TIME: 45 MINUTES

INSTRUCTIONS TO CANDIDATES:

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.

Anaesthetic Machines
The anaesthetic machine (or anaesthesia machine in America) is used by anaesthesiologists and
nurse anaesthetists to support the administration of anaesthesia. The most common type of
anaesthetic machine is the continuous-flow anaesthetic machine, which is designed to provide an
accurate and continuous supply of medical gases (such as oxygen and nitrous oxide), mixed with
an accurate concentration of anaesthetic vapour (such as halothane or isoflurane), and deliver this
to the patient at a safe pressure and flow. Modern machines incorporate a ventilator, suction unit,
and patient monitoring devices.

1. The manual is giving information about

A. how to use anaesthetic machines
B. types of anaesthetic machines
C. an overview of anaesthetic machines

Autoclaves and Sterilizers

Sterilization is the killing of microorganisms that could harm patients. It can be done by heat
(steam, air, flame or boiling) or by chemical means. Autoclaves use high pressure steam and
sterilizers use boiling water mixed with chemicals to achieve this. Materials are placed inside the
unit for a carefully specified length of time. Autoclaves achieve better sterilization than boiling
water sterilizers. Heat is delivered to water either by electricity or flame. This generates high
temperature within the chamber. The autoclave also contains high pressure when in use, hence
the need for pressure control valves and safety valves. Users must be careful to check how long
items need to be kept at the temperature reached.

2. Why autoclaves are better than boiling water sterilizers?

A. Heat is transferred to water by electricity or flame
B. Autoclaves use high pressure steam
C. Autoclaves generates high temperature within the chamber

ECG: How it works

The electrical activity is picked up by means of electrodes placed on the skin. The signal is
amplified, processed if necessary and then ECG tracings displayed and printed. Some ECG
machines also provide preliminary interpretation of ECG recordings. There are 12 different types
of recording displayed depending upon the points from where the recordings are taken.
Care must be taken to make the electrode sites clean of dirt before applying electrode jelly. Most
problems occur with the patient cables or electrodes.

3. The guidelines establish that the healthcare professional should

A. aim to make patients fully aware of how ECG works.
B. carefully clean the electrode sites.
C. respect the wishes of the patient above all else.

Benefits of electronic health records

EHR systems are complex applications which have demonstrated benefits. Their complexity
makes it imperative to have good application design, training, and implementation. Studies have
evaluated EHR systems and reported on various benefits and limitations of these systems.
Benefits included increase in immunization rates, improved data collection, increased staff
productivity, increased visitor satisfaction with services, improved communication, quality of
care, access to data, reduced medical errors, and more efficient use of staff time. Some of the
disadvantages noted were: time consuming data entry, slow access of data and decreased quality
of patient doctor interaction.

4. The notice is giving information about

A. pros and cons of electronic health records
B. necessity of electronic health records
C. demonstrated benefits of electronic health records

mHealth
The use of mobile technologies for data collection about individuals and interactive information
services are a part of a growing area of eHealth called mHealth. The GOe published a volume on
this subject in 2011 which documents the uptake of mHealth worldwide by types of initiatives
and main barriers to scale. Mobile technologies are emerging as a powerful tool for health
information transfer including making patient information portable. Such technologies can be
more fully utilized through electronic patient information such as EMRs and EHRs. Electronic
records will work best, however, if there are standards in place for their use and interoperability.

5. The note tells us that the mHealth

A. is a published volume on the GOe
B. is a powerful tool for information transfer
C. makes patient information portable

Systematized Nomenclature of Medicine (SNOMED)

SNOMED was designed to provide a comprehensive nomenclature of clinical medicine for the
purpose of describing records of clinical care in human medicine. It is a multi-axial and
hierarchical classification system. It is multiaxial in that any given clinical condition can be
described through multiple axes such as topography (anatomy), morphology, organisms such as
bacteria and viruses, chemicals such as drugs, function (signs and symptoms), occupation,
diagnosis, procedure, physical agents or activities, social context, and syntactic linkages and
qualifiers. SNOMED is hierarchical in that each of the axes has a hierarchical tree that proceeds
from general terms to more specific ones. For example, topography (anatomic) terms are first
divided into major organs such as lung, heart, and then into the smaller components of each.

6. What does this extract from a handbook tell us about Systematized Nomenclature of
Medicine?
A. is a multi-axial and hierarchical classification system
B. is a comprehensive nomenclature of trial medicines
C. is used to described any clinical condition through axis

All life is connected Cancer in Humans and Wildlife WILDLIFE—HUMAN LINKS

Paragraph 1
It may be that biologists, rather than physicians, will be the major contributors to the health of
our wildlife caused by the combined action of pesticides planet and its people. It was Rachel
Carson, a biologist, who researched and wrote of the harm to wildlife caused by the combined
action of pesticides and radiation. In the tradition of the observant biologist is Theo Colborn,
who, with her colleagues, provided a significant breakthrough in understanding the hormonal
effects of environmental contaminants. In July 1991, a gathering of some of the world’s most
astute, - scientists were held at the Wingspread Conference Center in Wisconsin, where they
defined the pattern of diverse endocrine malfunction seen throughout the animal kingdom. They
revealed a picture of the Brave New World we should rigorously seek not to leave as a legacy to
our children.

Paragraph 2
The conferees, studying wildlife over the globe, described ominous findings of disease and
linked to environmental pollution. Exposure to toxic chemicals that possess unintended h actions
has resulted in anatomic, physiologic, reproductive, carcinogenic, and behavioral abnormalities
across all forms of animal life: in mollusks, fish, birds, seals, and rodents. We humans as
canaries were to the miners. We must understand that the destruction of eons of evolutionary
function and development in wildlife foreshadows destruction of the entire biosphere, humans
included.

Paragraph 3
These widespread adverse effects were attributed to xenoestrogens. Xeno comes from a Greek
origin, meaning “foreign.” Foreign itself is not bad: how else do we share and spread culture and
ideas? But xenoestrogens are less foreigners than invaders, gaining entrance by the Trojan horse
of seemingly harmless routes: milk, meat, cheese, fish, the products we use to nourish ourselves
and families. Like the invaders of Troy, after the xenoestrogens gain entrance to the bodies of
animals and humans alike, they weaken defenses and wreak their harm of cancer, hormonal
disruption, immunological abnormalities, and birth defects.

Paragraph 4
Xenoestrogens are an insidious enemy, but they have had help from powerful allies: the
purveyors of products and chemicals, and legislators, regulators, and scientists reluctant to bite
the money- laden hands that feed them.
Wingspread researchers found that birds exposed to xenoestrogens show reproductive failure,
growth retardation, life-threatening deformities, and alterations in their brains and liver
functions.” There is direct experimental evidence for permanent [organizational] effects of
gonadal steroids on the brain as well as reproductive organs throughout life. This means that
offspring whose brains have been altered are unable to function as had their parents. They
become different in ability or function.
Paragraph 5
This means that the sea of hormonally active chemicals in which the fetus develops may change
forever the health and function of the adult, and in some cases, may alter the course of an entire
species. Worldwide there are reports of declining sperm counts and reduced ratio in births of
male babies. Without the capacity to reproduce, a species ceases to exist. Extinction is forever; a
species loss has never been reversed.

Paragraph 6
The data derived from animal observations are unequivocal: breast and genital cancers,
abnormalities, interference with sexual development, and changes in reproductive behavior all
expressions of a root cause. A possible connection between women with breast cancer and those
having children with reversed sexual orientation is a question that bears study. from science
fiction, considering what we have learned from observing wildlife and the effects inappropriate
hormonal influence upon the breast, brain, and reproductive organs. If an unequivocal answer
were to emerge from human observation, it could have a significant impact upon the prevailing
political and economic landscape, and may finally settle the nature or nu issue of sexual
orientation.

SILENT SPRING-SILENT WOMEN

Paragraph 7
Considering the accumulated knowledge linking chemical and radioactive contamination
environment with increasing breast cancer rates means we must focus our energies and
prevention. Early were the eloquent words and pleas for prevention from Rachel Carson. Her
book, Silent Spring, originally published in 1962, while she herself was suffering from breast
cancer, is still a best seller. Ms. Carson documented wholesale killing of species; animals, birds,
fish, insects; the destruction of food and shelter for wild creatures; failure of reproduction;
damage to the nervous system; tumors in wild animals; increasing rates of leukemia in children;
and chronicled the pesticides and chemicals known at that time to cause cancer. This was over 30
years ago!
Paragraph 8
Carson’s is a book for every citizen, for without understanding of our collective actions and
permissions, we cannot govern democratically. In Australia, a citizen is required to vote. In the
United States, proclaimed by some politicians as the “greatest democracy on earth,” often fewer
than 50% bother to vote in a major election. Of those who do take the time to register and vote,
few are sufficiently alert and/or educated to vote with intelligence, thought, and compassion.
Requiring participation in the governance of one’s own country is not a bad idea. Requiring
thoughtful voting may be more difficult, especially when it comes to such issues as cancer,
pesticide use, consumer products, nuclear radiation, toxic chemicals, and environmental
destruction. Taking this thought one step further; this democracy could do far worse than to
require reading of Silent Spring as a requirement to vote! Radical? Perhaps. But is the ongoing
cancer epidemic any less radical?
Paragraph 9
One successor to Ms. Carson has emerged in the person of Sandra Steingraber, an ecologist,
poet, and scientist. In her book, Living Downstream, she writes eloquently of the connections
between environmental contamination and cancer. Dr. Steingraber was diagnosed with bladder
cancer at age 20, a highly unusual diagnosis in a woman, a young woman, a nonsmoker and
nondrinker. She pursued the question, why? She realized a connection with our wild relations
and she asks: Tell me, does the St. Lawrence beluga drink too much alcohol and does the St.
Lawrence beluga smoke too much and does the St. Lawrence beluga have a bad diet. . . is that
why the beluga whales are ill? ...Do you think you are somehow immune and that it is only the
beluga whale that is being affected?

Paragraph 10
The portion of Dr. Steingraber’s book that struck me most personally was when she says: First,
even if cancer never comes back, one’s life is utterly changed. Second, in all the years I have
been under medical scrutiny, no one has ever asked me about the environmental conditions
where I grew up, even though bladder cancer in young women is highly unusual. I was once
asked if I had ever worked with dyes or had been employed in the rubber industry. (No and no.)
Other than these questions, no doctor, nurse, or technician has ever shown interest in probing the
possible causes of my disease-even when I have introduced the topic. From my conversations
with other cancers, patients, I gather that such lack of curiosity in the medical community is
usual.

Paragraph 11
I take her words as an indictment of the medical and scientific establishment, whose point of
view must be changed. Certainly, the lack of curiosity among physicians, scientists,
policymakers, and politicians has contributed to the epidemic of illness among humans and
wildlife alike. An equally talented woman is Terry Tempest Williams, an ecologist and wildlife
researcher whose book, Refuge: An Unnatural History of Family and Place, tells the story of her
Utah family, whom she “labels “a clan of one—breasted women.” Ms. Williams contrasts the
life-affirming awareness Great Salt Lake wildlife refuge against the erosion-of-being, as cancer
takes away the women in her family: her mother, her grandmothers, and six aunts. She writes: “I
cannot prove that my mother Diane Dixon Tempest, or my grandmothers, Lettie Romney Dixon
and Kathryn Blackett Tempest along with my aunts, developed cancer from nuclear fallout in
Utah. But I can’t prove that didn’t.”

Paragraph 12
Times are changing. It is becoming impossible to ignore the carnage of endocrine-disruption
chemicals, nuclear radiation, and chemical carcinogens, alone and in combination, invading
nearly every family with cancer. Facing this reality may be too much for some people, afraid to
look, or afraid of being the next victim. The story of cancer is not an easy one, and neither is
cancer. But if we do not exert our efforts to prevent this disease, we doom our children and
grandchildren to repeat our collective errors. What does it take to change from environmental
destruction and random killing to affirmation of life? Can the protection of life for ourselves and
our environment be accomplished by women with breast cancer; the women at risk for breast
cancer; the families of breast cancer victims? Who should lead? If we citizens can’t and don’t
try, what are our alternatives?

Questions 1-10
1. The author’s main contention is that
a. wildlife all around the world is being linked to environmental pollution
b. fish, birds, seals and canaries are being exposed to toxic chemicals
c. humans need to understand the link between destroying the planet’s wildlife, through
exposure to toxic chemicals, and the destruction of the entire biosphere — which includes
human life itself.
d. humans need to understand the link between destroying the planet’s wildlife, through
exposure to toxic chemicals, and behavioral abnormalities across all forms of life.

2. The author states that in an environment of “hormonally active chemicals”

a. males with higher sperm counts may result ‘
b. more male babies are born
c. lower sperm count in males may result in a particular species being wiped out ‘
d. males with more sperm count may result

3. Dr Sandra Steingraber, ecologist, poet and scientist:

 a. realized that contracting bladder cancer was not due to her alcohol drinking
b. realized her bladder cancer was not due to her smoking
c. believed her bladder cancer was due to environmental contamination
d. doctors, nurses and technicians were very interested in her unusual cancer

4. The wildlife researcher, Terry Tempest Williams, sees the dichotomy which exists in the Salt
Lake wildlife refuge area:
a. many women in her family have died from breast cancer after a nuclear fallout in Utah
b. many men in her family have died from breast cancer
c. her family have many one-breasted women — unusual for Utah
d. such wide-spread cancer is probably due to environmental, not genetic causes

5. Animal observations show:

a. changes in sexual maturity are not only due to a root cause
b. genital abnormalities may be due to a root cause
c. inappropriate hormones adversely affect the development of breast, brain and
reproductive organs
d. humans are not similarly affected.

6. The author puts forward several ideas about governance except for one of the following:
a. People who participate in elections are not alert and educated enough
b. Unless the wants and needs of the population are known, it is difficult for politicians to
govern democratically
c. People being required to vote, to participate in the decision-making process, is a good
idea
d. Reading Carson’s book, Silent Spring, should be made compulsory for all voters.

7. Rachel Carson’s book Silent Spring, written in 1962, revealed:

a. more had to be done to prevent chemical contamination of the environment
b. there was a link between pesticides, chemicals and cancer
c. chemicals were leading to an inability to reproduce leading to the eradication of entire
species of insects, birds, fish and animals
d. all of the above

8. Research about xenoestrogens reveals

a. they are everywhere
b. they are harmless
c. they are in our everyday foods
d. they are in our everyday foods and disrupt hormonal function
9. Xenoestrogens
a. lead to birth deformities
b. alters genetically inherited abilities
c. continues to be used by profiteering stakeholders
d. all of the above

10. The author asserts:

a. people need to be aware of the dangers of chemicals, radiation, carcinogens
b. tackling cancer should be embraced not shunned
c. change should not be left to only those suffering from breast cancer
d. all of the above

In this part of the test, there are two texts about different aspects of healthcare. For question
11-16 choose the answer (A, B, C or D) which you think fits best according to the text.

Does Tamiflu really work?

Paragraph 1
The British Medical Journal (BMJ) was dominated in 2009 by a cluster of articles on oseltamivir
(Tamiflu). Between them the articles conclude that the evidence that oseltamivir reduces
complications in otherwise healthy people with pandemic influenza is now uncertain and that we
need a radical change in the rules on access to trial data.

Paragraph 2
The use of meta-analysis is governed by the Cochrane review protocol. Cochrane Reviews
investigate the effects of interventions for prevention, treatment and rehabilitation in a healthcare
setting. They are designed to facilitate the choices that doctors, patients, policy makers and
others face in health care. Most Cochrane Reviews are based on randomized controlled trials, but
other types of evidence may also be taken into account, if appropriate.

Paragraph 3
If the data collected in a review are of sufficient quality and similar enough, they are summarized
statistically in a meta-analysis, which generally provides a better overall estimate of a clinical
effect than the results from individual studies. Reviews aim to be relatively easy to understand
for non-experts (although a certain amount of technical detail is always necessary). To achieve
this, Cochrane Review Groups like to work with “consumers”, for example patients, who also
contribute by pointing out issues that are important for people receiving certain interventions.
Additionally, the Cochrane Library contains glossaries to explain technical terms.

Paragraph 4
Briefly, in updating their Cochrane review, published in late 2009. Tom Jefferson and colleagues
failed to verify claims, based on an analysis of 10 drug company trials, that oseltamivir reduced
the risk of complications in healthy adults with influenza. These claims have formed a key part
of decisions to stockpile the drug and make it widely available.

Paragraph 5
Only after questions were put by the BMJ and Channel 4 News has the manufacturer Roche
committed to making “full study reports” available on a password protected site. Some questions
remain about who did what in the Roche trials, how patients were recruited, and why some
neuropsychiatric adverse events were not reported. A response from Roche was published in the
BMJ letters pages and their full point by point response is published online.

Paragraph 6
Should the BMJ be publishing the Cochrane review given that a more complete analysis of the
evidence may be possible in the next few months? Yes, because Cochrane reviews are by their
nature interim rather than definitive. They exist in the present tense, always to be superseded by
the next update. They are based on the best information available to the reviewers at the time
they complete their review. The Cochrane reviewers have told the BMJ that they will update
their review to incorporate eight unpublished Roche trials when they are provided with
individual patient data.

Paragraph 7
Where does this leave oseltamivir, on which governments around the world have spent billions
of pounds? The papers in last year’s journal relate only to its use in healthy adults with influenza.
But they say nothing about its use in patients judged to be at high risk of complications- pregnant
women, children under 5, and those with underlying medical conditions; and uncertainty over its
role in reducing complications in healthy adults still leaves it as a useful drug for reducing the
duration of symptoms. However, as Peter Doshi points out on this outcome it has yet to be
compared in head to head trials with nonsteroidal inflammatory drugs or paracetamol. And given
the drug’s known side effects, the risk-benefit profile shifts considerably if we are talking only in
terms of symptom relief.

Paragraph 8
We don’t know yet whether this episode will turn out to be a decisive battle or merely a skirmish
in the fight for greater transparency in drug evaluation. But it is a legitimate scientific concern
that data used to support important health policy strategies are held only by a commercial
organization and have not been subject to full external scrutiny and review. It can’t be right that
the public should have to rely on detective work by academics and journalists to patch together
the evidence for such a widely prescribed drug. Individual patient data from all trials of drugs
should be readily available for scientific scrutiny.

QUESTIONS 11-16
11. A cluster of articles on oseltamivir in the British Medical Journal conclude__________
a. complication is reduced in healthy people by oseltamivir
b. the efficacy of Tamiflu in now in doubt
c. complications from pandemic influenza are currently uncertain
d. a series of articles supporting Tamiflu

12. Cochrane Reviews are designed to __________

a. set randomized controlled trials to specific values
b. compile literature meta-analysis
c. peer review articles
d. influence doctor’s choice of prescription

13. According to the article, which one of the following statements about Tamiflu is FALSE?
a. The use of randomized controls is suspect
b. The efficacy of Tamiflu is certain
c. Oseltamivir induces complications in healthy people
d. Cochrane reviews are useful when examining the efficacy of Tamiflu

14. According to the article, Cochrane Review Groups __________

a. like to work for “consumers”.
b. is being overhauled.
c. use language suitable for expert to expert communication.
d. evaluate a clinical effect better than individual studies.

15. Which would make the best heading for paragraph 4?

 a. Analysis of 10 drug company trials
b. The stockpiling of Oseltamivir
c. Risk of complications in healthy adults
d. Tamiflu claims fail verification

16. According to the article, which one of the following statements about Roche is TRUE?
a. Full study reports were made freely available on the internet
b. Patients were recruited through a double-blind trial
c. The identities and roles of researcher in the Roche trials are not fully accounted for
d. Not all neuropsychiatric adverse events were reported