy has produced.
d) The gene therapy trials that have not produced promising results.

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TEST-10
Chronic obstructive pulmonary disease
PART A
TEXT 1
Chronic obstructive pulmonary disease (COPD) is serious, progressive and disabling
damage to the lungs which makes breathing difficult. There are several conditions
that are considered to be COPD. It is most commonly caused by cigarette smoking
but several working environments are known to lead COPD. Irritants such as silica
dust, coal dust and chemical fumes are key occupational hazards that can lead to
COPD.
Emphysema is when the air sacs in the lung are damaged, making it increasingly
difficult to get sufficient air exchange.
Chronic bronchitis is long term inflammation of the bronchi and bronchioles. These
become narrower and produce more mucous, making it harder to breathe and
causing excessive coughing.
Chronic asthma is long-term respiratory condition that causes inflammation and
tightening of the airways, making breathing difficult. It can be caused by an
overreaction to a stimulus such as exercise or cold air. Asthma affects people of all
ages, unlike other COPD conditions which are mostly age-related.

TEXT 2
Clinical assessment

•Take a thorough history including checking for allergies

• Ask about lifestyle activities including smoking and work environment

• Symptoms to check for:

breathlessness

a new or persistent cough, especially in a morning

production of a lot of mucous, which is swallowed or coughed up.

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wheezing

chest tightness

recurrent chest infections, increasing in frequency

Diagnostic tests:

•Spirometry

•Chest x-ray

•Blood test to eliminate anaemia

•Other test options include:

electrocardiogram (ECG)

echocardiogram

peak flow test

blood oxygen test

computerised tomography (CT) scan –

sputum sample

Differential diagnosis of COPD to Asthma

•Spirometry – key asthma diagnostic test

•Peak flow – diagnosis of asthma

•Age – COPD more common in over 50’s, asthma any age

•Response to medication - COPD slow to respond to medications, if at all. Asthma

very responsive

•Disease progression – COPD gradually worsening, asthma often flares up and then
settles

Allergy history – Asthma often secondary to allergies such as hay fever

TEXT 3

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Management of COPD

COPD cannot be cured but symptoms can be managed

•Stopping smoking is the most important way to ease symptoms

•Pulmonary rehabilitation – a specialised programme of exercise and

education

•Having an annual influenza vaccination and a possible one-off

pneumococcal vaccine

•Acting quickly if symptoms flare-up

•Home-based oxygen therapy in severe cases

•Lung surgery is rare and suitable for only a small number of people

Inhalers and medications

•Short acting broncho-dilators, or relievers taken to ease symptoms

•Long acting broncho-dilators taken long-term to control symptoms and

prevent flare-ups

•Flare-up (exacerbation) medication

Steroid tablets such as prednisone may be prescribed as a short course for 1 or 2

weeks if you have a sudden flare up of your COPD symptoms

•These medications may be administered via nebuliser when symptoms

become sever and no long responsive to inhalers

•Oral medications

Theophylline is a tablet that relaxes and opens up the airways. It's usually taken
twice a day. Sometimes a similar medication called aminophylline is also used

Possible side effects include:

- feeling and being sick

- headaches

- difficulty sleeping (insomnia)

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- noticeable pounding, fluttering or irregular heartbeats (palpitations)

Regular blood tests are needed if these medications are prescribed

Mucolytic medication called carbocisteine to thin out mucous

TEXT 4
Potential complications of COPD

• Susceptibility to respiratory infections

• Pulmonary hypertension
• An increased risk of heart disease
• Lung cancer (for smokers)
• Depression
• Frequent visits to hospital
• Reduced quality of life
Prevention of COPD
• Not smoking is the best way to avoid COPD
• If working in a high risk environment
• wear Personal Protective Equipment
• follow health and safety procedures

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 How to prevent COPD?__________________

2 The tests that may be carried out to diagnose COPD? __________________

3The different inhalers that might be prescribed to manage COPD?

______________________

4 How emphysema affects a person? ______________________

5 The link between asthma and allergies? ______________________

182
6 The oral medication options for COPD patients? ______________________

7
The possible complications of COPD? ______________________

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 age are most people who are diagnosed with COPD? ______________________

9 What part of the body is most affected by COPD? ______________________

10 What is the specialised programme of exercise and education that COPD sufferers
might benefit from? ______________________

11 What should people working in high risk environments wear, to reduce the risk of
developing COPD? ______________________

12 What is the key diagnostic test for asthma? __________________

13 Which condition causes airways to become narrower and produce more mucous?
______________________

14 What is the most important way to reduce the symptoms of COPD?

______________________

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 Pulmonary______________________is a potential complication of COPD.

16 Patients with COPD are often______________________to respond to medication, if

at all.

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17 Emphysema is when the______________________in the lung are damaged.

18 Having an annual influenza vaccination and a possible one-

off______________________can help with COPD management.

19 COPD is______________________and disabling damage to the lungs.

20 Production of a lot of______________________which is swallowed or coughed up is

a symptom of COPD.

184
 PART B

TEXT 1
Policy Statement – Management of Elective Surgery Booking lists

Booking List Hospitals are part of a national information system that collects
indicator data on waiting times for elective surgery. Administrative guidelines
(Booking List Information System Guidelines, Health Information Service, 2010) must
be used for the administration and submission of data from the automated booking
list systems at Booking List Hospitals.

BLIS provides an indicator of demand for surgical services across the system by
speciality and procedure and can be used to review caseload. It enables SA Health to
provide information to Booking List Hospitals about their comparative situation
within the state and to plan across the system.

Some procedures are excluded from the calculation of booking list statistics.
Hospitals should exclude records with procedure indicators of 181 (Check
Cystoscopy) and 999 (Dental or Obstetric surgery) and non-surgical treatment (eg
endoscopic treatment).

Questions 1-6
1) What is a key benefit of BLIS?
a) SA health gets an overview so they can see which hospitals have capacity to
perform dental extractions.
b) Patients can see which hospitals are able to provide surgical services to them.
c) SA health gets an overview so they can see which hospitals have capacity to
admit patients for particular operations.

TEXT 2
Heart scare a sign of things to come, expert fears

One of Australia's leading cardiologists fears that heart complaints in athletes will
become more common as the demands of professional sport grow. "I fear that with
higher levels of sporting excellence, that this may come at a cost — that cost being

186
more athletes presenting with heart conditions," said Chris Semsarian, the head of
the molecular cardiology program at the Centenary Institute. Professor Semsarian
said athletes were at higher risk of developing heart conditions because of their
occupation. "They're putting their heart under great strain during sports. That puts
pressure on the heart," he said. But he said heart problems were also more likely to
be diagnosed among athletes than among the general public due to the advanced
screening procedures used in professional sport. He said the competitive nature of
athletes meant persuading them to prioritise their health over sporting ambition was
challenging. "I am forever amazed at the way athletes will never give up," he said.

"You tell them that they have a major heart condition that could kill them and they
say, 'What do I need to take so I can get back on the field?'"

Questions 1-6
2) What discovery consistently astounds Professor Semsarian?
a) Athletes still want to exceed at their game even if it has a negative effect on
their health
b) Athletes have access to incredibly sophisticated diagnostic assessment tools,
as professional sportsmen
c) Athletes are increasingly at risk of developing serious illnesses despite being
super fit.

TEXT 3
Programmes and initiatives to address musculoskeletal disorders

Programs that support management and treatment of musculoskeletal conditions

include:

The Medicare Benefits Schedule, which provides subsidies for patient care and
includes Medicare items for the planning and management of chronic and terminal
conditions. Eligible patients can also be referred by a GP for up to five Medicare
subsidised allied health services that are directly related to the treatment of their
chronic condition, including musculoskeletal conditions.

The Pharmaceutical Benefits Scheme continues to provide subsidies for medicines

used in the treatment of musculoskeletal conditions and pain management.

187
The National Health and Medical Research Council (NHMRC) receives significant
investments for research into arthritic and rheumatoid conditions. Improving the
care of patients with multiple and complex chronic diseases, including
musculoskeletal conditions, has also been identified by the NHMRC as a major focus
in its 2013-15 Strategic Plan.

Arthritis Australia get funding to improve consumer awareness and to build and
implement a local exercise program on a national level.

Osteoporosis Australia receives funding to maintain and update resource materials,

improve osteoporosis management in primary care and deliver an exercise program
focussing on building bone strength and density.

Questions 1-6
3) Which of these initiatives is mostly involves in depth study of one or
more musculoskeletal disorder
a) Osteoporosis Australia
b) Medicare benefits schedule
c) NHMRC

TEXT 4
Drug categories of concern in the elderly: digoxin

Digoxin, a cardiac glycoside, is used to increase the force of myocardial contractions

and to treat supraventricular arrhythmias. However, it must be used with caution in
elderly patients. In men with heart failure and a left ventricular ejection fraction of ?
45%, serum digoxin levels > 0.8 ng/mL are associated with increased mortality risk.
Adverse effects are typically related to its narrow therapeutic index. One study found
digoxin to be beneficial in women when serum levels were 0.5 to 0.9 ng/mL but
possibly harmful when levels were ? 1.2 ng/mL. A number of factors increase the
likelihood of digoxin toxicity in the elderly. Renal impairment, temporary
dehydration, and NSAID use (all common among the elderly) can reduce renal
clearance of digoxin. Furthermore, digoxin clearance decreases an average of 50% in
elderly patients with normal serum creatinine levels. Also, if lean body mass is
reduced, as may occur with aging, volume of distribution for digoxin is reduced.
Therefore, starting doses should be low (0.125 mg/day) and adjusted according to

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response and serum digoxin levels (normal range 0.8 to 2.0 ng/mL). However, serum
digoxin level does not always correlate with likelihood of toxicity.

Questions 1-6
4) Which of the following serum digoxin levels can be beneficial in elderly
patients?
a) 0.8 - 2.0ng/mL
b) 0.5 - 0.9ng/mL
c) 0.5 - 0.9mg/mL

TEXT 5
Memo re: Tuberculosis Control

Hospital and Health Services included in the scope of this directive shall achieve
the following outcomes:

• All cases of suspected and confirmed TB are managed in co-operation with an

established TB Control Unit (TBCU)

• Implementation of statewide standardised diagnosis, treatment and ongoing

management protocols to minimise the risk of drug resistance, treatment failure
and/or relapse.

• Follow endorsed state and national guidelines for preventing the transmission of
TB in healthcare and community settings and to prevent TB in at-risk children
through Bacille Calmette-Guerin (BCG) vaccination.

• Notify the Department of Health of all cases of TB in accordance with the legislative
obligations of the Public Health Act 2005.

• Inform the Department of Health (CDB) within one business day of TB cases that pose an increased
public health risk, where there is potential for involvement or implication of another jurisdiction,
country or other governmental department or non-governmental organisation, and where there is
potential for heightened community interest in accordance with the Protocol for the Control of TB

Questions 1-6

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5) What key directives are included in this memo?
a) The need to: know the Protocol for the Control of TB; notify the Department
of Health of all cases of TB; administer the BCG to anyone suspected of having
TB
b) The need to: implement the statewide immunisation programme; admit all
cases of TB to a specialist TB unit; meet the Public Health Act (2005)
requirements
c) The need to: follow consistent practises relating to identifying, treating and
preventing TB; adhere to immunisation programme; follow reporting
protocols.

TEXT 6
Advanced Health Directives: Patient guidance

An Advance Health Directive (AHD) is a legal written document, containing your

decisions about your future health treatment. Anyone over 18 can prepare an AHD –
even healthy people prepare AHDs. If you lose your mental capacity, you are not
legally allowed to prepare an AHD and nobody else can do it for you. In WA, the law
allows you to write an AHD to say what treatments you want or don’t want in
specific circumstances. Or you can appoint someone to make medical treatment,
personal or lifestyle decisions on your behalf, when you are unable to make or
communicate your decision. You can make an AHD in which you either provide
consent, or refuse consent, to future treatments. For example, you may say that you
want or do not want a certain treatment. An AHD can only be completed while you
have the ability – or ‘mental capacity’ – to make and communicate decisions. As soon
as you lose the capacity to make and communicate decisions, you are no longer able
to complete or modify an AHD. No one else can complete an AHD for you once you
have lost capacity.

Questions 1-6
6) What advice should a healthcare professional give adolescents about
writing an AHD?
a) An AHD has to be approved by both parents if the person is under 18.
b) An AHD cannot be accepted unless a person is aged 18 or over.

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c) An AHD can only be put in place by people aged under 18.

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 PART C

TEXT 1
Sometimes the Tooth Fairy gives more than a dollar underneath your pillow. In the
case of Dr. Alysson Muotri, associate professor of pediatrics and cellular and
molecular medicine at UC San Diego School of Medicine and a noted expert on
autism, the Tooth Fairy gave new insight into what may make humans social.
Through Dr. Muotri's Fairy Tooth Kit Collection campaign, donated baby teeth from
both those with autism and those unaffected were collected for research. A tiny
brain was then created in a petri dish from the teeth.

These miniature brains may provide a window into the human spectrum of
sociability, helping us better understand why certain individuals like those with
autism have diminished social skills. It may also help us understand how humans
evolved to be as social as we generally are.

Called Brain or Cerebral Organoids, Dr. Muotri and his team were able to create
these so-called mini-brains by extracting the pulp cells in the teeth and converting
them into brain cells. This is done through the induced pluripotent stem cell (iPS)
technique, a reprogramming of cells to be in a stem cell-like state. These neural
progenitor cells are able to create networks similar to the developing cortex of a
human brain.Dr. Muotri's research showed that the organoids using cells from those
with autism had fewer neural connections than those unaffected.

While autism is generally associated with low degrees of sociability, Williams

syndrome is a rare genetic disorder where those affected have an extremely high
level of sociability to the point of talking with strangers. It is often referred to as the
"opposite of autism".

Dr. Muotri and his team of researchers at the University of California San Diego,
along with researchers at the Salk Institute of Biological Studies, examined organoids
grown from those affected by Williams syndrome. The team noticed that instead of
former fewer neural connections like the autism organoids, the organoids contained
an abnormally high level of neural connections.

Organoids derived from cells unaffected by a neurobiological disorder were right in

the middle. In other words, the level of neural connections in the mini-brains
correlated with the sociability of person. The higher the sociability (from autism to

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unaffected to Williams Syndrome), the greater the neural connections in the cerebral
organoid.

Speaking to New Scientist, Dr. Muotri said: The differences are striking, and go in
opposite directions. In Williams syndrome, one of the cortical layers makes large
projections linking into many other layers, and these are important for sociality. By
comparison, autism-linked brains are more immature, with fewer synapses."

The connection between synapses and sociality was also found by the research team
when examining donated brains from those who had autism or Williams syndrome.
In addition, another research team working with brain organoids recently found that
patients with idiopathic autism overproduced inhibitory neurons.

In the December 2015 issue of the journal Developmental Biology, researchers

Madeline Lancaster and Iva Kelava explored both the promise and challenges of
cerebral organoids. In the article, Dishing out mini-brains: Current progress and
future prospects in brain organoid research , they argue that brain organoids can
successfully model neurodevelopmental conditions such as idiopathic autism and the
brain organoids "model early human embryonic and fetal brain development to a
remarkably high degree." While the work on brain organoids is quite new, there
appears to be a great deal of promise in the research with unlocking some of the
secrets of the Brain.

Brain organoids (and organoid systems in general), which adequately model tissue
development and physiology, are a relatively new development, and the field has
exploded in the last several years. Thus, it is easy to envisage that in 10–20 years
from now (or even less) we will be able to almost fully mimic development of certain
tissues in vitro.In addition, further improvements in the technique might allow us to
model adult brain physiology and disorders of the adult and ageing brain."

Questions 7-14
7) In what way is the concept of Tooth Fairy related to the research mentioned in
first paragraph?
a) Because teeth for the research were collected from under the children’s
pillows.
b) Because the Tooth Fairy gave new insight into what may make humans social.
c) Because baby teeth were donated for the research.
d) Because a tiny brain was created from baby teeth.

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8) The research being performed on the tiny brains may provide us with various
pieces of information. Which of the following aspects are not mentioned in
second paragraph?
a) It may provide deeper insight into the human ability to socialize.
b) It can contribute to our understanding of autism.
c) They can contribute to our understanding of why those affected with autism
have a lower ability to socialize.
d) They can help us to understand why human beings have developed into social
beings.

9) In what way is Williams syndrome different from autism?

a) Autism is not a genetic disorder.
b) Autism affects people with fewer neural connections.
c) Williams syndrome is a genetic disorder.
d) Patients with Williams syndrome display a very high level of sociability.

10) Williams organoids:

a) Are produced from those affected by Williams syndrome.
b) Produce fewer neural connections.
c) Contain an unusually high quantity of neural connections.
d) Reach an unusually high level of neural connections.

11) What do we find out about people who don’t suffer from either autism or
Williams syndrome in eighth paragraph?
a) That they have a large number of synapses
b) That they have fewer synapses.
c) Their neural connections remain unaffected.
d) They have a moderate number of synapses.

12) What does the information in ninth paragraph suggest?

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 a) There has been a lot of research that supports the correlation between neural
connection and sociability.
b) There is other research that supports the correlation between neural
connection and sociability, as well.
c) That the correlation between neural connection and sociability was first
discovered many years ago
d) The correlation between neural connection and sociability was not discovered
in brain organoids.

13) What is the advantage of brain organoids?

a) They are a perfect match to the human brain.
b) They can be used to model human development.
c) They are an excellent representation of early human brain development.
d) They are an excellent guide to the early human brain development.

14) What kind of future is predicted for brain organoids in tenth paragraph?
a) Bright
b) Bleak
c) Foreseeable
d) Uncertain

TEXT 2
Waking up today, on so-called Blue Monday, the “most depressing day of the year”,
you may already be aware that this concept is based on a fraud. An almost
deliciously spurious mathematical formula was dreamed up by a PR agency, given
the veneer of academic rigour by attaching the name of a lecturer at a further
education college, and a media phenomenon was born. More than a decade’s worth
of articles and social media memes have at turns reinforced and defied the Blue
Monday myth, and it is often now held up as a case study of bad science.

It is, of course, laughable to have a formula where W stands for weather and days-
since-Christmas is raised to the power of Q, the days-since-we-quit-our-new-year-
resolutions. But the driver behind this mockable maths is a much more sinister lie,
one from which many struggle to escape 365 days of the year.

195
Blue Monday was originally invented for an advertising campaign for Sky Travel. Its
sole purpose was to sell holidays with the false promise that spending money would
raise flagging spirits. Blue Monday has now been used to sell everything from flowers
to Ferraris, takeaways to airport parking. Beat Blue Monday, they tell us (laughing
knowingly at the fact that it’s made up): buy something new today.

We’re told every day by advertisers that buying stuff will make us happy. A new pair
of shoes will help us to feel better after a breakup. New beauty products will give us
a sense that we’re “worth it”. A bigger car will give us social status. New toys will
make the children happy. Even loans are sold this way: one payday lender is
currently running a campaign with a smiling woman, snuggling a mug of tea and
feeling happy thanks to a 1,200% APR loan, an implausible scenario if ever there was
one. So it’s no wonder that on Blue Monday, the day our anxieties and misery are
supposed to peak, the advertisers scream that the path out of unhappiness is paved
with till receipts.

Sometimes the harm this causes is relatively trivial: overconsumption of stuff we

don’t need; a bit less money in the bank; a wardrobe that won’t close because we’re
not very good at throwing away our throwaway fashion buys.But the harm can be
deadly serious for people struggling with mental health problems. Imagine it: your
mood is low. You find yourself crippled by anxiety. You feel like a failure, a burden on
your family and friends. This is the moment when a lifetime of being told that stuff
will make you feel better takes its toll: in desperation, nine in 10 people with a
mental health problems find themselves spending more when they’re feeling unwell.

In my work at the research charity Money and Mental Health, I’ve lost count of the
stories I’ve heard that stop me in my tracks. Mothers spending their way through
months of postnatal depression – one who bought nearly 100 buggies over four
years. A man who tried to buy a villa in a country he didn’t have a visa for, convinced
it would turn his life around. A young woman who found buying something online
was the only way she could stop a panic attack, so she did it almost every day. A
husband who felt such a burden he’d buy endless presents he couldn’t afford for his
wife. And many of them tell us that the boxes sit in the living room, unopened,
unwanted, but impossible to ignore.

Because buying stuff is just the first part of the cycle. Next comes the guilt. People
with mental health problems are far more likely to be living on a low income, and the
financial damage that compulsive shopping can do is extraordinary. The boxes – or if
they’re actually opened, the new possessions – are a constant reminder of the
mistakes made. Too often, people don’t return unwanted goods: nearly half tell us

196
that’s because they just want to pretend it never happened. The guilt brings their
mood lower and then buying something for a temporary buzz feels like the only way
back up.

We have just launched a new tool, the Shopper Stopper, which is helping people to
curb their night-time shopping in particular by allowing them to set the opening
hours of online shops. But it’s going to take a wider societal shift to really shake us
out of these habits for good.

Questions 15-22

15) What does the author imply about the concept of Blue Monday?
a) It is a non-existent phenomenon.
b) It was conceived by a PR agency.
c) It was promoted by a university lecturer.
d) It is considered to be a result of bad research.

16) What is the underlying purpose of Blue Monday?

a) To make people sell holidays to feel better.
b) To make people feel better
c) To make people buy things under the pretense of feeling happier.
d) To make people sell things under the pretense of feeling happier.

17) On Blue Monday, advertisers

a) Take advantage of people’s unhappiness
b) Convince people that their supposed unhappiness will disappear with
shopping.
c) Try to sell as much as possible.
d) Convince people that as many receipts as possible will make them happy.

18) What are the consequences of Blue Monday for people who suffer from
anxiety?
a) They are unimportant.

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 b) They feel like failures
c) They feel desperate.
d) They spend more money.

19) What has the writer heard that stopped him / her in his / her tracks?
a) Large numbers of upsetting stories that left him feeling shocked.
b) Large numbers of upsetting stories that make him want to stop working for
the charity.
c) Advertisements which encourage people to buy things they don’t need.
d) Occasional stories which have had happy endings.

20) Which of the cases below have not been recorded by the author in his/her work
at the research charity?
a) A depressed mother who bought 100 prams.
b) A husband who wanted to buy numerous presents for his wife.
c) A husband who believed he could alleviate his stress by buying unaffordable
things for his wife.
d) A woman whose panic attacks were stopped only by buying things online.

21) Apart from the financial damage compulsive shopping can cause, the author
mentions another far more devastating issue:
a) Low income
b) Guilt
c) Mistakes they have made
d) Not returning unwanted goods.

22) What is the purpose of Shopper Stopper?

a) To control people’s night-time shopping.
b) To stop their night-time shopping.
c) To allow them to set limits on shopping to create good habits.
d) To get rid of the habit of shopping.

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TEST-11
Mumps
PART B
TEXT 1
What is mumps?
Mumps is a contagious viral infection that is most common in children between 5
and 15 years of age. Mumps is most recognisable by the painful swellings located at
the side of the face under the ears. Other symptoms include headache, joint pain
and a high temperature.
Mumps is a serious disease because it can lead to inflammation of the spinal cord
and brain, the brain itself, and the heart. About one in 200 children with mumps will
develop brain inflammation. Mumps can damage nerves leading to deafness. Males
might get mumps orchitis which is swollen testes. This can cause a reduced sperm
count but not enough to cause infertility. Women may miscarry during their first
trimester.
Mumps vaccination
Vaccination is the most effective way to control mumps. The Measles, Mumps and
Rubella (MMR) vaccine is part of the routine childhood immunisation schedule in
Australia.It is given as a course of two injections. The first injection of vaccine is
usually given at around 12 months of age. A second booster dose is usually given at
the age of four.
The increase in mumps
In 1998, concern was raised that there was a link between the MMR vaccine and
autism. This has been totally disproved but it did lead to a drop in the number of
children having the vaccine. 27% of all mumps cases have been in adults, in Australia
over the past five years, These adults have already received two doses of the
vaccination. The increase in cases might be due to the vaccine not lasting as long as
expected. It might also be the rise in the mumps virus in the wider community
because of reduced immunisation rates.

TEXT 2

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How is mumps spread?
Mumps is caused by the mumps virus, which belongs to a family of viruses known as
'paramyxoviruses'. Mumps is spread in the same way as colds and flu. Infected
droplets of saliva can be inhaled or picked up from surfaces and transferred into the
mouth or nose.
Mumps spreads rapidly because a person is most contagious a few days before the
symptoms appear. This means they do not realise they may be spreading the virus. A
person is infectious for a few days afterwards too. Anyone who comes into contact
with infectious mumps can get mumps, unless they have had mumps before or have
been immunised.
Mumps is so infectious that it is a recognised notifiable disease. This means
laboratories, school principals and directors of childcare centres must report all cases
of mumps to their local public health unit.
A doctor can usually diagnose mumps based on the person's symptoms and signs
alone. A blood test or sample from the throat, urine or spinal cord fluid may be taken
to confirm the diagnosis and ensure the incidence can be reported.
There is no specific treatment for mumps. Simple medication like paracetamol may
reduce pain and fever. Warm or cold packs to the swollen glands may provide relief.
Drinking plenty of fluids and resting is essential.

TEXT 3
Symptoms of mumps
Painful swellings at the side of the face in the parotid salivary glands is the most
common symptom of mumps. These glands are within the cheeks, near the jaw line,
below the ears. This gives the person a distinctive "hamster face" appearance.
The symptoms of mumps usually develop 14 to 25 days after a person is infected
with the mumps virus (the incubation period). The average incubation period is
around 17 days.
Common symptoms of mumps are:
- A general feeling of being unwell
- High temperature
- Discomfort when chewing
202
- Headache
- Joint pain
- Feeling sick
- Mild pain in the abdomen
- Feeling tired
- Loss of appetite
The face will be back to normal size in about a week. About one third of infected
people do not show any symptoms at all but they can still spread the virus.
The most common complication of mumps is mumps orchitis, according to statistics
from the Australian Government, Department of Health. Mumps is usually a more
severe illness in people infected after puberty. 7.1 % of people aged 5-14,
experienced additional complications from mumps. Only 3.8% of people aged 25 -59
had additional complications compared to 15.4% of those aged 60+. Nobody in the 0-
4 and 15-24 age ranges had additional complications.

TEXT 4
Preventing the spread of mumps
- MMR vaccine is the most effective way to stop a person developing mumps.
- People born after 1965 need to make sure they have had two doses of mumps
containing vaccine.
People with mumps should:
- Stay away from childcare, school, work and other places where people gather for
nine days after the onset of the swelling of the salivary glands
- Wash their hands regularly, using soap and water
- Always use a tissue to cover their mouth and nose when they cough and sneeze.
- Throw the tissue in a bin immediately after use
- Wait till the doctor says they are no longer infectious.
Vaccines have reduced the number of cases of mumps internationally but the rate of
mumps outbreaks is increasing.The number of mumps cases does fluctuate. The

203
World Health Organisation keeps track of the number of cases by country. In
Australia, there have been less than a 100 cases in some years since 1997. Between
2007 and 2014, there was an average of 232 cases per year. In 2015 there were 633
cases but in 2016, 800 cases were reported. In 2017, this rose to 806.

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 number of cases of mumps in Australia?__________________

2 The number of cases of mumps among adults in Australia in the past 5

years? _________________

3 What causes the hamster face linked to mumps? _________________

4 The way the mumps virus is spread? _________________

5 The condition that was linked to the MMR vaccine in

1998? ____________________

6 The incubation period for mumps symptoms to appear? ______________________

7 What people with mumps should do? ____________________

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 is the name of the family of viruses that the mumps virus belongs to?
____________________

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9 What is the most common age range when someone gets mumps?
_____________________

10 What does MMR stand for? _____________________

11 Which glands swell up around the face if a person has mumps?

_____________________

12 Mumps spreads in the same way as what two other conditions?

_____________________

13 How many cases of mumps were reported in Australia in 2017?

_____________________

14 At what stage of their pregnancy, might a woman with mumps miscarry her child?
_____________________

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 Mumps spreads rapidly because a person is_____________________a few days
before the symptoms appear.

16 MMR vaccine is the most effective way to stop a person_____________________

17 The most common complication of mumps is_____________________

18 The Measles, Mumps and Rubella (MMR) vaccine is part of the

routine_____________________schedule in Australia.

19 Directors of childcare centres must_____________________all cases of mumps to

their local public health unit.

20 Only_____________________of people aged 25 -59 had additional complications

from mumps.

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 PART B
TEXT 1
Use of ‘StoneChecker’ for Kidney Stone Evaluation

‘StoneChecker’ is medical imaging software used to measure key kidney stone

parameters to generate a set of textual metrics. It uses an application that analyses
the texture in an existing radiological scan. The aim is to help clinicians assess a
stone's heterogeneity and any characteristics not visible to the naked eye. In other
words, it creates a virtual 'map' of a kidney stone. The technology is designed to be
used with conventional CT scans to help clinical decision making about diagnosing
and treating people with kidney stones. It imports imaging data and calculates
metrics based on individual pixel data points within a given region of interest. These
metrics assess stone heterogeneity, including texture irregularity, not provided by
conventional CT scans.

Question
1) What do we learn about ‘StoneChecker’ in the first paragraph?
a) Kidney stones can be located using this device.
b) Such optical equipment measures microscopic surface features of kidney
stones
c) It is a computer program that helps clinicians visualize kidney stones.

TEXT 2
Postoperative Treatment of Knee Inflammation

A middle-aged man with a history of gout was hospitalized for a surgical procedure.
While in postoperative care, he experienced severe pain and swelling in his left knee.
An orthopaedic surgeon was consulted, and he prescribed Colchicine to treat the
acute gouty inflammation. The pharmacist overrode a high-dose alert, which
indicated that the patient should be treated with a maximum dose of 4.8 mg.
Instead, the patient received more than 10 mg of Colchicine before he started to
show signs of renal failure. The treatment was stopped, but the patient died. In this
instance, a policy concerning high drug doses had been in place. The investigation

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found that the pharmacist should have consulted with the prescribing physician for
alerts.

Postoperative Treatment of Knee Inflam

Questions 1-6
2) In the example described in the paragraph, what went wrong?
a) The pharmacist ignored critical information.
b) The prescription was incorrectly managed by the orthopaedic surgeon.
c) The prescribing physician fail to initiate the ‘alert’ process.
mation

TEXT 3
Gluten: It’s Not for Everyone

Removing gluten from one’s diet is no easy feat. Reading labels and understanding
where gluten may be hiding takes time and education. Gluten-free products are
typically more expensive, and, while varieties of foods and products are expanding,
there are still considerably fewer choices for gluten-sensitive consumers. While there
is considerable evidence to support the benefits of a gluten-free diet, the medical
community warns against it, if it is not deemed medically necessary. Removing
gluten from one’s diet can not only reduce the intake of essential vitamins and
minerals which are found in fortified foods, but it can also reduce the amount of
probiotics in the gut which boost the immune system.

Questions 1-6
3) What does the writer imply about gluten?
a) Eliminating gluten from your food intake is risky.
b) More people should take time to be educated about gluten.
c) Reducing the amount of gluten you consume is beneficial for your probiotics.

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TEXT 4
Blood Culture Policy

Any patient in a hospital setting who develops a fever or evidence of sepsis should
have blood cultures sent. As sepsis is one of the leading causes of deaths, rapid
identification of bloodstream infection is mandatory to perform adequate antibiotic
therapy. Multiple sets of blood cultures may be required, and cultures of other sites
should also be considered including urine, skin and throat. Smaller volumes are often
taken from babies and children. Standard precautions must be taken when taking
blood cultures. Ideally the skin should be washed with soap and rinsed with sterile
water. This should be followed by the application of an iodine-based solution, which
should then be washed off after 30 seconds of drying.

Questions 1-6
4) What does this article tell us about blood cultures?
a) Blood culture should always precede antibiotic therapy.
b) The amount of blood to be taken can vary.
c) The use of iodine does not interfere with correct blood culture procedures.

TEXT 5
Helmet Removal Procedures

With each passing year, more individuals are playing contact sports and riding
motorcycles. Therefore, healthcare workers involved in emergency care should be
proficient in the procedure of helmet removal. This procedure, which requires
minimal training, is a safe and quick process that gives care providers access to a
patient's airway and allows them to stabilize the patient's head and neck. If the
airway is unstable, facemask removal is all that is necessary to intubate the patient.
According to one study, face mask removal for the potential spine-injured patient is
safer than helmet removal for emergent airway access. Face mask removal results in
less motion in all three planes (sagittal, frontal, transverse), requires less completion
time, and is easier to perform.

Questions 1-6

209
5) What do we learn from this article about helmet removal?
a) Intubation to stabilize the airway is not possible while a helmet is in place.
b) Healthcare workers should focus on the integrity of the sagittal, frontal and
transverse planes.
c) It is not always necessary to remove a helmet.

TEXT 6
TYM Otoscope for Imaging the External Ear Canal

The TYM Otoscope (Cupris) uses iOS smartphones to let users capture images and
videos of the external ear canal and eardrum. These can then be reviewed and
shared securely with other healthcare professionals through the Cupris app. To use
the device, the user places their smartphone in the case and slides the otoscope
attachment over the lens of the phone camera. A speculum is then screwed onto the
attachment until locked into place. Images and videos are captured using the
smartphone's camera linked to the Cupris app. The Cupris app can be downloaded
from the Cupris website. The images and video captured using the device are stored
on a secure and encrypted cloud system and can be viewed on most phones or PC
computers.

Questions 1-6
6) What does this article tell us about the TYM Otoscope?
a) Healthcare professionals can transfer data from the device to their own
smartphones.
b) Without a smartphone, the TYM Otoscope cannot function.
c) Data can only be shared on iOS platforms.

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 PART C
TEXT 6
Over the past 50 years, the frequency of allergies and autoimmune diseases has risen
rapidly, but it is not clear why. In a study published today in Science Translational
Medicine, researchers point to a possible culprit: salt. In lab experiments, the
authors found that high concentrations of sodium chloride can influence the
differentiation of T helper 2 (Th2) cells, the immune cells responsible for allergies,
and that elevated levels of salt are present in the affected skin of people with atopic
dermatitis, an allergic skin condition.

“These are the sorts of studies that are really appreciated because they’re so
completely different, and that’s what we need because really there hasn’t been
much progress in understanding this epidemic of allergic disease,” says Charles
Mackay, an immunologist at Monash University in Australia who did not participate
in the work. In looking “at why we get an allergy or atopic dermatitis, I try to think of
the environmental factors,” he adds. This study “is an interesting new angle to Th2
immunity.”

Hay fever and atopic dermatitis have seen a two-fold upsurge since the 1970s, and
researchers do not attribute that to greater awareness or diagnosis. This recent rise
in the incidence of allergic diseases is much too fast to be explained by genetic
changes, so it’s more likely to be due to an environmental or behavioural cause,
according to co-author Christina Zielinski of the Technical University of Munich. “One
thing that also changed within the last fifty to sixty years is our diet. We are eating
much more fast food, and this also includes much more salt, so that’s how we
became interested in the question of whether salt can modulate the immune
system,” she says.

Zielinski and her colleagues started by upping the levels of sodium chloride in the
tissue culture medium used to grow either human CD4-positive memory T cells,
which give off a complex set of chemical signals based on previous exposure to
antigens, or naïve T cells, which have not been exposed to antigens before. In both
cell types, the salt boosted the abundance of cytokines and transcription factors
specific to Th2 cells, indicating that high salinity promotes Th2 cell differentiation.
The researchers also found that the effects of the salt seemed to enhance Th2-
related programs via two salt-sensitive transcription factors.

The authors next compared salt levels in the skin of adults with atopic dermatitis, an
allergic condition that causes red, itchy patches of skin. Lesioned skin had sodium

211
concentrations 30-fold higher than the patients’ unlesioned skin and skin from
healthy controls. The team also investigated sodium levels in affected and
unaffected skin of people with psoriasis, an autoimmune disorder characterized by
red, inflamed patches of skin. While both atopic dermatitis and psoriasis are both
chronic inflammatory skin conditions, psoriasis is mediated by a different type of T
helper cells. They found no difference in salt concentration in psoriatic lesions and
unaffected skin, which led them to rule out a role for inflammation in the differences
in sodium that they observed in people with atopic dermatitis. “We were very
surprised because atopic dermatitis has been . . . thoroughly investigated, and no
one has ever considered sodium chloride to play a role,” says Zielinski. She adds that
the next steps will be to investigate the connection between salt and allergies.

According to Chuan Wu, an immunologist at the National Cancer Institute who did
not participate in the work, this connection could involve nearby epidermal and
dermal cells, as well as the skin microbiome. “The skin is a big mucosal surface,
colonized with a huge amount of microbes, so investigating whether . . . the Th2
response is somehow connected to the skin bacteria could be interesting,” he says.
The authors discuss in the study that people with atopic dermatitis often have an
overgrowth of a salt-loving microbe (staphylococcus aureus) on their skin, which has
gone unexplained until now.

Mackay points out that the gut microbiome could also be involved, as high salt diets
have previously been shown to have effects on intestinal microbes. “Is it salt from
the diet somehow affecting atopic dermatitis? Or is there a gut connection here that
they haven’t explored yet?” he asks. “This connection to the diet is still very
speculative. There are some correlations and associations, but the definite proof is
still missing,” says Zielinski. “It could be that the sodium accumulation in the skin
follows some autonomous skin-intrinsic rules, which are completely independent of
diet.”

Over the past 50 years, the frequency of allergies and autoimmune diseases has risen
rapidly, but it is not clear why. In a study published today in Science Translational
Medicine, researchers point to a possible culprit: salt. In lab experiments, the
authors found that high concentrations of sodium chloride can influence the
differentiation of T helper 2 (Th2) cells, the immune cells responsible for allergies,
and that elevated levels of salt are present in the affected skin of people with atopic
dermatitis, an allergic skin condition.

“These are the sorts of studies that are really appreciated because they’re so
completely different, and that’s what we need because really there hasn’t been

212
much progress in understanding this epidemic of allergic disease,” says Charles
Mackay, an immunologist at Monash University in Australia who did not participate
in the work. In looking “at why we get an allergy or atopic dermatitis, I try to think of
the environmental factors,” he adds. This study “is an interesting new angle to Th2
immunity.”

Hay fever and atopic dermatitis have seen a two-fold upsurge since the 1970s, and
researchers do not attribute that to greater awareness or diagnosis. This recent rise
in the incidence of allergic diseases is much too fast to be explained by genetic
changes, so it’s more likely to be due to an environmental or behavioural cause,
according to co-author Christina Zielinski of the Technical University of Munich. “One
thing that also changed within the last fifty to sixty years is our diet. We are eating
much more fast food, and this also includes much more salt, so that’s how we
became interested in the question of whether salt can modulate the immune
system,” she says.

Zielinski and her colleagues started by upping the levels of sodium chloride in the
tissue culture medium used to grow either human CD4-positive memory T cells,
which give off a complex set of chemical signals based on previous exposure to
antigens, or naïve T cells, which have not been exposed to antigens before. In both
cell types, the salt boosted the abundance of cytokines and transcription factors
specific to Th2 cells, indicating that high salinity promotes Th2 cell differentiation.
The researchers also found that the effects of the salt seemed to enhance Th2-
related programs via two salt-sensitive transcription factors.

The authors next compared salt levels in the skin of adults with atopic dermatitis, an
allergic condition that causes red, itchy patches of skin. Lesioned skin had sodium
concentrations 30-fold higher than the patients’ unlesioned skin and skin from
healthy controls. The team also investigated sodium levels in affected and
unaffected skin of people with psoriasis, an autoimmune disorder characterized by
red, inflamed patches of skin. While both atopic dermatitis and psoriasis are both
chronic inflammatory skin conditions, psoriasis is mediated by a different type of T
helper cells. They found no difference in salt concentration in psoriatic lesions and
unaffected skin, which led them to rule out a role for inflammation in the differences
in sodium that they observed in people with atopic dermatitis. “We were very
surprised because atopic dermatitis has been . . . thoroughly investigated, and no
one has ever considered sodium chloride to play a role,” says Zielinski. She adds that
the next steps will be to investigate the connection between salt and allergies.

213
According to Chuan Wu, an immunologist at the National Cancer Institute who did
not participate in the work, this connection could involve nearby epidermal and
dermal cells, as well as the skin microbiome. “The skin is a big mucosal surface,
colonized with a huge amount of microbes, so investigating whether . . . the Th2
response is somehow connected to the skin bacteria could be interesting,” he says.
The authors discuss in the study that people with atopic dermatitis often have an
overgrowth of a salt-loving microbe (staphylococcus aureus) on their skin, which has
gone unexplained until now.

Mackay points out that the gut microbiome could also be involved, as high salt diets
have previously been shown to have effects on intestinal microbes. “Is it salt from
the diet somehow affecting atopic dermatitis? Or is there a gut connection here that
they haven’t explored yet?” he asks. “This connection to the diet is still very
speculative. There are some correlations and associations, but the definite proof is
still missing,” says Zielinski. “It could be that the sodium accumulation in the skin
follows some autonomous skin-intrinsic rules, which are completely independent of
diet.”

Over the past 50 years, the frequency of allergies and autoimmune diseases has risen
rapidly, but it is not clear why. In a study published today in Science Translational
Medicine, researchers point to a possible culprit: salt. In lab experiments, the
authors found that high concentrations of sodium chloride can influence the
differentiation of T helper 2 (Th2) cells, the immune cells responsible for allergies,
and that elevated levels of salt are present in the affected skin of people with atopic
dermatitis, an allergic skin condition.

“These are the sorts of studies that are really appreciated because they’re so
completely different, and that’s what we need because really there hasn’t been
much progress in understanding this epidemic of allergic disease,” says Charles
Mackay, an immunologist at Monash University in Australia who did not participate
in the work. In looking “at why we get an allergy or atopic dermatitis, I try to think of
the environmental factors,” he adds. This study “is an interesting new angle to Th2
immunity.”

Hay fever and atopic dermatitis have seen a two-fold upsurge since the 1970s, and
researchers do not attribute that to greater awareness or diagnosis. This recent rise
in the incidence of allergic diseases is much too fast to be explained by genetic
changes, so it’s more likely to be due to an environmental or behavioural cause,
according to co-author Christina Zielinski of the Technical University of Munich. “One
thing that also changed within the last fifty to sixty years is our diet. We are eating

214
much more fast food, and this also includes much more salt, so that’s how we
became interested in the question of whether salt can modulate the immune
system,” she says.

Zielinski and her colleagues started by upping the levels of sodium chloride in the
tissue culture medium used to grow either human CD4-positive memory T cells,
which give off a complex set of chemical signals based on previous exposure to
antigens, or naïve T cells, which have not been exposed to antigens before. In both
cell types, the salt boosted the abundance of cytokines and transcription factors
specific to Th2 cells, indicating that high salinity promotes Th2 cell differentiation.
The researchers also found that the effects of the salt seemed to enhance Th2-
related programs via two salt-sensitive transcription factors.

The authors next compared salt levels in the skin of adults with atopic dermatitis, an
allergic condition that causes red, itchy patches of skin. Lesioned skin had sodium
concentrations 30-fold higher than the patients’ unlesioned skin and skin from
healthy controls. The team also investigated sodium levels in affected and
unaffected skin of people with psoriasis, an autoimmune disorder characterized by
red, inflamed patches of skin. While both atopic dermatitis and psoriasis are both
chronic inflammatory skin conditions, psoriasis is mediated by a different type of T
helper cells. They found no difference in salt concentration in psoriatic lesions and
unaffected skin, which led them to rule out a role for inflammation in the differences
in sodium that they observed in people with atopic dermatitis. “We were very
surprised because atopic dermatitis has been . . . thoroughly investigated, and no
one has ever considered sodium chloride to play a role,” says Zielinski. She adds that
the next steps will be to investigate the connection between salt and allergies.

According to Chuan Wu, an immunologist at the National Cancer Institute who did
not participate in the work, this connection could involve nearby epidermal and
dermal cells, as well as the skin microbiome. “The skin is a big mucosal surface,
colonized with a huge amount of microbes, so investigating whether . . . the Th2
response is somehow connected to the skin bacteria could be interesting,” he says.
The authors discuss in the study that people with atopic dermatitis often have an
overgrowth of a salt-loving microbe (staphylococcus aureus) on their skin, which has
gone unexplained until now.

Mackay points out that the gut microbiome could also be involved, as high salt diets
have previously been shown to have effects on intestinal microbes. “Is it salt from
the diet somehow affecting atopic dermatitis? Or is there a gut connection here that
they haven’t explored yet?” he asks. “This connection to the diet is still very

215
speculative. There are some correlations and associations, but the definite proof is
still missing,” says Zielinski. “It could be that the sodium accumulation in the skin
follows some autonomous skin-intrinsic rules, which are completely independent of
diet.”

Over the past 50 years, the frequency of allergies and autoimmune diseases has risen
rapidly, but it is not clear why. In a study published today in Science Translational
Medicine, researchers point to a possible culprit: salt. In lab experiments, the
authors found that high concentrations of sodium chloride can influence the
differentiation of T helper 2 (Th2) cells, the immune cells responsible for allergies,
and that elevated levels of salt are present in the affected skin of people with atopic
dermatitis, an allergic skin condition.

“These are the sorts of studies that are really appreciated because they’re so
completely different, and that’s what we need because really there hasn’t been
much progress in understanding this epidemic of allergic disease,” says Charles
Mackay, an immunologist at Monash University in Australia who did not participate
in the work. In looking “at why we get an allergy or atopic dermatitis, I try to think of
the environmental factors,” he adds. This study “is an interesting new angle to Th2
immunity.”

Hay fever and atopic dermatitis have seen a two-fold upsurge since the 1970s, and
researchers do not attribute that to greater awareness or diagnosis. This recent rise
in the incidence of allergic diseases is much too fast to be explained by genetic
changes, so it’s more likely to be due to an environmental or behavioural cause,
according to co-author Christina Zielinski of the Technical University of Munich. “One
thing that also changed within the last fifty to sixty years is our diet. We are eating
much more fast food, and this also includes much more salt, so that’s how we
became interested in the question of whether salt can modulate the immune
system,” she says.

Zielinski and her colleagues started by upping the levels of sodium chloride in the
tissue culture medium used to grow either human CD4-positive memory T cells,
which give off a complex set of chemical signals based on previous exposure to
antigens, or naïve T cells, which have not been exposed to antigens before. In both
cell types, the salt boosted the abundance of cytokines and transcription factors
specific to Th2 cells, indicating that high salinity promotes Th2 cell differentiation.
The researchers also found that the effects of the salt seemed to enhance Th2-
related programs via two salt-sensitive transcription factors.

216
The authors next compared salt levels in the skin of adults with atopic dermatitis, an
allergic condition that causes red, itchy patches of skin. Lesioned skin had sodium
concentrations 30-fold higher than the patients’ unlesioned skin and skin from
healthy controls. The team also investigated sodium levels in affected and
unaffected skin of people with psoriasis, an autoimmune disorder characterized by
red, inflamed patches of skin. While both atopic dermatitis and psoriasis are both
chronic inflammatory skin conditions, psoriasis is mediated by a different type of T
helper cells. They found no difference in salt concentration in psoriatic lesions and
unaffected skin, which led them to rule out a role for inflammation in the differences
in sodium that they observed in people with atopic dermatitis. “We were very
surprised because atopic dermatitis has been . . . thoroughly investigated, and no
one has ever considered sodium chloride to play a role,” says Zielinski. She adds that
the next steps will be to investigate the connection between salt and allergies.

According to Chuan Wu, an immunologist at the National Cancer Institute who did
not participate in the work, this connection could involve nearby epidermal and
dermal cells, as well as the skin microbiome. “The skin is a big mucosal surface,
colonized with a huge amount of microbes, so investigating whether . . . the Th2
response is somehow connected to the skin bacteria could be interesting,” he says.
The authors discuss in the study that people with atopic dermatitis often have an
overgrowth of a salt-loving microbe (staphylococcus aureus) on their skin, which has
gone unexplained until now.

Mackay points out that the gut microbiome could also be involved, as high salt diets
have previously been shown to have effects on intestinal microbes. “Is it salt from
the diet somehow affecting atopic dermatitis? Or is there a gut connection here that
they haven’t explored yet?” he asks. “This connection to the diet is still very
speculative. There are some correlations and associations, but the definite proof is
still missing,” says Zielinski. “It could be that the sodium accumulation in the skin
follows some autonomous skin-intrinsic rules, which are completely independent of
diet.”

Over the past 50 years, the frequency of allergies and autoimmune diseases has risen
rapidly, but it is not clear why. In a study published today in Science Translational
Medicine, researchers point to a possible culprit: salt. In lab experiments, the
authors found that high concentrations of sodium chloride can influence the
differentiation of T helper 2 (Th2) cells, the immune cells responsible for allergies,
and that elevated levels of salt are present in the affected skin of people with atopic
dermatitis, an allergic

217
skin condition.

“These are the sorts of studies that are really appreciated because they’re so
completely different, and that’s what we need because really there hasn’t been
much progress in understanding this epidemic of allergic disease,” says Charles
Mackay, an immunologist at Monash University in Australia who did not participate
in the work. In looking “at why we get an allergy or atopic dermatitis, I try to think of
the environmental factors,” he adds. This study “is an interesting new angle to Th2
immunity.”

Hay fever and atopic dermatitis have seen a two-fold upsurge since the 1970s, and
researchers do not attribute that to greater awareness or diagnosis. This recent rise
in the incidence of allergic diseases is much too fast to be explained by genetic
changes, so it’s more likely to be due to an environmental or behavioural cause,
according to co-author Christina Zielinski of the Technical University of Munich. “One
thing that also changed within the last fifty to sixty years is our diet. We are eating
much more fast food, and this also includes much more salt, so that’s how we
became interested in the question of whether salt can modulate the immune
system,” she says.

Zielinski and her colleagues started by upping the levels of sodium chloride in the
tissue culture medium used to grow either human CD4-positive memory T cells,
which give off a complex set of chemical signals based on previous exposure to
antigens, or naïve T cells, which have not been exposed to antigens before. In both
cell types, the salt boosted the abundance of cytokines and transcription factors
specific to Th2 cells, indicating that high salinity promotes Th2 cell differentiation.
The researchers also found that the effects of the salt seemed to enhance Th2-
related programs via two salt-sensitive transcription factors.

The authors next compared salt levels in the skin of adults with atopic dermatitis, an
allergic condition that causes red, itchy patches of skin. Lesioned skin had sodium
concentrations 30-fold higher than the patients’ unlesioned skin and skin from
healthy controls. The team also investigated sodium levels in affected and
unaffected skin of people with psoriasis, an autoimmune disorder characterized by
red, inflamed patches of skin. While both atopic dermatitis and psoriasis are both
chronic inflammatory skin conditions, psoriasis is mediated by a different type of T
helper cells. They found no difference in salt concentration in psoriatic lesions and
unaffected skin, which led them to rule out a role for inflammation in the differences
in sodium that they observed in people with atopic dermatitis. “We were very
surprised because atopic dermatitis has been . . . thoroughly investigated, and no

218
one has ever considered sodium chloride to play a role,” says Zielinski. She adds that
the next steps will be to investigate the connection between salt and allergies.

According to Chuan Wu, an immunologist at the National Cancer Institute who did
not participate in the work, this connection could involve nearby epidermal and
dermal cells, as well as the skin microbiome. “The skin is a big mucosal surface,
colonized with a huge amount of microbes, so investigating whether . . . the Th2
response is somehow connected to the skin bacteria could be interesting,” he says.
The authors discuss in the study that people with atopic dermatitis often have an
overgrowth of a salt-loving microbe (staphylococcus aureus) on their skin, which has
gone unexplained until now.

Mackay points out that the gut microbiome could also be involved, as high salt diets
have previously been shown to have effects on intestinal microbes. “Is it salt from
the diet somehow affecting atopic dermatitis? Or is there a gut connection here that
they haven’t explored yet?” he asks. “This connection to the diet is still very
speculative. There are some correlations and associations, but the definite proof is
still missing,” says Zielinski. “It could be that the sodium accumulation in the skin
follows some autonomous skin-intrinsic rules, which are completely independent of
diet.”

Questions 7-14

7) What did the study published in Science Translational Medicine find?

a) Th2 cells can cause allergies and autoimmune diseases
b) Some people with atopic dermatitis were allergic to salt
c) Salt may play an important role in allergies and autoimmune diseases
d) Sodium Chloride causes atopic allergies in skinny people

8) When diagnosing allergies or atopic dermatitis, Charles Mackay usually

considers
a) The patient’s hereditary conditions
b) The patient’s surroundings

219
 c) The patient’s diet
d) The patient’s susceptibility to skin conditions

9) According to the third paragraph, cases of hay fever and atopic dermatitis
have
a) increased slightly
b) increased significantly
c) stayed the same
d) fluctuated two times

10) What was the result of the experiments described in paragraph four?
a) High salt intake causes allergies
b) Sodium Chloride helps CD4-positive memory T cells to grow
c) Naïve T cells react more quickly to salt than CD4-positive memory T cells
d) Elevated salt levels changed Th2 cell behaviour

11) According to the fifth paragraph, psoriasis is a condition that

a) lasts for a long time
b) is triggered by T helper cells
c) is identical to atopic dermatitis
d) causes immunity

12) According to Zielinski in paragraph five, what is the situation regarding

atopic dermatitis?
a) there is a clear link with sodium
b) more studies are needed to understand the condition
c) the condition has been examined in depth
d) the condition is surprising

13) Chuan Wu thinks that

a) The skin microbiome is not part of the epidermal system
220
 b) Epiderma and dermal cells are examples of skin bacteria
c) the Th2 response produces salt-loving microbes
d) the link between skin bacteria and Th2 response is worth further investigation

14) According to the information in paragraph seven, the presence of sodium

in the skin
a) may be unrelated to food consumption
b) could be explained by intestinal microbes
c) might be due to autonomous skin regeneration
d) can be seen by checking accumulation patterns

TEXT 2
Travel vaccinations are an essential part of holiday and travel planning, particularly if
your journey takes you to an exotic destination or 'off the beaten track'. The risks are
not restricted to tropical travel, although most travel vaccines are targeted at
diseases which are more common in the tropics. This article discusses the
vaccinations that are available and gives some idea of the time you need to allow to
complete a full protective course of vaccination.

The rise in worldwide and adventurous tourism has seen a massive increase in
people travelling to exotic destinations. This leads to exposure to diseases that are
less likely to occur at home. These are sicknesses against which we have no natural
immunity and against which most people are not routinely immunised. They include
insect-borne conditions such as malaria, dengue, yellow fever and Zika virus. In
addition, diseases could be acquired from eating and drinking, such as hepatitis A
and traveller's diarrhoea. Poor hygiene in some places could put you at risk from
hepatitis B and Ebola virus. These are illnesses which might not only spoil your
holiday but might also pose a risk to your life.

Before travelling outside your home country, it is important to check whether there
are any vaccinations available which could protect you. You can do this by making a
travel planning appointment at your doctor’s surgery. There are also several
websites which aim to offer up-to-date, country-specific advice on vaccinations and
on disease patterns.

221
Vaccination courses need to be planned well in advance. Some vaccinations involve a
course of injections at specified intervals and it can take a up to six months to
complete course. Some vaccinations can't be given together. Always check with your
surgery or online before travelling, particularly to unusual destinations, for local
outbreaks of disease which mean other specific vaccinations are advised. If a
vaccination certificate is issued keep it and update it over the years so that you have
a full record. Your doctor’s surgery will have a record of vaccines they have
administered to you and can often issue a copy.

It is worth remembering that the protection offered by vaccination is not always

100%. Vaccination will greatly reduce your chances of acquiring the disease and in
many cases the protection level offered is extremely high. The protection will also
not be lifelong, so you need to seek medical advice before you travel. However,
there isn't a vaccine available for every disease - for example, there is none at
present against malaria. Even where a vaccine is available, vaccination should not be
the only thing you rely on for protection against illness. It is important to know the
risks; taking sensible steps to avoid exposing yourself to disease is by far the most
useful thing you can do.

No vaccination is available against malaria. People who live permanently in malarial

zones have partial protection but they lose this swiftly when they move away.
Protection against malaria is through a combination of avoidance of mosquito bites
and the use of anti-malarial tablets. Tablets have to be started before entering the
malarial zone and continued for some days or weeks after leaving it. The
recommended tablet regime varies by area. Again, your doctor will have access to
up-to-date advice on recommendations for your journey.

People often at greatest risk when travelling are those visiting a country which they
think of as their place of origin, where members of their family live and their roots
may be. People often believe that as one-time residents who may have been born
and raised there, they have a natural immunity. They feel that they are not on
holiday but visiting home and that vaccinations aren't needed. Unfortunately, that is
not the case. We acquire natural immunity by living in a place and being constantly
exposed to the diseases that are present. When we leave the area for distant shores
that protection is rapidly lost and we need the protection of vaccination, together
with the other precautions listed above.

This is particularly true of malaria, where visitors 'going back home' may find their
relatives puzzled and even amused that they are taking anti-malarial medication.
Even so, it's very important to do so. It's only by living there all the time that you

222
acquire your resident relatives' level of immunity. Your immune system has a short
memory for this sort of partial immunity.

Remember, vaccinations have to be paid for, although some vaccinations such as

hepatitis A are usually free. Some aid workers and healthcare workers are often
offered free vaccinations against occupational risks but others have to pay. Anti-
malarial tablets are never free and can add a substantial amount to the cost of your
trip. Whilst this may seem expensive, it is usually a small sum relative to the costs of
your travel. Safeguarding your health should be considered an essential part of any
trip.

Questions 15-22

15) The purpose of this article is to inform readers about

a) A obtainable vaccines and how long you need to be vaccinated
b) B common tropical diseases and their cures
c) C vaccines and how many times you have to have them
d) D vaccines needed in exotic locations and their risks

16) In the second paragraph, the word ‘which’ refers to

a) natural immunities
b) diseases that you could contract in exotic places i
c) people who don’t get vaccinated
d) insect-borne diseases

17) Paragraph four infers that

a) all vaccinations can be given in a single visit to the doctor’s surgery
b) most people visit the doctor’s surgery six times for their vaccinations
c) vaccination certificates cannot be issued at the same time as the vaccination
d) more than one visit to the doctor’s surgery is usually necessary

18) If you have been vaccinated against a disease in the past

a) it is not necessary to be vaccinated again

223
 b) only the malaria vaccine provides lifelong protection
c) you need to have a new vaccination against malaria each time you travel
d) you should check if you need to have another immunisation

19) Any immunity that a person has against malaria

a) is never lost
b) is effective if they can avoid insect bites
c) doesn’t last a long time if they change locations
d) is better than immunity offered by tablets

20) If people are visiting their home countries

a) they have natural immunities to local diseases
b) vaccinations may depend on the distance they travel
c) it is necessary to take precautions
d) all family members should be immunised

21) In paragraph eight, what does the expression ‘to do so’ refer to?
a) having treatment against malaria
b) being amused
c) living in the country
d) going back home

22) What does the last paragraph tell us about the cost of vaccinations?
a) Amost vaccinations are free in the UK
b) most people have to pay for their vaccinations
c) travel vaccinations are covered by travel insurance
d) everyone has to pay for vaccinations

224
TEST-12
Necrotising Fasciitis
PART A
TEXT 1
Necrotising fasciitis (NF)
NF is a rare but serious bacterial infection that affects the tissue beneath the skin,
and surrounding muscles and organs (fascia). It is often called the "flesh-eating
disease", although the bacteria that cause it don't "eat" flesh – they release toxins
that damage nearby tissue.
NF is caused by bacteria that gain access to the body, often from only a relatively
minor injury, such as a small cut. The conditions gets worse very quickly and can be
life threatening if it's not recognised and treated early on. Around a quarter of
patients with NF will die of their infection, but this varies with the severity of the
infection and the underlying health of the patient.
Quite a few different types of bacteria can cause the disease. However, when they
cause infection elsewhere, many are only associated with mild disease. These include
group A streptococci, a common cause of tonsillitis, and Clostridium perfringens, a
cause of food poisoning. The infection can also be spread from person to person, but
this is very rare.
About 400 cases of NF are diagnosed in Australian hospitals each year, which is
similar to the incidence reported in other countries. Anyone can get necrotising
fasciitis, including young and otherwise healthy people. It tends to affect older
people and those in poor general health

TEXT 2
Contracting necrotising fasciitis

For a person to develop necrotising fasciitis, several factors relating to themselves,

the environment and the presence of certain bacteria all have to be present.

•Patient factors that increase their risk if exposed to bacteria include:

-impaired immunity
226
-obesity

-acne or asthma sufferers

-chronic diseases such as diabetes, peripheral vascular disease

-a breach of the skin such as:

- surgical wounds

- accidental wounds

- intravenous drug use

•Environmental factors that increase risk include:

-coral cuts in marine environments

-contaminated surgical environment or equipment

-contamination of intra venous injected substances

•Bacteria that can lead to issues include:

-Group A streptococci are commonly found in the throat and on the skin and is the
most common bacteria to cause NF

-Vibrio bacteria are gram-negative bacteria that grow well in salty environments

-Aeromonas are Gram-negative, anaerobic bacteria that occur in aquatic

environments

- Cleansing wounds, keeping wound covered and good hand hygiene are the main
ways to prevent necrotising fasciitis

TEXT 3
Symptoms of necrotising fasciitis

The symptoms of NF develop quickly over hours or days. They may not be obvious at
first and can be similar to less serious conditions such as flu, gastroenteritis or
cellulitis. It might take 3 or 4 days for symptoms to fully appear.

227
Skin becoming red, hot and blistered, together with the patient reporting intense
pain in the infected area are the main early symptoms.

Patients with NF report pain that is out of proportion to the changes in skin
condition. This is a key warning sign. The pain remains intense until the necrosis kills
the nerve endings.

Other symptoms include:

-oedema, or swelling

-crackling under the skin

-confusion

-dehydration

-diarrhoea and vomiting

-skin swells and changes colour, turning violet

-areas of tissue turn black and start to die

After 4 or 5 days, septicaemia is likely to develop causing high temperature,

dangerously low blood pressure, and they possible loss of consciousness. Without
treatment, necrotizing fasciitis is always fatal.

TEXT 4
Treatment and outlook
NF needs to be treated in hospital, usually in the intensive care unit

The main treatments are:

•surgery to remove infected tissue which may repeated several times to ensure all
the infected tissue is removed, and occasionally it may be necessary to amputate
affected limbs
•antibiotics, usually several different types, administered intravenously
•supportive treatment of blood pressure, fluid levels and organ functions

228
- People usually need to stay in hospital for several weeks.

NF can progress very quickly and lead to serious problems such as blood poisoning
(sepsis) and organ failure and even with treatment, it is estimated that 1 or 2 in
every 5 cases are fatal.

People who survive the infection are sometimes left with long-term disability as a
result of amputation or the removal of a lot of infected tissue.

They may need further surgery to improve the appearance of the affected area and
may need ongoing rehabilitation support to help them adapt to their disability.

Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once.
In which text can you find information about
1 What conditions can develop in a person with blood
poisoning? _________________

2 Ways to stop develop necrotising fasciitis? _________________

3 The prognosis for people with necrotising fasciitis? _________________

4 The preponderance of necrotising fasciitis diagnosed in Australian

hospitals? _________________

5 Underlying issues that can make person more susceptible to developing

NF? _________________

6 Operations that can be done to treat necrotising fasciitis? _________________

7 The timeframe for symptoms of NF to be full blown? _________________

Questions 8-14

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Answer each of the questions, 8-14, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both.
8 What types of lesions may let bacteria invade the body? _________________

9 What type of pain in the infected area do patients experience?

_________________

10 What type of infection is necrotising fasciitis? _________________

11 Which bacteria is most likely to lead to NF? _________________

12 Which part of a hospital are people with necrotising fasciitis usually treated?
_________________

13 What might a person cut themselves on in an ocean that could lead to them
getting necrotising fasciitis? _________________

14 For every 5 people with necrotising fasciitis, how many are likely to die, even with
treatment_________________

Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from
one of the texts. Each answer may include words, numbers or both.
15 People with necrotising fasciitis say their pain is_________________ to what can
be seen in the area.

16 Symptoms of NF might be vague at first and more like common conditions such
as_________________or cellulitis.

17 People who have conditions such as: _________________obesity and acne or

asthma have a greater chance of developing NF if they are exposed to Group A
streptococci bacteria.

18 Often multiple antibiotics are_________________to treat NF.

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19 NF is more likely to be a problem for_________________and those in poor
general health.

20 NF is commonly known as the_________________.

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 PART B
TEXT 1
Know the Difference: Infiltration vs. Extravasation

Intravenous infiltration is one of the most common problems that can occur when
fluid infuses into the tissues surrounding the venepuncture site. This sometimes
happens when the tip of the catheter slips out of the vein or the catheter passes
through the wall of the vein. If you are concerned an IV is infiltrated, standard
procedures should be followed by, for example, discontinuing the site and relocating
the IV.

Know the Difference: Infiltration vs. Extravasation

An extravasation occurs when there is accidental infiltration of a vesicant or

chemotherapeutic drug into the surrounding intravenous site. Vesicants can cause
tissue destruction and / or blistering. Irritants can result in pain at the site and along
the vein and may cause inflammation. The treatment for extravasation will vary
depending on hospital policy.

Question
1) What should you do if you think an IV is infiltrated?
a) You should terminate the procedure before trying again
b) You should change the catheter
c) You should irrigate the surrounding intravenous site

TEXT 2
Arterial Line Placement

Arterial line placement is a common procedure in various critical care settings. Intra-
arterial blood pressure measurement is more accurate than measurement by non-
invasive means, especially in the critically ill. Intra-arterial blood pressure
management permits the rapid recognition of changes that is vital for patients on
continuous infusions of vasoactive drugs. Overall, arterial line placement is
considered a safe procedure, with a rate of major complications that is below 1%.

Arterial Line Placement

233
In both adults and children, the most common site of cannulation is the radial artery,
primarily because of the superficial nature of the vessel and the ease with which the
site can be maintained. Additional advantages of radial artery cannulation include
the consistency of the anatomy and the low rate of complications.

Question
2) Why is the radial artery usually chosen for cannulation?
a) its low profile anatomy is ideal for primary cannulation
b) the site can be maintained during other non-invasive manipulations
c) it has a shallow position

TEXT 3
Clinically Important Symptoms of PTSD

People with clinically important symptoms of PTSD (Post-Traumatic Stress Disorder)

refer to those who are assessed as having PTSD on a validated scale, as indicated by
baseline scores above clinical threshold, but who do not necessarily have a diagnosis
of PTSD. They are typically referred to in studies that have not used a clinical
interview to arrive at a formal diagnosis of PTSD and instead have only used self-
report measures of PTSD symptoms. Complex PTSD develops in a subset of people
with PTSD. It can arise after exposure to an event or series of events of an extremely
threatening or horrific nature, most commonly prolonged or repetitive events from
which escape is difficult or impossible. The disorder is characterised by the core
symptoms of PTSD; that is, all diagnostic requirements for PTSD are met.

Question
3) According to this article, people with PTSD
a) have a high score on a validated scale, which includes complex PTSD factors
b) have experienced prolonged or repetitive symptoms
c) have not been examined by qualified clinicians

TEXT 4

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How to Assess a Peripheral Intravenous Cannula

Most patients need at least one peripheral intravenous cannula during their hospital
stay for intravenous fluids and medications, blood products or nutrition.
Complications are common but they can be prevented or minimised by routine
assessment. Explanations to patients should be provided, along with education
about the treatment. Ensure the patient knows why the treatment is being given,
and encourage them to speak up if there are any problems, such as pain, leaking,
swelling, etc. The cannula should not be painful. Pain is an early symptom of phlebitis
(inflammation of the vein) and could indicate that the cannula is not working well
and should be removed. Involving the patient and their family empowers them to
voice their concerns, and prompts nurses to address problems and remove

Question
4) According to this article, patients experiencing pain at the cannula site
should
a) tell someone
b) ask for medication to stop leaking and/or swelling
c) remove the cannula in order to avoid phlebitis (inflammation of the vein)
TEXT 5
Japan Approves New Cell Therapy Trial for Spinal Cord Injury

The Japanese government’s health ministry has given the go-ahead for a trial of
human induced stem cells to treat spinal cord injury. The treatment will be tested in
a handful of patients who suffered nerve damage in sports or traffic accidents.
Researchers at Osaka University plan to recruit adults who have sustained recent
nerve damage in sports or traffic accidents. The team’s intervention involves
removing differentiated cells from patients and ‘reprogramming’ them into neural
cells. Clinicians will then inject about two million of these cells into each patient’s
site of injury. The approach has been successfully tested in a monkey, which
recovered the ability to walk after paralysis. These tests follow researcher carried out
at Kyoto University which used cells to treat Parkinson’s disease.

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Question
5) How many people will be involved in the trial?
a) around two million
b) as many patients as possible
c) less than ten

TEXT 6
Steroid Nasal Sprays and Drops

A steroid nasal spray usually works well to clear all the nasal symptoms such as
itching or sneezing. It works by reducing inflammation in the nose. A steroid nasal
spray also tends to ease eye symptoms although it is not clear how this occurs.
However, they can take up to several days to build up to the full effect. Steroid nasal
sprays should be used each day over the hay fever season to keep symptoms away.
However, once symptoms have gone, the amount of steroid spray can often be
reduced to a low maintenance dose each day to keep symptoms manageable. Side-
effects or problems with steroid nasal sprays are rare.

Question
6) How long can a nasal spray be used?
a) While symptoms such as itching or sneezing occur and after
b) Before and during the time symptoms occur
c) Before, during the time symptoms occur and after

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 PART C
TEXT 1
Heat and ice have been used for many years to treat pain and to reduce swelling,
and many people have found them effective. More recently, studies have been done
to investigate whether heat and ice really make a difference to healing and the
results have been inconclusive. In general, when used sensibly, they are safe
treatments which make people feel better and have some effect on pain levels and
there are few harms associated with their use.

Heat is an effective and safe treatment for most aches and pains. Heat can be
applied in the form of a wheat bag, heat pads, deep heat cream, hot water bottle or
heat lamp. Heat causes the blood vessels to open wide (dilate). This brings more
blood into the area to stimulate healing of damaged tissues. It has a direct soothing
effect and helps to relieve pain and spasm. It can also ease stiffness by making the
tissues more supple. If heat is applied to the skin, it should not be hot; gentle
warmth will be enough. If excessive heat is applied there is a risk of burns and scalds.
A towel can be placed between the heat source and the skin for protection. The skin
must be checked at regular intervals.

Heat should not be used on a new injury. It will increase bleeding under the skin
around the injured area and may make the problem worse. The exception to this is
new-onset low back strains. A lot of the pain in this case is caused by muscle spasm
rather than tissue damage, so heat is often helpful. A large-scale study suggested
that heat treatment had a small helpful effect on how long pain and other symptoms
go on for in short-term back pain. This effect was greater when heat treatment was
combined with exercise.

Ice has traditionally been used to treat soft tissue injuries where there is swelling.
However, there is a growing body of evidence which suggests that applying ice packs
to most injuries does not contribute to recovery and may even prolong recovery.
This is related to the fact that reducing the temperature at the site of an injury will
delay the body's immune system response. It is the action of the immune system
which will heal the injury. In one study, some people who used ice said that it was
helpful for managing pain, although this did not translate into a lower use of
painkillers. Many people find that ice is helpful when used to manage pain in the
short term. It is unlikely that it will have much of a negative effect in the long term
when used in this way.

237
A review of studies into the effectiveness of ice treatment found that most studies
were inconclusive and others showed only a small effect. For example, a review of
studies using hot and cold therapy for osteoarthritis of the knee found that ice packs
reduced swelling and that ice massage improved muscle strength and range of
movement. Heat packs had no effect on pain and swelling. No side-effects were
reported to either heat or ice. Another study, which looked at a variety of treatments
for neck pain, found that neither heat nor cold was effective.

In the later, or rehabilitation, phase of recovery the aim changes to restoring normal
function. At this stage the effects of ice can enhance other treatments, such as
exercise, by reducing pain and muscle spasm. This then allows better movement. If
you are doing exercises as part of your treatment, it can be useful to apply an ice
pack before exercise. This is so that after the ice pack is removed the area will still be
a little numb. The exercises can also be done with the ice pack in place. This reduces
pain and makes movement around the injury more comfortable, although it can also
make the muscles being exercised stiffer.

Ice packs can be made from ice cubes in a plastic bag or wet tea towel. A packet of
frozen peas is also ideal and can be used very easily. These mould nicely and can go
in and out of the freezer. However, frozen vegetables should not be eaten if they
have been thawed and re-frozen. Purpose-made cold packs can also be bought from
pharmacies. Take care when using ice and cold packs from a deep freeze, as they can
cause ice burns quickly if used without care and proper protection.

Ideally, ice should be applied within 5-10 minutes of injury and for 20-30 minutes.
This can be repeated every 2-3 hours or so whilst you are awake for the next 24-48
hours. Do not use ice packs on the left shoulder if you have a heart condition. Do not
use ice packs around the front or side of the neck. Both heat and ice can be re-
applied after an hour if needed.

Questions 7-14
7) What have studies shown about heat and ice treatments?
a) Results show heat and ice really make a difference
b) Results are uncertain
c) Results have not been investigated
d) Results show they can cause harm

8) What do we learn about heat in the second paragraph?

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 a) it increases muscle tissue
b) it provokes tissue stiffness
c) it changes the behaviour of the blood flow
d) it can cause muscle spasm

9) What did the study mentioned in the third paragraph find?

a) heat made a problem worse
b) heat triggered muscle spasms
c) heat increased new-onset low back pain
d) heat changed the duration of back pain

10) In the fourth paragraph, what have results shown concerning the use of
ice?
a) Ice could lengthen the time it takes to improve
b) Ice stimulates the body’s immune response
c) Using ice therapies reduces the need for painkillers
d) Ice causes swelling in soft tissue injuries

11) In the fifth paragraph, the review found that

a) heat packs had some small side-effects
b) ice massage had a positive effect on some muscles
c) heat therapy worked best on cases of osteoarthritis of the knee
d) heat treatment was more effective than ice treatment

12) In the sixth paragraph, what positive effect of using ice packs is
described?
a) they eliminate the need for other treatments
b) they make some areas less sensitive to pain
c) they move the pain to a different area
d) they restore normal functions to injured muscles
13) In the seventh paragraph, what does the word ‘these’ refer to?

239
 a) frozen peas
b) ice cubes
c) wet tea towels
d) ice packs

14) How long can ice be applied to an injury?

a) for five to ten minutes
b) no more than half an hour
c) for two to three hours
d) for 24 to 48 hours

TEXT 2
We consider low-dose aspirin so innocuous that we call it baby aspirin. Though we
don’t give it to kids anymore, many adults take it every day (at the recommendation
of their doctor) to stave off heart attacks and strokes. But just as we now know not
to give babies aspirin, expert opinion has shifted on low-dose aspirin for adults, too.
Research in the last few years has made it clear that daily aspirin doesn’t help many
of the people taking it. If anything, it might hurt them.

New guidelines from the American College of Cardiology (ACC) and the American
Heart Association (AHA) say that aspirin, and even baby aspirin should no longer be
prescribed. These principles are largely in line with how other major organizations
have begun to view aspirin. The 2016 European guidelines on cardiovascular disease
prevention don’t recommend it as a primary method of heart attacks or stroke
prevention, and the U.S. Preventive Services Task Force recommends it only for
people in their 50’s with elevated cardiovascular disease risk. For the rest of the
population, it wasn’t clear whether there was a worthwhile benefit.

Aspirin is an antiplatelet drug, which means it prevents blood from clotting as easily.
Forming a blood clot is, of course, a crucial capability—if you couldn’t clot at all,
you’d bleed out from small wounds. But clots that form inside your blood vessels can
block flow entirely, causing a heart attack when that blood fails to get back to your
heart, or a stroke if the clot cuts off blood to part of your brain. In theory, preventing
platelets from doing their job means aspirin should help decrease the risk of both of
these problems. And that’s true, but only for a select group of people.

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The new guidelines note that aspirin is still very much recommended as a secondary
treatment, meaning it definitely helps people who have already had a heart attack or
stroke. These people are at a significantly higher risk of having another incident, and
aspirin can reduce that risk. What physicians are no longer recommending is its
widespread use as a primary treatment, for people who have never had a heart
attack or stroke before. In other words, if you've never had a heart attack, you
probably shouldn't consider it.

So-called baby aspirin may carry a low dose, but patients shouldn't assume that
taking it is harmless. Taking a drug that makes your blood less likely to clot puts you
at risk. If you start bleeding in your intestines or your brain, for instance, your
platelets are supposed to come to the rescue. If you're on daily aspirin, that happens
less effectively. A 2009 study in The Lancet found that there was a small, but not
insignificant increased risk of major bleeds amongst people taking aspirin regularly. A
2016 study found the same thing, as did a 2018 study in The New England Journal of
Medicine. Those same risks exist if you’ve had a heart attack already, but the
benefits you get from taking aspirin start to outweigh the potential downsides once
you're in this category. That trade-off is what the ACC/AHA cite in their revised
recommendations. Once your elevated risk of having a heart attack goes over 10
percent, the guidelines note, it becomes favourable to prescribe aspirin daily. That
goes for anyone between 40 and 70. There’s not enough evidence in people younger
than 40, and adults over 70 have such elevated risk of bleeding that most wouldn’t
do well on daily aspirin regardless of cardiac risk.

The overarching advice for everyone, though, is to discuss with your doctor whether
you should take low-dose aspirin before deciding to do so (or deciding to stop).
These guidelines note that there are likely to be exceptions, and your physician
should be assessing your personal health risks when deciding whether to prescribe
daily aspirin. This isn't actually all that new. Though research from the mid-20th
century suggested aspirin would help everyone, these changes to official
recommendations are based on many years of modern studies, which the ACC/AHA
note are far better designed and more rigorous than anything we’ve had before. If
your doctor scoffs and tells you baby aspirin is a great idea for everyone of a certain
age, their knowledge is out of date.

Reversals in expert opinion are, unfortunately, inevitable—it’s the scientific process

at work. Think of it less as flip-flopping and more as a correction to a formerly
mistaken belief. And please talk to your doctor before you prescribe yourself baby
aspirin.

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Questions 15-22

15) The first paragraph informs us that

a) even babies can have aspirin
b) the viewpoint of experts has changed regarding aspirin
c) aspirin can cause strokes
d) aspirin dosage depends on doctors’ recommendations

16) According to the second paragraph, the European guidelines

a) continue to recommend the use of aspirin
b) harmonize with the American guidelines
c) recommend aspirin for people in their 50’s
d) say that aspirin should not be prescribed to babies

17) The third paragraph informs us that aspirin

a) inhibits blood clotting
b) helps to heal small wounds
c) decreases the production of platelets
d) slows bleeding by stimulating clotting

18) What does the last word of the fourth paragraph refer to?
a) primary treatment
b) secondary treatment
c) aspirin
d) the new guidelines

19) The 2009 study published in ‘The Lancet’ found

a) that aspirin could be a factor in intestinal bleeding
b) risks that were different to the study in ‘The New England Journal of Medicine’
c) daily doses of aspirin were less effective

242
 d) that the risk of major bleeds was relevant

20) The revised recommendations in the fifth paragraph are that

a) people younger than 40 should take aspirin
b) people older than 70 can take aspirin to elevate risks
c) it’s a good idea for middle aged people to take aspirin if they have a higher
risk of heart attack
d) anyone with a high risk of heart attack should take aspirin

21) What do we learn in the sixth paragraph about modern studies?

a) they are superior to older studies
b) they confirm earlier studies about the use of aspirin
c) they quickly become out of date
d) they reveal data that doctors don’t accept

22) In the last paragraph, what does the writer infer about expert opinion?
a) experts shouldn’t keep changing their opinions
b) changes in opinion are unavoidable
c) opinions need to be corrected
d) some opinions are unscientific

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TEST-13
Tobacco Smoking
PART A
TEXT 1
Tobacco Smoking Statistics from the Australian Institute of Health and Welfare
Tobacco smoking is the single most important preventable cause of ill health and
death in Australia. Tobacco smoke contains over 7,000 chemicals, of which over 70,
cause cancer. Lung cancer, chronic obstructive airways disease and coronary heart
disease are the 3 main diseases linked to tobacco smoking.
Smoking-related diseases killed 14,900 Australians in the financial year 2004–05. This
equals 40 preventable deaths every day. Smoking resulted in over 750,000 days
spent in hospital and cost $670 million in hospital costs in the financial year 2004–05.
Smoking kills more men than women – 9,700 men compared to 5,200 women.
Cancer is the number one cause of tobacco-related death in men (57 per cent) and
women (51 per cent), with lung cancer accounting for around 75 per cent and 72 per
cent of cancers for men and women respectively. Lung cancer currently causes the
most cancer deaths in Australia and this is due mainly to smoking.
The trend for tobacco smoking is dropping with 12% of people aged 14 and older
smoking daily in 2016, which is a 24% reduction since 1991. The number of young
people who start smoking is also reducing. In 2010, the average age when 14–24
year-olds smoked their first full cigarette was 14.2, but it was 16.3 in 2016. In 1995,
31% of adults smoked in a home where there were dependent children. In 2016, this
was down to just 2.8%.

TEXT 2
Why do people smoke?

Cigarettes contain nicotine which does not cause the health issues linked to cigarette
smoking but is highly addictive. In small amounts, nicotine causes pleasant feelings
which makes the smoker want more. It does not take long before the time between
cigarettes gets less, because the smoker is keen to get the pleasant feelings they had
before. When a person becomes addicted to nicotine they soon start to have bad

245
feelings like being irritated and edgy when they are ready for another boost of
nicotine.

Most smokers started when they were teens and those who have friends and/or
parents who smoke are more likely to start smoking than those who don’t.

The tobacco industry spends billions of dollars each year to create and market their
products that show smoking as exciting, glamorous, and safe. Tobacco use is also
shown in video games, online, and on TV. Movies showing smokers are another big
influence and studies show that young people who repeatedly see smoking in movies
are more likely to start smoking.

Widespread advertising, price breaks, and other promotions for cigarettes have been
big influences in the past but now many governments are bringing in a lot of ways to
reduce the number of people who smoke.

In Australia, the government:

•does not allow cigarette advertising

•has had cigarettes moved to covered cupboards so they cannot be seen in places
like dairies, petrol stations and supermarkets

•has gradually increased the amount of tax added to a packet of cigarettes

TEXT 3
Stopping smoking is not easy

Common symptoms people have when they stop smoking include:

•Cravings for nicotine which may be strong at first but they

usually only last a few minutes

• restlessness and trouble concentrating or sleeping

• irritability, anger, anxiety, depression

• increase in appetite and weight gain

246
 • Less common symptoms include:

• cold symptoms such as coughing, sore throat and sneezing

• constipation

• dizziness or light-headedness

• mouth ulcers.

The benefits of quitting smoking are:

• immediate health benefits

• a dramatic reduction the risk of smoking-related diseases

Statistics include:

• Quitting before 30 years of age reduces the risk of lung cancer by 90 per cent

• After 15 years of being a non-smoker, the risk of stroke is reduced to that of a

person who has never smoked

• Within two to five years of quitting, there is a large drop in the risk of heart
attack and stroke

TEXT 4
Different support to stop smoking in Australia
• 'Cold turkey' is giving up smoking suddenly, without using medications.
• The prescription medications, bupropion (Zyban) and varenicline (Champix) which
reduce withdrawal symptoms from nicotine.
• Nicotine replacement therapy including patches, gum and lozenges.
• QuitCoach is an online tool developed to assist in quitting smoking.
• Quitline is a telephone service available to smokers who want to quit.
• Acupuncture involves treatment by applying needles or surgical staples to different
parts of the body.
• Hypnotherapy has not been shown to increase the likelihood of quitting in the long
term, although counselling or other treatments that may be offered with it can be
helpful to some smokers
E-Cigarettes/ Vaping are increasingly being used instead of traditional cigarettes.
However, there is limited evidence available on their quality, safety, efficacy for
smoking cessation or harm reduction, and the risks they pose to population health.

247
 In March 2015, the Chief Executive Officer (CEO) of Australia’s National Health and
Medical Research Council (NHMRC) issued a statement stating that: “there is
currently insufficient evidence to conclude whether e-cigarettes can benefit
smokers in quitting, or about the extent of their potential harms. It is recommended
that health authorities act to minimise harm until evidence of safety, quality and
efficacy can be produced”.

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 E-cigarettes and their role in stopping smoking? __________________

2 Statistics about smoking in Australia? __________________

3 The benefits of quitting smoking? __________________

4 The different support to stop smoking in Australia? _____________

5 The addictive features of nicotine? __________________

6 The 3 main diseases linked to tobacco smoking? __________________

7 The common symptoms people have when they stop

smoking? __________________

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 bad feelings might a person have when they are ready for another boost of
nicotine? __________________

9 What therapy includes patches, gum and lozenges? __________________

248
10 How old is a person if their risk of lung cancer reduces by 90 per cent if they stop
smoking? __________________

11 What percentage of adults smoked in a home where there were dependent

children in 2016? __________________

12 Who does not allow cigarette advertising? __________________

13 Who should act to minimise harm until evidence of safety, quality and efficacy of
e-cigarettes can be produced__________________

14 Young people are more likely to start smoking if they see what repeatedly?
__________________

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 12% of people aged 14 and older smoked daily in 2016, which is
a_________________reduction since 1991

16 Common symptoms of nicotine withdrawal include_________________and

depression

17 Cigarettes contain nicotine which does not cause the_________________linked

to cigarette smoking but is highly addictive.

18 Smoking kills more_________________

19 The prescription medications, bupropion (Zyban) and varenicline (Champix) which

reduce_________________from nicotine.

20 The Government in Australia has_________________the amount of tax added to

a packet of cigarettes.

249
 PART B
TEXT 1
The MIST Therapy system for the promotion of wound healing

The MIST Therapy system shows potential to enhance the healing of chronic, 'hard-
to-heal', complex wounds, compared with standard methods of wound
management. If this potential is substantiated, then MIST could offer advantages to
both patients and the hospitals.

However, comparative research has yet to be carried out. Further investigation is

necessary to reduce uncertainty about the outcomes of patients with chronic, 'hard-
to-heal', complex wounds treated by the MIST Therapy system compared with those
treated by standard methods of wound care. This research should define the types
and chronicity of wounds being treated and the details of other treatments being
used. It should report healing rates, durations of treatment (including debridement)
needed to achieve healing, and quality of life measures (including quality of life if
wounds heal only partially).

Question
1) Why should further research be carried out on the MIST Therapy system?
a) To investigate the range of wounds that this system can help to treat
b) To make sure that it offers improvements over the usual treatment option
c) To discover if this system can avoid deleterious outcomes for chronic wounds

TEXT 2
Assessing Risk and Prevention

Falls and fall-related injuries are a common and serious problem for older people.
People aged 65 and older have the highest risk of falling, with 30% of people older
than 65 and 45% of people older than 80 falling at least once a year. The human cost
of falling includes distress, pain, injury, loss of confidence, loss of independence and
mortality. Falling also affects the family members and carers of people who fall.

All people aged 65 or older are covered by all guideline recommendations as they
have the highest risk of falling. According to the guideline recommendations, all

251
people 65 or older who are admitted to hospital should be considered for a
multifactorial assessment for their risk of falling during their hospital stay.

Question
2) What does the article tell us about the risk of falling?
a) People over 65 need extra facilities to help them avoid falls
b) More people over 65 fall in hospital environments compared with other places
c) Only a minority of people over 65 fall at least once a year

TEXT 3
Dealing With Hazmat

One of the most challenging aspects of providing emergency medical care is

attending to patients who have been contaminated with hazardous materials.
HAZMAT is a term used to describe incidents involving hazardous materials or
specialized teams who deal with these incidents. Hazardous materials are defined as
substances that have the potential to harm a person or the environment upon
contact. These can be gases, liquids, or solids and include radioactive and chemical
materials.

The potential for exposure to hazardous materials in the United States is significant.
More than 60,000 chemicals are produced annually in the United States, of which
the US Department of Transportation considers approximately 2000 hazardous.
More than 4 billion tons of chemicals are transported yearly by surface, air, or water
routes.

Question
3) According to this article, what is HAZMAT?
a) Liquid, gaseous or solid materials that are bad for the environment
b) Events where harmful substances are released and the groups that deal with
the aftermath
c) Toxic chemicals that are transported by water, land or air.

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TEXT 4
How Does Blood Clot?

Within seconds of a blood vessel cut, the damaged tissue causes platelets to become
'sticky' and gather together around the cut. These 'activated' platelets and the
damaged tissue release chemicals which react with other chemicals and proteins in
the plasma, called clotting factors. A complex series of reactions involving these
clotting factors then occurs rapidly. Each reaction triggers the next reaction and this
process is known as a cascade.

The final chemical reaction is to convert a clotting agent called fibrinogen into thin
strands of a solid protein called fibrin. The strands of fibrin form a meshwork and
trap blood cells which form into a solid clot.

Question
4) According to this article, what is a cascade?
a) A series of events
b) The process that occurs when platelets become sticky
c) The reaction that precedes the formation of fibrin

TEXT 5
At the onset of a migraine attack, the patient should be given a full dose of painkiller.
For an adult this means 900 mg aspirin (usually three 300 mg tablets) or 1000 mg of
paracetamol (usually two 500 mg tablets). This dose can be repeated every four
hours if necessary. Soluble tablets have the advantage of being absorbed more
quickly than solid tablets.

253
Codeine and medicines containing codeine, such as co-codamol, are not
recommended for the treatment of migraine. This is because codeine can make
feeling sick (nausea) and being sick (vomiting) worse, which can aggravate the
migraine. They are also more likely than paracetamol or aspirin to cause a condition
called medication-overuse headache if they are used frequently.

Question
5) What do we learn about migraine treatment from this article?
a) Paracetamol doses should not exceed 1000mg
b) Aspirin can cause nausea and/or vomiting
c) Codeine can provoke conditions other than migraine

TEXT 6
Not all patients can independently move or position themselves in bed and their
immobility may be due to a wide range of factors. Positioning patients in good body
alignment and changing position regularly are essential aspects of nursing practice. It
is vital to provide meticulous care to patients who must remain in bed. Healthcare
givers’ measures should ensure to preserve the joints, bones and skeletal muscles
and must be carried out for all patients who require bed rest.

Positions in which patients are placed, methods of moving and turning should all be
based on the principles of maintaining the musculoskeletal system in proper
alignment. In addition, the health care provider must also use good body mechanics
when moving and turning patients to preserve his or her own musculoskeletal
system from injury.

Question
6) What information does the article give us about positioning patients?
a) Healthcare givers should position immobile patients in accordance with the
doctor’s instructions
b) Positioning patients is a fundamental part of a nurse’s job

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 c) Improper musculoskeletal manipulation can lead to immobility

PART C
TEXT 1
Once the preserve of hippies and activists, veganism has now hit the mainstream.
Forgoing meat, dairy and eggs is more popular than ever. While it’s positive that
people are taking a more ethically-conscious approach to food shopping, what
nutrients could vegetarians and vegans put themselves at risk of losing out on? And
how can you approach animal-free consumption in a healthy way?

Generally, people choose to be vegetarian or vegan for ethical reasons or because

they want to improve their health. A vegan diet is usually low in saturated fats and
rich in fruit and vegetables. 'Meat-free Monday' is a UK campaign, launched by Paul
McCartney in 2009, to encourage people to reduce their environmental impact and
improve their health by having at least one meat-free day each week. More and
more people are realising this is far more manageable than they first thought. When
you stop thinking a meal needs meat to be complete, vegetarian options start to look
a lot more appealing.

If you've decided to give up meat and have vowed to eat more vegetables, that's a
good first step. But vegetarians and vegans do have to be careful they're not missing
out on nutrients most easily found in meat and dairy sources. Protein is one of them.
Protein builds and repairs tissues and is a building block of bone, muscles, skin and
blood. It isn’t stored in your body, so you need to make sure you're getting enough
from your diet.

Unfortunately for vegetarians, meat is a rich source of this macronutrient. "Whilst

many plant-based foods contain protein too, they may not contain protein in the
correct balance that the body needs. Therefore, vegetarians need to make sure they
eat a combination of foods to achieve the right protein balance," says Dr Jan
Sambrook, a doctor who specialises in nutrition. Luckily, you can also find protein in
grains, pulses and dairy products. "If you eat any two of these, the protein will
balance," reveals Sambrook. "This doesn't necessarily need to be within a single
meal, as was previously thought. Examples of protein-balanced meals include cereal
with milk, or baked potato with beans and cheese."

A balanced vegetarian or vegan diet generally gives you plenty of vitamins. But if
you're not sure, there are some foods to look out for when it comes to specific
nutrients. "Vitamin A is found in eggs and dairy products. A different form of the

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vitamin, called beta carotene, is found in dark green leafy vegetables and in coloured
fruits and vegetables such as mango, carrots and red peppers," explains Sambrook.
Vitamin D, 'the sunshine vitamin', is also really important. It helps your body absorb
calcium and is also needed for our muscles to work properly. More recently, vitamin
D deficiency has been associated with numerous conditions, from heart disease, to
dementia and multiple sclerosis. "Vitamin D is mainly made in our skin by the action
of sunlight. However, it is also found in dairy products, mushrooms and in fortified
cereals and margarine," says Sambrook. "Oily fish and eggs are also among the top
dietary sources of vitamin D, so if you're adopting a vegan diet you're less likely to be
getting enough."

Most of the minerals we need are found in a wide variety of foods and anyone eating
a balanced diet can obtain enough of them. However, vegetarians and vegans must
make sure they're getting enough calcium and iron. Recently, the National
Osteoporosis Society (NOS) warned that the popularity of 'clean eating' and other
diets where major foods groups are cut out is setting young people up for a future of
weak bones. "Without urgent action being taken to encourage young adults to
incorporate all food groups into their diets and avoid particular 'clean eating'
regimes, we are facing a future where broken bones will become just the norm," said
Susan Lanham-New, a nutrition professor and clinical advisor to the NOS.

Vegans, who normally don’t consume dairy products, may find it challenging to
obtain calcium in their diet. "Calcium is, however, also present in leafy green
vegetables, dried figs, almonds, oranges, sesame seeds, seaweed and some types of
bean," reveals Sambrook. She explains that if non-dairy calcium is eaten with a
source of vitamin D, this will help the body absorb it.

You need iron in order for your blood to carry oxygen around your body. If you don't
get enough, you become anaemic. Whether we like it or not, red meat is the richest
dietary source of iron. But there are a few meat-free sources too. "Vegetarian
sources of iron include pulses such as chickpeas and lentils, sprouted seeds and
beans, breakfast cereals and bread. Spinach is famous for containing iron, but it is
also found in other green leafy vegetables such as broccoli and kale," explains
Sambrook. She adds that your body can absorb iron from food more easily if it is
eaten with vitamin C.

Questions 7-14
7) The first paragraph implies that
a) Becoming a vegan is an ethical choice

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 b) Hippies and activists have always been vegan
c) Food-shopping for animal-free products is essential for vegans
d) Being a vegan has potential drawbacks

8) Paul McCartney’s 2009 campaign

a) Helped the number of people who understand that meat-free cooking is
possible to increase
b) Was designed to help the environment for animals
c) Showed that vegetarian meals can be more attractive than meals prepared
with meat
d) Was aimed at reducing saturated fats in processed food

9) What do we learn about protein in the third paragraph?

a) The human body only has a small reserve of protein
b) Without protein, bones and muscle tissues may build more slowly
c) Levels of protein in your body need to be replenished regularly
d) It is not possible to find protein in meat-free diets

10) According to the fourth paragraph, how can vegans and vegetarians
consume the right kinds of protein?
a) They should stick to basic food groups, such as grains or pulses
b) They should have a mixture of food types
c) They should eat vegetables that contain the same macronutrients as dairy
products
d) They can enhance their diet by taking food supplements
11) What does the fifth paragraph tell us about vitamin deficiency?
a) Vegans can get enough vitamin D from sunlight on their skin

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 b) Coloured fruits and vegetables are good sources of vitamin D
c) Incidence of heart disease, dementia and multiple sclerosis among vegetarians
is the same as among vegans
d) Vegans have a higher than normal risk of vitamin D deficiency

12) What is the National Osteoporosis Society (NOS) concerned about?

a) Young people can cut themselves
b) More vegetarians and vegans will develop Osteoporosis
c) There may be a rise in a specific type of injury
d) Some people are not eating enough clean food

13) What does ‘it’ (the last word of the seventh paragraph) refer to?
a) Calcium
b) Vitamin D
c) Vitamin A
d) Protein

14) What does the last paragraph say about iron?

a) Vitamin C and iron consumed together is good for iron absorption
b) Vegans should consider eating red meat
c) You can become anaemic if you don’t eat enough vegetables
d) For oxygen-carrying blood cells, vitamin C is more important than iron

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TEXT 2
Jennifer Millar keeps rubbish bags and hand sanitizer near her tent, and she regularly
pours water mixed with hydrogen peroxide on the pavement nearby. Keeping herself
and the patch of concrete she calls home clean is her top priority. But this homeless
encampment near a Hollywood freeway slip road is often littered with needles and
rubbish. Rats occasionally run through, and Millar fears the consequences. “I worry
about all those diseases,” said Millar, 43, who said she has been homeless most of
her life.

Infectious diseases, including some that ravaged populations in the Middle Ages, are
resurging in California and around the country and are hitting homeless populations
especially hard. Los Angeles recently experienced an outbreak of typhus in city
centre streets, a disease spread by infected fleas on rats and other animals. Officials
briefly closed part of the City Hall after reporting that rodents had invaded the
building. Hepatitis A, also spread primarily through faeces, has infected more than
1,000 people in Southern California in the past two years. The disease also has
erupted in New Mexico, Ohio and Kentucky, primarily among people who are
homeless or use drugs.

Public health officials and politicians are using terms like “disaster” and “public
health crisis” to describe the outbreaks, and they warn that these diseases can easily
jump beyond the homeless population. “Our homeless crisis is increasingly becoming
a public health crisis,” California Governor Gavin Newsom said in his State of the
State speech in February, citing outbreaks of hepatitis A, syphilis and typhus in Los
Angeles.

Those infectious diseases are not limited to homeless populations, Newsom warned.
“Even someone who believes they are protected from these infections may not be.”
At least one Los Angeles city employee said she contracted typhus in the City Hall last
fall. And San Diego County officials warned in 2017 that diners at a four-star
restaurant were at risk of hepatitis A. Last month, the state announced an outbreak
of typhus in Los Angeles city centre that infected nine people, six of whom were
homeless. After city workers said they saw rodent droppings in City Hall, Los Angeles
City Council President Herb Wesson briefly shut down his office and called for an
investigation.

The infections around the country are not a surprise, given the lack of attention to
housing and health care for the homeless and the dearth of bathrooms and places to
wash hands, said Dr. Jeffrey Duchin, the health officer for Seattle, Washington State.

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“It’s a public health disaster,” he said. In his area, Duchin said, he has seen
shigellosis, trench fever and skin infections among homeless populations.

In New York City, where more of the homeless population lives in shelters rather
than on the streets, there have not been the same outbreaks of hepatitis A and
typhus, said Dr. Kelly Doran, an emergency medicine physician and assistant
professor at NYU School of Medicine. But Doran said different infections occur in
shelters, including tuberculosis, a disease that spreads through the air and typically
infects the lungs. These diseases sometimes get the “medieval” moniker because
people in that era lived in squalid conditions without clean water or sewage
treatment. People living on the streets or in homeless shelters are vulnerable to such
outbreaks because their weakened immune systems are worsened by stress,
malnutrition and sleep deprivation. Many also have mental illness and substance
abuse disorders, which can make it harder for them to stay healthy or get health
care.

One recent February afternoon, Community Clinic physician assistant Negeen

Farmand walked through homeless encampments in Hollywood carrying a backpack
with medical supplies. She stopped to talk to a man sweeping the sidewalks. He said
he sees “everything and anything” in the gutters and hopes he doesn’t get sick. “To
get these people to come into a clinic is a big thing,” she said. “A lot of them are
distrustful of the health care system.” On another day, 53-year-old Karen Mitchell
waited to get treated for a persistent cough by St. John’s mobile health clinic. She
also needed a tuberculosis test, as required by the shelter where she was living.
Mitchell, who said she developed alcoholism after a career in pharmaceutical sales,
said she has contracted pneumonia from germs from other shelter residents.
“Everyone is always sick, no matter what precautions they take.”

During the hepatitis A outbreak, public health officials administered widespread

vaccinations, cleaned the streets with bleach and water and installed hand-washing
stations and portable toilets near high concentrations of homeless people. But
health officials and homeless advocates said more needs to be done, including
helping people access medical and behavioural health care and affordable housing.
“It really is unconscionable,” said Bobby Watts, CEO of the National Homeless
Council, a policy and advocacy organization. “These are all preventable diseases.”

Questions 15-22
15) What is the most important thing for Jennifer Miller?
a) Avoiding diseases

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 b) Sanitizing her immediate environment
c) Finding a permanent home
d) Stopping rats and other rodents

16) What does the second paragraph tell us about Hepatitis A?

a) The recent outbreak was not confined to California
b) Hepatitis A is transmitted by fleas on rats and other animals
c) More than 1000 contracted the disease through sharing dirty needles
d) Some people in the City Hall now have Hepatitis A.

17) What problem did California Governor Gavin Newsom highlight?

a) Hepatitis A, syphilis and typhus have jumped into the homeless population
b) Politicians are not doing enough to stop the outbreak
c) The health situation in his state (California) is now a ‘disaster’
d) There is a link between public health and homelessness

18) What statistic is given in the fourth paragraph?

a) Four percent of restaurants were at risk of hepatitis A
b) Two thirds of typhus cases in Los Angeles city centre concerned people living
on the streets
c) Nine out of ten people are concerned about the crisis
d) Ninety percent of people believe they are protected from these infections

19) What does Dr. Jeffrey Duchin think?

a) The infections are surprising
b) There are insufficient washing facilities

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 c) Shigellosis and trench fever have disastrous consequences
d) More houses should be built for the homeless

20) What does the sixth paragraph help us to understand?

a) The conditions in New York shelters are worse than those in Los Angeles
b) Tuberculosis infections could be due to poor sewage treatment
c) Homeless people are more susceptible to these diseases for a number of
reasons
d) The pathology of these diseases has not changed since medieval times

21) What problem does Karen Mitchell have?

a) She has a chronic cough
b) She lost her job in pharmaceutical sales
c) She has to go to a new shelter
d) She has tuberculosis

22) In the final paragraph, what else needs to be done?

a) A Install more portable toilets and hand-washing stations
b) B Prevent more diseases
c) C Give free health care to homeless people
d) D Give assistance to people who want medical help or an inexpensive place to
live

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TEST-14
Stroke
PART A
TEXT 1
Stroke
A Cerebro-vascular accident (CVA)is commonly called a stroke. It happens when the
blood supply to the brain is interrupted. Blood contains oxygen and important
nutrients for your brain cells through a network of arteries. Blood flow may be
interrupted or stop moving through an artery because the artery is blocked
(ischaemic stroke) or bursts (haemorrhagic stroke). When brain cells do not get
enough oxygen or nutrients, they die. The area of brain damage is called a cerebral
infarct. Brain cells usually die shortly after the stroke starts. However, some can last
a few hours if the blood supply is not cut off completely.
Stroke is a largely preventable event and many risks can be reduced by making
lifestyle changes. There are other reasons that people have a stroke. If someone in a
persons close family, such as a sibling or parent, has had a stoke, then that person
has higher risk of having one too. If the person themselves has had a stroke or heart
attack then they are at risk. Men have stokes more often than women and people
aged over 65 are more likely to have a stroke than younger people.
Lifestyle factors likely to increase stroke risk are being overweight or obese, doing
very little regular exercise or having long term stress.Cigarette smoking is closely
linked to stroke but drinking too much alcohol and/or caffeine and having a lot of
food that has cholesterol in it, are also key causes of a person having a stroke

TEXT 2
Incidence of stroke in Australia
Information from the Australian Institute of Health and Welfare tells us that:
• in Australia, in 2013–14, there were 37,000 admissions to hospital for acute
care of stroke and 28,000 admissions for rehabilitation care for stroke
• the average length of stay in acute hospital care was 8 days, and in
rehabilitation care, 14 days
• between 2003–04 and 2013–14, stroke admission rates fell by 15%

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 • an increasing number of dedicated stroke units in hospitals are showing
significant improvements the health outcomes of patients
• two-thirds (67%) of patients received care stroke units in 2015

Death from stroke in Australia is getting less.

TEXT 3
The chances of a full or near complete recovery from a stroke increase significantly if a
person gets treatment as soon as possible. This means people need to be able to
recognise the signs and symptoms that a person is having a stroke so they can call an
ambulance.
The signs and symptoms of a stroke vary from person to person but usually begin
suddenly. The symptoms will depend upon the part of your brain affected and the
extent of any damage.
It is helpful to remember the word (acronym) 'FAST': Face-Arms-Speech-Time to
check if someone may be having a stroke.
• Face – the face may have dropped on one side, the person may not be able to
smile or their mouth or eye may have drooped.

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• Arms – the person with the suspected stroke may not be able to lift one or both
arms and keep them there because of arm weakness or numbness.

• Speech – their speech may be slurred or garbled, or the person may not be able
to talk at all despite appearing to be awake.

• Time – it is time to call for an ambulance immediately if you see any of these
signs or symptoms.
When the person gets to hospital they need to have the type of stroke they have
experienced diagnosed quickly. Tests that are commonly used include a
computer tomography (CT) scan, a magnetic resonance imaging (MRI) and an
angiogram.
- Ischaemic stroke is the most common and this is treated by getting the blood
supply returned to the affected area of the brain. This means the clot has to be
dissolved by giving the patient a dissolving agent through an intravenous drip.

TEXT 4
Rehabilitation following a stroke
As soon as the person is medically stable, rehabilitation starts. Strokes can cause
weakness or paralysis in one side of the body. Many people also have problems with
co-ordination and balance, and suffer from extreme tiredness (fatigue) in the first
few weeks after a stroke.
Rehabilitation is the therapy and activities that helps the person to re-learn or find
new ways of doing things that were affected by the stroke. It aims to stimulate the
brain’s ability to change and adapt, which is called neuroplasticity. By creating new
brain pathways, a person may learn to use other parts of the brain to recover the
functions of those parts that were affected by the stroke.
Physiotherapy focuses on setting goals and providing an exercise plan to improve
posture and balance. Speech and language therapy helps with problems with
communication, including difficulty speaking and understanding others.
The most rapid recovery occurs in the first 3 months after a stroke. Further recovery
is possible, but gains are usually slower and may take years.

Questions 1-7
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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 reasons people have a stroke? _____________________

2 The types of rehabilitation a person may have after a

stroke? _____________________

3 The signs and symptoms of a stroke? _____________________

4 The death rate from stroke in Australia? _____________________

5 The most common type of stroke? _____________________

6 The role of speech and language therapy in stroke

rehabilitation? _____________________

7 The lifestyle factors that are likely to increase the risk of

stroke? _____________________

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 How many people in Australia went into hospital for acute stroke care?
_____________________

9 What part of a stroke rehabilitation programme focuses on setting goals and

providing an exercise plan to improve posture and balance?
_____________________

10 What type of stroke occurs is an artery in the brain bursts?

_____________________

11 Which word is useful to check if someone may be having a stroke?

_____________________

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12 What is the brain’s ability to change and adapt called? _____________________

13 What kind of hospital units are showing significant improvements in the outcomes
for stroke patients? _____________________

14 How might a person’s speech sound if they are having a stroke?

_____________________

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 If a person is having a stroke you may notice their face
has_____________________on one side.

16 _____________________from stroke in Australia is getting less.

17 The most_____________________ occurs in the first 3 months after a stroke.

18 A stroke happens when the_____________________ to the brain is interrupted

19 The average length of stay in rehabilitation care

was_____________________ days.

20 The clot has to be dissolved by giving the patient

a_____________________ through an intravenous drip.

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 PART B
TEXT 1
E-Cigarettes May Threaten Goal of Achieving Tobacco Endgame

E-cigarettes have become the most popular tobacco products for youth and
adolescents in the United States and offer new pathways to nicotine addiction. These
products may be beneficial for helping some smokers quit or move to less harmful
products, but their long-term effects and net public health impact are unclear.
Concern is increasing that use of newer tobacco products may catalyse transition to
use of other tobacco products or recreational drugs. Robust U.S. Food and Drug
Administration regulation of all tobacco products is needed to avoid the economic
and population health consequences of continued tobacco use. The American Heart
Association supports minimizing use of all combustible tobacco products first, while
ensuring that other products do not addict the next generation of young people.

Question
1) What does this article tell us about e-cigarettes?
a) Long-term use of e-cigarettes is harmful
b) The catalyst used in e-cigarettes can be dangerous
c) It is thought that e-cigarettes could be useful in some circumstances.

TEXT 2
Echocardiography

The use of echocardiography as an imaging tool has increased substantially over the
past decade. Cardiologists perform most echocardiography studies, with internists
being the next most common providers of these studies. Tissue Doppler imaging
provides information about movement of cardiac structures. The relation between
the dynamics of cardiac structures and the hemodynamics of the blood inside these
structures provides information about cardiac diastolic and systolic function.

Dedicated training for competent performance and interpretation of

echocardiography is essential. The American College of Cardiology has
recommended a set of minimum knowledge and training requirements for the
performance and interpretation of echocardiography, including a minimum number

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of 150 performed and 300 interpreted examinations for level 2 competency in
interpreting echocardiography.

Question
2) What do we learn about echocardiology from this article?
a) Different types of information are combined to give an overall picture
b) Only cardiologists with a minimum level 2 qualification should interpret
echocardiographs
c) Movement of cardiac structures should be kept to a minimum during the
imaging process

TEXT 3
Intubation Procedure

This will follow administration of an induction agent (which may be intravenous or

inhalational or a combination of both) and a muscle relaxant. Intubation attempts
should not last for longer than 30 seconds. Begin by keeping your right hand free - it
will be needed to open the mouth, control the head and to use suction, etc. Inspect
the mouth for loose teeth or for dentures. If any are found, they should be removed.
Once a satisfactory view of the airway is available, the procedure can begin. Hold the
laryngoscope in the left hand and introduce the laryngoscope over the right side of
the tongue, sweeping the tongue to the midline. Position the tip of the blade in the
vallecula and lift upwards and away from yourself until the glottis is visualised.

Question
3) What does this article say about intubation attempts?
a) If the first attempt doesn’t succeed, more muscle relaxant can be
administered
b) More than one procedure can be tried, for a maximum duration of half a
minute
c) If the first intervention is unsuccessful, try putting the laryngoscope in your
other hand for the second attempt

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TEXT 4
Most Americans Report Good Health

Most Americans report having excellent or good health and have a usual place to go
for medical care, according to a report published recently for the National Health
Survey. The researchers note that from January to September 2018, 87.7 percent of
people had a usual place to go for medical care, which was not significantly different
from the 2017 estimate of 88.3 percent. From January to September 2018, 4.7
percent of persons failed to obtain needed medical care at some time during the
previous 12 months, which did not differ significantly from 4.5 percent in 2017. The
percentage of people who had excellent or very good health was 66.3 percent for
January to September 2018, which showed many similarities to the statistic for 2017,
which was 66.4 percent.

Question
4) What does the following report say about healthcare in the USA?
a) There were negligible differences between the reports
b) A significant number of people do not have usual medical care
c) In terms of healthcare provision (including perceived wellness), the overall
trends are positive

TEXT 5
The Management of Self-Harm in Primary Care

Primary care has an important role in the assessment and treatment of people who
self-harm. Careful attention to prescribing drugs to people at risk of self-harm, and
their relatives, could also help in prevention. When an individual presents in primary
care following an episode of self-harm, healthcare professionals should urgently
establish the likely physical risk, and the person's emotional and mental state, in an
atmosphere of respect and understanding.

All people who have self-harmed should be assessed for risk, which should include
identification of the main clinical and demographic features and psychological
characteristics known to be associated with risk, in particular depression,
hopelessness and continuing suicidal intent. The outcome of the assessment should

272
be communicated to other staff and organisations who become involved in the care
of the service user.

Question
5) What does this article tell us about the management of self-harm in
primary care?
a) Primary care providers must not administer drugs if the person appears to be
hopeless or suicidal
b) Clinical and demographic information is vital in determining risk of further
self-harm
c) Evaluation results need to be passed on to other concerned agencies

TEXT 6
Current Treatments: Migraines

Paracetamol and aspirin both work well for many migraine attacks. Doses should be
taken as early as possible after symptoms begin. The severity of the headache can be
significantly reduced if painkillers are taken early enough. A lot of people do not take
a painkiller until a headache becomes severe which is often too late for the painkiller
to work well.

Strictly speaking, aspirin is an anti-inflammatory painkiller. Recently, as it has

become associated with stomach bleeding, aspirin has fallen from favour for the
treatment of many painful conditions. However, for migraine, it is often worth a try.
Recent studies have confirmed that aspirin either takes away migraine pain, or
greatly reduces the pain, within two hours in more than half of the people who take
it.

Question
6) What does this article say about the use of aspirin for migraine
treatment?
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 a) Aspirin is no longer prescribed for migraines
b) The risks of using aspirin have to be weighed up with the potential benefits
c) Over 50% of sufferers found that aspirin was helpful

PART C
TEXT 1
It’s hard to keep up with the message on eggs. Are they good for you or not? In the
1960s, people were told: “Go to work on an egg.” But in the 1970s the public was
advised to avoid eggs because they were linked to high blood cholesterol. The
negative press on eggs continued in the 1980s when raw eggs were linked to
salmonella poisoning. The message changed in 1999 when a study, published in a
leading medical journal, found no link between egg consumption and the risk of
cardiovascular disease. This lack of a relationship between egg consumption and
cardiovascular disease was reaffirmed in 2013 in an analysis of 17 reports of studies
involving over three million participants. Indeed, eggs seemed to have been
rehabilitated as part of a healthy diet, so much so that it became fashionable to keep
chickens.

But now the doom merchants are back, warning that eggs can kill. This latest report,
published in JAMA, followed nearly 30,000 participants for an average of 17 years. Of
these 5,400 had a cardiovascular disease “event” (heart attack or stroke). The
researchers found that each egg consumed was associated with a 2.2% greater
absolute risk of cardiovascular disease over the follow-up period (roughly 22 extra
cases of cardiovascular disease per 1,000 participants). The statistical methods used
were robust, and the pooled data from six studies represents the ethnic diversity of
the U.S. population and the diets of ordinary Americans.

The study’s limitations are the dependence on a single measure of dietary intake at
the start of the study and the strong correlation of egg intake with obesity and
unhealthy lifestyles, such as smoking, eating lots of red and processed meat, and not
eating a lot of fruit and veg. Statistical adjustments were made to correct these
confounding factors. However, these corrections are imperfect and invalid when the
correlations with egg intake is very strong. For example, in the U.S. eggs are often
eaten with bacon, sausages, or burgers, so it’s impossible to disentangle the effects
on CVD risk of eggs from these fatty meat products. Also, the increased risk was
much greater than would be predicted from the known effects of eggs on blood

274
cholesterol levels. These findings need to be considered in the context of the North
American dietary pattern because they may not apply to other dietary patterns,
especially Asian.

The average egg consumption in most countries is usually only three or four eggs a
week. A medium-sized egg provides 226mg cholesterol and average cholesterol
intakes typically range between 200-250mg per day. It is easy to be confused by a
high blood cholesterol level, which increases the risk of cardiovascular disease, and
its relationship with dietary cholesterol, which is mainly provided by eggs. Very high
blood cholesterol levels are usually inherited or caused by a lack of some hormones
(such as thyroid hormone). But moderate increases in blood cholesterol are related
to diet.

Most adults in North America, Europe, and Australasia have moderately increased
blood cholesterol levels as a result of middle-aged spread, saturated fat intake and,
to some extent, cholesterol intake. Randomized controlled trials, where participants
are fed increasing amounts of eggs, have found that each 200mg of cholesterol from
eggs increases the harmful form of blood cholesterol by only a 3% rise.

Between a quarter and a third of the population inherit a version of the APOE gene
called e4 that makes them much more sensitive to dietary cholesterol than those
who carry the more common e3 version. They can show a 10% increase in LDL
cholesterol with dietary cholesterol from eggs. There is also variability on how much
cholesterol is absorbed. Most of the cholesterol in the small intestine is derived from
bile secreted from the liver rather from eggs. Plant sterols, which are added to some
foods, such as yogurt drinks and margarine, block cholesterol absorption and lower
LDL cholesterol by up to 10%. So even people with the e4 gene can eat eggs without
increasing their LDL cholesterol if they consume plant sterols in the same meal.

The American diet contains large amounts of meat and eggs, and it seems probable
that a high intake of cholesterol (equal to two to three eggs a day) adds to the risk of
cardiovascular disease, particularly in people with type 2 diabetes. There is also good
reason to caution younger people about the risks of following the fad of high-protein
diets that may include eating several eggs a day. Otherwise, eating eggs in
moderation (three to four eggs a week) makes a useful contribution to nutrient
intake and is harmless.

Questions 7-14
7) What does the first paragraph tell us about medical opinions concerning
egg consumption?
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 a) Although some experts have changed their opinion, eggs are still unsafe
b) Salmonella poisoning is no longer associated with egg consumption
c) Over the years, advice has been inconsistent
d) The risk of cardiovascular disease can be reduced by cutting your egg
consumption

8) What does the report in JAMA highlight?

a) Heart attacks and strokes occurred over a period of 17 years
b) Even eating just one egg had a quantifiable risk
c) Patients with robust health had fewer cardiovascular “events”
d) Egg consumption was not uniform across all ethnic groups

9) What does the third paragraph tell us about the study’s limitations?
a) Statistical adjustments are able to cancel out the factors of unhealthy diet
b) It is possible to isolate the clinical effect of egg consumption
c) Modifying the data does not alter the study’s key findings
d) People in the study were not permitted to eat a lot of fruit or vegetables

10) The study mentioned in the third paragraph

a) might have found different results among specific ethnic groups
b) should have included results among vegetarians
c) could be misinterpreted due to the known effects of eggs on blood cholesterol
levels
d) should be reanalysed to take into account North American dietary patterns

11) What do we learn about cholesterol from the fourth paragraph?

a) Cardiovascular disease has a strong correlation to dietary cholesterol
consumption
b) Eggs do not contain the dangerous form of cholesterol
c) Cardiovascular disease can be inherited
d) It is not easy to isolate the effect of dietary cholesterol

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12) In paragraph five, what were the findings of the randomized controlled
trial?
a) Cholesterol increases from egg consumption were really small
b) Middle aged people had higher levels of cholesterol
c) Even just 200mg increase of cholesterol was dangerous
d) Some participants in the study were allergic to eggs

13) What do we learn from the sixth paragraph?

a) The e3 gene is more sensitive to dietary cholesterol than other types of the
gene
b) Bile secreted from the liver can cancel out the effects of dietary cholesterol
c) Less than half of the population get the e4 gene from their parents
d) Neither the e3 nor the e4 gene reduce sensitivity to plant sterols

14) What does the last paragraph help us to understand?

a) People with type 2 diabetes should not eat eggs
b) Eating three to four eggs a week is worse than eating several eggs in one day
c) Young people are not concerned by high levels of cholesterol consumption
d) Some fashionable diets can have harmful effects

TEXT 2
By the age of 50, half of all men will have noticeable hair loss. By the age of 60, it will
affect around two thirds. The majority of men, therefore, will at some point in their
life, have hair loss. It's so common, in fact, going bald could be considered a normal
part of being male. It's actually more unusual not to go bald. Yet despite how
common male pattern baldness is, it causes untold distress and anguish to men. It's
strongly associated with the development of depression, anxiety and poor self-
image.

I work in mental health and I see a surprising number of men who confide in me that
the distress they experienced from their hair loss has led to their mental health

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problems. Yet men rarely discuss openly how much upset their hair loss is causing
them. It's a shameful secret. Sometimes the first anyone knows that it's even been
on their mind is when they have a hair transplant.

I have one friend, let’s call him Steve, who started going bald in his 20s. He was so
upset about it, he told me later, that he would sometimes feel unable to leave the
house. He had stubble tattooed on to his head (an increasingly popular intervention
that looks very convincing) to give him a full hairline. His wife, who he met after the
procedure still doesn't know that what she thinks is his hair is actually a clever
tattoo. I find it incredible that they've been together five years, yet Steve still doesn't
feel able to open up to her about his hair loss and what he's had done but it shows
how sensitive this is for men.

Even more take anti-hair loss medication, such as finasteride, on the quiet. It seems
astonishing that something that is going to affect the majority of us at some point in
our lives is still considered so shameful and embarrassing. Those who try to do
something are mocked for being vain, while those who are balding are mocked and
ridiculed for being old and unattractive. I know of at least four of my friends taking
finasteride, and that's just those who have confided in me. I suspect there are many
more, but they feel unable to discuss it because hair loss is such a sensitive issue for
so many men.

What's more, it doesn't just affect older men. A fifth of men will experience
significant hair loss by the age of 20, meaning that this is something that is an issue
affecting many of us, both young and old alike. There's an enduring idea that a man's
hair is linked with ideas of strength and power - think of the biblical story of Samson
and Delilah, where the source of his strength was his hair until she cut it off while he
was sleeping. The image of a fat, balding old man who is mocked because of his looks
strikes horror into the heart of many young men who find themselves thinning.
Because of its association with ageing, baldness reminds us of our mortality. It
speaks on a deep level to how we perceive ourselves and how we think others view
us. There is a sense of powerlessness and impotence - our bodies out of control.
Anxieties around hair loss often get bound up with other anxieties about our bodies
and feed into insecurities about our appearance or low self-esteem.

Of course, many men are able to embrace their thinning hair, such as the actors
Bruce Willis and Jason Statham. Some guys adopt a close-shaved look and frame it in
terms of evidence of their masculinity and manliness. For those who struggle to
accept the change and lament their hair loss, there is a multi-million-dollar industry
that, I'm sorry to say, promises a lot but tends not to deliver.

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There is no magic pill or miracle surgery to reverse hair loss. Even finasteride only
actually causes re-growth of hair in a small number of people who take it, with it
simply slowing the rate of loss for most. It only provides about 30% improvement in
hair loss over six months. Hair grafts and transplants have limitations and are very
costly with results varying considerably. Shampoos and lotions and potions have
limited - if any - effect.

That's why I often recommend men who are struggling with going bald see a clinical
psychologist to have a course of cognitive behavioural therapy (CBT) to address their
distress and help them to change their thinking about their hair loss. It sounds
unlikely, but it really does work. The fact is, it is much easier - and cheaper - to learn
to accept the hair loss than it is to reverse it.

Questions 15-22
15) In the first paragraph, what does the writer claim about the effects of
hair loss?
a) Two thirds of all men are affected by hair loss
b) It is linked to an increase in mental health issues
c) Most men lose as much as two thirds of their hair
d) Male pattern baldness is noticeable in unusual men

16) What effect of hair loss do we learn about in the second paragraph?
a) Hair loss in men can be surprising
b) The best cure for hair loss is a hair transplant
c) Men seldomly talk about their hair loss
d) Some men secretly like to be bald

17) What does Steve’s wife think?

a) She thinks his hair looks like a tattoo
b) She thinks her husband is really clever
c) She thinks her husband has normal hair
d) She thinks her husband is particularly sensitive

18) What do we learn about finasteride?

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 a) This medication is often taken in secret
b) Finasteride is the only effective anti-hair loss medication available
c) Only vain people use this medication
d) Four out of ten men use finasteride on a regular basis

19) In the fifth paragraph, what does the writer claim about hair?
a) Only older men are concerned with hair loss
b) Some hair styles can cause baldness
c) Hair can make some men feel insecure
d) People associate hair with strength and power

20) In the sixth paragraph, what does the writer say about the multi-
million-dollar industry?
a) It is used by famous actors, like Bruce Willis and Jason Statham
b) It is deceptive
c) It is promising
d) It promotes values such as masculinity and manliness

21) What do we learn about finasteride in the seventh paragraph?

a) It causes hair to grow again in some cases
b) 30% of users are disappointed by its results
c) Finasteride is a kind of magic pill
d) Finasteride should not be used for longer than six months

22) In the final paragraph, what is the writer’s advice?

a) It costs less to alter the way you think about the problem
b) CBT should be taken in combination with finasteride
c) Reversing hair loss is easier than CBT
d) Clinical psychologists can give advice of hair loss treatments

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TEST-15
Ganglion Cyst
PART A
TEXT 1
What is a ganglion cyst?
A ganglion cyst is a collection of synovial fluid in a sac, on or near tendon sheaths and
joint capsules. They usually appear on the on the dorsal aspect of hands, fingers and
wrists, and can also occur on the feet, ankles and knees. The cyst can range from the
size of a pea to the size of a golf ball. The size of a ganglion may increase over time,
especially if it near a joint where there are frequent repetitive movements.
About 65% of ganglia of the wrist and hand are dorsal wrist ganglia, followed by the
volar wrist ganglion constituting about 20 to 25% of ganglia. Flexor tendon sheath
ganglia and mucous cysts arising from the dorsal distal interphalangeal joint make up
the remaining 10 to 15%.
Ganglion cysts look and feel like a smooth lump under the skin and the wall of the
ganglion is smooth, fibrous, and of variable thickness. The cyst is filled with clear
gelatinous, sticky, or mucoid fluid of high viscosity. The fluid in the cyst is sometimes
almost pure hyaluronic acid. The cyst is attached to the tendon or joint by a pedicle
(stalk).
The cause of them is not known, however it is thought they may be caused by tiny
tears in the covering of a tendon or joint. Ganglion cysts are benign and appear in
isolation. Around 30 to 50 per cent of ganglion cysts resolve spontaneously without
medical intervention, though this can take many years.
Ganglia constitute about 60% of all chronic soft-tissue swellings affecting the hand
and wrist. They usually develop spontaneously in adults aged 20 to 50, with a
female:male preponderance of 3:1.People who have wear-and-tear arthritis in the
finger joints closest to their fingernails are at higher risk of developing ganglion cysts
near those joints.Joints or tendons that have been injured in the past are more likely
to develop ganglion cysts.

TEXT 2

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Diagnosing a ganglion cyst
Ganglia are evident on examination even if they cannot be seen by the naked eye. It
is important that cysts are examined by a doctor because there is another type of
ganglion on the dorsal wrist that occurs in people with rheumatoid arthritis.A doctor
can easily differentiate between them because a rheumatoid cyst is soft and
irregular in appearance. Also, a person with rheumatoid arthritis will also have
proliferative rheumatoid extensor tenosynovitis.
Most ganglion cysts do not cause symptoms, but the main symptoms people
experience are a noticeable swelling or lump. The lump is able to change its size,
including going away completely only to return. The lump is usually soft and
immobile. In some cases, the lump is painful and aching, particularly those at the
base of fingers. The ache and pain is made worse by moving any nearby joints. The
affected tendon may cause a sensation of muscular weakness. The back of the hands
and wrists are most commonly affected.
A medical examination is generally all that is needed to confirm diagnosis but other
tests could include: Aspirating some of the fluid with a syringe An ultrasound to
determine if the ganglion is solid or fluid filled X-ray and/or magnetic resonance
imaging may be needed if the cyst cannot be seen.

TEXT 3
Passive treatment options for a ganglion cyst
If a cyst is not causing any problems, a passive “watch and wait” approach is
recommended. This means the cyst is monitored and action only taken if it increases
to a point where it causes symptoms. However, even if there are no symptoms some
people prefer treatment for cosmetic reasons.
Temporarily immobilising the joints around a cyst may both slow down the rate at
which the cyst grows and reduce the size of the cyst. This may release the pressure
on nerves, relieving pain. If a person knows what activity is the likely cause such as
starting to play an instrument or using a new piece of equipment, it may be helpful
to stop or modify this activity.
Simple over the counter pain relievers and/or anti-inflammatory medications may be
required to alleviate pain. In some cases, modifying shoes or how they are laced can
relieve the pain associated with ganglion cysts on ankles or feet.

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A traditional old home remedy for a ganglion cyst consisted hitting the cyst with the
Bible. Thumping a cyst with any heavy object is not recommended because the force
of the blow can damage surrounding structures in the hand or foot.
Another TEXT 4

self-help approach is to try and "pop" the cyst by puncturing it with a needle. This is
unlikely to be effective and can lead to infection.
Some people advocate herbal remedies that have anti-inflammatory properties such
as turmeric and ginger. The true cause of ganglion cysts is not known but they are a
bulge in the lining of a structure. This means it is unlikely to be part of the
inflammatory process

Active treatment options for ganglion cysts.

If a cyst is causing problems, a needle aspiration performed by a qualified doctor.
This simple procedure is carried out in the GP surgery or hospital outpatients
department. It involves drawing the liquid contents of the cysts out of the sac via the
syringe.
Needle aspiration is usually the first active treatment option offered for ganglion
cysts as it is less invasive than surgery. However, nonsurgical treatment fails in about
40 to 70% of patients, necessitating surgical excision.
The cyst may be surgically removed using either open or keyhole approaches.
In open surgery the surgeon makes a medium-sized cut, usually about 5cm (2in) long,
over the site of the affected joint or tendon. The sac is removed at the pedicle to
reduce recurrence.
Keyhole surgery is often used if the ganglion cyst is near, or in a joint. Smaller
incisions are made and a tiny camera called an arthroscope is used by the surgeon to
look inside the joint and then pass instruments through the incision to remove the
cyst. Excision can be done via arthroscopic or standard open surgery. Recurrence
rates after surgical excision are about 5 to 15%.

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.
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In which text can you find information about
1 The ratio of ganglion cysts between sexes? ___________________

2 The primary dynamic way of removing ganglion cysts? ___________________

3 The investigations that may be done to confirm someone has a ganglion

cyst? ___________________

4 How keeping the affected area immobile for a time can reduce the effect of a
ganglion cyst? ___________________

5 Another type of ganglion cyst that can develop at the

wrist? ___________________

6 The role the bible used to play in managing ganglion cysts? ___________________

7 The contents of a ganglion cyst? ___________________

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 Where ganglion cysts are usually seen? ___________________

9 What percentage of ganglion cysts come back after a surgical excision?

___________________

10 Are ganglion cysts more common in men or women? ___________________

11 What can changing shoes achieve for people with ganglion cysts in lower limbs?
___________________

12 What are the two main complaints people with a ganglion cyst have?
___________________

13 What type of cysts develop from the fingers? ___________________

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14 What is often the first invasive treatment option offered for ganglion cysts?
___________________

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 An___________________shows if the ganglion is solid or not.

16 ___________________ganglia and mucous cysts in the DIP joints account for a

small number of all ganglion cysts.

17 No one really knows why ganglion cysts develop but there is

a___________________ in the membrane around a structure

18 A surgeon can look into a ganglion cyst around a joint with an arthroscope and
then___________________through an additional small cut in the skin to get rid of
the cyst.

19 A ganglion cyst on a tendon on can lead to a cause a feeling

of___________________weakness.

20 Needle aspiration involves pulling the___________________ of the cysts out of

the sac with a needle and syringe.

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 PART B

TEXT 1
What Nurses Need to Know About Celiac Disease and Gluten Sensitivity

Gluten is the group name for two proteins, gliadin and glutenin, which are primarily
derived from wheat, barley, rye and triticale. These proteins are responsible for the
bonding of particles, giving food its shape. When gluten is consumed, those with an
allergy experience an immune response which attacks the small intestine. Once the
villi of the small intestine are damaged, nutrients cannot be properly absorbed.
While some people may be asymptomatic throughout their lifetime, many
experience at least some symptoms.

Recent research shows there is no evidence to support an increased risk of celiac

disease when infants are introduced to gluten at an early age (less than 4 months).
However, delayed introduction (more than 7 months) to gluten may be associated
with an increased risk.

Question
1) What does the article say about the causes of celiac disease?
a) It can provoke damage to the small intestine
b) It could be linked to children’s diets
c) Normally, children don’t suffer from celiac disease

TEXT 2
Aspirin Guidelines

Aspirin should be taken with, or straight after, a meal or snack. This helps to reduce
the risk of any stomach irritation. Gastro-resistant tablets (also called enteric-coated
or EC tablets) can be taken before food as these have a special coating which will
help to protect the stomach from irritation. Gastro-resistant tablets should be
swallowed whole, they must not be crushed or chewed. If the patient is using
indigestion remedies, aspirin in this form must not be taken for at least two hours
before and the two hours after they are used. This is because the antacid in the
remedy can affect the way the coating on these tablets works. Melt-in-the-mouth
(orodispersible) tablets should be placed on the tongue and allowed to dissolve.
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Question
2) What do these guidelines say about when to take aspirin?
a) Aspirin taken close to meal times can irritate the stomach lining
b) Some types of aspirin have special indications
c) It can be taken in combination with indigestion remedies

TEXT 3
Assessing the Need for a Peripheral Intravenous Cannula

Many cannulas are left in without orders for intravenous fluids or medications. Some
patients end up with two, three, or even more concurrent cannulas, despite only
needing one in most cases. They are often left in 'just in case' they might be needed.
But any catheter leads directly to the bloodstream and can be a source of infection.
The need for the cannula must be constantly reassessed.

When a cannula is inserted, a flashback of blood in the chamber confirms it is in the

vein. Flushing the cannula with 0.9% saline before and after intravenous medications
reduces admixture of medicines and decreases the risk of blockage.

Question
3) What does this article say about the use of cannulas?
a) Cannula usage should be reviewed regularly
b) In most cases, concurrent cannula use is justified
c) Cannulas can be left in place so long as they are flushed with a 0.9% saline
solution

TEXT 4
Description of the ‘SecurAcath’ Device

SecurAcath’ is a single-use device to secure percutaneous catheters in position on

the skin. It is intended for use in adults and children who need a central venous

289
catheter which is a long, thin, flexible tube that is inserted into a vein through the
skin.

‘SecurAcath’ has two parts, a base and cover. The base is made up of two foldable
metal legs and two securement feet. The feet are placed under the skin at the
catheter insertion site and unfolded to make a subcutaneous anchor. The cover then
attaches to the catheter shaft and holds it in place when it is clipped onto the base.
The device stays in place as long as the catheter is needed and can be lifted off the
skin to allow cleaning of the insertion site.

Question
4) How should the ‘SecurAcath’ device be used?
a) The feet can be repositioned in order to clip them to the base
b) It should be correctly assembled before attaching the cover
c) The flexible tube should be inserted into a vein first

TEXT 5
Assessment of Colorectal Polyps During Colonoscopy

Colorectal polyps are small growths on the inner lining of the colon. Polyps are not
usually cancerous, most are hyperplastic polyps with a low risk of cancer. However,
some (known as adenomatous polyps) will eventually turn into cancer if left
untreated. Detecting and removing adenomas during colonoscopy has been shown
to decrease the later development of colorectal cancers. However, removal of any
polyps by polypectomy may have adverse effects such as bleeding and perforation of
the bowel.

It can take three weeks for a person to get the examination results for polyps that
were removed during colonoscopy, and they may feel anxious during this waiting
period. Using virtual chromoendoscopy technologies may allow real-time
differentiation of adenomas and hyperplastic colorectal polyps during colonoscopy,
which could lead to quicker results.

Question
290
5) What does the article tell us about colonoscopies?
a) Colonoscopy and polypectomy procedures are thought to be risk-free
b) Virtual chromoendoscopy technology could speed up the process
c) Most hyperplastic polyps become cancerous if left untreated

TEXT 6
Osteomyelitis After Traumatic Knee Injury

A 56-year-old woman was admitted to a hospital for the treatment of osteomyelitis

following a traumatic knee injury. She received the antibiotic Gentamicin in
accordance with the hospital’s usual protocol. Kinetics, blood drug levels, and renal
function were monitored, and dosage recommendations were made. However, a
permanent vestibulopathy (or balance disorder) resulted from the antibiotic.

During the case investigation, the patient testified that she experienced “roaring” in
her ears while hospitalized. (The roaring is a form of tinnitus) She further testified
that she was not ambulatory; she was restricted to bed rest. No staff member
inquired about unusual ear symptoms or told her to report such symptoms.
Consequently, a lawsuit was brought against the hospital, specifically against the
pharmacists.

Question
6) What went wrong in the treatment of the 56-year-old woman?
a) The woman was infected by vestibulopathy while in hospital
b) The correct dosage was not balanced
c) Staff members failed to take note of the woman’s symptoms

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 PART C

TEXT 1
Many adult hospital inpatients need intravenous (IV) fluid therapy to prevent or
correct problems with their fluid and/or electrolyte status. Deciding on the optimal
amount and composition of IV fluids to be administered and the best rate at which
to give them can be a difficult and complex task, and decisions must be based on
careful assessment of the patient's individual needs.

Errors in prescribing IV fluids and electrolytes are particularly likely in emergency

departments, acute admission units, and general medical and surgical wards rather
than in operating theatres and critical care units. Surveys have shown that many staff
who prescribe IV fluids know neither the likely fluid and electrolyte needs of
individual patients, nor the specific composition of the many choices of IV fluids
available to them. Standards of recording and monitoring IV fluid and electrolyte
therapy may also be poor in these settings. IV fluid management in hospital is often
delegated to the most junior medical staff who frequently lack the relevant
experience and may have received little or no specific training on the subject.

The ‘National Confidential Enquiry into Perioperative Deaths’ report in 1999

highlighted that a significant number of hospitalised patients were dying as a result
of infusion of too much or too little fluid. The report recommended that fluid
prescribing should be given the same status as drug prescribing. Although
mismanagement of fluid therapy is rarely reported as being responsible for patient
harm, it is likely that as many as one in five patients on IV fluids and electrolytes
suffer complications or morbidity due to their inappropriate administration.

There is also considerable debate about the best IV fluids to use (particularly for
more seriously ill or injured patients), resulting in wide variation in clinical practice.
Many reasons underlie the ongoing debate, but most revolve around difficulties in
interpretation of both trial evidence and clinical experience. For example, many
accepted practices of IV fluid prescribing were developed for historical reasons
rather than through clinical trials. Trials cannot easily be included in meta-analyses
because they examine varied outcome measures in heterogeneous groups,
comparing not only different types of fluid with different electrolyte content, but
also different volumes and rates of administration. In addition, most trials have been
undertaken in operating theatres and critical care units rather than admission units
or general and elderly care settings. Hence, there is a clear need for guidance on IV

292
fluid therapy for general areas of hospital practice, covering both the prescription
and monitoring of IV fluid and electrolyte therapy, and the training and educational
needs of all hospital staff involved in IV fluid management.

The aim of these guidelines is to help prescribers understand the physiological

principles that underpin fluid prescribing the pathophysiological changes that affect
fluid balance in disease states and the indications for IV fluid therapy. In developing
the guidelines, it was necessary to limit the scope by excluding patient groups with
more specialised fluid prescribing needs. It is important to emphasise that the
recommendations do not apply to patients under 16 years, pregnant women, and
those with severe liver or renal disease, diabetes or burns. They also do not apply to
patients needing inotropes and those on intensive monitoring, and so they have less
relevance to intensive care settings and patients during surgical anaesthesia. Patients
with traumatic brain injury (including patients needing neurosurgery) are also
excluded. The scope of the guidelines does not cover the practical aspects of
administration (as opposed to the prescription) of IV fluids. It is hoped that these
guidelines will lead to better fluid prescribing in hospitalised patients, reduce
morbidity and mortality, and lead to better patient outcomes.

The guidelines will assume that prescribers will use a drug's summary of product
characteristics to inform decisions made with individual patients. All patients
continuing to receive IV fluids need regular monitoring. This should initially include at
least daily reassessments of clinical fluid status, laboratory values (urea, creatinine
and electrolytes) and fluid balance charts, along with weight measurement twice
weekly. It is important to remember that patients receiving IV fluid therapy to
address replacement or redistribution problems may need more frequent
monitoring. Additional monitoring of urinary sodium may be helpful in patients with
high-volume gastrointestinal losses. Patients on longer-term IV fluid therapy whose
condition is stable may be monitored less frequently, although decisions to reduce
monitoring frequency should be detailed in their IV fluid management plan. Clear
incidents of fluid mismanagement (for example, unnecessarily prolonged
dehydration or inadvertent fluid overload due to IV fluid therapy) should be reported
through standard critical incident reporting to encourage improved training and
practice (see Consequences of fluid mismanagement to be reported as critical
incidents).

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Questions 7-14
7) What does the first paragraph tell us about intravenous (IV) fluid
therapy?
a) Most patients receive a standard composition of fluids
b) Electrolyte status should be kept at the optimal level
c) It is not easy to decide on the correct volume and speed of delivery of fluids
d) It is difficult to correct problems

8) What have surveys shown about intravenous (IV) fluid therapy?

a) There is often a lack of information about correct dosage
b) Sometimes, staff mixed up electrolyte fluids with standard IV fluids
c) Intravenous (IV) fluid therapy should be delegated to junior medical staff
d) Mistakes made in operating theatres were often fatal

9) What did the 1999 report highlight?

a) A small number of patients died because they were prescribed the wrong
medication
b) Around 20% of patients experience problems due to incorrect IV fluid therapy
c) Some hospitals fail to report deaths due to mismanaged procedures
d) Not all Perioperative deaths could be linked to IV fluid therapy

10) What does the fourth paragraph tell us about IV fluid therapy?
a) Seriously ill patients generally need more fluids that injured patients
b) There are historical reasons to prolong the use of IV fluid therapy
c) The best IV fluids are more expensive
d) Not everyone agrees on the most suitable fluids to use

11) Why is it difficult to perform meta-analyses of trials?

a) There are not enough qualified analysts
b) Trials usually don’t take place in different healthcare settings
c) The volume of data is too great to analyse
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 d) More hospital staff need training before the trials take place

12) What do we learn about the scope of the guidelines in the fifth
paragraph?
a) The guidelines are not appropriate for all types of patients
b) Patients needing inotropes and those on intensive monitoring were included
for historical reasons
c) Pathophysiological patients were excluded because they cannot be given IV
fluid therapy
d) The guidelines only apply to men (that is to say, adult male patients)

13) According the sixth paragraph, how often should clinical fluid status be
reassessed?
a) Twice a day or more frequently
b) Once every 24 hours
c) Twice a week
d) Never – routine reassessment can be monitored by machine

14) What should be done in the case of fluid mismanagement?

a) Additional monitoring should be carried out
b) Rehydration should be prolonged
c) Information about occurrences should be conveyed to the appropriate
authorities
d) The person or persons involved should be criticised

TEXT 2

A CT scan is a specialised X-ray test. It can give quite clear pictures of the inside of
your body. In particular, it can give good pictures of soft tissues of the body which do
not show on ordinary X-ray pictures. CT stands for computerised tomography. It is
sometimes called a CAT scan. CAT stands for Computerised Axial Tomography. The

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CT scanner looks like a giant thick ring. Within the wall of the scanner there is an X-
ray source. Opposite the X-ray source, on the other side of the ring, are X-ray
detectors. You lie on a couch which slides into the centre of the ring until the part of
the body to be scanned is within the ring. The X-ray machine within the ring rotates
around your body. As it rotates around, the X-ray machine emits thin beams of X-
rays through your body, which are detected by the X-ray detectors.

The detectors detect the strength of the X-ray beam that has passed through your
body. The denser the tissue, the less X-rays pass through. The X-ray detectors feed
this information into a computer. Different types of tissue with different densities
show up as a picture on the computer monitor, in different colours or shades of grey.
So, in effect, a picture is created by the computer of a slice (cross-section) of a thin
section of your body.

As the couch moves slowly through the ring, the X-ray beam passes through the next
section of your body. So, several cross-sectional pictures of the part of your body
being investigated are made by the computer. Newer scanners can even produce 3-
dimensional pictures from the data received from the various slices of the part of the
body being scanned.

A CT scan can be performed on any section of the head or body. It can give clear
pictures of bones. It also gives clear pictures of soft tissues, which an ordinary X-ray
test cannot show, such as muscles, organs, large blood vessels, the brain and nerves.
The most commonly performed CT scan is of the brain to determine the cause of a
stroke, or to assess serious head injuries.

Usually, very little preparation is necessary. It depends on which part of your body is
to be scanned. You will be given instructions by the CT department according to the
scan to be done. As a general rule, you will need to remove any metal objects from
your body, such as jewellery, hair clips, etc. It is best not to wear clothes with metal
zips or studs. You may be asked not to eat or drink for a few hours before your scan,
depending on the part of your body to be scanned.

The CT scan itself is painless. You cannot see or feel X-rays. You will be asked to stay
as still as possible, as otherwise the scan pictures may be blurred. Conventional CT
scans can take between 5-30 minutes, depending on which part of the body is being
scanned. More modern CT scans (helical CT scans) take less than a minute and also
use less radiation.

As the scan uses X-rays, other people should not be in the same room. The operator
controls the movement of the couch and scanner from behind a screen or in a

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separate control room so that they are protected from repeated exposure to X-rays.
However, communication is usually possible via an intercom, and you will be
observed at all times on a monitor. Some people feel a little anxious or
claustrophobic in the scanner room when they are on their own. You can return to
your normal activities as soon as the scan is over. The pictures from the scan are
studied by an X-ray doctor (radiologist) who sends a report to the doctor who
requested the scan.

CT scans use X-rays, which are a type of radiation. Exposure to large doses of
radiation is linked to developing cancer or leukaemia - often many years later. The
dose of X-ray radiation needed for a CT scan is much more than for a single X-ray
picture but is still generally quite a low dose. The risk of harm from the dose of
radiation used in CT scanning is thought to be very small but it is not totally without
risk. As a rule, the higher the dose of radiation, the greater the risk. So, for example,
the larger the part of the body scanned, the greater the radiation dose. And, repeat
CT scans over time cause an overall increase of dose. Various studies have aimed to
estimate the risk of developing cancer or leukaemia following a CT scan. In general,
the risk is small. In many situations, the benefit of a CT scan greatly outweighs the
risk.

Questions 15-22
15) What advantage does a CT scan give over a standard X-ray?
a) It emits less radiation
b) It can take pictures of bones and soft tissues
c) It is quieter and uses less electricity
d) The patient can lie down during the scan

16) What can be seen on a CT scan result?

a) Tissue thicknesses and densities can be shown using different colours
b) The computer displays the date, time and patient’s name on the result
c) When this article was written, CT scans could only show shades of grey on the
results
d) Cross-dimensional attributes are shown on the results in colour or shades of
grey

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17) What does the third paragraph tell us about the CT scans?
a) Usually, more than one picture is obtained
b) 3-dimensional pictures provide more information that standard cross-
sectional pictures
c) The CT ring can be programmed to move the coach slowly
d) Images and scans can be stored on computers for up to a year

18) What type of scan is carried out most frequently?

a) Scans of the head and neck
b) Scans of the chest and upper body
c) Whole body scans
d) Scans of the head only

19) What should you wear for your CT scan?

a) Clothing that is free of any metal
b) A standard hospital gown
c) There are usually no restrictions on clothing
d) Some scans require an absence of clothing

20) What can influence the clarity of CT images?

a) Temperature
b) Movement
c) Radiation levels
d) Levels of pain or discomfort

21) What does the article say about the number of people in the CT room?
a) A Only the operator will be with you in the CT room
b) You can ask for one or two people to stay with you during the scan
c) You can only be accompanied if you feel anxious or claustrophobic
d) You will be alone in the CT room

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22) What does the last paragraph say about the levels of risk?
a) Generally, the risks are not as significant as the potential advantages
b) Some people have developed cancer or leukaemia after a CT scan
c) CT scanners pose a lower risk than standard X-ray machines
d) There is a high risk of cancer if you have a large body

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TEST-16
Chicken Pox and Shingles
PART A
TEXT 1
Chickenpox and shingles
Chickenpox is a highly infectious viral illness caused by the Varicella-Zoster virus
which can reappear later in life as shingles. It is most commonly known to be a mild
childhood illness.
Chickenpox can be associated with severe complications and even death so must be
treated seriously in all cases. Infection with chickenpox during pregnancy can cause
miscarriage, foetal malformations, skin scarring, and other problems in the
baby. Chickenpox in adults and immunosuppressed people can be severe.
Shingles only develops in people who have had chickenpox in the past, usually as a
child. While anyone who has recovered from chickenpox may develop shingles, the
risk of shingles increases as they get older. About 1 in 3 people will develop shingles
at some stage during their lifetime. What causes the virus to reactive is usually
unknown, but reactivation often occurs when a disorder or drug weakens the
immune system.
Unlike chickenpox, shingles cannot be spread through person to person contact.
However, if a person has never had chickenpox, or received the chickenpox vaccine,
they may catch chickenpox from close contact with someone who has shingles,
because the shingles blisters contain the chickenpox virus.
A person who develops shingles has not done so because they were exposed to
someone with either chickenpox or shingles. This is because after a person recovers
from chickenpox, the virus stays in their body, moving to the roots of nerve cells near
the spinal cord and there it becomes inactive or dormant. Shingles is caused by the
reactivation of the virus. Again, unlike chickenpox, shingles poses no threat to
unborn babies.
In Australia, Chickenpox vaccine is now given free as part of the government
immunisation program. It is free under the National Immunisation Program
Schedule. Before routine vaccination began in November 2005, the incidence of
chickenpox appears to have decreased.
Zoster vaccine is also funded under the National Immunisation Program for persons
aged 70 years, with catch-up for those aged 71–79 years also funded until October
2021.

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TEXT 2
Diagnosing chickenpox and shingles
Chickenpox is so distinctive, a medical diagnosis is not required. Chickenpox starts
with red spots that can appear anywhere on the body and the spots are itchy, filled
with fluid and may burst. They might spread widely across the body or stay in a small
area. The spots scab over and eventually the scabs drop off. More blisters might
appear while others scab over. A high temperature above 38C, aches and pains,
generally feeling unwell and feeling miserable due to the itchiness of the spots are
other symptoms of chickenpox.
People with shingles develop symptoms before a rash appears. The symptoms
include: pain; a burning, tingling or itching sensation; a stabbing sensation; a feeling
of numbness in the affected area of the body; sensitivity to light; fever and/or
headache or fatigue.
Two to three days after the initial symptoms appear, a painful rash will appear on the sensitive area of
skin, often on the left or right side of the body. This rash at first consists of painful, red bumps that
quickly develop into fluid-filled blisters, which will eventually have a crusty surface.

TEXT 3
Managing chickenpox and shingles
The management of both chickenpox and shingles focusses on managing the rash
and reducing the risk of spreading the condition.
To manage the rash the main advice is to keep it as dry and as clean as possible.
Applying calamine lotion, cool compresses, baths or ice packs can reduce the urge to
scratch the rash as scratching may cause scarring and infection of the blisters. After a
bath or shower, skin should be gently patted dry with a clean towel rather than
rubbed vigorously to scratch the rash and wearing loose cotton clothes around the
parts of the body that are affected can also help. Covering the spots with sticking
plasters and using antibiotic creams are not recommended because they may slow
down the healing process. If the blisters are open, applying creams or gels is not
recommended because they might increase the risk of a secondary bacterial
infection.
For chickenpox sufferers, simple paracetamol and plenty of fluids are encouraged to
manage the fever.
To reduce the risk of spread of chickenpox either from chickenpox or shingles
sufferers need to stay away from school, nursery or work until all the spots have
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crusted over, usually 5 days after the spots first appeared. It is important for
sufferers to avoid contact with people who have a weak immune system and babies
less than 1 month old, along with anyone known to have not been exposed to
chickenpox, especially pregnant women. Sharing towels, playing contact sports, or
going swimming are also discouraged until the spots have dried up and de-roofed.
Minimising scratching of the spots is key to reducing the spread as it is the fluid in
them that is infectious and washing hands frequently will also reduce the risk of
spreading the virus.
People who are experiencing any symptoms of shingles should see their doctor as
soon as possible. If treatment with antiviral medications is commenced within 3 days
of shingles starting, it can reduce the condition's severity and the risk of further
complications.

TEXT 4
Varicella-Zoster virus is one of eight types of herpes viruses infect humans (Human Herpes Virus [HHV]).
After initial infection, all herpes viruses remain latent within specific host cells and may subsequently
reactivate. Human herpes viruses do not survive long outside a host; thus, transmission usually requires
intimate contact. In people with latent infection, the virus can reactivate without causing symptoms; in
such cases, asymptomatic shedding occurs and people can transmit infection.

Human herpes
Common name Most common manifestations
virus (HHV)
Herpes simplex virus HHV1 and Herpes labialis (cold sores), genital
Type 1 and Type 2 HHV2 herpes
Varicella-zoster virus HHV 3 Chickenpox, shingles
Epstein-Barr virus HHV 4 Glandular fever
Cytomegalovirus
HHV5 Congenital CMV
(CMV)
Roseola infantum Otis media with
- HHV6
fever
- HHV 7 Roseola infantum
Kaposi sarcoma– Kaposi sarcoma and AIDS-related
HHV 8
associated herpesvirus non-Hodgkin lymphomas

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Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once.
In which text can you find information about
1 What can happen if the spots are scratched? ___________________

2 The indications that a person might have chickenpox? ___________________

3 The human herpes virus’ ability to be infectious outside the

body? ___________________

4 The infectiousness of shingles? ___________________

5 The prevalence of people who will develop shingles? ___________________

6 The most common conditions caused by the human herpes

virus? ___________________

7 The signs that someone has shingles before a rash

appears? ___________________

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 How soon should a person who knows they have shingles start taking drugs to ease
their symptoms? ___________________

9 Is the loss of feeling where the rash is a symptom of chickenpox or shingles?

___________________

10 What part of the spots in a person with chickenpox or shingles transmits the
virus? ___________________

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11 What vaccines are available to manage chickenpox and shingles in Australia?
___________________

12 The virus that causes glandular fever is commonly called what?

___________________

13 After about how many days of symptoms, do the fluid filled spots appear for a
person with shingles? ___________________

14 Apart from pregnant women and unborn babies, infection with chickenpox can be
significant for which other two groups of people? ___________________

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 After the first episode of infection, all___________________, stay dormant in
certain cells.

16 Shingles is___________________problem for foetuses.

17 Chickenpox is so obvious, a___________________is not needed

18 The best guidance for someone with chickenpox is to___________________by

keeping it clean and dry.

19 In shingles, the rash starts out sore, with bumpy and red areas but soon develops
into___________________, which will eventually have a dry top.

20 People with Chickenpox or shingles have to need to stay away from public places
until all the spots have dried up, ___________________after they started.

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 PART B
TEXT 1
Blood Clotting Tests

If a blood clot forms within a healthy blood vessel it can cause serious problems. So,
there are chemicals in the blood that prevent clots from forming and chemicals that
'dissolve' clots. There is balance between forming clots and preventing clots.
Normally, unless a blood vessel is damaged or cut, the 'balance' tips in favour of
preventing clots forming within blood vessels.

A blood sample is taken into a bottle that contains a chemical which prevents the
blood from clotting. It is then analysed in the laboratory. There are a number of tests
that may be done. These tests measure the time it takes for a blood clot to form
after certain activating chemicals are added to the blood sample.

Question
1) What do we learn from this article about blood clotting?
a) Artificial chemicals exist that can be introduced to ‘dissolve’ clots
b) Most of the time, clots don’t form in blood vessels
c) It takes time for a damaged or cut blood vessel to form a clot

TEXT 2
Simple snoring is part of a spectrum of breathing disturbance during sleep. The
muscles around the upper airway relax during sleep. A narrowed airway can lead to
air turbulence, which causes vibration in soft tissues of the oropharynx, generating
the snoring sound during inspiration. The specific origin of the noise varies between
individuals and may include the soft palate. Snoring may disturb the sleep of the
patient and their bed partner and affect relationships.

A surgical procedure may be used for patients with problematic snoring where the
soft palate is implicated, and when snoring has not been improved by conservative
treatment. The aim of the procedure is to stiffen the soft palate over subsequent
weeks as a result of fibrosis.

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Question
2) What would be a suitable title for this article?
a) Snoring: Causes and proposed remedy
b) Soft palate intervention protocol
c) Oropharynx soft tissue syndrome and treatment options

TEXT 3
Apple Watch Detects Irregular Heart Beat In Large U.S. Study

The Apple Watch was able to detect irregular heart pulse rates that could signal the
need for further monitoring for a serious heart rhythm problem, according to data
from a large study funded by Apple Inc, demonstrating a potential future role for
wearable consumer technology in healthcare. Researchers hope the technology can
assist in early detection of atrial fibrillation (AF), the most common form of irregular
heartbeat. Patients with untreated AF are five times more likely to have a stroke.

Results of the largest AF screening and detection study, involving over 400,000 Apple
Watch users who were invited to participate, were presented on Saturday at the
American College of Cardiology meeting in New Orleans. Of the 400,000 participants,
0.5 percent, or about 2,000 subjects, received notifications of an irregular pulse.

Question
3) What do we learn in the following article?
a) Atrial fibrillation was found to be uncommon among Apple Watch users
b) In the future, everyone will use wearable consumer technology
c) Serious heart rhythm problems can be diagnosed by Apple watches

TEXT 4
Review of Computerized Clinical Decision Support in Community Pharmacy

Clinical decision support software (CDSS) has been increasingly implemented to

assist improved prescribing practice. Reviews and studies report generally positive

308
results regarding prescribing changes and, to a lesser extent, patient outcomes. Little
information is available, however, concerning the use of CDSS in community
pharmacy practice. Given the apparent paucity of publications examining this topic,
we conducted a review to determine whether CDSS in community pharmacy practice
can improve medication use and patient outcomes.

Most studies showed improved prescribing practice, via direct communication

between pharmacists and doctors or indirectly via patient education. Factors limiting
the impact of improved prescribing included alert fatigue and clinical inertia. No
study investigated patient outcomes and little investigation had been undertaken on
how CDSS could be best implemented.

Questions 1-6
4) What does the writer imply about CDSS in this article?
a) CDSS has an important role to play in improving patient outcomes
b) Previous studies concerning CDSS recommended changes
c) More research is needed to demonstrate its effectiveness

TEXT 5
Workplace Violence: A Serious Problem in Healthcare

There’s no industry that’s immune to workplace violence, whether it’s construction,

manufacturing, retail or media. However, healthcare professionals face a greater risk
of injury, trauma, emotional distress and even death as they go about their everyday
work responsibilities – giving injections, taking X-rays, drawing blood, and prepping
patients for surgery.

Violence against healthcare workers occurs in all types of settings, from busy
emergency rooms to surgery centres, from walk-in clinics to nursing homes. Too
often, it is perceived to be just part of the job and has a long-standing history in the
industry. According to American Nurse Today, 67% of all nonfatal injuries caused by
workplace violence occur in healthcare, even though the industry represents only
11.5% of the U.S. workforce.

Question
5) Which of the following statements is not true?
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 a) In the US, less than 20% of the overall labour force works healthcare
b) Historically, violence is more often directed at nurses rather than doctors
c) The hazard of violence at work has been found to be more serious for
healthcare workers compared to workers in other industries

TEXT 6
Bronchiolitis

Bronchiolitis is an acute viral infection of the lower respiratory tract that occurs
primarily in the very young. It is a clinical diagnosis based upon typical symptoms and
signs. Bronchiolitis is generally a self-limiting illness, and management is mostly
supportive.

There is some discrepancy between the use of 'bronchiolitis' in the UK and in the
USA and other parts of Europe, and no universally accepted definition for such a
common condition. In the UK, the term describes an illness in infants, beginning as
an upper respiratory tract infection (URTI) that evolves with signs of respiratory
distress, cough, wheeze, and often bilateral crepitations. In North America,
bronchiolitis is used to describe a wheezing illness associated with an URTI in
children up to the age of 2 years.

Question
What do we learn about bronchiolitis in this article?
o Not everyone agrees about the exact description of this infection
o Bronchiolitis affects a disproportionally high number of children over
the age of two
o Discrepancies in diagnosis are frequent

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 PART C
TEXT 1
According to Alzheimer's UK, 850,000 people in the UK have dementia, but by 2025
this number is expected to exceed 1 million. The condition has a profound effect on
everyday life, both for the person with dementia and for their nearest and dearest.
Many people think of dementia as solely being about forgetfulness. While memory
loss is one of the main symptoms, dementia is a term describing a number of
disorders that cause a loss of brain function, which usually progressively worsens
over time. "In the beginning, people might exhibit a number of early signs, such as
losing interest in day-to-day activities and becoming apathetic," explains Dr Jane
Mullins, dementia nurse specialist and author of the book Finding the Light in
Dementia. "On top of that, a person's mood might change; they might become easily
upset or frustrated and seem to lose confidence."

Often, Mullins, says, it's these emotional and mood-related symptoms that people
notice first. Alongside these, a person will commonly have language difficulties. For
example, struggling to find the right words and begin forgetting recent events,
names and faces. They may become more repetitive, and they may repeat a question
or statement after a very short interval. The person may also misplace items or put
them in odd places. "We all lose things now and again, but with dementia it's the
regularity with which these things happen that is difficult to deal with," Mullins
comments.

Commonly, people affected will have noticed themselves that something is

happening that just isn't right. This was the case with 91-year-old Salaam Kaffash
from North London, who was diagnosed with Alzheimer's disease in 2016. He had
been worried about his declining memory for some years before he eventually
visited his doctor. "He was aware that he was beginning to forget things, and he was
quite bothered by it," explains Salaam's wife, Gill, who is 79. "I was more bothered
by the change in his cognitive abilities - it was that slowing down of capacity to think
and absorb information.”

Mullins advises that, if you're worried someone close to you might have dementia,
you should broach the topic very sensitively. "It's not an easy conversation to have,
and how you go about it will depend on the relationship you have with the person,
everybody has to gauge that for themselves," she says. "The first thing is to slow
down, stand back and try to put yourself in their shoes and imagine if someone was
approaching you about changes in your memory, your thinking or your mood. How
would you feel about it? Empathy helps a lot."
311
It's important to choose a time when neither of you is tired. Mullins also
recommends knowing what you're going to say beforehand, and to avoid the word
'dementia'. Instead, simply tell the person that you're worried because you've
noticed changes in their memory or mood, for example, and ask if they have noticed
too. "Crucially, make sure you're prepared for any reaction," Mullins comments. "The
person might be relieved that you've brought it up, but if they're not ready to face
up to what's happening, they might be quite defensive." She adds that you may need
to have the conversation several times.

In the first instance the person should visit their doctor, who will try to establish the
degree of brain function decline, and importantly, rule out other causes of the
symptoms the person is experiencing. These might include depression, vitamin B12
deficiency, thyroid disease, or unstable blood glucose in people with diabetes. If the
doctor suspects dementia, they will make a referral to a specialist memory clinic for
more extensive tests.

Getting confirmation of dementia can be a very difficult blow for everyone, but for
Gill, her husband's diagnosis came as a relief. "It meant we could both get help," she
comments. "Salaam’s illness is developing all the time, but it helps to have support.
We still do things together, like yoga and visiting family, and I also go off and do
things on my own." Gill goes to an aqua fitness class every week and takes part in a
history club at the local community centre. She says it's also important that she gets
plenty of sleep and keeps as healthy as possible.

Mullins points out that remaining as active as possible is key, both for the person
with dementia and for their caregiver. Having some respite is equally important. "Try
to include friends and family so the person with dementia doesn't only rely on that
one person," she suggests. "Getting involved with community initiatives can also be a
good way to get out and about, and to enjoy activities both together and
separately."

"In my experience working with people with dementia and their families, the people
who cope better are those who are more socially active," Mullins says.

Questions 7-14
7) What do we learn about dementia in the first paragraph?
a) Dementia is a disorder characterized solely by memory loss
b) Apathetic people are more susceptible to dementia
c) Dementia can affect how a person feels

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 d) A symptom of dementia is increased sensitivity to light

8) The word ‘struggle’ in the second paragraph suggests

a) A person with dementia may have physical as well as emotional symptoms
b) Some mental activities become very difficult for people with dementia
c) Learning a new language may well be impossible for a person with dementia
d) People with dementia are unable to repeat questions satisfactorily

9) The example of Salaam Kaffash in the third paragraph is given to show

a) that dementia affects all ethnic groups
b) that forgetfulness is often accompanied by other symptoms of intellectual
decline
c) that physical slowness can be overlooked as an early sign of dementia
d) that usually the person with dementia is unaware of any symptoms
themselves

10) What advice is given in the fourth paragraph?

a) you should gauge your relationship with the person first
b) speaking slowly will enable the other person to understand more readily
c) only speak to a person with dementia when they are in a good mood
d) it is important to show compassion when discussing dementia

11) In the fifth paragraph, what may cause a person with dementia to
become defensive?
a) If the person sees a look of pity on your face
b) The person needs more time before they can accept the new situation
c) The person doesn’t feel as relieved as he should
d) It’s possible that the person is unable to understand because of the effects of
dementia
12) What does the sixth paragraph tell us about the medical assessment of
dementia?

313
 a) It may involve more than one assessment
b) Dementia assessments frequently include blood tests
c) Vitamin B12 deficiency can be ruled out very quickly
d) Assessments include an evaluation of body temperature

13) What was one result of Salaam’s diagnosis?

a) Gill could do yoga and aqua fitness
b) Salaam and his wife Gill were able to obtain assistance
c) Gill could get medicine for her husband
d) After many years, Salaam was able to see his family

14) The word ‘respite’ in the eighth paragraph suggests that

a) from time to time, people who care for dementia patients need a break
b) it may be necessary to motivate dementia patients to do more exercise
c) it is important not to rely solely on medication
d) there may be specialist facilities available in the community for people who
have dementia

TEXT 2
Frostbite, the most common type of freezing injury, is defined as the freezing and
crystalizing of fluids in the interstitial and cellular spaces as a consequence of
prolonged exposure to freezing temperatures. This article deals with the clinical
presentation and treatment of frostbite as a distinct entity. Frostbite may occur
when skin is exposed to extreme cold, at times combined with high winds, resulting
in vasoconstriction. The associated decrease in blood flow does not deliver sufficient
heat to the tissue to prevent the formation of ice crystals.

Because frostbite tends to occur in the same setting as hypothermia, most cases are
observed in the winter. Homeless individuals, those who work outdoors, winter sport
enthusiasts, and mountaineers are examples of those at risk. The prevalent use of
alcohol in colder climates is also a factor. High-altitude mountaineering frostbite, a
variant of frostbite that combines tissue freezing with hypoxia and general body
dehydration, has a worse prognosis.

314
Until the late 1950s, frostbite was a disease entity primarily reported by the world’s
military, which had the most experience in its diagnosis and treatment. Most of the
data in the current literature originated from military studies or from Scandinavian
countries. However, civilian physicians are becoming more cognizant of the diagnosis
and treatment of this condition in urban and rural civilian populations.

The goal of frostbite treatment is to salvage as much tissue as possible, to achieve

maximal return of function, and to prevent complications. This may involve both
medical and surgical measures as appropriate. The cutaneous circulation plays a
major role in maintaining thermal homeostasis. The skin loses heat more easily than
it gains heat. Thus, humans acclimatize better to heat than to cold. Cutaneous
vasodilation is controlled by direct local effects and decrease of sympathetic vascular
tone. Maximum reflex vasodilation occurs when the sympathetic system is blocked.
The fingers, toes, ears, and nose—the skin structures most at risk for frostbite—
contain multiple arteriovenous anastomoses that allow shunting of blood in order to
preserve core temperature at the expense of peripheral tissue circulation. Heat
conduction and radiation from deeper tissue circulation prevents freezing and ice
crystallization until the skin temperature drops below 0°C. Once tissue temperature
drops below 0°C, cutaneous sensation is lost and the frostbite injury cascade is
initiated.

Various authors have compared the effects of quick freezing and slow freezing at the
microscopic level. Rapid freezing is thought to increase intracellular ice formation
superficially, whereas slow freezing causes deeper and more extensive cellular injury
by causing freezing of water in the intracellular and extracellular spaces. Because
extracellular freezing progresses more rapidly than intracellular freezing, osmotic
shifts occur. These shifts cause intracellular dehydration, which decreases the
viability and survival of individual cells. As tissue is rewarmed, reperfusion injury
becomes prominent. Progressive oedema of the frostbitten area develops over the
first 48-72 hours, followed by bleb formation and necrosis of devitalized tissue.
Blood flow in the microcirculation resumed at near-normal levels after rewarming,
suggesting that the vascular structures were not damaged by freezing.

Generally, recovery is expected and occurs in about 10 days. When external warmth
is applied, ischemic insult may occur because perfusion from deep blood vessels
tends to return slowly relative to the accelerated tissue oxygen demand. Rapid
rewarming is favoured over slow rewarming because it minimizes this discrepancy.
Prolonged exposure to cold, refreezing of partially thawed tissue, and slow
rewarming predispose the tissue to greater ischemic insult, resulting in greater tissue
loss. Frostbite severity and resultant tissue injury are a function of two factors. Both

315
the absolute temperature and the duration of cold exposure play a role. With regard
to these factors, data suggest that the duration of exposure has the greater impact
on the level of injury and the amount of tissue damage; however, short-term
exposure to extreme cold may produce the same overall injury pattern as excessively
prolonged exposure to lesser degrees of cold.

The most commonly affected group includes adult males aged 30-49 years, although
all age groups are at risk. In one case series, the mean patient age was 41 years.
Younger children have less adaptive behavioural reaction to cold stress; therefore,
they have a greater risk of frostbite. Recent US military data indicate a decreasing
rate of cold-related injuries in general with increasing age. However, this data set did
not specifically address an association of age with frostbite.

Patients should be informed that the frostbitten area may be more sensitive to cold,
with associated burning and tingling. Individuals who have sustained a cold-related
injury are at a 2- to 4-fold greater risk of developing a subsequent cold-related injury.
Therefore, patients with frostbite should be counselled about their increased
susceptibility to frostbite injury and about appropriate strategies to avoid it. They
should also be given general advice on preparing for cold weather exposure.

Questions 15-22
15) According to the first paragraph, when does frostbite occur?
a) after skin has had protracted exposure to sub-zero temperatures
b) only when very low temperatures are combined with high winds
c) when fluid crystallization precedes vasoconstriction
d) after an increase in blood flow

16) What do we learn about frostbite in the second paragraph?

a) contact between alcohol and unprotected skin can cause frostbite
b) mountaineers have the worst prognosis
c) patients with frostbite sometimes have other winter-related conditions
d) some frostbite variants present before hypoxia occurs

17) Before the 1950s

a) frostbite was unknown outside of Scandinavian countries

316
 b) expertise in dealing with frostbite was present in the world’s armed forces
c) urban and rural civilian populations became cognizant of the dangers of
frostbite
d) only the Scandinavian army knew how to treat frostbite

18) According to the fourth paragraph, which of the following statements is

not true?
a) it is harder for skin to increase in temperature than it is to decrease
b) some parts of the human body have a higher risk of frostbite than other parts
c) up to a certain point, skin is protected by warmth from other parts of the body
d) ice cascade injuries can prolong loss of cutaneous sensation

19) What do we learn about frostbite in the fifth paragraph?

a) the rapidity of freezing is thought to be a factor in frostbite recovery
b) the seriousness of cellular injury depends on the presence of water in the
intracellular and extracellular spaces
c) it is not possible to rewarm damaged tissue
d) microcirculation can be interrupted by bleb formation

20) What advice is given in the sixth paragraph about treatment?

a) accelerated oxygen demand should be avoided
b) duration of exposure to cold is not a relevant factor is subsequent outcomes
c) warming affected areas quickly is better than doing it slowly
d) tissue that had short-term exposures should be rewarmed more slowly

21) The figure of 41 is given to demonstrate

a) the maximum age at which full frostbite recovery has been recorded
b) the average age of men who had frostbite, according to a series of studies
c) the world record for the number of individual frostbite injuries that one
person has received

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 d) the length of time (in years) that the US military has calculated statistics for
frostbite related injuries

22) What do we learn about frostbite in the last paragraph?

a) people who have had frostbite may get more colds in the future
b) frostbite can recur between 2 and 4 times
c) there could be some unpleasant after-effects of frostbite
d) patients should be given advice about moving to a warmer climate

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TEST-17
Varicose Veins
PART A
TEXT 1
Varicose veins are dilated superficial veins in the lower extremities. They may be
blue or dark purple, and are often lumpy, bulging or twisted in appearance. Varicose
veins are typically asymptomatic but may cause a sense of fullness, pressure, and
pain or hyperesthesia in the legs.
Healthy leg veins have one-way valves to help blood flow back up to the heart but
varicose veins may result from primary venous valve insufficiency with reflux or from
primary dilation of the vein wall due to structural weakness.
Blood that collects in varicose veins can leak into smaller blood vessels (capillaries),
which enlarge and form ‘thread veins’ or ‘spider veins’. These veins are different to
varicose veins because they are situated much closer or within the overlying skin.
Although they may be unsightly, they are not the same as varicose veins and can be
more difficult to treat.
In some people, varicose veins result from chronic venous insufficiency and venous hypertension. Most
people have no obvious risk factors. Varicose veins are common within families, suggesting a genetic
component. Varicose veins are more common among people who stand a lot, have limited mobility or
who are overweight. Menopause and pregnancy affects the oestrogen levels which in turn affects
venous structure. Pregnancy increases pelvic and leg venous pressures, or both. People who have had a
deep veined thrombosis or suffered trauma to a leg are at increased risk of developing varicose veins.

TEXT 2
Diagnosing varicose veins
Varicose veins may initially be tense and palpable but not necessarily visible. Later,
they may progressively enlarge, protrude, and become obvious. They can cause a
sense of fullness, fatigue, pressure, and superficial pain or hyperesthesia in the legs.
Varicose veins are most visible when the patient stands. Cramping or restless legs,
itchiness and swollen ankles are common signs of varicose veins. The symptoms are
usually worse during warm weather or after standing up for long periods of time.
They may improve with walking or resting with raised legs.
Less common effects of varicose veins include leg ulcers and clotting. For unclear
reasons, stasis dermatitis and venous stasis ulcers are uncommon. When skin
changes e.g. induration, pigmentation, eczema occur, they typically affect the medial

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 malleolar region. Ulcers may develop after minimal trauma to an affected area; they
are usually small, superficial, and painful.
Varicose veins occasionally thrombose, causing pain. Superficial varicose veins may
cause thin venous bullae in the skin, which may rupture and bleed after minimal
trauma. Very rarely, such bleeding, if undetected during sleep, is fatal
The Trendelenburg test which compares venous filling before and after release of a
thigh tourniquet is no longer commonly used to identify retrograde blood flow past
incompetent saphenous valves.
Duplex ultrasonography is an accurate test that uses high-frequency sound waves to
produce a picture of the veins in the legs. The picture shows the blood flow and
helps locate any damaged valves that might be causing the varicose veins.

TEXT 3
Managing varicose veins
Treatment of varicose veins is only necessary:
• To ease symptoms if they are causing pain or discomfort
• To treat complications such as leg ulcers, swelling or skin discolouration
• For cosmetic reasons so usually only available through the private health sector
6 months of self-care involving using compression stockings; exercising regularly;
avoiding standing up for long periods and elevating the affected area when resting.
People with varicose veins that are causing significant symptoms should be referred
to a vascular surgeon for further treatment. There are several options available.
• Sclerotherapy which involves injecting special foam into affected veins. The foam
scars the veins, which seals them closed.
• Endovenous laser treatment involves a laser delivering short bursts of energy
that heat up the vein and seal it closed. The laser is slowly pulled along the vein using
the ultrasound scan to guide it, allowing the entire length of the vein to be closed.
• Radiofrequency ablation involves heating the wall of the varicose vein using
radiofrequency energy. A probe is inserted into the catheter that sends out
radiofrequency energy that heats the vein until its walls collapse, closing it and
sealing it shut. Once the vein has been sealed shut, blood will naturally be redirected
to a healthy vein.
Ligation and stripping is surgery that involves tying off the vein in the affected leg and then removing it.
Two small incisions are made. The first is made at the top of the varicose vein and is approximately 5cm
in diameter. The second, smaller cut is made further down the leg. The top of the vein is tied up and
sealed. A thin, flexible wire is passed through the bottom of the vein and then carefully pulled out and
removed through the lower cut in the leg.

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TEXT 4
Potential complications from varicose veins
Most people who have varicose veins won't develop complications. If they do, it's
usually several years after varicose veins first appear. Some possible complications of
varicose veins are:
• Bleeding from the varicose veins near the surface of your skin which may be
difficult to stop.
• Blood clots can form in veins located just under the surface of your skin
leading to conditions such as:
o thrombophlebitis, a swelling of the veins in the leg
o deep vein thrombosis which can cause pain and swelling in the leg, and
may lead to serious complications like pulmonary embolism
• Chronic venous insufficiency when the blood in the veins doesn't flow
properly, interfering with the way skin exchanges oxygen, nutrients and waste
products with blood. It can sometimes cause other conditions to develop,
including:
o varicose eczema that causes skin to become red, scaly and flaky
o lipodermatosclerosis which causes skin, usually around the calf area, to
become hardened and tight, and you may find it turns a red or brown
colour
o venous leg ulcers which develop when there's increased pressure in the
veins of the lower leg, which may eventually cause an ulcer

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 times when varicose vein are usually more prominent?
____________________

2 What happens if blood seeps into the little blood vessels? ____________________

3 How people can manage varicose veins themselves? ____________________

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4 The changes that can happen to skin colour around the mid lower leg?
____________________

5 What varicose veins look like? ____________________

6 What used to be done to diagnose varicose veins? ____________________

7 The surgical procedure that might be performed to manage varicose veins?

____________________

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 is inflammation of the veins in the leg called? __________________

9 What is there in the veins that helps blood flow back up to the heart?
__________________

10 What treatment involves pushing foam through varicose veins?

__________________

11 What condition restricts the way skin moves vital nutrients and waste products to
and from blood? __________________

12 What conditions change both the hormone levels and the structure of the veins,
which can lead to varicose veins? _____________________

13 How long does it usually take for complications of varicose veins to develop?
_____________________

14 Approximately, how big is the cut made at the top of a varicose vein, during the
surgical procedure? _____________________

Questions 15-20

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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 If a patient is having endovenous laser treatment, a laser pushes
out__________________ of energy.

16 Varicose veins just under the skin may cause__________________.

17 Varicose veins do not usually cause any problems but may lead to
a__________________, heaviness, over sensitivity or pain in the legs.

18 To ease symptoms of varicose veins a person should avoid being on their feet for
long periods and should __________________the leg when relaxing.

19 Some people have varicose veins because they have chronic venous insufficiency
and__________________.

20 _________________makes the skin red, scaly and flaky.

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 PART B
TEXT 1
Urine Dipstick Analysis

There have been many studies evaluating the accuracy of dipsticks tests. These are
mostly in relation to their role detecting bacteriuria. A meta-analysis of 26 studies in
children, showed wide differences in diagnostic accuracy across studies. This could
not be fully explained by differences in age, or by differences in the definition of the
criterion standard. The lack of an adequate explanation for the heterogeneity of the
dipstick accuracy stimulates an ongoing debate. Overall, the sensitivity of the urine
dipstick test for nitrites has been found to be low (45-60% in most situations) with
higher levels of specificity (85-98%). The test for nitrites has its highest accuracy in
specific populations such as pregnant women, urology patients and elderly people.
The test for nitrites may perform better in asymptomatic patients and in patients
who are not on antibiotics.

Question
1) This article informs the reader that
a) there is no clear explanation for the variation in accuracy rates
b) use of antibiotics can affect the accuracy of dipstick tests
c) dipstick test accuracy was higher for child populations

TEXT 2
Most people want to die at home, surrounded by loved ones and free of pain.
However, many of these people do not have advanced directives, nor have they
spoken about their wishes to their family. End of life care begins with advanced
planning, so it is essential that family members discuss what is important to them
before they need end of life care. Putting these wishes in writing can help the family
during this most difficult time.

It is important to the healthcare provider to know and recognize when the services
that are needed by their patients. Identifying the various symptomology that might
be present at end of life will ensure the patient receives the symptom relief he or she
needs.

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Question
2) What would be a suitable title for the following article?
a) The importance of advanced directives
b) End of life care: ensuring needs are met
c) How to help your loved one during a most difficult time

TEXT 3
Abnormal Liver Function Tests

Most tests measure hepatocellular damage rather than function, so they are rather
misnamed. True liver function tests (LFTs) are those that measure synthesis of
proteins made by the liver or the liver's capacity to metabolise drugs. LFTs are not
specific to specific systems or disease processes, yet abnormalities may indicate
significant or serious disease. Interpreting abnormal LFTs and trying to diagnose any
underlying liver disease is a common scenario in Primary Care. Single abnormalities
in LFTs are difficult to localise and diagnose. However, the pattern of abnormalities
tests helps determine origin of the issue. This usually means dividing the clinical
picture into non-hepatic, hepatocellular and cholestatic patterns of abnormality.
When this is then combined with a clinical history, medication and drug history and
the presence of any current or recent symptoms, it is usually possible to develop a
differential diagnosis.

Question
3) How can healthcare providers use LFTs?
a) Along with clinical history and other relevant data, LFT results help to form a
diagnosis
b) They can determine if hepatocellular damage has occurred
c) True LFTs can isolate specific disease processes

TEXT 4
Tissue & Tissue Products

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Human cells or tissue intended for implantation, transplantation, infusion, or
transfer into a human recipient is regulated as a human cell, tissue, and cellular and
tissue-based product. Examples of such tissues are bone, skin, corneas, heart valves,
oocytes and semen. CBER does not regulate the transplantation of vascularized
human organ transplants such as kidney, liver, heart, lung or pancreas. The Health
Resources Services Administration (HRSA) oversees the transplantation of
vascularized human organs. Part 1271 requires tissue establishments to screen and
test donors, to prepare and follow written procedures for the prevention of
the spread of communicable disease, and to maintain records. FDA has published
three final rules to broaden the scope of products subject to regulation and to
include more comprehensive requirements to prevent the introduction, transmission
and spread of communicable disease.

Question
4) What is one reason given for the following regulations?
a) to allow transplantation of vascularized human organs
b) to limit the spread of infectious diseases
c) to allow the HRSA and the FDA to manage transplants and implants effectively

TEXT 5
WHO Launches New Global Influenza Strategy

The World Health Authority (WHO) today released a Global Influenza Strategy for
2019-2030 aimed at protecting people in all countries from the threat of influenza.
The goal of the strategy is to prevent seasonal influenza and prepare for the next
influenza pandemic. “The threat of pandemic influenza is ever-present.” said WHO
Director-General Dr Ghebreyesus. “The on-going risk of a new influenza virus
transmitting from animals to humans and potentially causing a pandemic is real. The
question is not if we will have another pandemic, but when. We must be vigilant and
prepared. The cost of a major influenza outbreak will far outweigh the price of
prevention.” Every year across the globe, there are an estimated 1 billion cases
which result in 290 000 to 650 000 influenza-related respiratory deaths.

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Question
5) According to this article, which of the following statements is not true?
a) The WHO strategy is aimed at protecting humans and animals, such as
livestock
b) The WHO strategy is twofold, prevention and preparation
c) It is highly likely that another global pandemic will occur

TEXT 6
What Is Medication-Induced Headache?

Medication-induced headache is caused by taking painkillers too often for headaches

of any kind. For example, you may have a series of tension headaches or migraines,
perhaps during a time of stress. You take painkillers more often than usual and your
body becomes used to the medication. A withdrawal (rebound) headache then
develops if you do not take a painkiller within a day or so of the last dose. You think
this is another tension headache or migraine, and so you take a further dose of
painkiller. When the effect of each dose wears off, a further withdrawal headache
develops, and so on. In time, you may have headaches on most days, and you end up
taking more and more painkillers.

Question
6) According to this article, what is the cause of medication-induced
headache?
a) When you don’t take medication
b) Taking the wrong type of medication
c) Stress and tension are major factors

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 PART C
TEXT 1
Most snakebites are innocuous and are delivered by non-poisonous species.
Worldwide, only about 15% of the more than 3000 species of snakes are considered
dangerous to humans. The family Viperidae is the largest family of venomous snakes,
and members can be found in Africa, Europe, Asia, and the Americas. The family
Elapidae is the next largest family of venomous snakes.

Venom dosage per bite depends on the elapsed time since the last bite, the degree
of threat perceived by the snake, and size of the prey. Nostril pits respond to the
heat emission of the prey, which may enable the snake to vary the amount of venom
delivered. Coral snakes have shorter fangs and a smaller mouth. This allows them
less opportunity for envenomation than the crotalids, and their bites more closely
resemble chewing rather than the strike for which the pit vipers are famous. Both
methods inject venom into the victim to immobilize it quickly and begin digestion.

Evidence suggests that the differences between the venom components of different
snake species resulted from a diet directed evolution occurring over time. Venom is
mostly water. Enzymatic proteins in venom impart its destructive properties.
Proteases, collagenase, and arginine ester hydrolase have been identified in pit viper
venom. Neurotoxins comprise around 40% of coral snake venom. Enzyme
concentrations vary among species, thereby causing dissimilar envenomations.
Copperhead bites generally are limited to local tissue destruction. Rattlesnakes can
leave impressive wounds and cause systemic toxicity. Coral snakes may leave a small
wound that later results in respiratory failure from systemic neuromuscular
blockade.

The local effects of venom serve as a reminder of the potential for systemic
disruption of organ system function. One effect is local bleeding; coagulopathy is not
uncommon with severe envenomation. Another effect, local oedema, increases
capillary leak and interstitial fluid in the lungs. Pulmonary mechanics may be altered
significantly. The final effect, local cell death, increases lactic acid concentration
secondary to changes in volume status and requires increased minute ventilation.
The effects of neuromuscular blockade result in poor diaphragmatic excursion.
Cardiac failure can result from hypotension and acidosis. Myonecrosis raises
concerns about myoglobinuria and renal damage.

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In the United States, more than 40% of victims put themselves in danger by either
handling pets or attempting to capture reptiles in the wild. The popularity of keeping
exotic species has increased the number of envenomations by non-native species.
UTMCK data support this by reporting that 12 of 25 patients were bitten handling
snakes; 2 of these were involved in religious ceremonies.

Generally, only localized reporting of international data is available. Most snakebites

and deaths due to snakebites are not reported, especially in the developing world.
An estimated 1.8-2.5 million venomous snakebites occur worldwide each year,
resulting in an estimated 100,000 to 125,000 annual deaths, but this may be
underreported. Worldwide, snakebites disproportionately affect low socioeconomic
populations in more rural locations. They are often seen as bites to the lower
extremities by farmers or workers who step on or disturb a snake in the field or rice
paddies, or they can present as a bite to the head or trunk in individuals sleeping
outside on the ground.

In the USA, national studies report 50% of patients were aged 18-28 years. 95% of
bites were located on an extremity, especially the hand. National studies report a
seasonal occurrence of 90% from April to October. In the paediatric population, most
snakebites occurred in school-aged children and adolescents around the perimeter
of the home during the afternoon in summer months. The most frequent wound
sites were the lower limbs.

Full recovery is the rule, though local complications from envenomation may occur.
Death occurs in less than 1 bite in 5000. A review of morbidity associated with
snakebites from Kentucky, USA was published. Most bites were from copperheads
and resulted in 8 days of pain, 11 days of extremity oedema, and 14 days of missed
work. A review specifically of copperhead bites in West Virginia described similar
outcomes and noted that the peak effects of envenomation were not present until
longer than 4 hours after the bite.

Local tissue destruction rarely contributes to long-term morbidity. Occasionally, skin

grafting is required to close a defect from fasciotomy, but wounds requiring
fasciotomy to reduce compartment pressures from muscle oedema are infrequent. A
new web site (Australian Venom Research Unit) based at the University of
Melbourne in Australia comprehensively outlines the species, first aid, and treatment
of all venomous creatures indigenous to the region. The web site is easily navigated
and sectionally divided for the practitioner, interested epidemiologists, snake
fanciers, and children of Australia and the Asia/Pacific region.

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Questions 7-14
7) Around the world, how many snakes are thought to be dangerous to
humans?
a) About 3000 species of snakes altogether
b) Less than one in five species
c) 15% of all snakes
d) 15% of the family Viperidae

8) In the second paragraph, which of the following is not mentioned?

a) Various factors determine the venom dosage per bite
b) Different species of snake have different bite characteristics
c) Pit vipers deliver a higher amount of venom per bite than coral snakes
d) One effect of venom is to stop the victim moving

9) What do we learn about venom from the third paragraph?

a) There is significantly more water in venom than other constituents.
b) Venom is another term for enzymatic destruction
c) Pit viper venom is the most destructive, compared to other species
d) Rattlesnakes are more impressive than copperhead or coral snakes

10) The fourth paragraph informs the reader that

a) snakebites can have fatal consequences
b) not all snakebites result in bleeding
c) lactic acid increases can lead to coagulopathic leakage
d) neuromuscular blockage can lead to loss of balance

11) The UTMCK data is quoted in order to highlight

a) Most snake bite victims were among people who hunt snakes in the wild
b) Twice as many victims in the USA were bitten during religious ceremonies
c) Non-native species are more dangerous than species native to the USA
d) More than half of all victims did not deliberately seek contact with snakes
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12) According to international data, which group is at the highest risk of
snake bites?
a) Poor people who live outside of cities
b) Children who are bitten during the summer months
c) People who keep venomous snakes as pets
d) All populations are equally vulnerable

13) What do the statistic mentioned in the seventh paragraph point to?
a) 95% of patients are aged between 18-25 years
b) In the US, there are seasonal variations in the number of cases
c) 95% of snakebites are extremely serious
d) Children are safer at home than outside the home perimeter

14) The study carried out in West Virginia is quoted to highlight

a) There are many similarities of morbidity among snake species
b) Most symptoms of copperhead envenomation do not occur straightaway
c) Death rates from snakebites are very low
d) Some complications of snakebites are difficult to manage

TEXT 2
The first months of the year can be a miserable time. Holiday festivities are over,
money is tight and pressure to keep up your resolutions is mounting. This can lead to
feelings of anxiety, depression and even failure. For many, these symptoms begin
even earlier as the seasons change from autumn to winter. According to the Royal
College of Psychiatrists, around every 3 in 100 people suffer from significant seasonal
depression, which can interfere with daily life. We explore why winter leaves so
many feeling down and how you can tackle it at home.

Symptoms of seasonal affective disorder (SAD) typically develop between September

and November and continue until early spring, often reaching their peak during
December, January and February. To determine whether you have SAD or non-

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seasonal depression, it can be useful to record your symptoms over time. If you show
none of the common signs of depression during the summer months for two years or
more, it is likely that you have SAD.

Dr Mark Winwood, director of Psychological Services for AXA PPP Healthcare,

explains: "In non-seasonal depression, people commonly sleep less and eat less.
Whereas with SAD, they usually sleep more and eat more as if they are in
hibernation." Dr Preethi Daniel, clinical director at the London Doctors Clinic, lists
other common symptoms of SAD as persistent low mood, lack of energy, difficulty
concentrating or achieving deadlines, lack of interest or pleasure in usual activities
and feelings of worthlessness compared to others who are coping fine.

It is thought that the lack of sunlight, shorter days and cold temperatures bring on
the so-called 'winter blues' in several ways. Levels of melatonin (the hormone that
controls your body's sleep-wake cycle) and the brain chemical serotonin (which plays
a major role in mood) are affected; we are unable to produce enough vitamin D (the
'sunshine vitamin') naturally and our sleep cycle is triggered early by the dark
evenings. There is also a theory that SAD can be triggered by traumatic or upsetting
past events that occurred around the same time, although there are not many
studies investigating this further.

If you are experiencing a persistent low mood and that does not subside when it
reaches the summer months, you could be suffering from depression. Make an
appointment with your doctor to talk things through and figure out the best course
of treatment.

Your circadian rhythm, also known as the circadian clock or sleep/wake cycle, is a
"24-hour internal clock running in the background of your brain", telling you when
it's time to wake up and go to sleep, according to the National Sleep Foundation.
"Natural daylight supports our circadian clock and helps us sleep at night," reveals
Winwood. So, if you're going to work and coming home when it's dark, you're more
likely to feel depressed from lack of sunlight and a disrupted sleep pattern.

A way to combat sluggish mornings and low mood is light therapy. This involves
using a lamp or light box that is designed to replicate sunlight. "By mimicking natural
sunlight, your body is tricked into feeling good and energetic," says Dr Daniel. One
study found light therapy to cause a significant reduction in depression symptoms
when treating SAD and had similar effectiveness to antidepressants. For light therapy
to be an effective treatment for SAD, you are advised to use your light for around 30
minutes a day, preferably in the morning, and will usually feel the effects after 3-4

334
days. It's important to use the light continually throughout the winter for it to be
beneficial. My own experiences with SAD light therapy have been very positive and it
has become a key part of my morning routine while I get ready. I use a lamp
manufactured by a company called ‘Lumie’. Although light therapy can be an
effective treatment, the cost of a lamp can be a barrier for many.

However, there are other things you can try without the need to splash out. It's well-
known that sunshine provides our bodies with vitamin D, as much as 90% of it! "On
cloudy days, we make less of it and deplete our stores quickly. This not only affects
our mood, but it also causes general aches and pains," notes Dr Daniel. Taking a daily
vitamin D supplement during the winter can also aid good bone health and combat
tiredness. Low levels have also been linked to an increased risk of heart disease and
even multiple sclerosis. As well as taking supplements, ask to sit by a window in the
office if possible, and open the curtains at home even on cloudy days. Daniel also
suggests making time for a daily walk in your lunch hour.

It may sound obvious, but having a routine keeps you focused. It can be hard to get
up in the mornings when it's cold, so perhaps time the heating to come on for when
you need to get up or lay your clothes out the night before. Winter often leaves us
wanting to sleep most of the time, except when it comes to bedtime. A good night's
sleep is essential for optimal mental and physical well-being, insists Winwood.

Questions 15-22

15) What does the first paragraph say about seasonal depression?
a) Some people are affected by holiday festivities
b) The majority of people are unaffected by this problem
c) Around 13% of people have this type of depression
d) 3 in 100 people report significantly worse symptoms during winter months

16) According to the second paragraph, how can a person make a self-
assessment?
a) a person does not notice the usual indications of depression in the summer
b) it is important to keep a record of sleep patterns
c) a doctor can evaluate symptoms such as mood and/or feelings
d) a person may notice changes in appetite

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17) What does the third paragraph say about the causes of SAD?
a) it seems there are a number of different contributing factors
b) an imbalance of melatonin and serotonin occurs
c) too much sleep can affect the levels of vitamin D
d) psychological factors are thought to outweigh physiological factors

18) In the fifth paragraph, what is thought to be conducive to healthy

sleep?
a) reducing the amount of light when it is time to sleep
b) a well-adjusted sleep/wake cycle
c) making sure that the circadian rhythm is running in the background of your
brain
d) getting enough daylight

19) According to Dr Daniel, why are special light boxes effective?

a) they imitate ordinary light
b) they can boost circadian rhythms
c) they are an inexpensive alternative to antidepressants
d) they can amplify natural sunlight

20) What does the reader learn about vitamin D from Dr Daniel?
a) it is not necessary to splash vitamin D out
b) overuse of vitamin D can lead to general aches and pains
c) the body does not retain vitamin D for extended periods
d) Vitamin D does not need to be supplemented if you sit near a window

21) What does the reader learn about sleep in the eighth paragraph?
a) it is not beneficial to lay on your clothes
b) optimal sleep is more difficult to achieve during the winter
c) the temperature has little or no effect on sleep patterns
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 d) in the winter, a person’s desire for sleep can diminish at certain times of the
day

22) What would be a suitable title for this text?

a) New Treatments to Boost Circadian Rhythms
b) Seasonal Affective Disorder – Why Your Sleep is to Blame
c) How to Look After Your Mental Health This Winter
d) ‘Lumie’ – A New Cure for SAD

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