INDEX

• DIABETES
• IRRITABLE BOWEL SYNDROME (IBS)
• HYPERTENSION
• MIGRAINES
• VITAMIN C DEFICIENCY
• ACUTE DIARRHEA
• DENGUE FEVER
• BED BUGS
• OBSTETRIC ULTARSOUND
• SURVEY ON SKIN-LIGHTENING CREAMS
 PART A

DIABEITES
TEXT A

Diabetes is a defect in the body’s ability to convert glucose (sugar) into energy. Glucose is the
main source of fuel for the body. When food is digested, it is converted into fats, protein, or
carbohydrates. Foods that affect blood sugars are called carbohydrates, which, when digested,
change into glucose. Examples of some carbohydrates are: bread, rice, pasta, potatoes, corn, fruit,
and milk products. Individuals with diabetes should eat carbohydrates but must do so in
moderation. Glucose can then be transferred to the blood and used by the cells for energy. In order
for glucose to be transferred from the blood into the cells, the hormone insulin is needed. Insulin
is produced by the beta cells in the pancreas (the organ that produces insulin) but, in individuals
with diabetes, this process is impaired. Diabetes develops when the pancreas fails to produce
sufficient quantities of insulin (Type 1 diabetes) or the insulin produced is defective and can’t
move glucose into the cells (Type 2 diabetes).

Text B

There are two main types of diabetes. In type 1 diabetes, the cells in the pancreas that make insulin
are destroyed. If you have type 1 diabetes, you need to inject your body with insulin from shots or
a pump every day. Most people can learn to adjust the amount of insulin they take according to
their physical activity and eating patterns; this makes it easier to manage your diabetes when you
have a busy schedule. In type 2 diabetes, the pancreas still makes some insulin but cells are unable
to use it very well. If you have type 2 diabetes, you may need to take insulin injections or pills to
help your body’s supply of insulin work better. Type 2 used to be called “adult onset diabetes” but
now more teenagers and young people are getting type 2, especially if they are overweight.

Text C

Prevalence of diabetes and prediabetes by age-group on the basis of HbA1c (left panel) and FPG
(right panel).
Text D

Short-term Diabetes Complications

Hypoglycemia-Hypoglycemia is low blood glucose (blood sugar). It is possible for your blood
glucose to drop, especially if you’re taking insulin or a sulfonylurea drug (those make your body
produce insulin throughout the day). With these medications, if you eat less than usual or were
more active, your blood glucose may dip too much. Other possible causes of hypoglycemia include
certain medications (aspirin, for example, lowers the blood glucose level if you take a dose of more
than 81mg) and too much alcohol (alcohol keeps the liver from releasing glucose).

The signs and symptoms of low blood glucose are easy to recognize:

Rapid heartbeat, Sweating, Whiteness of skin, Anxiety, Numbness in fingers, toes, and lips,

Sleepiness, Confusion, Headache, Slurred speech

PART A
TIME: 15 minutes

• Look at the four texts , A – D, in the separate Text Booklet

• For each question, 1-20, look through the texts, A-d, to find the relevant
information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.
DIABETES

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes
from. You may use any letter more than once

1. Rapid heartbeat as a sign of hypoglyamia ……………………..

2. Where the insulin is produced? ……………………..
3. Diabetes which occurs in people especially if they are overweight …………..
4. The percentage of diabetic patients aged between 60 and 69 ……………
5. The food items which contain carbohydrates ……………………
6. The drug which makes our body to produce insulin throughout the day
……………….
7. The prevalence of diabetes in 30-39 age-groups is 3.4% ……………..

Questions 8-14
Answer each of the questions, 8-4, with a word or short phrase from one of the texts. Each
answer may include words, number of the both. Your answers should be correctly spelled.

8. What is the term used to denote low blood glucose?

………………………………………………………………….
9. Which organ produces insulin?
…………………………………………………………………….
10. What is the prevalence of diabetes in 50-59 age-group on the basis of FPG
…………………………………………………………………….
11. Which type of diabetes develops when the pancreas fails to produce sufficient
quantities of insulin?
…………………………………………………………………….
12. Which medication causes hypoglycemia when a dose of more than 81 mg is taken?
 …………………………………………
13. Which hormone helps in transferring glucose from blood into cells?
…………………………………………
14. The foods that affect blood sugars are called?
…………………………………………

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, number or both. Your answers should be correctly spelled

15. Prevalence of diabetes and prediabetes by age –group on the basis of ----------------
and FPG
16. Type 2 diabetes used to be called as ----------------------------
17. It is possible for your blood glucose to drop especially if you are taking insulin or a
------------------
18. When food is digested , it is converted into fats--------------- or carbohydrates
19. Diabetes is a defect in the body’s ability to convert------------------- in to energy
20. In type 1 diabetes, the cells in the pancreases that make insulin are-------------------
READING SUB-TEST : PART B
In this part of the test, there are six short extracts relating to the work of health professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best according to the text. Write
your answers on the separate Answer Sheet
Questions 1-6

1.
2.
Common descriptive nomenclature

Using common universal descriptive names from a single internationally accepted source is key to
comparing inspection procedures, inspection times, failure rates, service costs and other important
maintenance management information from facility to facility. Although manufacturers have specific
names for devices, it is important to store the common name of the device as listed in the
nomenclature system.
3. The guidelines establish that the healthcare professional should use

A. common universal descriptive names for devices from a internationally accepted source

B. specific names for devices from the user manual given by the manufacturer

C. common descriptive nomenclature from the directory of healthcare facility

Drains and drainage systems

Drains are used to drain physiological or pathological fluids from the body.
The use of drains and drainage systems in surgery significantly affects the
overall healing process. The accumulated fluid can endanger the whole body as
it has a mechanical and toxic effect on the surrounding tissue and is a breeding
ground for microorganisms. Drains are used to drain fluids from body cavities,
organs, wounds and surgical wounds (e.g. blood, wound secretion, bile,
intestinal contents, pus etc.) and air (chest drainage).
4. The purpose of these notes about drains and drainage systems is to
A. help maximize efficiency of healing process.
B. give guidance on certain medical procedures.
C. avoid accumulation of fluid in body cavities.
Decontamination

Decontamination procedures include mechanical cleaning, which removes impurities

and reduces the presence of microorganisms. In the event of contamination by
biological material, it is necessary to include mechanical cleaning before the disinfection
process. Detergents with a disinfectant effect are applied manually or by washing and
cleaning machines, pressure guns, ultrasonic devices, etc. All tools and equipment
must bekept clean. Cleaning machines and other equipment are used inaccordance
with the manufacturer ’s instructions, including checks of the cleaning process.

5. What must all staff involved in the physical disinfection process do?
A. Boil under atmospheric pressure for at least 20 minutes
B. Boil under atmospheric pressure for at least 30 minutes
C. Boil in pressurized containers for at least 30 minutes

6. In advance directive
a. Patient can make decisions about his or her medical treatment
b. An attending physician can withhold medical interventions from a terminally ill patient
c. Family members have the authority to interpret it to the patient along with physician.

LIVING WILL

A Living Will is the oldest type of health care advance directive. It is a signed, witnessed
(ornotarized) documentcalleda“declaration”or“directive.”Most declarations instruct an
attending physician to withhold or withdraw medical interventions from its signer if he/she is
in a terminal con dition and is unable to make decisions about medical treatment.
Sinceanattendingphysicianwhomaybeunfamiliarwiththesigner’swishesand values has the
power and authority to carry out the signer’s directive, certain terms contained in the
document may be inter preted by the physician in a manner that was not intended by the
signer. Family members and others who are familiar with the signer’s values and wishes have
no legal standing to interpret the meaning of the directive.
Text C1

Going blind in Australia

Paragraph 1

Australians are living longer and so face increasing levels of visual impairment. When we look at the problem
of visual impairment and the elderly, there are three main issues. First, most impaired people retire with
relatively “normal” eyesight, with no more than presbyopia, which is common in most people over 45 years
of age. Second, those with visual impairment do have eye disease and are not merely suffering from “old
age”. Third, almost all the major ocular disorders affecting the older population, such as cataract, glaucoma
and age-related macular degeneration (AMD), are progressive and if untreated will cause visual impairment
and eventual blindness.

Paragraph 2

Cataract accounts for nearly half of all blindness and remains the most prevalent cause of blindness
worldwide. In Australia, we do not know how prevalent cataract is, but it was estimated in 1979 to affect the
vision of 43 persons per thousand over the age of 64 years. Although some risk factors for cataract have
been identified, such as ultraviolet radiation, cigarette smoking and alcohol consumption, there is no proven
means of preventing the development of most age-related or senile cataract. However cataract blindness
can be delayed or cured if diagnosis is early and therapy, including surgery, is accessible.

Paragraph 3

AMD is the leading cause of new cases of blindness in those over 65. In the United States, it affects
8–11% of those aged 65–74, and 20% of those over 75 years. In Australia, the prevalence of AMD is
presently unknown but could be similar to that in the USA. Unlike cataract, the treatment possibilities for
AMD are limited. Glaucoma is the third major cause of vision loss in the elderly. This insidious disease is often
undetected until optic nerve damage is far advanced. While risk factors for glaucoma, such as ethnicity and
family history, are known, these associations are poorly understood. With early detection, glaucoma can be
controlled medically or surgically.

Paragraph 4

While older people use a large percentage of eye services, many more may not have access to, or may
underutilise, these services. In the United States, 33% of the elderly in Baltimore had ocular pathology
requiring further investigation or intervention. In the UK, only half the visually impaired in London were known
by their doctors to have visual problems, and 40% of those visually impaired in the city of Canterbury had
never visited an ophthalmologist. The reasons for people underutilising eye care services are, first, that many
elderly people believe that poor vision is inevitable or untreatable. Second, many of the visually impaired
have other chronic disease and may neglect their eyesight. Third, hospital resources and rehabilitation
centres in the community are limited and, finally, social factors play a role.
Paragraph 5

People in lower socioeconomic groups are more likely to delay seeking treatment; they also use fewer
preventive, early intervention and screening services, and fewer rehabilitation and after-care services. The
poor use more health services, but their use is episodic, and often involves hospital casualty departments
or general medical services, where eyes are not routinely examined. In addition, the costs of services are
a great deterrent for those with lower incomes, who are less likely to have private health insurance. For
example, surgery is the most effective means of treatment for cataract, and timely medical care is required
for glaucoma and AMD. However, in December 1991, the proportion of the Australian population covered
by private health insurance was 42%. Less than 38% had supplementary insurance cover. With 46% of
category 1 (urgent) patients waiting for more than 30 days for elective eye surgery in the public system, and
54% of category 2 (semi-urgent) patients waiting for more than three months, cost appears to be a barrier
to appropriate and adequate care.

Paragraph 6

With the proportion of Australians aged 65 years and older expected to double from the present 11% to
21% by 2031, the cost to individuals and to society of poor sight will increase significantly if people do not
have access to, or do not use, eye services. To help contain these costs, general practitioners can actively
investigate the vision of all their older patients, refer them earlier, and teach them self-care practices. In
addition, the government, which is responsible to the taxpayer, must provide everyone with equal access
to eye health care services. This may not be achieved merely by increasing expenditure – funds need to be
directed towards prevention and health promotion, as well as treatment. Such strategies will make good
economic sense if they stop older people going blind.

Part C - Text C1: Questions 1– 8

1 In paragraph 1, the author suggests that ……
A many people have poor eyesight at retirement age.
B sight problems of the aged are often treatable.
C cataract and glaucoma are the inevitable results of growing older.
D few sight problems of the elderly are potentially damaging.

2 According to paragraph 2, cataracts ……

A may affect about half the population of Australians aged over 64.
B may occur in about 4–5% of Australians aged over 64.
C are directly related to smoking and alcohol consumption in old age.
D are the cause of more than 50% of visual impairments.

3 According to paragraph 3, age-related macular degeneration (AMD) ……

A responds well to early treatment.
B affects 1 in 5 of people aged 65–74.
C is a new disease which originated in the USA.
D causes a significant amount of sight loss in the elderly.
QUESTIONS

4 According to paragraph 3, the detection of glaucoma ……

A generally occurs too late for treatment to be effective.
B is strongly associated with ethnic and genetic factors.
C must occur early to enable effective treatment.
D generally occurs before optic nerve damage is very advanced.

5 Statistics in paragraph 4 indicate that ……

A existing eye care services are not fully utilised by the elderly.
B GPs are generally aware of their patients’ sight difficulties.
C most of the elderly in the USA receive adequate eye treatment.
D only 40% of the visually impaired visit an ophthalmologist.

6 According to paragraph 4, which one of the following statements is NOT true?

A Many elderly people believe that eyesight problems cannot be treated effectively.
B Elderly people with chronic diseases are more likely to have poor eyesight.
C The facilities for eye treatments are not always readily available.
D Many elderly people think that deterioration of eyesight is a product of ageing.

7 In discussing social factors affecting the use of health services in paragraph 5, the author points
out that ……
A wealthier people use health services more often than poorer people.
B poorer people use health services more regularly than wealthier people.
C poorer people deliberately avoid having their eye sight examined.
D poorer people have less access to the range of available eye care services.

8 According to paragraph 6, in Australia in the year 2031 ……

A about one tenth of the country’s population will be elderly.
B about one third of the country’s population will be elderly.
C the proportion of people over 65 will be twice the present proportion.
D the number of visually impaired will be twice the present number.
Text C2

Exercise, fitness and health

Paragraph 1

Physical inactivity is a substantial risk factor for cardiovascular disease. Exercise probably works by increasing
physical fitness and by modifying other risk factors. Among other benefits, it lessens the risk of stroke and
osteoporosis and is associated with a lower all-cause mortality. Moreover, it has psychological effects that
are surely underexploited. A pervasive benefit is the gain in everyday reserve capacity – that is, the ability
to do more without fatigue. Nevertheless, there is much debate about how intense the exercise should be.
Some studies show a dose-response relation between activity and reduction of risk, with a threshold of
effect; some suggest that vigorous aerobic activity is needed and others that frequent moderate exercise
is adequate – and indeed safer if ischaemic heart disease might be present. A few surveys have found a
slightly increased risk of heart attack with extreme activity, though further analysis in one study suggested
this applied only to men with hypertension.

Paragraph 2

A commonly recommended minimum regimen for cardiovascular benefit is thrice weekly exercise for 20
minutes, brisk enough to produce sweating or hard breathing (or a heart rate 60–80% of maximum). Indeed,
this is what the Allied Dunbar national survey of fitness among adults in the UK recommends. It conveys a
simple popular message of broad minimum targets for different age groups expressed in terms of activities
of different intensity. The aim is to produce a training effect through exercise beyond what is customary for
an individual.

Paragraph 3

The main reason why people fail to take exercise is lack of time. Thus an important message is that exercise
can be part of the daily routine – walking or cycling to work or the shops, for instance. Relatively few people
in the national fitness survey had walked continuously for even 1–25 km in the previous month (11–30%
depending on age and sex), and other surveys have also found little walking. Cycling is also beneficial,
however many are put off cycling to work by the danger. Certainly more cycle routes are needed, but even
now life years lost through accidents are outweighed by the estimated life years gained through better health.
Employers could encourage people to make exercise part of the working day by providing showers and
changing rooms, flexible working hours, individual counselling by occupational health or personnel staff, and
sometimes exercise facilities – or at least encouragement for exercise groups.

Paragraph 4

In the promotion of exercise, children, women, middle aged men, and older people need special thought.
Lifelong exercise is most likely to be started in childhood, but children may have little vigorous exercise.
Women tend to be much less active than men and are less fit at all ages. The proportion judged on a treadmill
test to be unable to keep walking at 5km/h up a slight slope rose with age from 34% to 92% – and over half
of those aged over 54 would not be able to do so even on the level. Women have particular constraints:
young children may prevent even brisk walking. Thus they need sensitive help from health professionals and
women’s and children’s groups as well as the media.

Paragraph 5

A high proportion of men aged 45–54, who have a high risk of coronary heart disease, were not considered
active enough for their health. Promotion of exercise and individual counselling at work could help. Forty
percent of 65–74 year olds had done no “moderate” activity for even 20 minutes in a month. Yet older people
especially need exercise to help them make the most of their reduced physical capacity and counteract the
natural deterioration of age. They respond to endurance training much the same as do younger people.
Doctors particularly should take this challenge more seriously.
www.occupationalenglishtest.org 29
 Paragraph 6

People need to be better informed, and much can be done through the media. For instance, many in the
survey were mistaken in thinking that they were active and fit. Moreover, many gave “not enough energy”
and “too old” as reasons for not exercising. Precautions also need publicity – for example, warming up
and cooling down gradually, avoiding vigorous exercise during infections, and (for older people) having a
medical check before starting vigorous activity. Doctors are in a key position. Some general practitioners
have diplomas in sports medicine, and a few are setting up exercise programmes. As the Royal College of
Physicians says, however, all doctors should ask about exercise when they see patients, especially during
routine health checks, and advise on suitable exercise and local facilities. Their frequent contact with women
and children provides a valuable opportunity. Excluding ischaemic heart disease and also checking blood
pressure before vigorous activity is started are important precautions. But above all doctors could help to
create a cultural change whereby the habit of exercise becomes integral to daily life.

Part C Questions 11–18

11 All of the following are mentioned in paragraph 1 as benefits of exercise EXCEPT ……
A increase in the capacity to withstand strenuous activity.
B significant decrease in the risk of osteoporosis.
C reduction of the risk of heart disease.
D weight control and decrease in levels of body fat.

12 According to paragraph 2, the recommendations of the report on the national fitness survey included
……
A long, vigorous aerobic sessions for all men, women and children.
B no more than three, 20 minute exercise sessions per week.
C avoiding any exercise that brought on hard breathing.
D different levels of exercise intensity for different age groups.

13 According to paragraph 3, one reason many people do not exercise is ……

A they are unaware of its importance.
B difficulty in fitting it into their daily routine.
C they are unaware of its long-term health benefits.
D they live too far from work to walk or cycle.

14 Which one of the following is mentioned in paragraph 3 as a way in which employers can help
improve the physical fitness and health of their staff?
A Making it mandatory for employees to exercise during lunch breaks.
B Providing encouragement and advice from staff within the organisation.
C Hiring trained sports educators to counsel members of staff about exercise.
D Setting an example, as individuals, by regularly exercising themselves.

30 www.occupationalenglishtest.org
QUESTIONS

15 According to paragraphs 4 and 5, older men and women need to remain physically active and fit
because ……
A they need to counteract the risk of coronary disease.
B fitness levels decrease rapidly over the age of 54.
C they need to guard against poor health and inactivity.
D exercise works against the physical effects of ageing.

16 Which one of the following is NOT mentioned in paragraph 6 as a precaution to be taken when
considering exercise?
A The need to balance aerobic activity with stretching.
B The need to warm up before and cool down after exercise.
C The need to eliminate the risk of ischaemic heart disease before starting.
D The need to exclude strenuous exercise from the routine during infection.

17 Which one of the following needs in relation to the improvement of national fitness is NOT mentioned
in the article?
A The need for people to make exercise a regular daily habit.
B The need to provide information on health and fitness to the community.
C The need for doctors themselves to improve their own fitness levels.
D The need to consult a doctor before starting an exercise program.

18 According to the article, which one of the following is FALSE?

A It is unsafe for people with high blood pressure to do regular moderate exercise.
B Experts agree on the importance of both type and intensity of exercise.
C Men are generally fitter and more active than women.
D Cycling, though unsafe, is a beneficial form of exercise.

END OF PART B - TEXT 2

END OF READING TEST

www.occupationalenglishtest.org 31
 PART A

IRRITABLE BOWEL SYNDROME (IBS)

Text A

Irritable Bowel Syndrome (IBS) is a functional bowel disorder characterized by chronic abdominal
pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic
cause. It is a chronic gastrointestinal disorder of an unknown cause. Common symptoms include:
abdominal cramping or pain, bloating and gassiness and altered bowel habits. Irritable bowel
syndrome has been called spastic colon, functional bowel disease, and mucous colitis. However,
IBS is not a true "colitis." The term colitis refers to a separate condition known as inflammatory
bowel disease (IBD). Irritable bowel syndrome is not contagious, inherited, or cancerous.
However, IBS often disrupts daily living activities. The prevalence is greater in women (it affects
twice as many women as men). Though most of the patients are older than 60 years, IBS can affect
all ages. IBS is not life threatening.

Text B

What are the causes of Irritable Bowel Syndrome (IBS)? The cause of
irritable bowel syndrome is currently unknown. IBS is thought to result from interplay of abnormal
gastrointestinal (GI) tract movements, increased awareness of normal bodily functions, and a
change in the nervous system communication between the brain and the GI tract. Abnormal
movements of the colon, whether too fast or too slow, are seen in some, but not all, people who
have IBS.

Irritable bowel syndrome has sometimes also developed after episodes of gastroenteritis. It has
been suggested that IBS is caused by dietary allergies or food sensitivities, but this has never been
proven. Symptoms of irritable bowel syndrome may worsen during periods of stress or during
menstruation, but these factors are unlikely to be the cause that leads to the development of IBS.
What are the signs and symptoms of Irritable Bowel Syndrome (IBS)? The primary symptoms of
IBS are: • Abdominal pain or discomfort • Frequent diarrhea or constipation (change in bowel
habits) • Feeling of incomplete evacuation (tenesmus) • Bloating or abdominal distention •
Gassiness (flatulence) • Passing mucus from the rectum Gassiness (flatulence) • Passing mucus
from the rectum • Weight loss • Vomiting, nausea • Fever.

How is it diagnosed? After discussing

your medical history, your health care provider will examine your abdomen and may do a rectal
examination. There is no specific test for IBS. Depending on your history and the results of the
examination, your provider may do the following tests to look for other possible causes of your
symptoms: • blood tests •tests of bowel movement samples to check for blood and infection • x-
rays • colonoscopy or sigmoidoscopy (procedures that allow your provider to see the inside of
your colon with a thin, flexible, lighted tube) • barium enema (a procedure in which a special
liquid is passed into the colon through the rectum before x-rays are taken) to check the colon lining.
Your health care provider may ask you to try a milk-free diet to see if lactose intolerance (trouble
digesting milk) may be causing your symptoms.

Text C

Text D

What are the complications of IBS?

The complications of IBS can affect the patient not only physically, but also mentally and
emotionally. Individuals with IBS have been found to have decreased diversity and numbers of
bacteroidetesmicrobiota. Preliminary research into the effectiveness of fecal microbiota transplant
in the treatment of IBS has been very favorable with a 'cure' rate of between 36 percent and 60
percent with remission of core IBS symptoms persisting at 9 and 19 months follow up Treatment
with probiotic strains of bacteria has shown to be effective, though not all strains of
microorganisms confer the same benefit and adverse side effects have been documented in a
minority of cases. There is increasing evidence for the effectiveness of mesalazine (5-
aminosalicylic acid) in the treatment of IBS. Mesalazine is a drug with anti-inflammatory
properties that has been reported to significantly reduce immune mediated inflammation in the gut
of IBS affected individuals with mesalazine therapy resulting in improved IBS symptoms as well
as feelings of general wellness in IBS affected people. It has also been observed that mesalazine
therapy helps to normalize the gut flora which is often abnormal in people who have IBS. The
therapeutic benefits of mesalazine may be the result of improvements to the epithelial barrier
function.
PART A

TIME: 15 minutes

• Look at the four texts , A – D, in the separate Text Booklet

• For each question, 1-20, look through the texts, A-d, to find the relevant information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.

IRRITABLE BOWEL SYNDROME (IBS) TEXT

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once

1. 5- amino salicylic acid plays a greater role in the treatment of IBS. …………..

2. There is no specific test for IBS. ………………

3. IBS is not fatal. …………….

4. The treatment protocol for IBS. ………………

5. IBS may cause depression in individuals. …………………….

6. IBS is not a true colitis, not cancerous. ……………..

7. The patient may have the feeling of incomplete evacuation. ……………..

Questions 8-14

Answer each of the questions, 8-4, with a word or short phrase from one of the texts. Each
answer may include words, number of the both. Your answers should be correctly spelled.

8. Which medication is used to treat constipation when osmotic laxative is not effective?

………………………………………………

9. What are the two psychological complications of IBS?

……………………………………………….

10. Which medications can be administered in case of abdominal pain?

……………………………………………..
11. Which therapy is found to be useful in normalizing the gut flora?

…………………………………………….

12. What is the name of the procedure in which a thin flexible tube with a light is passed in to the
colon to examine it?

………………………………………………

13. What are checked by the stool test?

……………………………………………………..

14. Which medication is given when antidiarrtieals fail?

……………………………………………………

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, number or both. Your answers should be correctly spelled.

15. Symptoms of irritable bowel syndrome may worsen during periods of …………………. or
during menstruation.

16. The term colitis refers to a separate condition known as…………………..

17. IBS is a chronic gastro intestinal disorder of an --------------------cause.

18. Intolerance to certain foods causes ----------------------deficiencies.

19. ………………. is detected by antibody tests.

20…………………….. is the procedure in which a special liquid is introduced into the colon
through the rectum and x ray are taken to examine the colon lining.
 Why is the Queensland Bedside Audit conducted each year?

Ⓐ To improve the quality of health service supply.

Ⓑ To find out how parties feel about their treatment.

Ⓒ To allow facilities to make advancements in technology.

Memo: Queensland Bedsite Audit

The Queensland Bedside Audit (QBA) is a major clinical patient safety audit
undertaken within Queensland every year. The data collected during the audit are
used by Hospital and Health Services as evidence in meeting National Safety and
Quality Health Service (NSQHS) Standards and other key safety and quality
indicators.

The information is collected at the bedside and the results help to identify areas for
improvement and establish a safety and quality framework that enables the delivery
of the best possible care to patients.

The Queensland Bedside Audit consists of:

 A review of clinical documentation for all eligible patients

 A physical examination of consenting patients
 Asking patients questions on elements of their healthcare
 A review of the bed area.

By participating each year in the QBA, a facility can compare key outcome and
process measures over time to assess the impact of their improvement initiatives.
4. The guidelines on alcohol withdrawal treatment informs healthcare
professionals about

Ⓐ Determining the quantity of medication required.

Ⓑ Reducing the dosage as the symptoms improve.

Ⓒ Various types of drugs to prescribe to patients.

Guidelines: Alcohol Withdrawal Treatment

Alcohol withdrawal can present as a life-threatening emergency and requires

treatment at a hospital. Providers use algorithms to determine when and how
much medication to administer for a safe and optimal outcome. A key
component of this assessment is determining the severity of alcohol withdrawal
using the Clinical Institute Withdrawal Assessment for Alcohol (CIWAAr). The
scale contains 10 subjective and objective items that can be queried and scored
in minutes. Symptoms asked about include nausea, vomiting, tremors, sweating,
anxiety, agitation, tactile/auditory/visual disturbances, headache, and cognitive
dysfunction. Every hospital has different cutoffs for treatment, but as a general
rule, treatment with benzodiazepines begin starting at a score 8–10, with higher
scoring indicating increasing amount and frequency of medication.
5. The notice on indwelling urinary catheters provides information about

Ⓐ the order for correct insertion.

Ⓑ optimal positioning of the patient

Ⓒ how best to avoid harming patients.

Indwelling urinary catheters

Urethral, prostate or bladder neck injury resulting in false tracts, strictures and
bleeding are related to traumatic urethral insertion. Traumatic injury is less likely to
occur with appropriate catheter selection, lubrication, correct patient positioning and
insertion into a full bladder. Retention balloons should only be inflated inside the
bladder, which is indicated by urine return with IUC inserted to the hilt. If there is any
uncertainty regarding catheter placement, the balloon should not be inflated. If the
patient experiences pain with inflation, deflate the balloon immediately and reassess
IUC position as this may indicate the catheter is outside the bladder. IUCs should be
used with caution in patients at risk of self-extraction, such as those with dementia or
who are delirious. When available, ultrasonography is recommended to evaluate
bladder volumes and guide SPC insertions.

.
3. Evaluation of breast cancer by using PET/CT scan
a) provides accurate results than the PET scan alone
b) to be compared with PET or CT scan alone
c) has been receiving no attention because it’s results to be compared with

the PET or CT scan alone.

The Role of PET/CT for Evaluating Breast Cancer

Positron emission tomography combined with computed tomography (PET/CT)

has been receiving increasing attention during the recent years for making the
diagnosis, for determining the staging and for the follow-up of various malignancies.
The PET/CT findings of 58 breast cancer patients (age range: 34 79 years old, mean age:
50 years) were retrospectively compared with the PET or CT scans alone. PET/CT was
found to be better than PET or CT alone for detecting small tumors or multiple
metastases, for accurately localizing lymph node metastasis and for monitoring the
response to chemotherapy in breast cancer patients.

2. The notice gives information about;

A. two different technologies used in treatment.
B. ineffectiveness of the SCS.
C. DRG and SCS comparison.

Spinal cord stimulation

For many years, Spinal cord stimulation has been used as a salvage treatment for
intractable CRPS even though many studies have not proven long-term benefit. In
multiple studies published by a European neurosurgical group, there has been great
benefit from this technology in the first year but the vast majority of patients experience a
return of symptoms by year six. Newer dorsal root ganglion (DRG) stimulation technology
may be more promising. In the most recent DRG stimulation trial, patients with CRPS have
been shown to decrease pain by fifty percent or greater in 93% of patients with chronic
intractable pain at three-month follow-up, versus 72% of patients with an SCS implant.
Unfortunately, this product is currently only FDA approved for treatment in the lower
extremity.
 Text C1: Animal testing
Paragraph 1
The use of living animals in research and teaching, while first documented around 2000 years ago,
became prominent in the second half of the 19th century as part of the development of the emerging
sciences of physiology and anatomy. In the mid 1900s, the rapid expansion of the pharmaceutical
and chemical industries gave rise to an enormous increase in the use of animals in research. Today it
is a multi-billion dollar industry, involving not only the pharmaceutical and chemical industries, but
also university and government bodies. There is, additionally, a sizeable industry providing support
services in relation to animal research, including animal breeding, food supply and cage manufacture,
among many others.

Paragraph 2
The types of research that animals are subjected to include the traditional forms of physiological
research, which typically involves the study of body function and disease, and psychological
research, which often entails controlling the eating, movement or choices of animals in experimental
contexts. Other more recent forms of research include agricultural research directed towards intensive
farming methods and increasing the efficiency of animals kept for food or food products. The genetic
engineering of species used in agriculture is common amongst sheep and cattle, for example, in an
attempt to increase the production of wool or milk, or to alter the characteristics of the end product
(finer wool, for instance). Safety testing, or toxicology testing, is another common type of research
where medicines, agricultural chemicals and various other chemical products, such as shampoos and
cosmetics, are assessed for safe human use by testing the products on animals.

Paragraph 3
While accurate global figures for animal testing are extremely difficult to obtain, estimates indicate
that anywhere from 50 to 100 million vertebrates are used in experiments every year (although this
figure does not include the many more invertebrates, such as worms and flies, that are employed).
The most commonly used vertebrates are mice, attractive to researchers for their size, low cost, ease
of handling, and fast reproduction rate, as well as the fact that their genetic makeup is comparable to
that of human beings. Other types of vertebrates used in the pursuit of science include fish, chickens,
pigs, monkeys, cats, dogs, sheep and horses.

Paragraph 4
Perhaps one of the most widely-known examples of animals being used for the purposes of scientific
research is Ivan Pavlov’s ‘conditioned reflex’ experiments in the late 19th early 20th centuries. Pavlov
and his researchers were investigating the gastric functions of dogs and the chemical composition of
their saliva under changing conditions, when Pavlov noticed that the animals began salivating before
food was delivered. Pavlov’s team then changed the focus of their experiments and embarked on a
series of experiments on conditional reflexes that earned Pavlov the 1904 Nobel Prize in Physiology
and Medicine for his work on the physiology of digestion. What is less well-known about Pavlov’s
research is that these experiments included surgically implanting fistulas in animals’ stomachs, which
enabled him to study organs and take samples of body fluids from animals while they continued to
function normally. Also, further work on reflex actions involved involuntary reactions to extreme
stress and pain.

2
Paragraph 5
Supporters of animal testing argue that virtually every medical achievement in the 20th century relied on
the use of animals in some way and that alternatives to animal testing, such as computer modelling, are
inadequate and fail to model the complex interactions between molecules, cells, tissues, organs, organisms
and the environment. Opponents argue that such testing is cruel to animals and is poor scientific practice, that
results are an unreliable indicator of the effects in humans, and that it is poorly regulated. They also point
to the fact that many alternatives to using animals have been developed, particularly in the area of toxicity
testing, and that these developments have occurred most rapidly and effectively in countries where the use of
animals is prohibited.

Paragraph 6
Although animal rights groups have made slow headway, there are signs that the issues they are concerned
about are being heard. Most scientists and governments state, publicly at least, that animal testing should cause
as little suffering to animals as possible, and that animal tests should only be performed where necessary.
The ‘three Rs’ of replacement, reduction and refinement are the guiding principles for the use of animals in
research in most countries. They are designed to minimise the use of animals in scientific research by using
other types of research where possible, by reducing the number of animals used in research, and by refining
research techniques to minimise the animals’ pain and distress.

Part C -Text C1: Questions 1-08

1 According to paragraph 1, research using animals ……

A was non-existent before 1850.
B is most common in the medical industry.
C generates trade for offshoot industries.
D is on the rise.

2 According to paragraph 1, the use of living animals in research and teaching ……

A has taken place for at least two millennia.

B rose to prominence around 2,000 years ago.
C emerged in the second half of the 19th century.
D originated in the pharmaceutical and chemical industries.

3 According to paragraph 2, one of the new applications of animal testing is concerned

with ……

A combining the traditions of physiological and psychological research.

B finding ways to improve farm animals’ productive capacity.
C controlling the eating, movement or choices of animals.
D revisiting the age-old study of body function and disease.

TURN OVER 3

QUESTIONS

4 According to paragraph 3, global figures for animal testing are ……

A subsiding.
B elusive.
C confronting.
D extreme.

5 According to paragraph 3, which one of the following statements about mice

is TRUE?

A They are much more popular with researchers than invertebrates.

B They have a genetic make-up which is at odds with that of humans.
C They are very attractive to researchers because of their speed and aptitude.
D They pose fewer constraints than other vertebrates in terms of care and expense.

6 According to paragraph 4, Pavlov’s research ……

A was unethical at the time.
B involved hurting animals deliberately.
C was conducted solely on dogs.
D did not focus on dogs initially.

7 According to paragraph 4, Pavlov’s groundbreaking research into conditional

reflexes ……

A was prompted by the observation that dogs salivated when they were hungry.
B came about by accident while he was investigating something else.
C was triggered by his noticing chemical changes in the dogs’ saliva.
D led to a larger-scale investigation of the gastric functions of dogs.

8 According to paragraph 5, animal testing proponents argue that ……

A many of the alternative methods still rely on the use of animals in some way.
B it was crucial in the 20th century before viable alternatives became available.
C computer modelling requires improvement before it can replace animal testing.
D medical advancement in the 20th century would have been hindered without it.
 Text C2: Oral health and systemic disease
Paragraph 1
The relationship between oral health and diabetes (Types 1 and 2) is well known and documented. In the
last decade, however, an increasing body of evidence has given support to the existence of an association
between oral health problems, specifically periodontal disease, and other systemic diseases, such as those
of the cardiovascular system. Adding further layers of complexity to the problem is the lack of awareness
in much of the population of periodontal disease, relative to their knowledge of more observable dental
problems, as well as the decreasing accessibility and affordability of dental treatment in Australia. While
epidemiological studies have confirmed links between periodontal disease and systemic diseases, from
diabetes to autoimmune conditions, osteoporosis, heart attacks and stroke, in the case of the last two the
findings remain cautious and qualified regarding the mechanics or biological rationale of the relationship.
Paragraph 2
Periodontal diseases, the most severe form of which is periodontitis, are inflammatory bacterial infections
that attack and destroy the attachment tissue and supporting bone of the jaw. Periodontitis occurs when
gingivitis is untreated or treatment is delayed. Bacteria in plaque that has spread below the gum line release
toxins which irritate the gums. These toxins stimulate a chronic inflammatory response in which the body, in
essence, turns on itself, and the tissues and bone that support the teeth are broken down and destroyed. Gums
separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected. As the
disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Often, this destructive
process only has very mild symptoms. Eventually, however, teeth can become loose and may have to be
removed.
Paragraph 3
The current interest in the relationship between periodontal disease and systemic disease may best be
attributed to a report by Kimmo Mattila and his colleagues. In 1989, in Finland, they conducted a case-
control study on patients who had experienced an acute myocardial infarction and compared them to control
subjects selected from the community. A dental examination was performed on all of the subjects studied,
and a dental index was computed. The dental index used was the sum of scores from the number of carious
lesions, missing teeth, and periapical lesions and probing depth measures to indicate periodontitis and the
presence or absence of pericoronitis (a red swelling of the soft tissues that surround the crown of a tooth
which has partially grown in). The researchers reported a highly significant association between poor dental
health, as measured by the dental index, and acute myocardial infarction. The association was independent
of other risk factors for heart attack, such as age, total cholesterol, high-density lipoprotein triglycerides, C
peptide, hypertension, diabetes, and smoking.
Paragraph 4
Since then, researchers have sought to understand the association between oral health, specifically periodontal
disease, and cardiovascular disease (CVD) – the missing link explaining the abnormally high blood levels of
some inflammatory markers or endotoxins and the presence of periodontal pathogens in the atherosclerotic
plaques of patients with periodontal disease. Two biological mechanisms have been suggested. One is that
periodontal bacteria may enter the circulatory system and contribute directly to atheromatous and thrombotic
processes. The other is that systemic factors may alter the immunoflammatory process involved in both
periodontal disease and CVD. It has also been suggested that some of these illnesses may in turn increase
the incidence and severity of periodontal disease by modifying the body’s immune response to the bacteria
involved, in a bi-directional relationship.

6
Paragraph 5
However, not only is ‘the jury out’ on the actual mechanism of the relationship, it also remains impossible to say
whether treating gum disease can reduce the risk of cardiovascular disease and improve health outcomes for those
who are already sufferers. Additional research is needed to evaluate disease pathogenesis. Should the contributing
mechanisms be identified, however, it will confirm the role of oral health in overall well-being, with some implications
of this being the desirability of closer ties between the medical and the dental professions, and improved public health
education, not to mention greater access to preventive and curative dental treatment. In time, periodontal disease may
be added to other preventable risk factors for CVD, such as smoking, high blood cholesterol, obesity and diabetes.

Part C -Text C2: Questions 12-19

12 According to paragraph 1, oral health problems have recently been linked to ……

A periodontal disease.
B heart conditions.
C diabetes.
D economic factors.

13 According to paragraph 1, periodontal disease is unknown to many Australians

because ……

A dental treatment is no longer affordable.

B the problem has a high degree of complexity.

C information on dental problems is inaccessible.
D it is not as prominent as other dental issues.

14 The most suitable heading for paragraph 2 is ……

A ‘Types of periodontal disease’.

B ‘The treatment of gingivitis’.
C ‘The body’s response to toxins’.
D ‘The process of periodontitis’.

15 According to paragraph 3, the 1989 study in Finland ……

A prompted further interest in the link between oral health and systemic disease.
B did not take into account a number of important risk factors for heart attacks.
C concluded that people with oral health problems were likely to have heart attacks.
D was not considered significant when it was first reported but is now.

TURN OVER 7

QUESTIONS

16 The research study described in paragraph 3 found that the relationship

between poor dental health and heart attacks was ……

A inconclusive.
B coincidental.
C evident.
D inconsequential.

17 According to paragraph 3, the dental index was used to ……

A indicate whether periodontitis was present.
B assess the overall oral health of patients.
C establish whether pericoronitis was present.
D predict the likelihood of acute myocardial infarction.

18 According to paragraph 4, it has been proposed that ……

A cardiovascular disease could actually exacerbate periodontal disease.
B periodontal disease could modify the body’s immune response.
C there is a bi-directional relationship between periodontal disease and bacteria.
D systemic factors may contribute directly to atheromatous and thrombotic processes.

19 According to paragraph 5, if the processes by which gum disease contributes

to CVD can be discovered there will be ……

A less need for doctors and dentists to work in conjunction.

B a reduced emphasis on other preventable risk factors for CVD.
C a concomitant link between smoking and periodontal disease.
D more support for dental care in the public health system.

END OF PART B - Text 2

END OF READING TEST

 Hypertension
Text A

Hypertension is one of the most common lifestyle diseases to date. It affects people from all walks
of life. Let us get to know hypertension more by its definitions.
Hypertension is defined as a systolic blood pressure greater than 140 mmHg and a diastolic
pressure of more than 90 mmHg. This is based on the average of two or more accurate blood
pressure measurements during two or more consultations with the healthcare provider. The
definition is taken from the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure.
Text B

Etiology and pathophysiology

1. Etiology is complex; begins insidiously; changes in arteriolar bed cause increasedresistance;

increased blood volume may result from hormonal or renal dysfunction; arteriolar thickening
causes increased peripheral vascular resistance; abnormal reninrelease constricts arteriolesa. 90%
to 95% have an unidentifiable cause (essential or primary hypertension);multiple factors such as
the renin-angiotensin-aldosterone mechanism, sympathetic nervous system activity, and insulin
resistance may be involvedb. 5% to 10% have identifiable causes (secondary hypertension);
pathophysiology isrelated to condition causing the rise in pressure; conditions include Reno
vascular disease; primary hyperaldosteronism; Cushing’s syndrome; diabetes mellitus; neurologic
disorders; dysfunction of thyroid, pituitary, or parathyroid glands; coarctation of the aorta; and
pregnancyClassification of BP by the Joint National Committee on Prevention,
Detection,Evaluation, and Treatment of High Blood Pressure (JNC 7) (JNC 8 will be
availablesummer 2011)
a. Normal: systolic less than 120 mm Hg and diastolic less than 80 mm Hg
b. Prehypertension: systolic 120 to 139 mm Hg or diastolic 80 to 89 mm Hg
c. Stage 1 hypertension: systolic 140 to 159 mm Hg or diastolic 90 to 99 mm Hg
d. Stage 2 hypertension: systolic 160 mm Hg or more, or diastolic 100 mm Hg or more

TextC
Text D

Care of Clients with Hypertension

Assessment/Analysis

1. Vital signs in both upright and recumbent positions; use appropriate cuff (width should be 40%
of the arm’s circumference); avoid errors of parallax when readingsphygmomanometer

2. Baseline weight

3. Presence of risk factors and clinical evidence of target organ damage

Planning/Implementation

1. Monitor levels of electrolytes, blood urea nitrogen (BUN), creatinine, lipid profile, andurine for
protein

2. Encourage weight reduction if indicated; weigh daily to monitor fluid balance whenthere is
threat of heart failure

3. Teach to monitor own BP; a BP of 180/120 mm Hg or higher represents a

hypertensiveemergency; advise to change position slowly and avoid hot showers to
preventorthostatic hypotension when taking antihypertensives

4. Support expression of emotions; encourage relaxation techniques

5. Reinforce that hypertension is not cured, but controlled

PART A

TIME: 15 minutes

• Look at the four texts , A – D, in the separate Text Booklet

• For each question, 1-20, look through the texts, A-d, to find the relevant information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.

HYPERTENSION

1. Stages of CVD prevention …………….

2. Assessment of baseline weight ………………..
3. Hypertension affects people from all walks life ………….
4. The range of blood pressure represents stage I hypertension ………….
5. Checking vital signs in both upright and recumbent positions ………….
6. Causes of hypertension ……………
7. Teaching client to check his/her own BP ……………

Questions 8-14

Answer each of the questions, 8-4, with a word or short phrase from one of the texts. Each answer
may include words, number of the both. Your answers should be correctly spelled.

8. What is the minimum diastolic pressure in person with pre hypertension?

9. The client who is with normal blood pressure should be educated on what?
10. What should be avoided while reading sphygmomanometer?
11. What must be checked daily to monitor fluid balance when there is threat of heart failure?
12. What is the maximum systolic pressure in client with stage 1 hypertension?
13. The client with over weight is required to be encouraged on …………?
14. In how many visits the BP should be checked once the stage 1 hypertension is determined?
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, number or both. Your answers should be correctly spelled

15. Presence of risk factors and …………. of target organ damage are assessed in the
hypertensive patients.
16. Hypertension is one of the most common ………………..diseases to date.
17. The definition of hypertension is taken from the ………………. report of the joint
National Committee
18. ………………..% have identifiable causes (secondary hypertension )
19. Reinforce that hypertension is not……. but controlled.
20. Monitor levels of electrolytes, BUN…….. lipid profile and urine for protein.

ANSWER
READING SUB-TEST : PART B

In this part of the test, there are six short extracts relating to the work of health professionals.
For questions 1-6, choose answer (A, B or C) which you think fits best according to the text.

Questions 1-6

1. The notice is giving information about

A. ways of checking that breathing exercises has been done
correctly.
B. how breathing exercises are performed and recommended.
C. which staff should perform breathing exercises.

Breathing exercises
Breathing exercises can be performed separately or they can be part of
fitness or specially targeted exercises. Breathing exercises (breathing
gymnastics) have preventative and therapeutic importance. These are
included if it is necessary to increase lung ventilation, improve
expectoration of secretions from the respiratory tract, etc. Exercise
should be according to the current medical condition of the patient; the
usual recommendation is 20 times, at least 4 – 5 times a day.

2. The policy document tells us that

A. stop dates aren't relevant in all circumstances.
B. anyone using EPMA can disregard the request for a stop date.
C. prescribers must know in advance of prescribing what the stop date should be.

Prescribing stop dates

Prescribers should write a review date or a stop date on the electronic prescribing system
EPMA or the medicine chart for each antimicrobial agent prescribed. On the EPMA, there
is a forced entry for stop dates on oral antimicrobials. There is not a forced stop date on
EPMA for IV antimicrobial treatment - if the prescriber knows how long the course of
IV should be, then the stop date can be filled in. If not known, then a review should be
added to the additional information, e.g. 'review after 48 hrs'. If the prescriber decides
treatment needs to continue beyond the stop date or course length indicated, then it is their
responsibility to amend the chart. In critical care, it has been agreed that the routine use of
review/stop dates on the charts is not always appropriate.
3. The manual informs us that the tonometer

A. is activated by pulling a button by the patient or the staff

B. display mostly the blood pressure systolic and diastolic values

C. display only the pulse value of the patient immediately

Single-Use Medical Equipments

Critical and semi-critical medical equipments labeled as single-use must not be reprocessed and
reused unless the reprocessing is done by a licensed reprocessor. Health care settings that wish to
have their single-use medical equipments reprocessed by a licensed reprocessor should ensure that
the reprocessor’s facilities and procedures have been certified by a regulatory authority or an
accredited quality system auditor to ensure the cleanliness, sterility, safety and functionality of the
reprocessed equipments.

Operation and service manuals

Ideally, the maintenance programme will have an operation (user) manual and
a service manual for each model of medical equipment. The operation manual
is valuable not only for equipment users but also for equipment technicians
who need to understand in detail how the equipment is used in clinical
practice. The service manual is essential for inspection, preventive
maintenance, repair, and calibration. Unfortunately, operation manuals and
service manuals are not always available, or may be in a language not spoken
by equipment technicians. Therefore, it is important to take steps that allow
them access to such manuals.
4. The purpose of this email is to take steps that allow
A. both equipment users and equipment technicians access to operation
manuals
B. only the equipment technicians access to operation manuals
C. only the equipment users access to operation manuals
OET Online Reading Part B
 
Part B : Multiple Choice Questions Time Limit: 20~25 Minutes

Task 2: The Mental Health Risks of Adolescent Cannabis Use

Author: Wayne Hall
Source: Public Library of Science

Paragraph 1
Since the early 1970s, when cannabis first began to be widely used, the proportion of
young people who have used cannabis has steeply increased and the age of first use
has declined. Most cannabis users now start in the mid-to-late teens, an important
period of psychosocial transition when misadventures can have large adverse effects
on a young person’s life chances. Dependence is an underappreciated risk of cannabis
use. There has been an increase in the numbers of adults requesting help to stop using
cannabis in many developed countries, including Australia and the Netherlands.
Regular cannabis users develop tolerance to many of the effects of delta-9-
tetrahydrocannabinol, and those seeking help to stop often report withdrawal
symptoms. Withdrawal symptoms have been reported by 80% of male and 60% of
female adolescents seeking treatment for cannabis dependence.

Paragraph 2
In epidemiological studies in the early 1980s and 1990s, it was found that 4% of the
United States population had met diagnostic criteria for cannabis abuse or dependence
at some time in their lives and this risk is much higher for daily users and persons
who start using at an early age. Only a minority of cannabis-dependent people in
surveys report seeking treatment, but among those who do, fewer than half succeed in
remaining abstinent for as long as a year. Those who use cannabis more often than
weekly in adolescence are more likely to develop dependence, use other illicit drugs,
and develop psychotic symptoms and psychosis.

Paragraph 3
Surveys of adolescents in the United States over the past 30 years have consistently
shown that almost all adolescents who had tried cocaine and heroin had first used
alcohol, tobacco, and cannabis, in that order; that regular cannabis users are the most
likely to use heroin and cocaine; and that the earlier the age of first cannabis use, the
more likely a young person is to use other illicit drugs. One explanation for this
pattern is that cannabis users obtain the drug from the same black market as other
illicit drugs, thereby providing more opportunities to use these drug.

Paragraph 4
In most developed countries, the debate about cannabis policy is often simplified to a
choice between two options: to legalize cannabis because its use is harmless, or to
continue to prohibit its use because it is harmful. As a consequence, evidence that
cannabis use causes harm to adolescents is embraced by supporters of cannabis
prohibition and is dismissed as “flawed” by proponents of cannabis legalisation.
OET Online Reading Part B
 

Paragraph 5
A major challenge in providing credible health education to young people about the
risks of cannabis use is in presenting the information in a persuasive way that
accurately reflects the remaining uncertainties about these risks. The question of how
best to provide this information to young people requires research on their views
about these issues and the type of information they find most persuasive. It is clear
from US experience that it is worth trying to change adolescent views about the health
risks of cannabis; a sustained decline in cannabis use during the 1980s was preceded
by increases in the perceived risks of cannabis use among young people.

Paragraph 6
Cannabis users can become dependent on cannabis. The risk (around 10%) is lower
than that for alcohol, nicotine, and opiates, but the earlier the age a young person
begins to use cannabis, the higher the risk. Regular users of cannabis are more likely
to use heroin, cocaine, or other drugs, but the reasons for this remain unclear. Some of
the relationship is attributable to the fact that young people who become regular
cannabis users are more likely to use other illicit drugs for other reasons, and that they
are in social environments that provide more opportunities to use these drugs.

Paragraph 7
It is also possible that regular cannabis use produces changes in brain function that
make the use of other drugs more attractive. The most likely explanation of the
association between cannabis and the use of other illicit drugs probably involves a
combination of these factors. As a rule of thumb, adolescents who use cannabis more
than weekly probably increase their risk of experiencing psychotic symptoms and
developing psychosis if they are vulnerable—if they have a family member with a
psychosis or other mental disorder, or have already had unusual psychological
experiences after using cannabis. This vulnerability may prove to be genetically
mediated.

Part B : Multiple Choice Questions

1. In paragraph 1, which of the following statements does not match the
information on cannabis use?
a. The use of cannabis by teenagers has been increasing over the past 40
years.
b. Cannabis use has adverse effects on young people.
c. Withdrawal symptoms are more common in males.
d. People try cannabis for the first time at a younger age than previously.
 
2. Epidemiological studies in the 1980s & 1990s have found that….
a. 4% of the US population currently suffer from cannabis abuse or
dependence.
b. starting cannabis use at a young age increases the risk of dependence
or abuse.
c. only a minority of surveys researched treatment options for cannabis
dependent people.
d. people who start cannabis use at a young age have high risk of
becoming daily users.
OET Online Reading Part B
 

3. The main point of paragraph 3 is that…

a. alcohol, tobacco and cannabis can lead to the use of heroin and
cocaine.
b. most adolescents who have used cocaine or heroin first try alcohol,
followed by tobacco and then cannabis.
c. there is a clear link between habitual cannabis use and the use of
heroin and cannabis.
d. the black market is the main source of illicit drugs.

4. Which of the following would be the most appropriate heading for

paragraph 4?
a. Opinion on an effective cannabis policy is divided.
b. Cannabis use is harmful to adolescents and should be prohibited.
c. Cannabis use is a serious problem in a majority of developed countries.
d. Cannabis use should be legalised.

5. The word closest in meaning credible in paragraph 5 is…

a. believable
b. possible
c. high quality
d. inexpensive

6. Cannabis use in the US declined during the 1980s because…

a. parents were able to explain the health risks of cannabis use.
b. there was good health education regarding the health risks associated
with cannabis use available at that time.
c. cannabis had increased in price
d. young people had became more worried about its effect on their health

7. The word relationship in paragraph 6 refers to the connection between…

a. legal drugs such as alcohol and nicotine and illegal drugs such as
cannabis, cocaine and heroin.
b. cannabis use and dependency.
c. the use of hard drugs such as heroin and cocaine and cannabis use.
d. regular users and their partners.

8. Which of the following statements best matches the information in the last
paragraph?
a. Regular cannabis use produces changes in brain function.
b. Regular adolescent cannabis users with a genetic predisposition to
mental disorders have an increased risk of encountering psychosis.
c. Regular adolescent users of cannabis are vulnerable to psychosis.
d. Occasional use of cannabis can make other drugs more appealing.
OET Online Reading Part B
 
Part B : Multiple Choice Questions Time Limit: 20~25 Minutes

Task 5

Fluoride
Goldman AS, Yee R, Holmgren CJ, Benzian H
Globalization and Health 2008, 4:7 (13 June 2008)  

Paragraph 1
Globalization has provoked changes in many facets of human life, particularly in diet.
Trends in the development of dental caries in population have traditionally followed
developmental patterns where, as economies grow and populations have access to a
wider variety of food products as a result of more income and trade, the rate of tooth
decay begins to increase. As countries become wealthier, there is a trend to greater
preference for a more "western" diet, high in carbohydrates and refined sugars. Rapid
globalization of many economies has accelerated this process. These dietary changes
have a substantial impact on diseases such as diabetes and dental caries.

Paragraph 2
The cariogenic potential of diet emerges in areas where fluoride supplementation is
inadequate. Dental caries is a global health problem and has a significant negative
impact on quality of life, economic productivity, adult and children's general health
and development. Untreated dental caries in pre-school children is associated with
poorer quality of life, pain and discomfort, and difficulties in ingesting food that can
result in failure to gain weight and impaired cognitive development. Since low-
income countries cannot afford dental restorative treatment and in general the poor
are most vulnerable to the impacts of illness, they should be afforded a greater degree
of protection.

Paragraph 3
By WHO estimates, one third of the world's population have inadequate access to
needed medicines primarily because they cannot afford them. Despite the inclusion of
sodium fluoride in the World Health Organization's Essential Medicines Model List,
the global availability and accessibility of fluoride for the prevention of dental caries
remains a global problem. The optimal use of fluoride is an essential and basic public
health strategy in the prevention and control of dental caries, the most common non-
communicable disease on the planet. Although a whole range of effective fluoride
vehicles are available for fluoride use (drinking water, salt, milk, varnish, etc.), the
most widely used method for maintaining a constant low level of fluoride in the oral
environment is fluoride toothpaste.

Paragraph 4
More recently, the decline in dental caries amongst school children in Nepal has been
attributed to improved access to affordable fluoride toothpaste. For many low-income
nations, fluoride toothpaste is probably the only realistic population strategy for the
control and prevention of dental caries since cheaper alternatives such as water or salt
fluoridation are not feasible due to poor infrastructure and limited financial and
technological resources. The use of topical fluoride e.g. in the form of varnish or gels
for dental caries prevention is similarly impractical since it relies on repeated
OET Online Reading Part B
 
applications of fluoride by trained personnel on an individual basis and therefore in
terms of cost cannot be considered as part of a population based preventive strategy.

Paragraph 5
The use of fluoride toothpaste is largely dependent upon its socio-cultural integration
in personal oral hygiene habits, availability and the ability of individuals to purchase
and use it on a regular basis. The price of fluoride toothpaste is believed to be too
high in some developing countries and this might impede equitable access. In a
survey conducted at a hospital dental clinic in Lagos, Nigeria 32.5% of the
respondents reported that the cost of toothpaste influenced their choice of brands and
54% also reported that the taste of toothpastes influenced their choice.

Paragraph 6
Taxes and tariffs on fluoride toothpaste can also significantly contribute to higher
prices, lower demand and inequity since they target the poor. Toothpastes are usually
classified as a cosmetic product and as such often highly taxed by governments. For
example, various taxes such as excise tax, VAT, local taxes as well as taxation on the
ingredients and packaging contribute to 25% of the retail cost of toothpaste in Nepal
and India, and 50% of the retail price in Burkina Faso. WHO continues to recommend
the removal taxes and tariffs on fluoride toothpastes. Any lost revenue can be restored
by higher taxes on sugar and high sugar containing foods, which are common risk
factors for dental caries, coronary heart disease, diabetes and obesity.

Paragraph 7
The production of toothpaste within a country has the potential to make fluoride
toothpaste more affordable than imported products. In Nepal, fluoride toothpaste was
limited to expensive imported products. However, due to successful advocacy for
locally manufactured fluoride toothpaste, the least expensive locally manufactured
fluoride toothpaste is now 170 times less costly than the most expensive import. In the
Philippines, local manufacturers are able to satisfy consumer preferences and compete
against multinationals by discounting the price of toothpaste by as much as 55%
against global brands; and typically receive a 40% profit margin compared to 70% for
multinational producers.

Paragraph 8
In view of the current extremely inequitable use of fluoride throughout countries and
regions, all efforts to make fluoride and fluoride toothpaste affordable and accessible
must be intensified. As a first step to addressing the issue of affordability of fluoride
toothpaste in the poorer countries in-depth country studies should be undertaken to
analyze the price of toothpaste in the context of the country economies.
OET Online Reading Part B
 
Part B : Multiple Choice Questions
 
1. Which  of  the  following  would  be  the  most  appropriate  heading  for  
the  paragraph  1?  
a. High  sugar  intake  and  increasing  tooth  decay  
b. Globalisation,  dietary  changes  and  declining  dental  health  
c. Dietary  changes  in  developing  nations  
d. Negative  health  effects  of    a  western  diet  
 
2. Which  of  the  following  is  not  mentioned  as  a  negative  effect  of  
untreated  dental  caries  in  pre-­school  children?  
a. Decreased  mental  alertness  
b. Troubling  chewing  and  swallowing  food  
c. Lower  life  quality  
d. Reduced  physical  development  
 
3. According  to  paragraph  3,  which  of  the  following  statements  is  
correct?  
a. Dental  caries  is  the  most  contagious  disease  on  earth.  
b. Fluoride  in  drinking  water  is  effective  but  rarely  used  
c. Fluoride  is  too  expensive  for  a  large  proportion  of  the  global  
population.      
d. Fluoride  toothpaste  is  widely  used  by  2/3  of  the  world’s  
population.  
 
4. Fluoride  toothpaste  is  considered  the  most  effective  strategy  to  
reduce  dental  caries  in  low  income  countries  because…..  
a. it  is  the  most  affordable.  
b. topical  fluoride  is  unavailable.  
c. it  does  not  require  expensive  infrastructure  or  training.    
d. it  was  effective  in  Nepal.  
 
5. Which  of  the  following  is  closest  in  meaning  to  the  word  impede?  
a. stop  
b. prevent  
c. hinder  
d. postpone  
 
6. Regarding  the  issue  of  taxation  in  paragraph  6  which  of  the  following  
statements  is  most  correct?  
a. Income  tax  rates  are  higher  in  Burkina  Faso  than  India  or  Nepal.  
b. WHO  recommends  that  tax  on  toothpaste  be  reduced  .  
c. Governments  would  like  to  reduce  tax  on  toothpastes  but  can’t  as  
it  is  classified  as  a  cosmetic.  
d. WHO  suggests  taxing  products  with  a  high  sugar  content  instead  of  
toothpastes.    
 
 
 
OET Online Reading Part B
 
 
 
 
 
 
 
7. Which  of  the  following  is  closest  in  meaning  to  the  word  advocacy?  
a. marketing  
b. demand  
c. development  
d. support  
 
8. Statistics  in  paragraph  7  indicate  that….  
a. local  products  can’t  compete  with  global  products  and  make  a  
profit  at  the  same  time.  
b. Philippine  produced  toothpaste  is  profitable  while  being  less  than  
half  the  price  of  global  brands.  
c. in  Nepal,  fluoride  toothpaste  is  limited  to  imported  products  which  
are  very  expensive  
d. toothpaste  produced  in  the  Philippines  has  a  higher  profit  margin  
than  internationally  produced  toothpaste.    
 Reading: Part A – Text Booklet

Instructions
TIME LIMIT: 15 MINUTES
• Complete the summary on pages 1 and 2 of Part A - Answer booklet using the information in the four
texts (A1-A4) below.

• You do not need to read each text from beginning to end to complete the task. You should scan the texts
to find the information you need.

• Gaps may require 1, 2 or 3 words. Answer ALL questions. Marks are NOT deducted for incorrect
answers.

• You should write your answers next to the appropriate number in the right-hand column.

• Please use correct spelling in your responses. Do not use abbreviations unless they appear in the texts.

Text A1 Migraines: Texts

Title: Management of migraine in New Zealand General Practice
Authors: Spark, Vale & Mills (2006)
OBJECTIVES: To determine the proportion of patients who have a diagnosis of migraine in a sample of
New Zealand general practice patients, and to review the prophylactic and acute drug treatments used by
these patients.
DESIGN, SETTING AND PARTICIPANTS: A cohort of general practitioners collected data from about
30 consecutive patients each as part of the BEACH (Bettering the Evaluation and Care of Health) program;
this is a continuous national study of general practice activity in New Zealand. The migraine substudy was
conducted in June-July 2005 and December 2005-January 2006.
MAIN OUTCOME MEASURES: Proportion of patients with a current diagnosis of migraine; frequency of
migraine attacks; current and previous drug treatments; and appropriateness of treatment assessed using
published guidelines.
RESULTS: 191 GPs reported that 649 of 5663 patients (11.5%) had been diagnosed with migraine.
Prevalence was 14.9% in females and 6.1% in males. Migraine frequency in these patients was one or
fewer attacks per month in 77.1% (476/617), two per month in 10.5% (65/617), and three or more per
month in 12.3% (76/617) (missing data excluded). Only 8.3% (54/648) of migraine patients were currently
taking prophylactic medication. Patients reporting three or more migraines or two migraines per month
were significantly more likely to be taking prophylactic medication (19.7% and 25.0%, respectively) than
those with less frequent migraine attacks (3.8%) (P < 0.0001). Prophylactic medication had been used
previously by 15.0% (96/640). The most common prophylactic agents used currently or previously were
pizotifen and propranolol; other appropriate agents were rarely used, and inappropriate use of acute
medications accounted for 9% of “prophylactic treatments”. Four in five migraine patients were currently
using acute medication as required for migraine, and 60.6% of these medications conformed with
recommendations of the National Prescribing Service. However, non-recommended drugs were also used,
including opioids (38% of acute medications).
CONCLUSIONS: Migraine is recognised frequently in New Zealand general practice. Use of acute
medication often follows published guidelines. Prophylactic medication appears to be underutilised,
especially in patients with frequent migraine. GPs appear to select from a limited range of therapeutic
options for migraine prophylaxis, despite the availability of several other well documented efficacious
agents, and some use inappropriate drugs for migraine prevention.

48 www.occupationalenglishtest.org
Text A2

Table 1: Economic burden of migraine in the USA

US$ million

Cost element Men Women Total

Medical 193 1,033 1,226
Missed workdays 1,240 6,662 7,902
Lost productivity 1,420 4,026 5,446
TOTAL 14,574

Text A3

Case studies: migraine sufferers and work

Case 1:
“Jane” experienced pressure from employers due to her migraine absences. She had three days off
work in the first quarter of the year, and this was deemed unacceptable and unsustainable by her
employers; therefore she has just resigned from her job and hopes that her future employers will be
more understanding.

Case 2:
“Sally’s” employers and colleagues are aware of her migraine symptoms and are alert to any behaviour
changes which might indicate an impending attack. In addition, colleagues have supporters’ contact
numbers, should she need to be escorted during a migraine. As her employers are part of the
government ‘Workstep Programme’, she has accessed a number of allowances and initiatives: her
migraines have been classified as a long-term health condition rather than sickness absence, which
permits her a higher absence threshold. She now works flexible hours and has received funding for eye
examinations, prescription glasses, and a laptop to enable her to work from home.

Text A4

Research brief on migraines in the US

• Migraine prevalence is about 7% in men and 20% in women over the ages 20 to 64.
• The average number of migraine attacks per year was 34 for men and 37 for women.
• Men will need nearly four days in bed every year. Women will need six.
• The average length of bed rest is five to six hours.
• Only about 1 in 5 sufferers seek help from a doctor.

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

www.occupationalenglishtest.org 49
PART A -QUESTIONS AND ANSWER SHEET

Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes
You may use any letter more than once.
In which text can you find information about;
1. US expense 5446 million US & to treat the migraine in women
2. The average length of bed rest is 5-6 hours
3. Migraine prevalence is about 20% in women over the ages 20-64
4. The migraine sub study was conducted in January 2006 in New Zealand
5. Women needs 6 days in bed yearly to manage migraine
6. Prophylactic medication has been used previously by 15.0%
7. Four in five patient using acute medication for migraine

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. Your answers should be correctly spelt.

8. How many patients were studied in sparks program me?

9. The average length of bed rest to treat migraine?
10. What are the prophylactic agents used frequently?
11. How much USA economic expense for migraine?
12. How many migraines suffers seek medical help?
13. What are the non-recommended drugs used by the migraine patient?
14. What is the prevalence of migraine in females in the study conducted I n 2006?
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. Your answers should be correctly spelt.

15. By contrast, the study found that a large proportion of migraine suffers used
______________________
16. The case of _________ demonstrates that employers many not tolerate
17. Migraine incidence was different across genders, with a ___________________
Proportion of men diagnosed umpired in women
18. Being able to work ____________________ hours and having capacity to work at
home makes working life more manageable.
19. Of the patient surveyed by spark, just over 8% were taking ______________ at the
time of study.
20. Concerning interventions, the US report found that most migraine suffers in the
survey ________________ medical practice.
READING SUB-TEST : PART B
In this part of the test, there are six short extracts relating to the work of health professionals .
For questions 1-6, choose the answer (A, B or C) which you think fits best according to the text. Write
your answers on the separate Answer Sheet
Questions 1-6

1 What is correct about gait disturbance?

A. Pelvic tilt is common
B. Fast gait speed and improved gait pattern is the most important goal of stroke
rehabilitation
C. A hemiplegic gait may include body asymmetry, decreased weight bearing on
the affected side.

Gait disturbance

Gait disturbance is the most common problem after stroke. This problem is related
to poor ADL and mobility, and increases the risk of fall in severe cases. The body
alignment of stroke patients becomes asymmetric if they have a hemi-paralysis,
muscle weakness, motor and sensory function decrease. These problems produce a
hemiplegic gait in stroke patients. It may include poor equilibrium reaction, and
impaired selective motor control. Good body alignment is very important clinically
because asymmetry leads to inefficient energy during walking, the risk of
musculoskeletal injury in the unaffected side, and loss of bone density. Excessive
pelvic elevation and the pelvic tilt angle is directly connected to hemiplegic gait
and poor motor function in stroke patient causes an excessive pelvic tilt during gait
2. The risk to the unborn baby may occur;
A. During the first half of the pregnancy.
B. When baby get primary infection through mother.
C. When infected with virus during first pregnancy.

CMV Infection

About one out of every 150 babies are born with a congenital CMV infection.
However, only about one in five babies with a congenital CMV infection will be
sick from the virus or will have long-term health problems.
If a woman is newly infected with CMV while pregnant, there is a risk that her
unborn baby will also become infected (congenital CMV). Infected babies may,
but not always, be born with a disability.
Infection during one pregnancy does not increase the risk for subsequent
pregnancies. However, if primary infection occurs, consideration should be given
to wait for at least 12 months for next pregnancy.
Studies conducted in Australia have shown that out of 1,000 live births, about 6
infants will have congenital CMV infection and 1-2 of those 6 infants (about 1 in
1000 infants overall) will have permanent disabilities of varying degree. These can
include hearing loss, vision loss, small head size, cerebral palsy, developmental
delay or intellectual disability, and in rare cases, death.
Sometimes, the virus may be reactivate while a woman is pregnant but reactivation
does not usually cause problems to the woman or to the fetus.
4. Food-borne botulism is known to

Ⓐ take a long time to develop in most patients.

Ⓑ require a specific course of treatment.

Ⓒ cause death in severe cases.

Manual extract: food-borne botulism

Food-borne botulism is due to absorption of a preformed toxin from the gastro-

intestinal tract. The timing of symptoms is dependent on the dose of the toxin
absorbed. Typically, however, onset is 12-26 hours (median 24 hours) post-
ingestion, but can occur from 6 hours to 8 days after eating contaminating food.
Food-borne botulism can be associated with symptoms such as nausea, vomiting,
diarrhoea, and abdominal cramps, followed by constipation. Diagnosis is by
detection of the botulism toxin or by isolation of the organism. A defined equine-
derived antitoxin must be given as soon as possible — do not wait for diagnostic
tests. Repeat doses may be given within 24 hours if deterioration continues. There
is no specific antibiotic for this condition. Supportive care including ventilation,
hydration and nutrition will be required during recovery.
5. The Aboriginal and Torres Strait Islander Liaison Service assists by

Ⓐ Establishing stronger connections between people.

Ⓑ Ensuring improved healthcare for everyone.

Ⓒ Educating patients about their rights.

Hospital Liaison Officers

The Aboriginal and Torres Strait Islander Liaison Service acts as a cultural link
between health professionals, identified Aboriginal and Torres Strait Islander
patients, and patient’s families.

The service, and liaison officers, assists in breaking down any perceived barriers of
communication so that Aboriginal and Torres Strait Islander patients and/or their
families have a better understanding of their hospitalisation and treatment.

Patients and their families are supported by:

 Providing information, emotional and cultural support for Aboriginal and

Torres Strait Islander patients, and patient’s families to assist in delivering
services.
 Coordination of patient travel and accommodation.
 Mediation and advocacy for referrals to social workers and support services
when required.
 Consultation with hospital staff seeking further information on patient/family
history or discussing any special needs of Aboriginal and Torres Strait
Islander people.

Facilitating referrals to other facilities and community-based services. Providing

support and practical assistance to significant others and/or family members.
6. What needs to be considered when recommending the use of cough and
cold medicines in children?

Ⓐ The possible dangers.

Ⓑ The low success rate.

Ⓒ The age of the child.

Cough and cold medicines for children

Health professionals are advised of the following:

No changes have been made to the scheduling of over-the-counter (OTC) cough

and cold medicines and a prescription is not required. However, a recommendation
for treatment with these medicines in a child under 6 years of age constitutes off-
label use. These recommendations for treatment should not be made without
serious consideration of the risks and benefits. There is no robust evidence of
efficacy for these medicines in children and there are a number of safety concerns.
While the safety concerns are lower in children aged 6 - 11 years than in children
aged less than 6 years, they should be taken into consideration when advising
parents on the management of coughs and colds.
  
Part C : Multiple Choice Questions Time Limit: 20~25 Minutes

Task 3
Seasonal  Influenza  Vaccination  and  the  H1N1  Virus  
Authors: Cécile Viboud & Lone Simonsen
Source: Public Library of Science

As the novel pandemic influenza A (H1N1) virus spread around the world in
late spring 2009 with a well-matched pandemic vaccine not immediately
available, the question of partial protection afforded by seasonal influenza
vaccine arose. Coverage of the seasonal influenza vaccine had reached 30%–
40% in the general population in 2008–09 in the US and Canada, following
recent expansion of vaccine recommendations.

Unexpected Findings in a Sentinel Surveillance System

The spring 2009 pandemic wave was the perfect opportunity to address the
association between seasonal trivalent inactivated influenza vaccine (TIV)
and risk of pandemic illness. In an issue of PLoS Medicine, Danuta
Skowronski and colleagues report the unexpected results of a series of
Canadian epidemiological studies suggesting a counterproductive effect of
the vaccine. The findings are based on Canada's unique near-real-time
sentinel system for monitoring influenza vaccine effectiveness. Patients
with influenza-like illness who presented to a network of participating
physicians were tested for influenza virus by RT-PCR, and information on
demographics, clinical outcomes, and vaccine status was collected. In this
sentinel system, vaccine effectiveness may be measured by comparing
vaccination status among influenza-positive “case” patients with influenza-
negative “control” patients. This approach has produced accurate measures
of vaccine effectiveness for TIV in the past, with estimates of protection in
healthy adults higher when the vaccine is well-matched with circulating
influenza strains and lower for mismatched seasons. The sentinel system
was expanded to continue during April to July 2009, as the H1N1 virus
defied influenza seasonality and rapidly became dominant over seasonal
influenza viruses in Canada.

Additional Analyses and Proposed Biological Mechanisms

The Canadian sentinel study showed that receipt of TIV in the previous
season (autumn 2008) appeared to increase the risk of H1N1 illness by 1.03-
to 2.74-fold, even after adjustment for the comorbidities of age and
geography. The investigators were prudent and conducted multiple
sensitivity analyses to attempt to explain their perplexing findings.
Importantly, TIV remained protective against seasonal influenza viruses
circulating in April through May 2009, with an effectiveness estimated at
56%, suggesting that the system had not suddenly become flawed. TIV
appeared as a risk factor in people under 50, but not in seniors—although
senior estimates were imprecise due to lower rates of pandemic illness in
that age group. Interestingly, if vaccine were truly a risk factor in younger

 
  
adults, seniors may have fared better because their immune response to
vaccination is less rigorous.

Potential Biases and Findings from Other Countries

The Canadian authors provided a full description of their study population

and carefully compared vaccine coverage and prevalence of comorbidities in
controls with national or province-level age-specific estimates—the best one
can do short of a randomized study. In parallel, profound bias in
observational studies of vaccine effectiveness does exist, as was amply
documented in several cohort studies overestimating the mortality benefits
of seasonal influenza vaccination in seniors.

Given the uncertainty associated with observational studies, we believe it

would be premature to conclude that TIV increased the risk of 2009
pandemic illness, especially in light of six other contemporaneous
observational studies in civilian populations that have produced highly
conflicting results. We note the large spread of vaccine effectiveness
estimates in those studies; indeed, four of the studies set in the US and
Australia did not show any association whereas two Mexican studies
suggested a protective effect of 35%–73%.

Policy Implications and a Way Forward

The alleged association between seasonal vaccination and 2009 H1N1 illness
remains an open question, given the conflicting evidence from available
research. Canadian health authorities debated whether to postpone
seasonal vaccination in the autumn of 2009 until after a second pandemic
wave had occurred, but decided to follow normal vaccine recommendations
instead because of concern about a resurgence of seasonal influenza viruses
during the 2009–10 season. This illustrates the difficulty of making policy
decisions in the midst of a public health crisis, when officials must rely on
limited and possibly biased evidence from observational data, even in the
best possible scenario of a well-established sentinel monitoring system
already in place.

What happens next? Given the timeliness of the Canadian sentinel system,
data on the association between seasonal TIV and risk of H1N1 illness during
the autumn 2009 pandemic wave will become available very soon, and will
be crucial in confirming or refuting the earlier Canadian results. In addition,
evidence may be gained from disease patterns during the autumn 2009
pandemic wave in other countries and from immunological studies
characterizing the baseline immunological status of vaccinated and
unvaccinated populations. Overall, this perplexing experience in Canada
teaches us how to best react to disparate and conflicting studies and can aid
in preparing for the next public health crisis.
Part C : Multiple Choice Questions
 
1. The question of partial protection against H1N1 arose…
a. before spring 2009
b. during Spring 2009
c. after spring 2009
d. during 2008-09

2. According to Danuta Skowronski….

a. the inactivated influenza vaccine may not be having the desired effects.
b. Canada’s near-real-time sentinel system is unique.
c. the epidemiological studies were counterproductive
d. the inactivated influenza vaccine has proven to be ineffective.

3. The vaccine achieved higher rates of protection in healthy adults when….

a. it was supported by physicians.
b. the sentinel system was expanded.
c. used in the right season.
d. it was matched with other current influenza strains.

4. Which one of the following is closest in meaning to the word prudent?

a. anxious
b. cautious
c. busy
d. confused
 
5. The Canadian sentinel study demonstrated that…..
a. age and geography had no effect on the vaccine’s effectiveness.
b. vaccinations on senior citizens is less effective than on younger people.
c. the vaccination was no longer effective.
d. the risk of H1N1 seemed to be higher among people who received the
TIV vaccination.

6. Which of the following sentences best summarises the writers’ opinion

regarding the uncertainty associated with observational studies?
a. More studies are needed to determine whether TIV increased the risk
of the 2009 pandemic illness.
b. It is too early to tell whether the risk of catching the 2009 pandemic
illness increased due to TIV.
c. The Australian and Mexican studies prove that there is no association
between TIV and increased risk of catching the 2009 pandemic illness.
d. Civilian populations are less at risk of catching the 2009 pandemic
illness.
 Reading Part C : Multiple Choice Questions
Instructions
• Read the following text and answer the Multiple Choice Questions which follow.
• Each question has four suggested answers or ways of finishing.
• You must choose the ONE which you think fits best. For each question, indicate on
your answer sheet the letter A, B, C or D.,
• Answer ALL questions. Marks are NOT deducted for incorrect answers.
• Time Limit: 20-25 minutes

Task 1: Breast Cancer and the Elderly

Source: Public Library of Science
Paragraph 1
Breast cancer is one of the highest-profile diseases in women in developed
countries. Although the risk for women younger than 30 years is minimal,
this risk increases with age. One-third of all breast cancer patients in
Sweden, for example, are 70 years or older at diagnosis. Despite these
statistics, few breast cancer trials take these older women into account.
Considering that nowadays a 70-year-old woman can expect to live for at
least another 12–16 years, this is a serious gap in clinical knowledge, not
least because in older women breast cancer is more likely to be present
with other diseases, and doctors need to know whether cancer treatment
will affect or increase the risk for these diseases.

Paragraph 2
In 1992, guidelines were issued to the Uppsala/Orebro region in Sweden
(with a population of 1.9 million) that all women with breast cancer should
be able to receive equal treatment. At the same time, a breast cancer
register was set up to record details about patients in the region, to ensure
that the guidelines were being followed. Sonja Eaker and colleagues set out
to assess data from the register to see whether women of all ages were
receiving equal cancer treatment.

Paragraph 3
They compared the 5-year relative survival for 9,059 women with breast
cancer aged 50–84 years. They divided them into two age groups: 50–69
years, and 70–84 years. They also categorized the women according to the
stage of breast cancer. They looked at differences between the proliferative
ability of breast cancer cells, estrogen receptor status, the number of lymph
nodes examined, and lymph node involvement. The researchers also
compared types of treatment—i.e., surgical, oncological (radiotherapy,
chemotherapy, or hormonal)—and the type of clinic the patients were
treated in.

Paragraph 4
They found that women aged 70–84 years had up to a 13% lower chance of
surviving breast cancer than those aged 50–69 years. Records for older
women tended to have less information on their disease, and these women
were more likely to have unknown proliferation and estrogen receptor
status. Older women were less likely to have their cancer detected by
mammography screening and to have the stage of disease identified, and
they had larger tumours. They also had fewer lymph nodes examined, and
had radiotherapy and chemotherapy less often than younger patients.

Paragraph 5
Current guidelines are vague about the use of chemotherapy in older
women, since studies have included only a few older women so far, but this
did not explain why these women received radiotherapy less often. Older
women were also less likely to be offered breast-conserving surgery, but
they were more likely to be given hormone treatment such as tamoxifen
even if the tumours did not show signs of hormone sensitivity. The
researchers suggest that this could be because since chemotherapy tends to
be not recommended for older women, perhaps clinicians believed that
tamoxifen could be an alternative.

Paragraph 6
The researchers admit that one drawback of their study is that there was
little information on the other diseases that older women had, which might
explain why they were offered treatment less often than younger patients.
However, the fact remains that in Sweden, women older than 70 years are
offered mammography screening much less often than younger women—
despite accounting for one-third of all breast cancer cases in the country—
and those older than 74 years are not screened at all. Eaker and co-workers'
findings indicate that older women are urgently in need of better treatment
for breast cancer and guidelines that are more appropriate to their age
group. Developed countries, faced with an increasingly aging population,
cannot afford to neglect the elderly.

Questions-Part B

1. The main idea presented in paragraph one is that……

a. only older women need to be concerned about breast cancer.
b. breast cancer trials seldom consider older women.
c. breast cancer is more common than other diseases in older woman.
d. older woman do not take part in breast cancer trials.

2. Regarding cancer treatment in paragraph one, it can be concluded

that….
a. doctors know cancer treatment will increase the risk of disease in
elderly patients.
b. cancer treatments too risky for elderly people
c. it is unknown whether or not cancer treatments will affect the
treatment of other diseases in elderly people.
d. older woman are less likely to have other diseases
7. Which one of the following is closest in meaning to the word alleged?
a. reported
b. likely
c. suspected
d. possible

8. Canadian health authorities did not postpone the Autumn 2009 seasonal
vaccination because…
a. of a fear seasonal influenza viruses would reappear in the 2009-10
season.
b. there was too much conflicting evidence regarding the effectiveness of
the vaccine.
c. the sentinel monitoring system was well established.
d. observational data may have been biased.
3. According to paragraph two, the 1992 Guidelines issued to the
Uppsala/Orebro region in Sweden stated that…
a. Sweden has a population of 1.9 million.
b. women with breast cancer need to register their condition to ensure
they receive equal treatment.
c. identical breast cancer treatment should be available to women of
all ages.
d. all women with breast cancer should have access to equivalent
breast cancer treatment.

4. According to paragraph 3, which of the following was not part of Sonja

Eaker and her colleagues research?
a. Comparing ability of breast cancer cells to increase in number.
b. Grouping woman according to their survival rate.
c. Identifying differences in treatment methods.
d. Splitting the groups based on age.

5. According to paragraph 4, which of the following statements is true?

a. Older women have fewer lymph nodes
b. Mammography screening is not able to detect cancer in older women
c. Only 13% of women aged 70~84 survive breast cancer
d. Women aged 50~69 have a lower mortality rate than women aged
70~84

6. In paragraphs 5, findings by the researchers indicate that…….

a. older women are not usually advised to have chemotherapy
b. older women prefer hormone treatment such as tamoxifen
c. breast conserving surgery was not popular among older women
d. older women respond better to chemotherapy than to hormone
treatment.

7. The word vague is paragraph 5 means……

a. uncertain
b. unclear
c. unknown
d. doubtful

8. According to paragraph 6, one limitation of the study is that…..

a. older women are treated less often than younger women.
b. older women have a lower incidence of breast cancer.
c. younger women are treated more often than older women.
d. there is a lack of information on other diseases which older women
have.
TEXT A

Vitamin C Deficiency
Scurvy is a life-threatening condition due to dietary vitamin C deficiency. Those affected are
mostly refugees or victims of famine, alcoholics, older people, fad dieters, or children with
autism or idiosyncratic behavioural abnormalities. Diagnosis is often delayed due to incomplete
review of dietary history.
Vitamin C deficiency may result from a diet deficient in fresh fruits and vegetables. Also,
cooking can destroy some of the vitamin C in food.
The following conditions can significantly increase the body’s requirements for vitamin C and
the risk of vitamin C deficiency:
 Pregnancy
 Breastfeeding
 Disorders that cause a high fever or inflammation
 Diarrhoea that lasts a long time
 Surgery
 Burns
 Smoking, which increases the vitamin C requirement by 30%

TEXT B

The recommended daily intake of vitamin C varies by age, gender, pregnancy, lactation and
smoking status.
 TEXT C

Symptoms

The symptoms of scurvy develop only after a few months of deficiency.

Adults feel tired, weak, and irritable. They may lose weight and have vague muscle and joint
aches.
Bleeding may occur under the skin (particularly around hair follicles or as bruises), around the
gums, and into the joints. The gums become swollen, purple, and spongy. The teeth eventually
loosen. The hair becomes dry and brittle, and the skin becomes dry, rough, and scaly. Fluid
may accumulate in the legs. Anaemia may develop. Infections may develop, and wounds do not
heal.
Infants may be irritable, have pain when they move, and lose their appetite. Infants do not gain
weight as they normally do. In infants and children, bone growth is impaired and bleeding and
anaemia may occur.
Normal examination has also been reported, presumably when symptoms have developed in
the setting of very low but not critical body stores.
Examination
Although no consistent order of presenting signs is established, the earliest signs of scurvy are
often gingival abnormalities and a comprehensive examination of the mouth when scurvy is
recommended in patients presenting relatively early.
If the test is available, measuring the vitamin C level in blood can help establish diagnosis.
Blood tests to check for anaemia.
In children, x-rays to check for impaired bone growth.
Treatment
For scurvy in adults, ascorbic acid 100 to 500 mg orally twice daily must be given for 1 to 2
weeks, until signs disappear, followed by a nutritious diet supplying 1 to 2 times the daily
recommended intake of fresh fruits and vegetables.
In scurvy, therapeutic doses of ascorbic acid restore the functions of vitamin C in a few days.
The symptoms and signs usually disappear over 1 to 2 weeks. Chronic gingivitis with extensive
subcutaneous haemorrhage persists longer

Text D
VITAMIN C EXCESS AND TOXICITY

High doses of vitamin C are usually not toxic to healthy adults. Occasionally, higher doses
cause nausea or diarrhoea and interfere with the interpretation of some blood test results.

Some people take high doses of vitamin C because it is an antioxidant, which protects cells
against damage by free radicals. Free radicals are thought to contribute to many disorders,
such as atherosclerosis, cancer, lung disorders, the common cold, eye cataracts, and
memory loss. Whether taking high doses of vitamin C protects against or has any beneficial
effect on these disorders is unclear. Evidence of a protective effect against cataracts is
strongest.
 Part A

TIME: 15 minutes

 Look at the four texts, A-D, in the separate Text Booklet.

 For each question, 1-20, look through the texts, A-D, to find the relevant
information.
 Write your answers on the spaces provided in this Question Paper.
 Answer all the questions within the 15-minute time limit.
 Your answers should be correctly spelt.

VITAMIN C: Questions

Questions 1-7

For each of the questions, 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 types of people usually affected by scurvy? ----------------

2. the physical effects of scurvy? ----------------

3. tests that can be conducted to check for scurvy? ----------------

4. adequate intake totals for vitamin C each day? ----------------

5. the effects of taking high doses of vitamin C? ----------------

6. conditions that increase a person’s need for vitamin C? ----------------

7. recovery time for a patient suffering from scurvy? ----------------

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 frequently seen as an early indication of scurvy?

------------------------------------------------------------------------------------------
 9. What can occur in the gums, joints and under the skin of a patient with
scurvy?
--------------------------------------------------------------------------------------------
10. How many extra milligrams each day of vitamin C does a smoker require?
---------------------------------------------------------------------------------------------
11. What increases the need for vitamin C by 30%?
--------------------------------------------------------------------------------------------
12. What is the maximum amount of vitamin C per day that should be given to
infants?
-------------------------------------------------------------------------------------------
13. What do high levels of vitamin C protect cells from?
--------------------------------------------------------------------------------------------
14. Which condition is most likely to benefit from higher levels of vitamin C?
--------------------------------------------------------------------------------------------

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. Scurvy takes only a ------------------------------------------------------------ of

deficiency to develop.

16. In infants and children, --------------------------------------------------------------------

and anaemia may be present.

17. Incomplete review of dietary history frequently results in diagnosis being -------

--------------------------------------------

18. RDA sufficiently meets the vitamin C requirements in ---------------------------------

------------------------------------------- of patients.

19. 75mg of vitamin C daily is recommended for women who are ----------------------

------------------------------------.

20. It takes only a few days' worth of -----------------------------------------------------------

------- for the normal functions of vitamin C to return.
1. The guidelines on paediatric procedural sedation suggest that

Ⓐ Patients who are sick should not receive sedation.

Ⓑ Sedation is likely to be more difficult in elderly patients.

Ⓒ The approach to sedation changes depending on the patient.

Extract from guidelines: Paediatric Procedural Sedation

Clinicians who administer procedural sedation to patients must have a thorough

understanding of the actions of the medication being administered, including
modifications for age, concurrent drug therapy and disease processes. Knowledge
of the correct procedures is also required to safely administer sedation.

Patient selection is a major factor in achieving safe and successful procedural

sedation. The approaches described in this Guide are intended for use with patients
who are generally healthy or have only mild systemic disease.

More severely ill patients, those with complex medical problems and infants under
12 months of age or less than 10 kilograms, should not be sedated outside of the
operating theatre. Children, who are very anxious prior to the procedure, need
special consideration and may be more suitable for general anaesthesia in an
operating theatre.
2. Under what circumstances should a doctor pass on confidential
information given by a patient?

Ⓐ When the patient’s treatment might otherwise suffer.

Ⓑ When not disclosing information could cause further harm.

Ⓒ When it could be considered breaking the law if they didn’t.

Confidentiality- reporting gunshot and knife wounds

Trust is an essential part of the doctor patient relationship and confidentiality is

central to this. Patients may avoid seeking medical help, or may under-report
symptoms, if they think that their personal information will be disclosed by doctors
without consent, or without the chance to have some control over the timing or
amount of information shared.

Doctors owe a duty of confidentiality to their patients, but they also have a wider
duty to protect and promote the health of patients and the public. If you consider
that failure to disclose information would leave individuals or society exposed to a
risk so serious that it outweighs the patient’s and the public interest in maintaining
confidentiality, you should disclose relevant information promptly to an appropriate
person or authority.
3. This memo is providing information about

Ⓐ Who should wear PPE.

Ⓑ When to wear PPE.

Ⓒ Why to wear PPE.

Memo: Decision-making about Personal Protective equipment (PPE)

PPE is designed and issued for a particular in a protected environment and should
not be worn outside that area. Protective clothing provided for staff in areas where
there is high risk of contamination (e.g. operating suite/room) must be removed
before leaving the area. Even where there is a lower risk of contamination, clothing
that has been in contact with patients should not be worn outside the patient-care
area. Inappropriate wearing of PPE (e.g. wearing operating suite/room attire in the
public areas of a hospital or wearing such attire outside the facility) may also to a
public perception of poor practice within the facility.
4. The Aboriginal and Torres Strait Islander Liaison Service assists by

Ⓐ Establishing stronger connections between people.

Ⓑ Ensuring improved healthcare for everyone.

Ⓒ Educating patients about their rights.

Hospital Liaison Officers

The Aboriginal and Torres Strait Islander Liaison Service acts as a cultural link
between health professionals, identified Aboriginal and Torres Strait Islander
patients, and patient’s families.

The service, and liaison officers, assists in breaking down any perceived barriers of
communication so that Aboriginal and Torres Strait Islander patients and/or their
families have a better understanding of their hospitalisation and treatment.

Patients and their families are supported by:

 Providing information, emotional and cultural support for Aboriginal and

Torres Strait Islander patients, and patient’s families to assist in delivering
services.
 Coordination of patient travel and accommodation.
 Mediation and advocacy for referrals to social workers and support services
when required.
 Consultation with hospital staff seeking further information on patient/family
history or discussing any special needs of Aboriginal and Torres Strait
Islander people.

Facilitating referrals to other facilities and community-based services. Providing

support and practical assistance to significant others and/or family members.
 5. The purpose of the safety notice about sharps injuries is to

Ⓐ Praise staffs who has been following sharps protocols.

Ⓑ Reduce the frequency of future sharps harm to staff.

Ⓒ Remind staff about the risks of working with sharps.

Hospital Bulletin Board Safety Alert Communication

Situation
 Last week, there were 4 reported sharps injuries at the Medical Centre in a 6
day period.
 In comparison, there were 18 sharps injuries in the previous calendar year,
about 1-2 per month.
Background
 Although we have gone many weeks without an employee lost time injury,
sharps injuries can be potentially serious events.
Assessment
 A through cause analysis investigation completed with staff involved, their
managers and the occupational health and safety team, revealed that each
of these injuries was preventable.
Recommendation
 Verify and validate: verify that features available on sharps have fully
engaged before transporting or discarding a needle. Complete a visual check
and listen for the ‘click’.
 Star: make sure your fingers are not in the path of a needle when holding
soft tissue for injection.
 Seek help: if required, obtain assistance from a co-worker before injecting a
patient.

.
6. This email to staff indicates that older patients

Ⓐ are being prescribed too many potentially dangerous drugs.

Ⓑ are being unfairly targeted by pharmaceutical companies.

Ⓒ are being burdened by the cost of expensive medication.

To : All staff

Subject: Medication use in older persons

Frequently prescribed medicines in older people include those with anticholinergis

and sedative effects. These medicines are used in adult to treat medical conditions
that often occur later in life, such as urinary incontinence, sleep and pain disorders,
dementia and mental illness.

In many instances the benefits of theses medicines do not justify the risk of harm for
older adults. The use of these medicines is associated with adverse effects including
(but not limited to): impairment of physical and cognitive function, sedation, falls and
fractures, and an increased risk of mortality. Their use in older people is also
associated with economic costs such as an increase risk of hospitalisation.
In this part of the test, there are two texts about different aspects of healthcare. For
questions 7-22, choose the answer (A, B, C or D) which you think fits best according
to the text.

Text 1: Migraines

Migraines are often misunderstood, or dismissed as “just a headache.”Yet they have

the capacity to disrupt a person’s life, relationships, and sense of well-being. A study

from Thomas Jefferson University in Philadelphia found that chronic migraine

sufferers experience as much social stigma as people with epilepsy—a disease that

produces far more obvious and dramatic symptoms. Some of that stigma is

external—for example, getting treated differently by friends or colleagues. “Migraines

are the unseen and undocumented pain that takes them away from work,” says Dr.

R. Joshua Wootton, of pain psychology at the Arnold Pain Management Center, and

assistant professor of anesthesia at Harvard Medical School. “There’s no empirical

test for migraine yet. That’s why people who report these problems with chronic pain

are often not believed or are thought to be exaggerating in the work environment’.

Effective migraine treatments are available—but many migraine sufferers don’t take

advantage of them, either because they don’t seek help or they mistakenly believe

they’re just suffering from regular headaches. ”l think 80% of all migraine sufferers

can be effectively helped, but only about a quarter of them are effectively helped at

the present time,” says Dr. Egilius Spierings, associate clinical professor of

neurology at Harvard Medical School. The gold standard for migraine relief is a class

of drugs called triptans. When taken at the first twinge of a migraine, triptans can

relieve pain, nausea, and light sensitivity. “These medications have been on the

market for about 20 years now,” Dr. Spierings says. “They are generally very safe

and well tolerated, and also very effective.”

Despite being the seventh leading cause of time spent disabled worldwide, migraine

“has received relatively little attention as a major public health issue,” Dr. Andrew

Charles, a California neurologist, wrote recently in The New England Journal of

Medicine. It can begin in childhood, becoming more common in adolescence and

peaking in prevalence at ages 35 to 39. While the focus has long been on head pain,

migraines are not just pains in the head. They are a body-wide disorder that recent

research has shown results from “an abnormal state of the nervous system involving

multiple parts of the brain,” said Dr. Charles, of the U.C.L.A. Goldberg Migraine

Program at the David Geffen School of Medicine in Los Angeles. He hopes the

journal article will educate practicing physicians, who learn little about migraines in

medical school.

Before it was possible to study brain function through a functional M.R.I. or PET

scan, migraines were thought to be caused by swollen, throbbing blood vessels in

the scalp, usually affecting one side of the head. This classic migraine symptom

prompted the use of medications that narrow blood vessels, drugs that help only

some patients and are not safe for people with underlying heart disease.

Neurologists who specialise in migraine research and treatment now approach

migraine as a brain-based disorder, with symptoms and signs that can start a day or

more before the onset of head pain and persist for hours or days after the pain

subsides. Based on the new understanding, there are now potent and less disruptive

treatments already available or awaiting approval. However, to be most effective, the

new therapies may require patients to recognise and respond to the warning signs of

a migraine in its so-called prodromal phase — when symptoms like yawning,

irritability, fatigue, food cravings and sensitivity to light and sound occur a day or two

before the headache.

Even with current remedies, people typically wait until they have a full-blown

headache to start treatment, which limits its effectiveness, Dr. Charles said. His

advice to patients: Learn to recognise your early symptoms signaling the onset of an

attack and start treatment right away before the pain sets in. Conditions that can

trigger a migraine in susceptible people include skipped meals, irregular intake of

caffeine, erratic sleep habits and stress. Accordingly, Dr. Charles suggests practicing

consistent dietary, sleep, caffeine and exercise habits to limit the frequency of

migraines. Keeping a migraine diary that includes your stress level and what you’ve

eaten and drunk can also help identify triggers.

But they aren’t just a physical condition. Living with chronic pain, or the constant

worry that they may strike at any moment, can take an emotional toll, too. Migraines

have been linked to an increased risk of depression. A study presented at the

American Academy of Neurology’s annual meeting found that women with a history

of migraines are 41 % more likely to be depressed than those without the condition.

“When you can’t find effective ways to manage your migraines that frequently results

in feeling helpless, hopeless and as if everyone is against you,” Dr Wootton says. If

you’re having these feelings, it can be helpful to see a psychiatrist or psychologist,

particularly at a center that specialises in pain management. “If you have

considerable anxiety and/or depression, addressing those issues is important

because they can negatively affect migraine. They also make it much more difficult

to cope with a condition like migraine:’

Text 1: Questions 7-14

7. The writer makes the comparison between migraines and epilepsy to show

Ⓐ How the sufferers of both conditions feel a lot of shame.

Ⓑ How people suffering from these conditions have social problems.

Ⓒ How both conditions affect the amount of work a person is able to

do.

Ⓓ How friends and colleagues find it hard to trust people with these
conditions

8. In the second paragraph, Dr Egilius Spierings says he believes

Ⓐ There aren’t enough migraine medications, but those that do exist

work well.

Ⓑ At least 80% of people with migraines are helped by medication.

Ⓒ Only 25% of migraine sufferers currently take medication.

Ⓓ Not enough migraine sufferers take medication.

9. What does Dr Andrew Charles hope will change as a result of his journal article?

Ⓐ More doctors will understand that migraines are more than just
head pain.

Ⓑ More doctors will realise that migraines can be a life-long problem.

Ⓒ More doctors will learn about migraines in medical school.

Ⓓ More doctors will read about the issue of migraines.

10. What point does the writer make in the fourth paragraph?

Ⓐ In the past, there was no way to accurately test patients for

migraine.

Ⓑ The triggers for migraine are more complex than was originally
believed.

Ⓒ Medications that narrow blood vessels in migraine patients are no

longer useful.

Ⓓ Enlarged blood vessels in a person’s scalp are now seen on both

sides of the head

11. In the fourth paragraph, the writer suggests patients should

Ⓐ Try a range of improved therapies.

Ⓑ Seek specialised treatment earlier.

Ⓒ Start taking new types of medication.

Ⓓ Become more aware of their triggers.

12. The use of the adjective ‘full-blown’ indicates

Ⓐ The treatment of the headache.

Ⓑ The duration of the headache.

Ⓒ The severity of the headache.

Ⓓ The location of the headache.

13. What does the word ‘they’ in the final paragraph refer to?

Ⓐ Triggers.

Ⓑ Migraines.

Ⓒ Pains and worries.

Ⓓ Physical conditions.

14. According to Dr Wootton, if a person is suffering with migraines

Ⓐ They can feel quite alone.

Ⓑ It can be very difficult to recover.

Ⓒ They may develop pain in other areas.

Ⓓ They should see a mental health professional.

Text 2: Water Consumption

How much fluid should you drink each day for good health? Eight glasses a day has

been the widely circulated advice. But recently, two large studies have suggested

that’s probably overkill. It turns out that under normal circumstances, you get most

of the liquid you need each day from what you routinely eat and drink, including

coffee, tea, soft drinks, and even some alcoholic drinks.

So where did this notion of ‘eight glasses a day’ come from? In 1945, the Food and

Nutrition Board of the United States National Research Council wrote: ‘A suitable

allowance of water for adults is 2.5 liters daily in most instances. Most of this quantity

is in prepared foods: But in the 1990’s Dr Heinz Valtin undertook a comprehensive

investigation into the myths surrounding water consumption in humans. He found

healthy people who drank more water didn’t have a higher ‘output of stool’, and that

there was no scientific evidence high fluid intake could relieve constipation.

And what of the belief that thirst is not a good indicator of a need to drink? Valtin

states that while ‘a rise in plasma osmolality’ (which is an internal chemical change)

of less than two per cent can elicit thirst, dehydration is defined as a rise of at least

five per cent. This is a complicated way of saying you get thirsty before your body

starts to dehydrate, so thirst is a good guide.

Australia’s current dietary guidelines don’t recommend a specific amount of water,

but simply recommend we ‘drink plenty of water’. “How much water each one of us

needs depends on a range of factors,” said CSIRO dietitian PennieTaylor.”This can

include our gender, bodyweight and how much physical activity we do: ‘The

guidelines also encourage drinking water over juices, soft drinks, cordials or the like.

Also, pregnant or breastfeeding women (who require more fluid), people who live or
work in extremely hot climates, and people with high protein diets (the kidneys may

need more fluid to help process the increased amount of protein) are encouraged to

drink more water. It’s on hot days that most of us notice we’re thirstier than normal.

This is because we’re sweating more, and we lose fluid through sweat. “We can lose

between 1 to 3 per cent of our fluid quite easily,” Ms Taylor said.

Associate Professor Ben Desbrow from Griffith University agrees. “Those who work

or exercise in hot climates lose the most fluid — up to 2.5 liters of sweat in an hour in

extreme circumstances. You need to replace those fluids pretty quickly; otherwise it’s

going to fairly rapidly have an effect on your subsequent performance.” Your body

will give you some pretty clear signs that you’re not getting dehydrated. So keep an

eye out for symptoms such as a dry mouth, headache and feeling dizzy. Also pay

attention to your toilet habits, the colour of your urine and how frequently you go to

the toilet. It is true that ‘copious and clear’ is a good indicator of healthy wee. But

‘clear’ does not mean colourless. The depth of colour in urine will vary, what you

need to look out for is cloudiness — that’s the indicator of a problem. “Your kidneys

do a great job in fluid regulation, so frequency of urination and colour of urination are

your two best guides,” Associate Professor Desbrow said.

What about the idea that a person may be drinking too much water. There isa thirst

control centres in our brain that controls water intake, says Dr Michael McKinley,

Senior Fellow at Florey Neuroscience Institute. When we drink water, this part of our

brain stops us feeling thirsty long before the water has been fully absorbed into the

bloodstream. “Usually if we take in too much water, it’ll suddenly feel like hard work

to drink,” he said. However, in some circumstances when people drink a large

volume of water, they can over-ride the thirst control centre in the brain. When this

happens, their sodium levels can drop too low. This can lead to a condition known as
hyponatremia, where the body also starts to retain the excess water. “Normally if we

drink too much water, our kidneys would excrete it [as urine],” Dr McKinley said. But

sometimes, factors like heat, physical stress or certain drugs can switch off the

hormonal signal that causes the kidneys to excrete excess water. Then there is a

double whammy effect. Not only have you drunk a lot of water, but you start to hang

onto all the water in your body. Drinking more just makes things worse. “This is when

things can get dangerous,” Dr McKinley said.

Text 2: Questions 15-22

15. Drinking eight glasses of water a day is described as ‘overkill’ because

Ⓐ Staying hydrated isn’t as important as we used to believe.

Ⓑ It is now considered unnecessary to drink so much.

Ⓒ The benefits have been known for many years.

Ⓓ There are better ways to stay hydrated.

16. What do we learn about water consumption in the second paragraph?

Ⓐ There was no scientific evidence to support past ideas about water.

Ⓑ Healthy people don’t need to drink as much water as unhealthy

people.

Ⓒ Not everything we previously believed about drinking water was

correct.

Ⓓ No one knows the origins of how we came to drink the amount we

do.

17. In the third paragraph, the word ‘this’ refers to

Ⓐ The chemical changes that occur within a person’s body.

Ⓑ The lack of rules about how much water to drink.

Ⓒ The idea that thirst has no connection to dehydration.

Ⓓ The reasons why a person gets thirsty.

18. Why don’t Australia’s dietary guidelines state a specific amount of water to drink?

Ⓐ Because everyone differs physically.

Ⓑ Because there are too many factors to consider.

Ⓒ Because drinking any amount of water has benefits.

Ⓓ Because there is no current agreement among dieticians.

19. In the fifth paragraph, Associate Professor Ben Desbrow says he believes fluid
loss

Ⓐ Happens at a very fast rate.

Ⓑ Is a sign of hydration issues.

Ⓒ Can result in physical decline.

Ⓓ Doesn’t occur in cool climates.

20. When commenting on urine Professor Desbrow suggests

Ⓐ Variations in colour are uncommon.

Ⓑ It should always be clear or colourless.

Ⓒ Frequency is a good indication of a problem.

Ⓓ If it isn’t clear, there may be something wrong

21. What idea does Dr McKinley express in the final paragraph?

Ⓐ Drinking a lot of water can supress a person's appetite.

Ⓑ Not having enough water can affect concentration levels.

Ⓒ Our bodies usually tell us when we've had enough water.

Ⓓ Processing large amounts of water can stress our arteries.

22. Dr McKinley expresses concern about people who

Ⓐ Drink dangerous quantities of water.

Ⓑ Have trouble passing surplus urine.

Ⓒ Consumes small amounts of salt.

Ⓓ Take pills in extreme weather.

 PART A

Acute Diarrhea

Text A

Acute diarrhea is one of the most commonly reported illnesses in the United States, second only
to respiratory infections. Worldwide, it is the leading cause of mortality in children younger than
four years old (infants and young children are always much more susceptible) in both developing
and underdeveloped countries.

Definition: An abnormal looseness of the stool, changes in stool frequency, consistency, urgency
and continence (an increased number of stools or looser form than is customary for the patient,
lasting less than 2 weeks, and often associated with abdominal symptoms such as cramping,
bloating and gas). Although often mild, acute diarrhea can lead to severe dehydration as a result
of large fluid and electrolyte losses.

Text B

Acute, watery diarrhea is usually caused by a virus, rotavirus (viral gastroenteritis.) It can also
occur due to food poisoning (common agents are salmonella and campylobacter). Medications
such as antibiotics and drugs that contain magnesium products are also common offenders.
Recent dietary changes can also lead to acute diarrhea; these include: intake of coffee, tea, colas,
dietetic foods, gums or mints that contain poorly absorbable sugars. Acute bloody diarrhea
suggests a bacterial cause like campylobacter, salmonella or shigella.

Traveling to developing areas of the world can result in exposure to bacterial pathogens common
in certain areas and eating contaminated foods such as ground beef or fresh fruit can cause
diarrhea due to E.coli 0157:H7. Most episodes of acute diarrhea resolve themselves quickly and
without antibiotic therapy, with simple dietary modifications. See a doctor if you feel ill, have
bloody diarrhea, severe abdominal pain or diarrhea lasting more than 48 hours.

In patients with mild acute diarrhea, no laboratory evaluation is needed because the illness
generally resolves itself quickly (patients typically recover in 10-15 days). Your doctor may
perform stool cultures or parasite exams if your diarrhea is severe or bloody, or if you traveled to
an area where infections are common. The doctor will want to talk to you about your symptoms
to try to identify a cause. The doctor will also want to examine you, including your abdomen and
possibly your back passage. The most important test to perform at this stage is an examination of
your stool to determine whether there are any infective agents present that might be the cause of
the diarrhea and other symptoms. It may also be necessary to examine the bowel by endoscopy
to determine whether there is inflammation in the rectum or colon (colitis).
TEXT C
TEXT D

Treatment for diarrhea:

Always see your doctor if you experience serious symptoms. Babies and young children with
diarrhoea need prompt medical attention.

Treatment for diarrhoea depends on the cause, but may include:

Plenty of fluids to prevent dehydration
Oral rehydration drinks to replace lost salts and minerals. These drinks are available from
pharmacies. An alternative is one part unsweetened pure fruit juice diluted with four parts of
water
Intravenous replacement of fluids in severe cases
Medications such as antibiotics and anti-nausea drugs
Anti-diarrheal medications, but only on the advice of your doctor. If your diarrhea is caused by
infection, anti-diarrheal drugs may keep the infection inside your body for longer
Treatment for any underlying condition, such as inflammatory bowel disease.
PART A
TIME: 15 minutes

• Look at the four texts , A – D, in the separate Text Booklet

• For each question, 1-20, look through the texts, A-d, to find the relevant
information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.
ACUTE DIARRHEA

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes
from. You may use any letter more than once

1. Causes of acute diarrhea ………………..

2. Pathological investigation involved in case of severe diarrhea. ……………….
3. Information regarding maintenance of hydration. …………………….
4. Information regarding symptoms associated with acute diarrhea. ………………..
5. An explanation regarding evaluation of severity of dehydration.
…………………….
6. Information regarding treatment of diarrhea. …………………..
7. Acute diarrhea can be managed without antibiotics. …………………

Questions 8-14

Answer each of the questions, 8-4, with a word or short phrase from one of the texts.
Each answer may include words, number of the both. Your answers should be correctly
spelled.

8. What is the causative organism for acute watery diarrhea?

…………………………………………………………
9. In which classification of dehydration, skin elasticity is very poor?
………………………………………………………..
10. What is recommended to maintain the lost minerals in the body due to diarrhea?
……………………………………………………….
11. What should be done if acute diarrhea does not resolve by itself with simple
dietary modification?
……………………………………………………..
 12. What are the abdominal symptoms associated with acute diarrhea?
……………………………………………………..
13. What happens to the urine output, when a person suffers from severe dehydration?
…………………………………………………….
14. What is the causative organism for acute diarrhea?
…………………………………………………….

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, number or both. Your answers should be correctly
spelled

15. ---------------------- are administered in case of severe diarrhea.

16. ---------------------- may keep the infection inside the body if diarrhea is caused by
an infection.
17. Acute diarrhea is leading cause of________________ in younger children
worldwide.
18. If diarrhea is severe or bloody, the GP may perform ______________
19. Anterior fontanelle of infants would be _____________in case moderate
dehydration.
20. It takes _______________to the pinched skin folds to disappear in case o severe
dehydration.
TEXT A

Dengue: virus, fever and mosquitoes

Dengue fever is a viral disease spread only by certain mosquitoes – mostly Aedes aegypti or
“dengue mosquitoes” which are common in tropical areas around the world.

There are four types of the dengue virus that cause dengue fever – Dengue Type 1, 2, 3 and 4.
People become immune to a particular type of dengue virus once they’ve had it, but can still get
sick from the other types of dengue if exposed. Catching different types of dengue, an even
year apart, increases the risk of developing severe dengue. Severe dengue causes bleeding
and shock, and can be life threatening.

Dengue mosquitoes only live and breed around humans and buildings, and not in bush or
rural areas. They bite during the day – mainly mornings and evenings. Dengue mosquitoes
are not born with dengue virus in them, but if one bites a sick person having the virus in their
blood, that mosquito can pass it on to another human after about a week. This time gap for
the virus to multiply in the mosquito means that only elderly female mosquitoes transmit
dengue fever. The mosquitoes remain infectious for life, and can infect several people.
Dengue does not spread directly from person to person

TEXT B

Signs and Symptoms

Classic dengue fever, or “break bone fever,” is characterised by acute onset of high fever 3–14
days after the bite of an infected mosquito. Symptoms include frontal headache, retro-orbital
pain, myalgias, arthralgias, hemorrhagic manifestations, rash, and low white blood cell count.
The patient also may complain of weight loss and nausea. Acute symptoms, when present,
usually last about 1 week, but weakness, malaise, and weight loss may persist for several
weeks. A high proportion of dengue infections produce no symptoms or minimal symptoms,
especially in children and those with no previous history of having a dengue infection.
TEXT C

Steps to take when seeing a suspected case of dengue fever

Step 1: Notify your nearest Public Health Unit immediately upon clinical suspicion.
Step 2: Take a comprehensive travel history and determine whether the case was acquired
overseas or locally.
Step 3: Note the date of onset of symptoms to identify the correct diagnostic test, as suitable
laboratory tests depend on when the blood sample is collected during the illness.
 Another useful test is full blood count. Cases often have leucopenia and/or
thrombocytopenia.
The table below shows which test to order at which stage of illness:
NSI
TEST TYPE PCR IgM IgG
ELISA

Days after onset of From day 5 From day 8

0-5 days 0-9 days
symptoms onwards onwards
Stage 4: Provide personal protection advice.
 The patient should stay in screened accommodation and have someone stay home to
look after them.
 The patient should use personal insect repellent particularly during daylight hours to
avoid mosquito bites.
 All household members should use personal insect repellent during daylight hours.
 Advise family members or associates of the case who develop a fever to present
immediately for diagnosis.

TEXT D

Prior to discharge:

 Tell patients to drink plenty of fluids and get plenty of rest.

 Tell patients to take antipyretics to control their temperature. Children with dengue are at
risk for febrile seizures during the febrile phase of illness.
 Warn patients to avoid aspirin and anti-inflammatory medications because they increase
the risk of haemorrhage.
 Monitor your patients’ hydration status during the febrile phase of illness. Educate
patients and parents about the signs of dehydration and have them monitor their urine
output.
 Assess hemodynamic status frequently by checking the patient’s heart rate, capillary
refill, pulse pressure, blood pressure, and urine output. If patients cannot tolerate fluids
orally, they may need IV fluids.
 Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.
 Continue to monitor your patients closely during defervescence. The critical phase of
dengue begins with defervescence and lasts 24–48 hours.
 Part A

TIME: 15 minutes

 Look at the four texts, A-D, in the separate Text Booklet.

 For each question, 1-20, look through the texts, A-D, to find the relevant
information.
 Write your answers on the spaces provided in this Question Paper.
 Answer all the questions within the 15-minute time limit.
 Your answers should be correctly spelt.

DENGUE FEVER : Questions

Questions 1-7

For each of the questions, 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 different types of dengue virus? ---------------------------

2. how fever presents in patients? ---------------------------

3. how dengue fever is transmitted? ---------------------------

4. the stages at which to conduct tests for dengue fever? --------------------------

5. monitoring and assessing a patient’s condition? ---------------------------

6. what advice to give patients to avoid mosquito bites? ---------------------------

7. advice for patients regarding medication? ----------------------------

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 long after being bitten by an infected mosquito does high fever occur?
----------------------------------------------------------------------------------------------
 9. What might patients with dengue fever complain of?
---------------------------------------------------------------------------------------------
10. Which test should only be ordered 5 days after symptoms appear?
---------------------------------------------------------------------------------------------
11. What other test is also useful when checking for dengue fever?
---------------------------------------------------------------------------------------------
12. Who is at risk of seizures during the febrile stage of dengue?
----------------------------------------------------------------------------------------------
13. What takes places in the most lethal cases of dengue?
-----------------------------------------------------------------------------------------------
14. How long does the most serious stage of dengue last?
-----------------------------------------------------------------------------------------------

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. Dengue fever does not spread ----------------------------------------------------------

16. In many ------------------------------------------------------------------------------- dengue

infections cause almost no symptoms.

17. Within three days of symptoms beginning a PCR or -----------------------------------

---------------------------------------- can be ordered.

18. To avoid haemorrhage patients mustn’t take anti-inflammatory medications or

-------------------------------------------------------------------------------------------

19. Advise patients be cared for by someone at home in ---------------------------------

-------------------------------------- accommodation.

20. Patients must be made aware of the need to check their ----------------------------

----------------------------------.
In this part of the test, there are six short extracts relating to the work of health
professionals. For questions 1-6, choose the answer (A, B or C) which you think fits
best according to the text.

1. Which type of hazard does the workplace extract relate to?

Ⓐ Chemical agents.

Ⓑ Biological agents.

Ⓒ Physical agents.

Extract from Workplace Policy Document: Hazard Assessment

Hazards to Look for When Inspecting Hospitals

Examples of typical hazards include bacteria, viruses, fungi, and other living
organisms that can cause acute and chronic infections by entering the body through
ingestion, inhalation or breaks in the skin. They also include exposure to blood or
other body fluids or to clients or patients with infectious diseases (e.g., MRSA,
staph, HIV, HBV, HCV, influenza, tuberculosis). Hospital workers can be exposed to
blood borne pathogens from blood and other potentially infectious materials if not
following universal precautions.
2. The policy extract is explaining

Ⓐ Why to make a LAM submission.

Ⓑ How to make a LAM submission.

Ⓒ Where to make a LAM submission.

Requesting a change to the list of approved medicines (LAM)

Any hospital staff member can request a change to the list of approved medicines
(LAM). It is expected that applications for changes will include input from a senior
prescriber. Changes should be requested by completing either the standard or, in
limited circumstances, a minor submission form. A standard submission form is
available online or from your local pharmacy department. A minor submission form
can be obtained through contacting the relevant Secretariat. Staffs are also
encouraged to flag potential issues regarding the use of medicines or
pharmaceuticals in writing, with evidence attached. Requests from pharmaceutical
manufacturers or their agents will not be accepted.
3. What point do the guidelines make about leadership for doctors?

Ⓐ The role of a doctor should go beyond practising medicine.

Ⓑ Doctors are the most important clinician in a health care setting.

Ⓒ There could be harsh penalties for doctors who don’t improve their
skills.

Guidelines: Leadership and Management for all Doctors

This guidance sets out the wider management and leadership responsibilities of
doctors in the workplace. The principles in this guidance apply to all doctors,
whether they work directly with patients or have a formal management role.

Being a good doctor means more than simply being a good clinician. In their day-to-
day role doctors can provide leadership to their colleagues and vision for the
organisations in which they work and for the profession as a whole. However,
unless doctors are willing to contribute to improving the quality of services and to
speak up when things are wrong, patient care is likely to suffer. You must be
prepared to explain and justify your decisions and actions. Serious or persistent
failure to follow this guidance will put your registration, and so you’re right to
practice medicine, at risk.
4. The purpose of this memo to staff is to

Ⓐ State the potential risks to patients who smoke electronic cigarettes.

Ⓑ Provide information about the substances used in electronic

cigarettes.

Ⓒ Advise that no position has yet been reached about electronic

cigarettes

Memo to staff: Electronic Cigarettes

Electronic cigarettes (e-cigarettes) are battery operated devices that heat a liquid
(called ‘e-liquid’) to produce a vapour that users inhale. Although the composition of
this liquid varies, it typically contains a range of chemicals, including solvents and
flavouring agents, and may or may not contain nicotine.

Electronic cigarettes are a topic of contention among public health and tobacco-
control advocates, some of whom argue they don’t pose the same dangers to
smokers as traditional cigarettes. Others, however, argue that electronic cigarettes
should not be promoted as a lower threat option for smokers when their long-term
safety is unknown.
5. As a result of an update in favour of patient-centeredness what is going to
happen?

Ⓐ There will be a greater focus on hospital wait times.

Ⓑ More staff will be required to undertake training.

Ⓒ New standards of practice will be developed.

Patient-centered Interdisciplinary Goal Setting in Rehabilitation Services

Although goal setting is fundamental to rehabilitation practice and optimal patient

outcomes, it typically varies in the practices taught across different health
professions, and the preparedness of rehabilitation clinicians to undertake it.
Patient-centeredness has been shown to improve patient care experiences and
create value for public services through increasing the quality and safety of health
care.

Hospital pressures to facilitate discharge and decrease length of stay have been
identified by staff as barriers to implementing patient-centered goal setting practice.
This has resulted in goal setting often being hospital driven rather than patient
driven. Furthermore, staff has recently expressed a lack of strategies or tools to
implement patient-centered principles in care processes such as goal setting. There
is therefore a need to enable rehabilitation services to improve goal setting models
and patient engagement in health care related goals and decisions.

.
6. According to the procedure, when inserting a catheter clinicians should

Ⓐ Only use a catheter once.

Ⓑ Carefully follow all guidelines.

Ⓒ Ensure the patient isn’t left alone.

Catheter Insertion Procedure

Where possible, use a two clinician buddy system to carry out the procedure. The
patient’s ethical, religious and cultural beliefs and personal history should be
considered when appointing clinicians to perform a catheterisation. A chaperone may
also be required to observe the procedure.

It is recommended that the patient’s genital area be washed with soap and water
prior to catheterisation. If unable to insert a catheter after two attempts (includes
changing to a different catheter size), seek further assistance from a senior clinician.
A new catheter should be used for each attempt.
In this part of the test, there are two texts about different aspects of healthcare. For
questions 7-22, choose the answer (A, B, C or D) which you think fits best according
to the text.

Text 1: Restless Leg Syndrome

The relatively common neurologic movement disorder known as restless legs

syndrome (RLS) is poorly understood. Patients describe uncomfortable sensations in
their legs that often are worse at night, having a huge impact on their ability to sleep
and overall quality of life. Experts now speculate that patients with RLS, like those
with unrelieved chronic pain, might feel hopeless, leading to suicidal thoughts and
actions. The risk correlates with history of depression, and is independent of the
severity of restless leg symptoms and demographic factors.

Although evaluating restless legs syndrome and finding effective treatments is

challenging, a recent study suggests that it’s important to assess not only the impact
of RLS on the patient’s life, but also the presence of suicidal thoughts. People with
severe RLS are more likely to plan and attempt suicide than people without it, even
after controlling for depression, according to new research. “Lifetime suicidal ideation
and attempts are very prevalent among people with restless legs syndrome and
seem to be independent of demographic factors and depression and seem to be
associated with severity of restless legs,” said Brian Koo, MD, director of the Yale
Center for Restless Legs Syndrome, Yale University, New Haven, Connecticut.

Until now, RLS and its potential relationship with suicide had not been studied in any
depth. The Yale team investigated the frequency of lifetime suicidal behaviour in 198
patients with severe RLS and 164 controls. All participants completed the Suicidal
Behaviour Questionnaire-revised (SBQ-R) and the Brief Lifetime Depression Scale.
RLS and controls were similar in age (mean age, 51), income, and gender.
Compared with controls, patients with RLS were more often white (96% vs 88%),
less often had higher education (84% vs 96%), were more often married (72% vs
60%), and were less often employed or retired (80% vs 90%). Significantly more
patients with RLS than controls were at high suicide risk (SBQ-R score ≥7) and had
lifetime suicidal thoughts or behaviour, independent of depression history.
“Mood and anxiety disorders are highly comorbid in RLS patients,” noted John W.
Winkelman, MD, PhD, from Harvard Medical School and Massachusetts General
Hospital, Boston.”My feeling is that the suicidal ideation, or even plan or intent, and
even some who have followed through, is the same thing you see in patients with
chronic pain. In many respects, RLS is a chronic pain disorder. And if you have
chronic pain, for which you feel there is no appropriate treatment and your physician
may not understand what you have, or may not know how to treat it appropriately, it
can lead you to feeling hopeless, and I think pain and hopelessness can lead to
those kinds of thoughts,” Winkelman said.

One such case is Lisa, a 45-year-old married woman who came to see a psychiatrist
initially for depressive symptoms. During the initial evaluation, she complained of
difficulty in falling asleep and other depressive symptoms such as low mood,
difficulty with concentration, poor appetite, and low energy along with daytime
fatigue. Depression was diagnosed. A selective serotonin reuptake inhibitor (SSRI)
was prescribed on an as-needed basis, and the patient was advised to take a nightly
dose of diphenhydramine to help her sleep. Three days later—after staying up nearly
all night—Lisa called her doctor in despair and complained of worsening insomnia.
On more detailed questioning about the insomnia, Lisa revealed that for the past 2
years, she has experienced leg discomfort when she gets into bed. She is so
uncomfortable that she needs to walk or ride on her exercise bike past 2 or 3 am
until the discomfort subsides. While not painful, this leg discomfort sometimes
prevents her from relaxing and watching television because she just “has to move”
her legs.

Lisa describes a deep uncomfortable sensation that feels like “bugs crawling in her
legs:’ she also reveals that her mother used to suffer from similar night-time leg
restlessness. Lisa’s leg discomfort became more intense and was lasting most of the
night. After secondary causes of RLS, such as iron deficiency anaemia, pregnancy,
uraemia, and neuropathy were ruled out, SSRI and diphenhydramine therapy were
stopped. Low-dose dopamine agonist therapy was started, after which the symptoms
subsided. However, despite resolution of the RLS symptoms, her depressive
symptoms continued. This only serves to further reinforce the need to investigate
and treat any associated mood or anxiety disorders in conjunction with RLS
symptoms.
Text 1: Questions 7-14

7. The writer suggests that restless legs syndrome (RLS)

Ⓐ Is impossible to cure.

Ⓑ Could lead to depression.

Ⓒ Doesn’t occur during the day.

Ⓓ May relate to pain management.

8. Dr Brian Koo suggests it’s important for clinicians to treat any suicidal thoughts
because

Ⓐ Older people are more likely to suffer from RLS.

Ⓑ The effects of RLS can be better identified.

Ⓒ It makes managing RLS much easier.

Ⓓ RLS is a mental health condition.

9. What did the Yale team learn from their investigations?

Ⓐ Some people in the control group had previously suffered from RLS.

Ⓑ The likelihood of someone developing RLS depends on various

factors.

Ⓒ Answers to the questionnaires didn’t provide a lot of useful data

about RLS.

Ⓓ A person with RLS is more likely to attempt suicide than someone

without it.
10. The expression ‘followed through’ refers to

Ⓐ RLS patients who have attempted suicide.

Ⓑ The relationship between RLS and pain.

Ⓒ A time when RLS has been resolved.

Ⓓ Management of RLS by the doctor.

11. John Winkelman’s comments in the fourth paragraph show his

Ⓐ Concern that a lot of doctors have never heard of RLS.

Ⓑ Belief that RLS relates to many other health conditions.

Ⓒ Frustration that too many people with RLS commit suicide.

Ⓓ Understanding of the situation facing a lot of RLS sufferers.

12. The case involving Lisa highlights that

Ⓐ Some patients don’t follow the recommended advice for RLS.

Ⓑ Regular exercise is recommended for people with RLS.

Ⓒ Sleep problems and exhaustion could indicate RLS.

Ⓓ Medication is important in the treatment of RLS.

13. In the final paragraph, the writer suggests Lisa’s treatment was changed
because

Ⓐ A new diagnosis was made.

Ⓑ She no longer had depression.

Ⓒ SSRI medication wasn’t working for her.

Ⓓ She developed a range of new symptoms.

14. What does the word ‘this’ in the final paragraph refer to?

Ⓐ Low-dose dopamine agonist therapy.

Ⓑ The differences between therapies.

Ⓒ The end of her RLS symptoms.

Ⓓ Lisa’s unresolved depression.

Text 2: Statins- How Safe Are They?

Heart disease is the leading cause of death in the U.S and statins are a commonly
prescribed medicine that helps to lower harmful levels of LDL cholesterol in the blood
and mitigate the risks of cardiovascular disease, including heart attack and stroke.
Trials have consistently demonstrated a clear correlation between reducing LDL
cholesterol with statins and a decrease in cardiovascular risk. So it may appear
puzzling that uncertainty over statins still remains.

As the body of evidence evaluating statins has expanded, so too have the
indications for the drug. Guidelines released in 2013 by the American College of
Cardiology (ACC) and the American Heart Association (AHA) recommended that
statin therapy might be beneficial for people with cardiovascular disease, people who
have high LDL cholesterol levels, people aged 40 to 75 years with diabetes and high
LDL levels and people aged 40 to 75 years without diabetes, but with high LDL
cholesterol levels and a predicted 10-year risk of cardiovascular disease of 7.5
percent or higher. However, experts questioned the 2013 guidelines, arguing that a
7.5 percent threshold seemed too low.

In 2015, two research teams examined the 7.5 percent threshold and published their
findings. The first paper, led by Dr. Udo Hoffmann at Massachusetts General
Hospital and Harvard Medical School – both in Boston - found that compared with
guidelines published in 2004, the 2013 guidelines were more accurate at identifying
individuals at a greater risk of cardiovascular disease. They estimated that by
adopting the 2013 guidelines, between 41,000 and 63,000 cardiovascular events
would be prevented over 10 years compared with previous guidelines. The second
paper, led by Drs. Ankur Pandya and Thomas A. Gaziano at the Harvard T.H. Chan
School of Public Health - also in Boston - assessed the cost-effectiveness of the 10-
year cardiovascular disease threshold. The researchers concluded that the risk
threshold of 7.5 percent or higher had an acceptable cost-effectiveness profile.

As a result of the expansion of the groups reported to benefit from statins, suspicions
have been raised about the pharmaceutical industry and of the prescribing
healthcare professionals. Alarm bells started ringing that people were being
overmedicated and put at risk of adverse effects. Statins are generally considered to
be safe and well tolerated. However, as with any medication, statins may have
negative effects in some people. “We know that statins can prevent a significant
number of heart attacks and strokes. We know there is a small increase in the risk of
diabetes, and at high doses there is a very small increase in myopathy, but overall
the benefits greatly outweigh the harms,” says Peter Sever, professor of clinical
pharmacology and therapeutics at Imperial College London. “Widespread claims of
high rates of statin intolerance still prevent too many people from taking an
affordable, safe, and potentially life-saving medication.”

Some people, however, believe heart disease is better treated by other means, such
as diet. A study found those who had a diet rich in vegetables, nuts, fish and oils,
such as a Mediterranean-style diet were a third less likely to die early, compared with
those who ate larger quantities of red meat, such as beef, and butter. Sir David
Nicholson, former chief executive of the National Health Service (NHS) in the UK,
entered the debate over statins when he said he had stopped taking them as part of
his medication for diabetes. “If a lifestyle change works then why would you take the
statin? The trouble is that they give you a statin straightaway, so you don’t know
what is working,” he said.

While a heart-healthy diet, regular physical activity, and maintaining a healthy weight
are all components that may help to reduce cholesterol and lower the risk of heart
disease and stroke, certain factors are unable to be influenced - such as genetics. In
some people, lifestyle changes alone are not enough to lower cholesterol. According
to a study published in the Journal of the American Medical Association, from 1969
to 2013, deaths from heart disease fell by 68 percent, and there were 77 percent
fewer deaths from stroke. There may be a link between the rise in statin use and the
fall of deaths connected to cardiovascular disease. However, the progress made
could be attributed to the “cumulative effect of better prevention, diagnosis, and
treatment,” says Wayne D. Rosamond, Ph.D., professor of epidemiology at the
University of North Carolina in Chapel Hill.

The mounting research appears to overturn debate around statins and aims to
reassure doctors and patients that the risks of not taking statins - heart attack or
stroke - far outweigh concerns about side effects associated with the drug. Serious
side effects are rare, and study authors seem to agree that the substantial proven
benefits of statins have been compromised by “serious misrepresentations of the
evidence for its safety.”
Text 2: Questions 15-22

15. The writer suggests that uncertainty over the use of statins is puzzling because

Ⓐ No other medication is used as often to treat cardiovascular

disease.

Ⓑ Heart disease kills large numbers of people in the United States.

Ⓒ Extensive studies have been conducted about their use.

Ⓓ They are so effective in lowering LDL cholesterol.

16. In the second paragraph, what do we learn about the guidelines released in
2013?

Ⓐ They were seen as worse than the previous guidelines.

Ⓑ They recommended the use of statins for anyone with high LDL
levels.

Ⓒ They contained a lot of advice that health professionals didn’t agree

with.

Ⓓ They suggested a connection between heart disease and other

conditions.

17. The research papers written in 2015 concluded that the 7.5 percent threshold
would

Ⓐ Focus more on patient health than the previous guidelines.

Ⓑ Result in lower treatment costs for most patients.

Ⓒ Reduce the amount of cardiovascular disease.

Ⓓ Take many years to implement.

18. The writer uses the phrase ‘alarm bells started ringing’ to indicate

Ⓐ Some health professionals have been overprescribing statins.

Ⓑ The numbers of people taking statins has grown too quickly.

Ⓒ There are too many risks associated with taking statins.

Ⓓ Research into the use of statins has cost too much.

19. What concerns does Peter Sever have about statins in the fourth paragraph?

Ⓐ They aren’t being promoted as widely as they should be.

Ⓑ They are linked to several other health conditions.

Ⓒ They are too expensive for some patients.

Ⓓ They aren’t being used enough.

20. Sir David Nicholson’s comments show that he believes statins

Ⓐ Should only be prescribed after other options have been tried.

Ⓑ Aren’t as effective as diet in improving a person’s health.

Ⓒ Only work after you have been taking them for a while.

Ⓓ Don’t work as an effective treatment for diabetes.

21. In the sixth paragraph, Wayne D. Rosamond attributes a reduction in deaths from
heart attack and stroke to

Ⓐ A combination of different factors that work together.

Ⓑ The rise in medications that treat heart disease.

Ⓒ A person’s family history and background.

Ⓓ Improved diet and regular exercise.

22. The benefits of statins are described as having been ‘compromised’ because

Ⓐ Their benefits are too few in number.

Ⓑ A lot more research needs to be done.

Ⓒ There is still a lot of debate around their use.

Ⓓ Too many lies have been told about their effects.

READING SUB-TEST – QUESTION PAPER: PART A

Bed Bugs: Texts

Text A

Bed bugs have feasted on sleeping humans for thousands of years. After World War II, they were eradicated from
most developed nations with the use of DDT. This pesticide has since been banned because it's so toxic to the
environment. Spurred perhaps by increases in international travel, bed bugs are becoming a problem once again.
The risk of encountering bed bugs increases if you spend time in places with high turnovers of night-time guests -
such as hotels, hospitals or homeless shelters. Bed bugs are reddish brown, oval and flat, about the size of an
apple seed. During the day, they hide in the cracks and crevices of beds, box springs, headboards and bed frames.
It's a daunting task to eliminate bed bugs from your home. Professional help is recommended.

Symptoms

It can be difficult to distinguish bed bug bites from other insect bites. In general, the sites of bed bug bites usually
are:
• red, often with a darker red spot in the middle
• itchy
• arranged in a rough line or in a cluster
• located on the face, neck and arms

Text B

Reactions to bed bug bites in humans

Skin reactions are commonly associated with bed bugs, which result from the saliva injected during feeding. Some
individuals, however, do not react to their bite, whereas others note a great deal of discomfort often with loss of
sleep from the persistent biting. Reactions to the bites may be delayed, up to 9 days before lesions appear.
Common allergic reactions include the development of large wheals, often >1-2 cm, which are accompanied by
itching and inflammation. The wheals usually subside to red spots but can last for several days. Bullous eruptions
have been reported in association with multiple bed bug bites and anaphylaxis may occur in patients with severe
allergies. In India, iron deficiency in infants has been associated with severe infestations. It has been suggested
that allergens from bed bugs may be associated with asthmatic reactions.

Text C

Bed bug-detecting canines

ABSTRACT The bed bug, Cimex lectularius L., like other bed bug species, is difficult to visually locate because it is
cryptic. Detector dogs are useful for locating bed bugs because they use olfaction (smell) rather than vision. Dogs
were trained to detect the bed bug (as few as one adult male or female bug) and viable bed bug eggs (as few as
five, collected 5-6 days after feeding) by using a modified food and verbal reward system. Their efficacy was
tested with adult bed bugs and viable bed bug eggs placed in vented polyvinyl chloride containers. Dogs were
able to discriminate bed bugs from the insects Camponotus floridanus (Buckley), Blattella germanica L., and
Reticulitermes flavipes (Kollar), with a 97.5% positive indication rate (correct indication of bed bugs when
present) and 0% false positives (incorrect indication of bed bugs when not present). Dogs also were able to
discriminate live bed bugs and viable bed bug eggs from dead bed bugs, cast skins, and feces, with a 95% positive
indication rate and a 3% false positive rate on bed bug feces. In a controlled experiment in hotel rooms, dogs
were 98% accurate in locating live bed bugs. A pseudoscent prepared from pentane extraction of bed bugs was
recognized by trained dogs as bed bug scent (100% indication). The pseudoscent could be used to facilitate
detector dog training and quality assurance programs. If trained properly, dogs can be used effectively to locate
live bed bugs and viable bed bug eggs.

Text D

Bed bugs as vectors of human disease

Transmission of more than 40 human diseases has been attributed to bed bugs, but there is little evidence that
such transmission has ever occurred. Older scientific literature postulated that bed bugs may be vectors of
plague, yellow fever, tuberculosis, relapsing fever, leprosy, filariasis, kala azar (leishmaniasis), cancer, smallpox,
and Chagas disease (Trypanosoma cruzi). Recently, the possibility of human immunodeficiency virus and hepatitis
B virus transmission by bed bugs has been investigated. Human immunodeficiency virus can be detected in bed
bugs up to 8 days after ingestion of highly concentrated virus in experimental blood meals. However, no viral
replication has been observed within the insects and no virus has been detected in bed bug feces. Mechanical
transmission of human immunodeficiency virus has not been demonstrated using an artificial system of feeding
bed bugs through membranes.

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

Part A

TIME: 15 minutes

• Look at the four texts, A-D, in the separate Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers on the spaces provided in this Question Paper.
• Answer all the questions within the 15-minute time limit.
• Your answers should be correctly spelt.

Bed Bugs: Questions

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. normal allergic reactions to bed bugs?

______________

2. signs that bed bugs may spread diseases?

______________

3. dogs can be trained to detect bed bug eggs?

______________

4. bed bugs showed no viral replication?

______________

5. bed bug bites may be seen in a cluster?

______________

6. places where bed bugs are found?

______________

7. what is used to facilitate quality assurance programs?

______________

Questions 8-15

Answer each of the questions, 8-15, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.

8. How much was the false positive indication rate of bed bugs by detector dogs?
______________

9. What was used to eliminate bed bugs from developed countries?

______________

10. What is the usual symptom exhibited by bed bug infestation?

______________

11. What was detector dogs’ positive indication rate for distinguishing live and dead bed bugs?
______________

12. What caused serious infestations of bed bugs in newborns?

______________

13. What is the reason for reappearance of bed bugs in developed countries?
______________

14. How many diseases are said to be spread by bed bug being vectors?
______________

15. What are responsible for asthma symptoms caused by bed bugs?
______________

Questions 16-20

Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.

16. The usage of ____________________________ is prohibited as it is proven to be very harmful to our

surroundings.

17. The presence of ____________________________ is not detected in ordure of the bed bugs.

18. To locate bed bugs, detector dogs use olfactory senses despite their ____________________________.

19. Numerous bed bug bites are found to produce ________________________.

20. ____________________________ is made from the pentane extraction of bed bugs.

END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED

READING SUB-TEST – QUESTION PAPER: PARTS B & C

TIME: 45 MINUTES

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper until you are told to do so.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the test, hand in this Question Paper.
DO NOT remove OET material from the test room.

HOW TO ANSWER THE QUESTIONS:

Mark your answers on this Question Paper by filling in the circle using a 2B pencil.

Part B

In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6,
choose the answer (A, B or C) which you think fits best according to the text.

1. According to the extract, every physicians must

A. declare modifications regarding requirement of seasonal influenza immunization.

B. provide help to get proper immunization against the seasonal influenza virus.
C. get a flu vaccination from an appropriate place that offer a valid substantiation.

The seasonal influenza immunization

In an effort to protect our patients, visitors, and colleagues, we are announcing an important change regarding
the requirement of seasonal influenza immunizations for all employees, physicians, active volunteers, vendors,
contracted staff, and students. As health care providers, it is our responsibility and obligation to protect our
patients, visitors, and colleagues—as well as ourselves and our family members—by being immunized against the
seasonal influenza virus. As we have done in the past, seasonal influenza immunizations will be provided free of
charge to all employees, physicians, contracted staff and active volunteers. Participation in this year’s seasonal
influenza immunization program is required. All employees, physicians, contracted staff, active volunteers and
students will be required to do one of the following:
• Receive a flu vaccination through RH Occupational Health Office.
• Provide proof of immunization if you received a vaccination outside of RH’s planned immunization program—
from another health care provider or local pharmacy, for example.

2. The policy document tells us that tolerance for risk is greater for permanently implanted medical devices

A. in pediatric patients with a limited life expectancy.

B. such as pacemaker pulse generators.

C. in a healthy pediatric population.

Risk Assessment of Medical Devices

The risk assessment should consider the proposed clinical use of the device, including the anatomical location,
duration of exposure, and intended use population. For example, for pediatric patients with a limited life
expectancy, the tolerance for risk associated with a permanently implanted medical device may be higher than
the tolerance for risk from the same device in an otherwise healthy pediatric population. The potential exposure
duration should also consider which material components of the device have direct or indirect contact with
tissue, and whether exposure would be a one-time exposure, a constant exposure over time, or an intermittent
exposure over time that could have a cumulative effect. For example, pacemaker pulse generators commonly
contain internal electronic components made from chemicals that could be toxic to the body, but appropriate
bench testing can demonstrate that the pulse generator is hermetically sealed and will limit exposure of those
chemicals to the surrounding tissues.

3. What is being described in this section of the guidelines?

A. changes in procedures.
B. best practice procedures.

C. exceptions to the procedures.

Patient Admission

If the patient medically requires hospital inpatient services and the physician believes that the patient will need to
stay in the hospital at least 2 midnights, the physician should order inpatient admission. If the patient does not
medically require inpatient hospital services or the physician does not expect the patient to stay past 2 midnights,
the physician should order observation or outpatient services. The certification must be signed and documented
in the medical record prior to patient discharge. Hospitals may choose to have physicians record these elements
of the certification either on a specific form or throughout the medical record such as in the orders, history and
physical, or physician progress notes.

Guidelines:

• Excellent patient care should continue to be the top priority.

• Document the diagnosis, medical rationale, plan of care and anticipated discharge.
• Sign the admission order and certification (if appropriate) prior to discharge.

4. The purpose of these instructions is to explain

A. how to wear respirators effectively

B. how to use respirators appropriately

C. necessity of wearing proper respirators

Respirators

Respirators are an effective method of protection against designated hazards when properly selected and worn.
Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of
comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator
itself can become a hazard to the worker. Workers who occasionally wear filtering face-piece respirators on a
voluntarily basis must be aware of the following information. This information is intended for employees who are
not required to wear respirators for protection from recognized airborne hazards. Employees who perceive
exposures to any airborne contaminants, particularly outside of a chemical fume hood, should request an
exposure evaluation before selecting a respirator.

5. The extract informs us that your

A. input will help evaluate the current HOCC program and its future program review.

B. participation ensure that patients’ needs are met exclusively by physicians.

Csupport and elaborate retrospect will help in fulfilling targets of HOCC program review.

Hospital On-Call Coverage Program Review

We are requesting your assistance with the detailed review of the Hospital On-Call Coverage (HOCC) Program;
your input will help evaluate the current HOCC program and assist to identify future directions. With your
participation, we can ensure that the HOCC program meets the needs of patients, participating physicians and
other health care stakeholders.

The HOCC Program review has three primary objectives:

1. To identify and examine the effectiveness of key elements of the program already in place at hospitals. These
elements include eligibility criteria, compensation structures, process metrics, resource requirements, and others.
2. To develop recommendations for improving the organization and delivery of on-call services based on evidence
and best practices identified through the data and information collection processes.
3. To explore specific issues: Participation of doctors, use of regional call networks, and coverage for long-term
care, sexual assault centres, chronic care facilities and palliative care programs.

6. What point does the extract make about processing of medical devices?

A. could significantly affect the biocompatibility of the medical devices.

B. includes passivating surface of medical devices by acid bath or other method.

C. uses resin supplier to remove all processing solvents from medical devices.

Identification of Potential Risks

An assessment of potential biocompatibility risk should include not only chemical toxicity, but also physical
characteristics that might contribute to an unwanted tissue response. These characteristics can include surface
properties, forces on surrounding tissue, geometry, and presence of particulates, among others. In addition,
changes in manufacturing and processing parameters can also have an impact on biocompatibility. For example,
the original processing for an implanted device might include placing the device in an acid bath to facilitate
passivation of the implant surface. If this passivation process is changed to eliminate the acid bath in favor of a
different method of passivating the surface, removal of the acid bath might unintentionally lead to a smaller
reduction in pyrogenic material, which could result in pyrogenic reactions (fever) following implantation of the
device. Another common change that might impact biocompatibility is a change in resin supplier. For example, if
the new resin supplier does not remove all processing solvents (some of which may be known toxic compounds,
such as formaldehyde), the final manufactured device could cause unexpected toxicities that were not seen with
devices manufactured from the original resin.

Part C

In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the
answer (A, B, C or D) which you think fits best according to the text.

Text 1: Measuring Life

Somewhere out in the future there's a final moment with our name on it: life's only certainty is death. It's coming,
and the only mystery about mortality's last call is: when? But if your doctor could tell you, would you want to hear
how long you are likely to live? American researchers now believe that they are able to determine a person's
"natural" life span from a simple blood test. They have identified the ability of a common gene to influence the
ageing process, and the form it takes in any given individual can they say, indicate medical vulnerability and predict
when the person may die. The news has created much excitement but it also has raised concerns about the ethical
dilemmas involved if science is able to read our lifelines and forecast our susceptibility to deadly diseases. It's a
development that revives the eternal question: should a doctor tell?

Apo E, as it's known, is not a new discovery but, hitherto, scientists believed that its only function was to remove
cholesterol from the bloodstream. Only lately as they have been able to study the ever increasing numbers of
elderly, has the gene's relationship with longevity become apparent. It apparently operates as a kind of caretaker
gene, maintaining the system's cells and keeping them running smoothly, and its efficiency can determine the rate
at which the body holds up or wears out. "Apo E is one of those genes that we suspect controls life span because it
affects people’s susceptibility to diseases of ageing”, says Dr Jan Vigh; a molecular geneticist at Beth Israel Hospital,
in Boston. The gene has three variants, known as E2, E3, E4, and we all inherit one of them from each of our
parents. More than half of us are born with two E3s, but it is the distribution of the other two forms that has
proved so compelling to scientists that they have been analyzing data on the elderly.

People with one or – more rarely – two E2s tend to survive the longest, while those with E4s die considerably
earlier than the rest. Studies in Canada, France, Sweden and Finland found that E2 carriers were about four times
more likely to reach their 100th birthday than those born with an E4. The E2 is, it seems, an excellent caretaker. By
comparison, E4 does sloppy work and its inadequacies at cell upkeep make those who have it vulnerable to illness
and early death. Doctors now accept that the presence of the Apo E4 gene signals a risk of heart disease and
Alzheimer's. American studies show that middle aged women with an E4 are twice as likely to develop coronary
heart disease as those who don't, while E4 men have a 50 per cent higher risk than other men. Among men under
40 who require surgery for clogged heart arteries, the incidence of two E4s is 16 times higher than among others in
their age group And Dr Alan Roses, the Duke University neurologist who first made the link between Apo E and
Alzheimer's, says those with two E4s have about six times the normal risk of developing the disease, while people
born with two E2s may be protected from it.

More than 4 million Americans are afflicted by this devastating brain disorder and nearly two-thirds of them have
at least one Apo E4 gene, compared with only 15 percent in the general population. So Apo E may be a critical
marker for life span and vulnerability to grave diseases, and evidence of its presence is in the records of millions of
blood tests conducted for other reasons. But is it ethical or wise for doctors to use that information to tell people
something they may not want to know and which, in any case, alerts them to threats that may be unavoidable?
“We consulted bioethicists and got a variety of opinions," says Dr Norman Relkin, the New York neurologist who
gathered other concerned doctors to discuss the issue at a conference in Chicago. After two days, they called for
more research to establish the nature and the risks of the Apo E family but many researchers seem opposed to
confronting people with alarming news about conditions that cannot be fought, based on blood samples given for
other purposes.

"Have you done them a service?" asks Dr Lindsay Farrer, an Alzheimer 's researcher at Boston University Medical
Centre. "What good does it do to tell someone about being at risk from a dreaded disease that can neither be
prevented nor effectively treated?" Dr Rudolph Tanzi, an Alzheimer's specialist at Massachusetts General Hospital,
agrees but, because his own family has a history of early heart problems, he was unable to resist having his own
Apo E analyzed. He is an E3, in the same wide, neutral middle ground as most of humanity. The problems raised by
Apo E are varied and complex. Some doctors worry about possible discrimination from employers and insurance
companies if people are routinely told they may have a predisposition to serious illness and premature death.
Because blows to the head seem to increase the risk of getting Alzheimer's among people with the E4 gene, should
boxers and other athletes, and children wanting to play contact sports, be tested for their Apo classification?
“Already!”, says Dr Relkin, pregnant women are asking for their fetuses to be screened so they can consider
abortion if their babies show two E4s.

Duke University's Dr Roes is working with a major drug company to try to define what gives Apo E2 its ability to
improve the body's defenses, so that its protection can be duplicated in the laboratory. "The hope is that we shall
be able to make a drug that does what Apo E2 does," he says. Meanwhile, for millions of people around the world,
their destiny -how they will live, when they will die is perhaps already foretold in a dusty medical file.

Text 1: Questions 7-14

7. Researchers have identified ______

A. a way to monitor a person's life span from a blood test.

B. a gene which could affect the process of ageing in humans.

C. the mystery about mortality's last call.

D. a way to predict the vulnerability of an individual.

8. The discovery of being able to estimate the life span of a person ______

A. has generated apprehension about peoples predisposition to deadly diseases..

B. has initiated an ethical puzzle involved in being able to predict disease.

C. has rekindled debate about a perpetual dilemma for doctors.

D. has been instrumental in forecasting deadly diseases.

9. Apo E functions within a person's system as ______

A. a cholesterol gene controller..

B. a maintainer of the gene's relationship with longevity.

C. a gene which monitors and determines the ageing process.

D. the gene which inhibits the rate at which the body degenerates.

10. Scientists have been in a position to study the Apo E phenomenon because _____

A. of the steadily ageing population in North America.

B. Apo E has been known about for many years.

C. diseases which affect the elderly have increased.

D. they knew that its only function is to remove the cholesterol from the blood.

11. A molecular geneticist in Boston has found that ______

A. we all inherit Apo E2, E3 or E4 from either parent.

B. the greater number of us inherit three variants of Apo E from both parents.

C. the majority of us will inherit two Apo E3s from both parents.

D. more than half of us inherit either two Apo E2s or two Apo E4s from both parents.

12. Middle aged women with an Apo E4 gene _____

A. are at greater risk of being vulnerable to illnesses.

B. have a 50% higher risk factor than men.

C. experience a higher incidence of Alzheimer’s disease.

D. are more likely to develop heart disease.

13. Which statement is not true?

The neurologist who made initial connection with Apo E and Alzheimer' s believes people with _____

A. 2 E4s are more likely to develop the disease.

B. 2 E4s are more likely to be protected by it.

C. 2 E4s are six times more at risk of vulnerability to Alzheimer's than others.
D. 2 E2s are less in 15% of general population who have the disease.

14. Neurologists and bioethicists who met at a conference in Chicago _____

A. were mildly in favor of telling people alarming news about their condition.

B. agreed that there was sufficient information to establish risks of Apo E gene.

C. agreed that it was insufficient to determine extent of risks using Apo E information.

D. were not in favor of giving bad news based on blood samples only.

Text 2: E. coli Outbreak

An outbreak of E. coli in Germany that has killed at least 16 people and left hundreds battling infection across
Europe raises questions about what risks the infection continues to pose and what fallout it will cause. The source
of the E. coli outbreak is still unknown but has been traced to cucumbers imported to Germany from Spain. It is not
clear whether the vegetables were infected at source or in transit. The European Center for Disease Prevention
and Control (ECDPC) says transmission of the strain of bacterium, commonly found in cattle, usually occurs through
contaminated food or water and contact with animals. Infections have so far only been linked to Spanish
cucumbers originating from the cities of Almeria and Malaga, but there are fears other raw vegetables such as
lettuce and tomatoes could be affected. The European Union says a suspect batch of cucumbers imported from
either Denmark or the Netherlands and sold in Germany is under investigation.

The ECDCP says the bacteria's impact on individuals can be affected by their age with children under five usually at
higher risk of developing disease and dying from infection. However, statistics published on May 27 showed that of
276 cases, 87% were adults and 68% were women. One hospital in Hamburg said it had up to 700 infected
patients. Of 85 people at risk of renal failure, 20 were children and 65 were adults. Sweden, which appears to have
the biggest cluster of cases outside of Germany, has reported several dozen people hospitalized. Escherichia coli (E.
coli) is a bacteria found living in the intestines of people and animals. It can be transmitted through contaminated
water or food -- especially raw vegetables and undercooked meat. It is usually harmless, but can cause brief bouts
of diarrhea. Some nastier strains can cause severe diarrhea and followed by serious organ system damage such as
kidney failure. Healthy adults usually recover within a week, but young children and older adults can develop a life-
threatening kidney failure.

The European Food Safety Alert Network identifies the bacteria linked to the contaminated cucumbers as EHEC, or
enterohemorrhagic Escherichia coli, a strain which is particularly virulent and resistant to antibiotics. In Hamburg,
up to 30% of people admitted to hospital with the infection were said to have developed haemolytic-uremic
syndrome, a life-threatening form of kidney failure. The ECDPC says the outbreak is the largest in the world of its
kind. So far there have been more than a dozen E. coli-linked deaths in Germany and hundreds of infections, but
more are expected. Infections have also been reported across Western Europe but so far the cases in Austria,
Britain, Denmark, France Netherlands, Sweden and Switzerland have all involved people returning from travel to
Germany. The European Food Safety Alert Network said E. coli had been found in cucumbers from Spain, packaged
in Germany, and distributed to countries including Austria, the Czech Republic, Denmark, Germany, Hungary and
Luxembourg.
Germany is advising people to avoid all raw vegetables, particularly cucumber, lettuce and tomatoes. The ECDPC
says there is a risk of person-to-person transmission from people carrying the infection. "Personal hygiene
messages are important," it says. With exports of Spanish vegetables "paralyzed" according to officials, weekly
losses of about €200 million ($288 million) are predicted. There are also concerns about the long-term impact this
will have on Spain's fruit and vegetable market, last year worth €8.6 billion. Producers have already reported that
seeded fruit exports are being affected, despite being unrelated to the scare. In addition to Germany, a number of
European countries including Russia and Belgium have banned vegetable imports from Spain. Germany has
reportedly also drastically reduced imports from the Netherlands. The cucumber alert could also have diplomatic
fallout, with producers urging Spain's prime minister to step in, complaining German authorities have condemned
Spanish produce without proof.

Leire Pajin, the Spanish Health Minister, has discussed the outbreak on Twitter, saying: "In the absence of proof,
we're not ruling out using all necessary measures to make sure there's compensation for the (economic) damage,"
she wrote. "From the first day, the government launched a diplomatic offensive to prevent the linking of this
health crisis with our products." While Germany accounts for much of Spain's vegetable export market, the
country does export further afield to countries including Russia and the United States. There is also the risk of so-
called "secondary clusters" of infection caused by person-to-person transmission by anyone who had become
contaminated during a visit to Germany.

Text 2: Questions 15-22

15. What is the meaning of the word ‘fallout’ in the first paragraph?

A. What effects the infection will have on the infected people.

B. What the causes of the infection are.

C. What effects the breakout will have.

D. What the causes of eating too many cucumbers are.

16. The source of the E. Coli outbreak is thought to be caused by_____

A. cucumbers exported from Germany.

B. infected cattle.

C. contaminated food or water and contact with animals.

D. cucumbers exported from Spain to Germany.

17. Which one of the following statements is not true?

A. Cucumbers from Almeria and Malaga are thought to be infected.

B. Tomatoes and lettuce from Spain may be affected.

C. A suspect batch of cucumbers sold in Denmark or the Netherlands is under investigation.

D. A suspect batch of cucumbers imported to Germany is under investigation.

18. What do the statistics published on May 27 show?

A. That women are less likely to be infected.

B. That children are more likely to be infected.

C. That adults are more likely to be infected.

D. That men are more likely to be infected.

19. Which of the following statements is correct?

A. A Hospital in Hamburg reported 276 cases of E.coli.

B. 700 cases have been reported worldwide.

C. Sweden has reported the most cases of E. coli.

D. 85 people are at risk of renal failure in a hospital in Hamburg.

20. How is E. coli transmitted?

A. From person to person.

B. Through contaminated water or food.

C. Through eating the kidney’s of animal products.

D. From young children to older adults.

21. Why is this strain of E.Coli so deadly?

A. It is particularly virulent and resistant to antibiotics.

B. It leads to haemolytic-uremic syndrome.

C. It is a bacteria linked to contaminated cucumbers.

D. Because 30% of people with E.Coli have died.

22. Which of the following is not true?

Infections have been reported in people who ______

A. live in Australia and Spain.

B. have returned from traveling in Germany.

C. live in Austria, Britain, Denmark, France, Netherlands, Sweden and Switzerland.

D. have eaten cucumbers which were from Spain and packaged in Germany.
Sample Test 1

READING SUB-TEST – ANSWER KEY

PART A: QUESTIONS 1-20

1. B
2. D
3. C
4. D
5. A
6. A
7. C
8. 0%
9. DDT
10. skin reactions
11. 95%
12. iron deficiency
13. international travel
14. 40
15. allergens
16. DDT
17. human immunodeficiency virus
18. vision
19. bullous eruptions
20. pseudoscent

PART B: QUESTIONS 1-6

1. C get a flu vaccination from an appropriate place that offer a valid substantiation.
2. A in pediatric patients with a limited life expectancy.
3. B best practice procedures.
4. C necessity of wearing proper respirators
5. C support and elaborate retrospect will help in fulfilling targets of HOCC program review.
6. A could significantly affect the biocompatibility of the medical devices.

PART C: QUESTIONS 7-14

7. B a gene which could affect the process of ageing in humans.

8. C has rekindled debate about a perpetual dilemma for doctors.
9. C a gene which monitors and determines the ageing process.
10. A of the steadily ageing population in North America.
11. C the majority of us will inherit two Apo E3s from both parents.
12. D are more likely to develop heart disease.
13. B 2 E4s are more likely to be protected by it.
14. C agreed that it was insufficient to determine extent of risks using Apo E information.

PART C: QUESTIONS 15-22

15. C What effects the breakout will have.

16. D cucumbers exported from Spain to Germany.
17. C A suspect batch of cucumbers sold in Denmark or the Netherlands is under investigation.
18. C That adults are more likely to be infected.
19. D 85 people are at risk of renal failure in a hospital in Hamburg.
20. B Through contaminated water or food.
21. A It is particularly virulent and resistant to antibiotics.
22. A live in Australia and Spain.
READING SUB-TEST – QUESTION PAPER: PART A

Obstetric Ultrasound: Texts

Text A

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

Text B

Abstract: Implementing a obstetric ultrasound training program in rural Africa

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

Text C

The Role of Obstetric Ultrasound in Low Resource Settings

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

Text D

"Entertainment" Ultrasound Examinations

It has been proposed that natural-appearing 3-D ultrasound images of the fetus could improve parent fetal
bonding. Given the recognized importance of maternal-child bonding immediately postpartum, it seems
reasonable that extending this bonding experience into the fetal period could be beneficial. However, a
psychological benefit of viewing fetal photos has not been proven, and obtaining such images largely remains in
the realm of "entertainment". In some countries, parents are able to enter a photography studio with ultrasound
facilities and leave with pictures suitable for framing: no physician involvement is needed for this event. The use
of ultrasound for non-diagnostic purposes has been condemned by the American Institute of Ultrasound in
Medicine and the American College of Obstetricians and Gynecologists. Concerns that were raised in their policy
statements include possible adverse bio-effects of ultrasound energy, the possibility that an examination could
give false reassurance to women, and the fact that abnormalities may be detected in settings where personnel
are not prepared to discuss and provide follow-up for concerning findings.

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

Part A

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper or the Text Booklet until you are told to do so.
Write your answers on the spaces provided on this Question Paper.
You must answer the questions within the 15-minute time limit.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the 15 minutes, hand in this Question Paper and the Text Booklet.
DO NOT remove OET material from the test room.

TIME: 15 minutes

•Look at the four texts, A-D, in the separate Text Booklet.

•For each question, 1-20, look through the texts, A-D, to find the relevant information.
•Write your answers on the spaces provided in this Question Paper.
•Answer all the questions within the 15-minute time limit.
•Your answers should be correctly spelt.

Obstetric Ultrasound: Questions

Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more
than once.

In which text can you find information about

1. alternative name for professionals who do ultrasound scan?

________

2. benefits of obstetric ultrasound scan?

________

3. benefits of three dimensional ultrasound images?

________

4. places which recorded high maternal mortality?

________

5. who condemned non-diagnostic uses of ultrasound?

________

6 who conducted the study in rural Africa?

________

7 differences among countries regarding maternal mortality?

________

Questions 8-15

Answer each of the questions, 8-15, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.

8. What is the maximum frequency limit of diagnostic ultrasound?

________

9. What does ‘MDG’ stand for based on the information given in the texts?

________

10. How many participants were there in the study conducted in rural Africa?

________

11. What type of frequencies travel more into human body?

________

12. Which millennium development goal aim to reduce maternal mortality?

________

13. What is the alternate term for ultrasound scan?

________

14. What is the maternal mortality ratio in comparison with live births in developed nations?

________

15. How many transverse presentations were identified in the study conducted in rural Africa?

________

Questions 16-20

Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.

16. ____________________________ in a hinterland backdrop, which is assisted remotely is very practical.

17. The adverse bio-effects of ultrasound energy is a major _________________ brought up by the American
Institute of Ultrasound in Medicine.

18. Advancements in ____________________________ is vital to eliminate the adverse outcomes of MCH globally.

19. ____________________________ can penetrate through skin and provide superior image quality.

20. The significance of ____________________________ is identified as essential, soon after the fetal period.

END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED

READING SUB-TEST – QUESTION PAPER: PARTS B & C

TIME: 45 MINUTES

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper until you are told to do so.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the test, hand in this Question Paper.
DO NOT remove OET material from the test room.

HOW TO ANSWER THE QUESTIONS:

Mark your answers on this Question Paper by filling in the circle using a 2B pencil.
Part B

In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6,
choose the answer (A, B or C) which you think fits best according to the text.

1. This extract informs us that multidisciplinary care is

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

B. enhancing the residents quality of life to meet the needs of residents.

C. providing an integrated team approach by addressing the problems.

Multidisciplinary Care

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

2. What is being described in this section of the guidelines?

A. changes in protocols.

B. best practice protocols.

C. exceptions to the protocols.

Protected Health Information

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

3. The carcinogenicity potential should be assessed for

A. all medical devices with direct human contact.

B. reviewing the carcinogenicity of novel materials.

C. all medical devices with lasting human contact.

Carcinogenicity

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

4. According to the extract, the best way to address the biocompatibility of a device is through

A. clinical testing

B. clinical studies

C. clinical experience

Clinical experience

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

5. Which is not an alternate term for a medical committee?

A. drug and medicine committee.

B. pharmacy and therapeutics committee.

C. medicine and therapeutics committee.

Drugs in Hospital

A hospital exists to provide diagnostic and curative services to patients. Pharmaceuticals are an integral part of
patient care. Appropriate use of medicines in the hospital is a multidisciplinary responsibility shared by
physicians, nurses, pharmacists, administrators, support personnel, and patients. A medical committee,
sometimes called the drug and therapeutics committee, pharmacy and therapeutics committee, or the medicine
and therapeutics committee, is responsible for approving policies and procedures and monitoring practices to
promote safe and effective medicine use. The pharmacy department, under the direction of a qualified
pharmacist, should be responsible for controlling the distribution of medicines and promoting their safe use. This
task is challenging because medicines are prescribed by physicians, administered by nurses, and stored
throughout the hospital. The control of narcotics is of particular concern in the hospital setting and requires a
systematic approach for the prevention and detection of abuse.

6. What point does the extract make about known genotoxins?

A. can assume a positive result for the devices containing genotoxic materials.

B. cannot absolutely negate the negative results for other device components.

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

Genotoxicity

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

Part C

In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the
answer (A, B, C or D) which you think fits best according to the text.

Text 1: Eye Damages in Divers

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

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

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

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

The researchers used retinal angiography to assess the tissue damage in divers. The abnormalities that they
detected in the angiograms of divers were very similar to those seen in sickle-cell disease. There was clear
evidence of obstruction to the capillaries. The researchers suggested three mechanisms to explain how diving
causes this obstruction. When divers come back to the surface air bubbles sometimes form in their veins and their
lungs. If bubbles also form in the arteries, they would block the capillaries. Bubbles forming in the lungs trigger
changes in the body's clotting mechanism which could result in minute clots becoming trapped in the capillaries.

The third suggestion is that the mechanism might also be similar to that of sickle-cell disease. The pressure that
divers experience at 30 meters causes their white blood cells to become rigid just as red blood cells do during a
sickle-cell crisis. The researchers hope that clues to the cause of the obstruction will come from investigations into
the individual differences between divers. Some of the divers studied had relatively little damage even though they
had been diving for many years and done a great deal of deep diving. On the other hand, a few inexperienced
divers had quite extensive damage.

Text 1: Questions 7-14

7. According to the article, _____

A. low blood pressure can cause eye problems in divers.

B. diving is becoming more and more dangerous.

C. eyes can be severely harmed as a result of diving.

D. many divers experience approximately 50% vision loss.

8. The study suggests that ______

A. divers should have at least two years of experience..

B. experienced divers can avoid the risk of eye damage.

C. professional divers are more careful than amateur divers.

D. none of the above.

9. Damage to the retina is caused by ______

A. obstructions to blood circulation.

B. loss of pigment in the epithelium.

C. pressure on the central nervous system.

D. all of the above.

10. Approximately 5 per cent of professional divers ______

A. develop bone necrosis.

B. have annual bone x-rays.

C. get the 'bends'.

D. are nervous when diving.

11. All of the following were used by doctors to examine the health of practicing divers except _____

A. nuclear magnetic resonance imaging.

B. post-mortem examinations.

C. memory tests and reaction tests.

D. neurological examinations.

12. Which of the following statements is true according to the article?

A. Small dead patches always develop in divers' bones.

B. Brain damage is common among North Sea divers.

C. Neurological problems may not be immediately apparent.

D. Spinal cord damage in divers is easily detected.

13. Which of the following is not true according to the article?

A. Sickle-cell anemia is a common disease among divers.

B. Neurological and bone tissue damage are similar.

C. Tissue damage of divers results from blockage of blood.

D. Researchers avoided the use of surgery in their investigations.

14. Retinal angiography ______

A. involves the injection of fluoroscein dye into the pupil.

B. provides graphic information about blood supply to retinas.

C. causes considerable discomfort to the patient.

D. none of the above.

Text 2: Plumbism

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

Paragraph 2
A naturally occurring element, lead may be dispersed by natural processes such as erosion, volcanic eruptions and
forest fires. Overwhelmingly, however, hazardous human exposure to lead is due to its release into the
environment through industrial processes, and to the widespread use of lead-containing products, most
notoriously petrol, paints, and plumbing and building materials. Many everyday household items including
adhesives, batteries, ceramics, glassware and children's toys may also contain lead, particularly if manufactured in
the twentieth century. Other items that have traditionally contained lead include bullets and radiation shields.
Industrial sources of lead contamination of soil, water and air include mining and smelting of lead and lead-
containing ore, car manufacture and combustion of large quantities of fuels such as coal in the generation of
electricity. The leading cause of lead poisoning among adults is occupational exposure, particularly for those
working in the industries previously mentioned.
Paragraph 3
To alleviate the incidence of environmental exposure due to contact with building materials and other products
containing lead, industry guidelines and government legislation have been introduced in many countries: drinking
water is no longer prone to lead contamination where alternatives to lead pipes and lead-soldered fittings, roofs
and water tanks are required in new houses; maximum allowable lead content in domestic paint is now specified in
a growing number of jurisdictions; and the last two decades or so have seen leaded petrol banned in most
countries around the world. However, exposure to lead particles is still a significant health risk due to the lingering
contamination of soil and dust from past fuel emissions, from continuing industrial exposure, and from contact
with older lead-based products still in use.

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

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

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

Text 2: Questions 15-22

15. Based on the first paragraph, lead _____

A. is excreted completely from the human body.

B. accumulates mainly in the lungs and intestines.

C. can be taken into the body through the skin.

D. moves about the body via blood circulation.

16. Which is the most likely source of lead poisoning in humans?

A. Exposure in the workplace.

B. A contaminated water supply.

C. Common household items.

D. Medical imaging procedures.

17. Legislation in many countries has resulted in _____

A. lead pipes being replaced in all housing.

B. petrol being produced without added lead.

C. the use of leaded paint being made illegal.

D. drinking water being guaranteed lead free.

18. The third paragraph describes _____

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

B. the elimination of lead contamination in some countries.

C. twenty years of legislation restricting the use of lead.

D. difficulties in removing lead from construction sites.

19. The effects of lead in a person's body _____

A. are not easy to observe.

B. cannot be reversed.
C. sometimes cause death.

D. depend on several factors.

20. The preferred method for measuring lead levels in the body depends on _____

A. how old the person is.

B. how sick the person is.

C. how intense the exposure was.

D. how long ago the exposure was.

21. Young children are at greater risk of lead poisoning than adults due to _____

A. the continuing presence of lead in children's toys.

B. their more frequent exposure to contaminated materials.

C. a higher capacity for lead absorption into their bodies.

D. the increased retention of lead in developing brains.

22. In sixth paragraph research links a fall in incidents of violent crime to _____

A. environmental changes during the 1990s.

B. reduced exposure to lead in the workplace.

C. behavioral changes from lead poisoning.

D. the widespread use of unleaded petrol.

READING SUB-TEST – QUESTION PAPER: PART A

Survey On Skin-Lightening Creams: Texts

Text A

A British Skin Foundation survey found that fifteen per cent of dermatologists believe lightening creams are
'completely unsafe' and four in five feel they are only safe when prescribed by a dermatologist. "Many skin-
lightening creams contain illegal compounds that can damage your health," says Indy Rihal of the British Skin
Foundation. "The most common compounds are high-dose steroids." Although steroids can be useful in treating
some skin diseases, such as psoriasis and eczema, this must take place under the supervision of a skin specialist.
"Unmonitored use of high-dose steroids can lead to many problems," says RihaI. If you've used a skin-lightening
cream and are worried about the effect it has had, see a G P. "Medically approved preparations prescribed by a
GP or a dermatologist are not dangerous, within reason," says Rihal. A cream that you buy over the counter is not
necessarily medically approved and could permanently damage your skin.

Text B

The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal

Many women of childbearing age from sub-Saharan Africa use topical skin lighteners, some of which present a
risk of toxic systemic effects. The goals of this study were to evaluate, in this environment, the frequency of this
practice during pregnancy, as well as eventual consequences on pregnancy. Ninety nine women from 6 to 9
months pregnant were randomly selected among those attending a standard maternal centre in Dakar for a
prenatal visit. Investigations consisted of questions about the use of skin lighteners, a standard clinical
examination, follow-up until delivery and a morning blood sample for plasma cortisol levels. Sixty-eight of the 99
selected women used skin lighteners during their current pregnancy, the main active ingredients being
hydroquinone and highly potent steroids (used by 44 and 24 women, respectively). No difference in the main
outcomes of pregnancy were found between skin lightener users and the others; however, women using highly
potent steroids, when compared with those who did not, had a statistically significant lower plasma cortisol level
and a smaller placenta, and presented a higher rate of low-birth-weight infants. Skin lightening is a common
practice during pregnancy in Dakar, and the use of steroids may result in consequences in the mother and her
child.

Text C

Tanning: Biological and Health Effects

Tanning is the skin's response to ultraviolet (UV) radiation, a type of light exposure. As skin cells are exposed to
UV radiation, they produce a brown pigment (melanin) to protect themselves from further UV exposure. This
results in a darkening of the skin (tanning), which is the body's natural defense mechanism and attempt to
prevent further damage from UV radiation. Sunlight and artificial tanning methods, such as tanning booths or
salons, are sources of UV exposure. Sufficient amounts of UV exposure are known to cause adverse health effects
in humans and are a public health concern. Tanning and burning play a role in health effects, including skin
cancer. UV radiation damage to DNA in skin cells can result in mutations that promote or cause cancer, and
recurring UV exposures may result in aging (wrinkles, loss of elasticity, and sun spots). Other short-term effects
on skin are sunburns, fragility, and scarring. Cataracts are a known health effect from UV radiation exposure and
eye protection is essential when tanning.

Text D

Banned Sunbeds

Unsupervised sunbeds have "no redeeming features", says Wales' chief medical officer. Dr Tony Jewell spoke as
the facilities are being banned in Wales: laws to clamp down on sunbed use are extended. From Monday,
businesses with unstaffed coin-operated sunbeds could be fined £5,000. Welsh cancer charity Tenovus said the
ban was important as skin cancer is the most common cancer in 15 to 24-year-olds in the UK, and south Wales
has one of the highest incidences in the country. "Skin cancer incidence is very strongly linked to over-exposure to
ultra-violet radiation through sunbeds, levels of which can be six times stronger than the Australian midday sun,"
said Tenovus head of research Dr Ian Lewis. "Wales alone has 500 cases of malignant melanoma a year, the most
dangerous and potentially fatal form of skin cancer, resulting in nearly 100 deaths annually. "The rise in incidence
of this type of skin cancer is truly alarming; between 2006 and 2016, Wales saw the rate of malignant melanoma
in men and women double."

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

Part A

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper or the Text Booklet until you are told to do so.
Write your answers on the spaces provided on this Question Paper.
You must answer the questions within the 15-minute time limit.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the 15 minutes, hand in this Question Paper and the Text Booklet.
DO NOT remove OET material from the test room.

TIME: 15 minutes

•Look at the four texts, A-D, in the separate Text Booklet.

•For each question, 1-20, look through the texts, A-D, to find the relevant information.
•Write your answers on the spaces provided in this Question Paper.
•Answer all the questions within the 15-minute time limit.
•Your answers should be correctly spelt.

Survey On Skin-Lightening Creams: Questions

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 contents of skin lightening creams?

____________

2 . the risks of over-exposure to UV radiation?

____________

3 . the sources of ultra-violet exposure?

____________

4 . who use topical skin lighteners?

____________

5 . reason for increase in rate of malignant melanoma?

____________

6 . the risks of repeated UV exposures?

____________

7 . the usual practice during pregnancy?

____________

Questions 8-15

Answer each of the questions, 8-15, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.

8 . Which kind of skin lighteners are used by women in sub-Saharan Africa?

____________

9 . What type of sunbeds are subjected to penalties in Wales?

____________

10 . How many death cases of malignant melanoma were reported annually in Wales?
____________

11 . Which is the common eye disease related to damage from UV radiation exposure?
____________

12 . What was the main active ingredient in the skin lighteners used by majority of women in Dakar?
____________

13 . What are the most common sources of UV exposure other than sunlight?
____________

14 . Which skin cell pigment offers guard against UV exposure?

____________
15 . Which type of UV exposures could accelerate the aging processes?
____________

Questions 16-20

Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.

16 . ____________________________ are proven to be effective in the treatment of some dermal conditions.

17 . The soaring prevalence of ____________________________ is genuinely appalling.

18 . Darkening of the skin plays a role in ____________________________, including skin cancer.

19 . Women who used ____________________________ had comparatively small placenta.

20 . ____________________________ is vital when the skin is darkened.

END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED

READING SUB-TEST – QUESTION PAPER: PARTS B & C

TIME: 45 MINUTES

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper until you are told to do so.
One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
At the end of the test, hand in this Question Paper.
DO NOT remove OET material from the test room.

HOW TO ANSWER THE QUESTIONS:

Mark your answers on this Question Paper by filling in the circle using a 2B pencil.

Part B

In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6,
choose the answer (A, B or C) which you think fits best according to the text.

1. As explained in the extract, material standards are

A. absolutely helpful to inform a risk assessment.

B. insufficient to find biocompatibility risks.

C. used to find the biocompatibility evaluation.

Medical device standards

Standards specific to a particular device type or material may be helpful to inform a risk assessment; however,
the extent to which the standard could be utilized may be dependent on the specificity of the standard and/or
the specific material. Ideally, a standard would have sufficient specificity to provide useful information regarding
material risks. For example, standards that outline both mechanical and chemical properties of a device type with
pass/fail criteria may be particularly informative because of the specificity of such a standard. Standards that
address bulk material composition can also be informative as a starting point for incorporating material
characterization into a risk assessment. For example, it may be appropriate to use material standards to support
the biocompatibility evaluation of stainless steel surgical vascular clamps, as long as any risks associated with
manufacturing are appropriately considered and mitigated. Given the effects that manufacturing and processing
may have on a polymer as incorporated into the final finished medical device, use of material standards may not
be sufficient to identify biocompatibility risks for devices made from polymers.

2. The results of the studies described in the memo may explain why the relationship between

A. enough RN staffing and lower hospital related morbidity.

B. nurse patient ratios interpret gastrointestinal bleeding.

C. RN staffing for post- surgical patients and pulmonary compromise.

Failure To Rescue

The number of patients a Registered Nurse (RN) cares for can directly and indirectly impact patient safety during
their hospitalization. “Safety” in this case refers to infection rates, patient falls, hospital-acquired pressure ulcers,
and even death. Multiple studies using different methodology and from a variety of disciplines consistently show
associations between adequate RN staffing and lower hospital related morbidity, mortality and adverse patient
events. RN staffing levels for post- surgical patients have been shown to have an inverse relationship with urinary
tract infections, pneumonia, thrombosis and pulmonary compromise; in medical patients, higher nurse patient
ratios translated into a reduction in gastrointestinal bleeding, shortened length of stay, and lower rates of ‘failure
to rescue’. Failure to rescue is the term used when early warning signs of upper gastrointestinal bleeding, sepsis,
deep venous thrombosis, shock or cardiac arrest are not detected and acted upon.

3. What is the most recommended implantation testing?

A. clinically relevant implantation study.

B. in vivo animal study.

C. toxicology implantation study

Implantation

For implantation testing, if there are characteristics of the device geometry that may confound interpretation of
this test, it may be acceptable to use device sub-components or coupons instead of the device in its final finished
form, with appropriate justification. For example, it may be acceptable to use a coupon instead of a stent, if
information is provided to demonstrate that the manufacturing and resulting surface properties are comparable.
Instead of a traditional toxicology implantation study in subcutaneous, muscle, or bone tissues, a clinically
relevant implantation assessment may be more appropriate for certain implant devices with relatively high safety
risks. Clinically relevant implantation studies are critical to determine the systemic and local tissue responses to
the implant in a relevant anatomical environment under simulated clinical conditions. In some cases, the toxicity
outcomes that would be obtained from a clinically relevant implantation study can be assessed as part of in vivo
animal studies that are performed to assess overall device safety.

4. The term ‘mass immunizer’ refers to a

A. Medicare-enrolled provider offering either influenza vaccinations or pneumococcal vaccinations

B. traditional Medicare provider offering neither influenza vaccinations nor pneumococcal vaccinations

C. non-traditional provider offering influenza vaccinations, pneumococcal vaccinations, or both

Mass Immunization Providers

To increase vaccination availability to Medicare beneficiaries, the Centers for Medicare & Medicaid Services
(CMS) created the mass immunizer program and simplified the influenza and pneumococcal vaccination claims
process by creating roster billing for mass immunizers. CMS defines a ‘mass immunizer’ as a Medicare-enrolled
provider offering influenza vaccinations, pneumococcal vaccinations, or both to a group of individuals (e.g., the
public, senior center participants, retirement community or retirement housing residents).

A mass immunizer can be either:

• A traditional Medicare provider or supplier, such as a hospital outpatient department; or
• A non-traditional provider that is usually ineligible to enroll in the Medicare Program, such as a supermarket,
senior citizen home, public health clinic or an individual practitioner.
5. The guidelines inform us that device materials should not

A. cause any exposure to the body.

B. have benefits that outweigh any potential risks.

C. have any potential risks that outweigh benefits

Evaluation of Local and Systemic Risks

Biological evaluation of medical devices is performed to determine the acceptability of any potential adverse
biological response resulting from contact of the component materials of the device with the body. The device
materials should not, either directly or through the release of their material constituents: (i) produce adverse
local or systemic effects; (ii) be carcinogenic; or (iii) produce adverse reproductive and/or developmental effects,
unless it can be determined that the benefits of the use of that material outweigh the risks associated with an
adverse biological response. Therefore, evaluation of any new device intended for human use requires
information from a systematic analysis to ensure that the benefits provided by the device in its final finished form
will outweigh any potential risks produced by device materials over the intended duration and use of the device
in or on the exposed tissues. When selecting the appropriate endpoints for biological evaluation of a medical
device, one should consider the chemical characteristics of the device materials and the nature, degree,
frequency, and duration of exposure to the body.

6. What point does the extract make about designated nursing units?

A. have a team of nurses, mental health technician and behavioral counselor.

B. have specially trained nurses for work exclusively using different strategies.

C. a place where medically stabilized behavioral health patients seeking care are placed.

Behavioral Health Response Plan

A robust Behavioral Health Response Plan has been established to support staff and patients for the growing
number of behavioral health patients seeking care. When patients are medically stabilized, up to 11 patients may
be cohorted in a specially designed unit to promote patient and staff safety while patients await placement at
behavioral health specialized facilities. For patients who require medical treatment, whenever possible they are
placed on designated nursing units. Nurses working on these units have received special training and are adept at
various communication techniques and strategies. This specialized unit team also consists of a mental health
technician and a behavioral counselor.
Part C

In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the
answer (A, B, C or D) which you think fits best according to the text.

Text 1: Birth Control Pill and Sexual Problems

In the January issue of The Journal of Sexual Medicine, researchers have published a new investigation measuring
sex hormone binding globulin (SHBG) before and after discontinuation of the oral contraceptive pill. The research
concluded that women who used the oral contraceptive pill may be exposed to long-term problems from low
values of "unbound" testosterone potentially leading to continuing sexual, metabolic, and mental health
consequences. Sex hormone binding globulin (SHBG) is the protein that binds testosterone, rendering it
unavailable for a woman's physiologic needs. The study showed that in women with sexual dysfunction, elevated
SHBG in "Oral Contraceptive Discontinued-Users" did not decrease to values consistent with those of "Never-Users
of Oral Contraceptive". Thus, as a consequence of the chronic elevation in sex hormone binding globulin levels, pill
users may be at risk for long-standing health problems, including sexual dysfunction.

Oral contraceptives have been the preferred method of birth control because of their ease of use and high rate of
effectiveness. However, in some women oral contraceptives have ironically been associated with women's sexual
health problems and testosterone hormonal problems. Now there are data that oral contraceptive pills may have
lasting adverse effects on the hormone testosterone. The research, in an article entitled: "Impact of Oral
Contraceptives on Sex Hormone Binding Globulin and Androgen Levels: A Retrospective Study in Women with
Sexual Dysfunction" published in The Journal of Sexual Medicine, involved 124 premenopausal women with sexual
health complaints for more than 6 months. Three groups of women were defined: i) 62 "Oral Contraceptive
Continued-Users" had been on oral contraceptives for more than 6 months and continued taking them, ii) 39 "Oral
Contraceptive Discontinued-Users" had been on oral contraceptives for more than 6 months and discontinued
them, and iii) 23 "Never-Users of Oral Contraceptives" had never taken oral contraceptives. SHBG values were
compared at baseline (groups i, ii and iii), while on the oral contraceptive (groups i and ii), and well beyond the 7
day half-life of sex hormone binding globulin at 49-120 (mean 80) days and more than 120 (mean 196) days after
discontinuation of oral contraceptives (group ii).

The researchers concluded that SHBG values in the "Oral Contraceptive Continued-Users" were 4 times higher than
those in the "Never-Users of Oral Contraceptives". Despite a decrease in SHBG values after discontinuation of oral
contraceptive pill use, SHBG levels in "Oral Contraceptive Discontinued-Users" remained elevated when compared
to "Never-Users of Oral Contraceptives". This led to the question of whether prolonged exposure to the synthetic
estrogens of oral contraceptives induces gene imprinting and increased gene expression of SHBG in the liver in
some women who have used the oral contraceptives. Dr. Claudia Panzer, an endocrinologist in Denver, CO and
lead author of the study, noted that "it is important for physicians prescribing oral contraceptives to point out to
their patients potential sexual side effects, such as decreased desire, arousal, decreased lubrication and increased
sexual pain. Also if women present with these complaints, it is crucial to recognize the link between sexual
dysfunction and the oral contraceptive and not to attribute these complaints solely to psychological causes."

"An interesting observation was that the use of oral contraceptives led to changes in the synthesis of SHBG which
were not completely reversible in our time frame of observation. This can lead to lower levels of 'unbound'
testosterone, which is thought to play a major role in female sexual health. It would be important to conduct long-
term studies to see if these increased SHBG changes are permanent," added Dr. Panzer. Dr. Andre Guay, study co-
author and Director of the Center for Sexual Function/Endocrinology in Peabody, MA affirmed that this study is a
revelation and that the results have been remarkable. "For years we have known that a subset of women using
oral contraceptive agents suffer from decreased sex drive," states Dr. Guay. "We know that the birth control pill
suppresses both ovulation and also the male hormones that the ovaries make in larger amounts during the middle
third of the menstrual cycle. SHBG binds the testosterone, therefore, these pills decrease a woman's male
hormone availability by two separate mechanisms. No wonder so many women have had symptoms."

"This work is the culmination of 7 years of observational research in which we noted in our practice many women
with sexual dysfunction who had used the oral contraceptive but whose sexual and hormonal problems persisted
despite stopping the birth control pill," said Dr. Irwin Goldstein, a urologist and senior author of the research.
"There are approximately 100 million women worldwide who currently use oral contraceptives, so it is obvious
that more extensive research investigations are needed. The oral contraceptive has been around for over 40 years,
but no one had previously looked at the long-term effects of SHBG in these women. The larger problem is that
there have been limited research efforts in women's sexual health problems in contrast to investigatory efforts in
other areas of women's health or even in male sexual dysfunction." To better appreciate the scope of the problem,
oral contraceptives were introduced in the USA in 1960 and are currently used for reversible pharmacologic birth
control by over 10 million women in the US, including 80% of all American women born since 1945 and, more
specifically, 27% of women ages 15-44 and 53% of women age 20-24 years. By providing a potent synthetic
estrogen (ethinyl estradiol) and a potent synthetic progesterone (for example, norethindrone), highly effective
contraception is achieved by diminishing the levels of FSH and LH, thereby reducing metabolic activity of the ovary
including the suppression of ovulation.

Several studies over the last 30 years reported negative effects of oral contraceptives on sexual function, including
diminished sexual interest and arousal, suppression of female initiated sexual activity, decreased frequency of
sexual intercourse and sexual enjoyment. Androgens such as testosterone are important modulators of sexual
function. Oral contraceptives decrease circulating levels of androgens by direct inhibition of androgen production
in the ovaries and by a marked increase in the hepatic synthesis of sex hormone binding globulin, the major
binding protein for gonadal steroids in the circulation. The combination of these two mechanisms leads to low
circulating levels of "unbound" or "free" testosterone.

Text 1: Questions 7-14

7. Which statement is the most accurate summary of the method of the study?

A. Levels of SHBG were monitored over a period of time in women who were using the pill.

B. Levels of SHBG were measured in women using pill and women who had stopped using pill, and these were
compared to women who had never used pill.

C. Levels of SHBG were compared in women who were using the pill, women who had stopped using the pill, and
women who had never used the pill.

D. Medical complications were compared between women using the pill and those who had stopped using the pill.

8. What is the role of SHBG?

A. To prevent sexual dysfunction in human females..

B. To prevent testosterone from being used in the female body.

C. To prevent women from needing to take traditional contraceptive pills.

D. To prevent oncological complications.

9. Which group had the highest level of unbound testosterone?

A. Women with a genetic predisposition for higher testosterone levels.

B. Women who had never taken the pill.

C. Women who had previously taken the pill but since stopped.

D. Women who were taking the pill during the study.

10. Which of the following reasons is given in the study for popularity of oral contraceptive pill?

A. Less interference with sexual routine than other contraceptives.

B. High percentage of contraceptive success.

C. Favorable aesthetic effects on women’s physiques due to reduced testosterone.

D. Low cost.

11. Which is the most accurate description of the study discussed in the article?

A. It involved one hundred and twenty four pre-pubescent girls.

B. It involved 124 premenstrual women who had sexual health issues for 6 months or more.

C. SHBG levels were monitored at different times in three groups of adult women with various status regarding
contraceptive pill usage.

D. SHBG levels were compared at regular intervals in each of three groups of women who had different status
regarding contraceptive pill usage.

12. Levels of SHBG decreased in women who had stopped using the contraceptive pill ______

A. due to increased gene expression of SHBG in the livers of these women.

B. in spite of lengthened exposure to artificial estrogen found in pills.

C. because of psychological factors associated with taking the pill.

D. but their levels remained elevated compared to women who had never used pill.

13. Which of the following is an opinion of Dr. Panzer?

A. SHBG levels remained higher in women who discontinued pill use for the duration of the study.

B. The use of oral contraceptives led to changes in SHBG levels which were not reversible within the timeframe of
the study.

C. Physicians usually mention the sexual side effects of the pill to their patients.

D. Further studies should determine whether SHBG levels ultimately return to normal over longer periods.

14. Which of the following statements has the same meaning as a statement in the text?

A. The contraceptive pill was invented in the USA in 1960.

B. The pill has been used by over 100 million women globally.

C. Dr. Goldstein monitored women with a history of pill use and sexual dysfunction in his clinic for seven years.

D. Lower levels of unbound testosterone is a result of both higher SHBG and accelerated metabolism in the
ovaries.

Text 2: Bovine Spongiform Encephalopathy

Vets at the Ministry of Agriculture have identified a new disease in cows that is causing dairy farmers some
consternation. The fatal disease, which they have called bovine spongiform encephalopathy, causes degeneration
of the brain. Afflicted cows eventually become uncoordinated and difficult to handle. The first case was reported in
1985. Now there are 92 suspected cases in 53 herds, mostly in the south of England. So far 21 cases in 18 herds
have been confirmed. All are Friesian/Holstein dairy animals. Gerald Wells and his colleagues at the Central
Veterinary Laboratory in Weybridge, Surrey, describe the symptoms and pathology in the current issue of The
Veterinary Record. No one yet knows the cause of the disease but there are some similarities with a group of
neurological diseases caused by the so called "unconventional slow viruses".

This group of progressive diseases includes scrapie in sheep and goats, chronic wasting disease in mule deer and
transmissible mink encephalopathy. In humans Kuru and Creutzfeldt-Jakob disease, both fatal neurological
diseases, come into the same category. The precise nature of the agents causing this group of diseases is a matter
of intense debate but all are infectious. Like scrapie and the other diseases, bovine spongiform encephalopathy is
insidious and progressive. A farmer is unlikely to suspect that a cow has the disease until it has almost run its
course. Previously healthy animals become highly sensitive to normal stimuli, they grow apprehensive and their
movements uncoordinated. In the final stages the cows may be frenzied and unpredictable and have to be
slaughtered. At autopsy, Wells and his colleagues found that some areas of the brain were full of holes, giving it a
spongy appearance. The pattern of holes shows some similarity with that in the other unconventional
encephalopathies.

In all these diseases an important diagnostic feature is the presence of proteinaceous fibrils seen in brain extracts
in the electron microscope. No one knows for certain what the fibrils are – whether they are the agents of the
disease, a type of subviral particle, as some researchers suggest, or are a product of the disease. The veterinary
researchers analyzed the brain tissue from cows that died from the disease and found similar fibrils. Brain tissue
from healthy cows did not contain fibrils. At the moment researchers at the Central Veterinary Laboratory are
keeping an open mind on the cause of the disease. If it is not a scrapie-like agent it might be something to do with
the genetics of Friesian cows. Another suggestion is that contaminated food might be to blame. "It is too early to
come to conclusions," said a spokesman at the Ministry of Agriculture. "It might be caused by toxic products, or
food, or it might be genetic."

According to Richard Kimberlin, of the AFRC/MRC Neuropathogenesis Unit in Edinburgh: "The similarities are
enough to make us think that it's in the scrapie family, but without evidence of transmission it's impossible to say
anything more certain". Scientists at the Neuropathogenesis Unit will look for evidence of transmission in
experiments on mice, while Wells and his colleagues try to transmit the disease in cows. It will take at least two
years of experiments before transmission can be proved. What is certain is that the number of reported cases is
increasing rapidly. Not all reports will turn out to be bovine spongiform encephalopathy. Farmers and vets might
just be getting better at recognizing symptoms. In the past farmers probably got rid of nutty middle-aged cows
without thinking too much about it. If the disease turns out to be transmissible then it might spread to other
breeds of cows. Many countries ban the import of sheep from areas where scrapie occurs.

In the US, consumer rights groups won a ban on the purchase of meat from scrapie flocks because no one could
rule out absolutely the possibility of transmission to humans. If bovine spongiform encephalopathy turns out to be
infectious, it could cause problems out of proportion to the number of cases. Vacuoles in the brain prevent the
passage of nerve impulses (left). Fibrils in brain tissue resemble those that are diagnostic of scrapie.

Text 2: Questions 15-22

15. Bovine spongiform encephalopathy is a disease which is currently found in _____

A. all dairy cows.

B. some beef cows.

C. beef and dairy cows.

D. Freisian/Holstein dairy cows.

16. When bovine spongiform encephalopathy is confirmed in cows, which of the following symptoms do they not
exhibit?
A. chronic wasting.

B. ungainly action.

C. frantic and agitated behavior.

D. sensitivity to usual stimuli.

17. Bovine spongiform encephalopathy is similar to other neurological diseases caused by 'unconventional slow
viruses', which ______

A. is transmitted rapidly.

B. develops inconspicuously.

C. is caused by the same agents.

D. can be treated when detected early.

18. Pathology tests conducted on brains of cows which died of bovine spongiform encephalopathy show the
presence of

A. fibrils which cause the disease.

B. fibrils which are caused by the disease.

C. fibrils which are also found in other animals infected with unconventional encephalopathies.

D. fibrils similar to those found in healthy cows.

19. Which of the following is not being considered as a cause of bovine spongiform encephalopathy?

A. the intake of contaminated food.

B. a genetic deficiency peculiar to Freisian cows.

C. parasite-produced vacuoles in the brain.

D. exposure to toxic products.

20. Bovine spongiform encephalopathy in cows appears similar to scrapie in sheep because _____
A. it is transmitted in a similar way.

B. the fibrils in diseased brains are similar.

C. it occurs in animals of a similar age.

D. of the rate at which the disease is transmitted.

21. Vets in Surrey are conducting experiments which will attempt to _____

A. infect healthy mice with bovine spongiform encephalopathy.

B. infect healthy sheep with bovine spongiform encephalopathy.

C. infect healthy humans through milk from bovine spongiform encephalopathy infected cows.

D. infect healthy cows with bovine spongiform encephalopathy.

22. The purchase of meat from scrapie infected flocks is banned in some countries because ______

A. the disease may then be transmitted to humans.

B. the disease will then be transmitted to humans.

C. it may lead to the spread of scrapie to other sheep.

D. it will lead to the spread of scrapie to other sheep.