VOL. 1 (OET 2.0 Reading Books by Maggie Ryan)

OET 2.0READINGSUB-TEST

EXERCISES& ANSWER KEY

All rights reserved. No part of this book shall bereproduced, stored in a retrieval system, or transmittedby any means, electronic, mechanical, photocopying,recording, or otherwise, without written permission

from the publisher, No patent liability is assumed withrespect to the use of the information contained herein,

Although every precaution has been taken in thepreparation of this book, the publisher and author

assume no responsibility for errors or omissions. Nor isany liability assumed for damages resulting from the

use of the information contained herein.OET is a registered trademark of Cambridge Boxhill

Language Assessment Trust, which was not involvedin the production of, and does not endorse, this

product.

PREFACEThis book is specifically designed for Amazon free kindle-reading app, whichis supported on any device( smartphones, laptops, computers, ebook readers,etc) on any platforms (windows, android, apple ios, etc). Therefore, you canread this book on multiple devices you own.

How this book is different from other booksavailable in the market?Unlike paper books and other e books, you don’t have to scroll or turn pagesback and forth while answering questions. One-touch navigation links (withone single touch you will execute the intended action) are available betweeneach questions and their respective texts/paragraphs, and vice versa. This willsave you a lot of time, and makes your answering quicker.Apart from this, one-touch reference links are available for every word inthis book (including any words from paragraphs, questions, instructions, oreven these words, which you are reading right now).There are mainly five types of reference links are available in this book. Theyare:1. Dictionary:– in-built dictionaries are available for referring any word youtouch and hold. This feature helps you save a lot of time by:

a. You don’t have to search through a paper bind dictionary to find themeaning of the word.

b. You don’t have to check out a word list under the heading‘vocabulary’ to improve your vocabulary. While reading this bookyou can learn the meaning of words that you don’t know, by just asingle touch and hold over the unknown word that you find.

c. There is an in-built Oxford English dictionary available for yourreference, which shows the meaning in a pop up dialogue box. If youprefer detailed meaning or the meaning of phrases related to theword, then you can easily choose full definition in the pop-up box forfurther details and pronunciation.

d. In-built English – Native languages dictionaries are also available,

if you desire to know more about the word in your mother tongue.This will increase levels of understanding the word in detail andhelpful to remember quickly later.

2. Wikipedia:– in-built Wikipedia reference is available for referring anyword you touch and hold. This feature helps you save a lot of time by:

a. You don’t have to manually browse internet to find the Wikipediareference of the word.

b. You can read Wikipedia reference without closing or minimizing thekindle app in which you are reading the book.

c. Wikipedia reference of the word you selected is available in bothpop-up dialog box and in detail as you choose.

d. This helps in the better understanding of technical and technologicalterms.

3. Translation:– in-built quick translation to selected native language isavailable for referring any word you touch and hold.4. Web-search:– helps you search about the word in your browser for anextended research.5. In book search:– helps you find the selected word appearing in the bookitself in other locations.In addition to above-mentioned features, this book is totally customizable inkindle reading app. You can adjust the text size, font style, spacing andmargins. You can also change color theme (background color) fromwhite(default) to black (for reading during night) or sepia (if you likebackground of real paper bind book) or green (for vision(eye) –friendlyreading). These options can be accessed by clicking ‘Aa’ button on the toptool bar that appear on every page.This book is fully supported in Amazon free kindle reading app; so, use onlyfree kindle reading app to enjoy all the mentioned features.

ContentsEase of AccessOverview of OET 2.0 Reading Sub-TestMethod of AnsweringPractice Test 1Practice Test 2Practice Test 3Practice Test 4Practice Test 5Practice Test 6Practice Test 7Practice Test 8Practice Test 9Practice Test 10Practice Test 11Practice Test 12Practice Test 13Practice Test 14Practice Test 15Practice Test 16Practice Test 17Practice Test 18Practice Test 19Practice Test 20Answer Key

MOREOET BOOKS

BYMAGGIE RYAN

Overview of OET 2.0 Reading Sub-Test

The topics are of generic healthcare interest and are thereforeaccessible to candidates across all professions. The Reading sub-test contains three parts and a total of 42 question items, Part Aaccounts for 20 marks, Part B accounts for 6 marks and Part Caccounts for 16 marks. All three parts take a total of 60 minutes tocomplete. You will not be given extra time at the end of the sub-test to check your answers, and it is up to you to manage your time.The test is designed so that the time available is enough for you toread, choose your answers, and check your work.

NB: Abbreviations are not accepted in the Reading sub-test unlessthey appear in the texts.

NB: You must use correct spelling in the Reading sub-test to getthe marks. Responses that are not spelled correctly will not receiveany marks. American and British English spelling variations areaccepted, e.g., color and colour are both acceptable.

Part A – 15 minutes

Reading Part A tests your ability to skim and scan quickly acrossdifferent texts on a given topic in order to locate specificinformation. For that purpose, Part A is strictly timed and you mustcomplete all 20 question items within the allocated 15 minutes. Tocomplete the task successfully, you will also need to understand theconventions of different medical text types and understand the

presentation of numerical and textual information. The 20questions consist of matching, sentence completion and shortanswer questions.

NB: In Part A you should write your answers clearly in the spacesgiven in the question booklet.

NB: Please remember that there is a strict time limit for Part A, andPart A materials will be collected from you after 15 minutes. Youwill therefore not have any time to check your Part A answers laterin the test.

NB: In Part A you must use exactly the same form of the word orshort phrase as given in the four texts.

Part B and Part C – 45 minutes

NB: In Part B and Part C, you must shade the circle next to theappropriate answer. Answers written elsewhere in your booklet willnot be marked.

Part B

Part B assesses your ability to identify the detail or main point ofsix short texts sourced from the healthcare workplace. The textsmight consist of extracts from policy documents, hospitalguidelines, manuals or internal communications, such as emails ormemos. For each text, there is one three-option multiple-choice

question. To complete the task successfully, you will need toidentify specific ideas at sentence level.

Part C

Part C assesses your ability to identify detailed meaning andopinion in two texts on topics of interest to healthcareprofessionals. For each text, you must answer eight four-optionmultiple choice questions. Reading Part C tests your ability tounderstand the explicit or implied meaning as well as the attitude oropinion presented in a longer text. To complete the tasksuccessfully, you will need to identify the relationship betweenideas at sentence and paragraph level. Part C also tests your abilityto accurately understand lexical references and complex phraseswithin the text.

METHOD OF ANSWERINGSTEP 1.

FLASH READINGFlash reading refers to high-speed reading of the whole readingpassage in few minutes, without thinking anything in your head(not even trying to guess meaning of the unfamiliar words/phrases).It helps to provide a vague idea about the matters that are discussedin the reading passage. It also forms a clear map in mind showingthe order of statements as they appear in the passage, which easeslocating the extract/paragraph referred in questions whileanswering.

STEP 2.FOCUSED READING

After finishing flash reading, start answering the questions.Eliminate all the irrelevant and impossible options from themultiple choices. Find a quick fix on location of theextract/paragraph referred in the questions and read theextract/paragraph quickly (strictly not more than twice, if it is aparagraph and not more than thrice if it is a short extract) withcomplete focus. Write the answer you had found only if you aresure enough.If the answer is confusing (if you find more than one possibleanswer for the question), write the answer you think to have morepossibility to be correct on your answer sheet, along noting thequestion and two or three other possible answer for later reference.This will avoid wastage of time due to fixating over confusingquestions.

If the question is so tough that you fail to find a proper answer to it,then leave it blank and note the question number for later reference.Focused reading helps to answer all easy question in the readingtest correctly, instead of losing marks on them in the last minuterush.

STEP 3.THOROUGH READING

After finishing all the questions in the test, you can start answeringthe tough questions by reading thoroughly the referredextract/paragraph by reading. Thorough reading refers to slowreading with maximum concentration to find all possible meaningsbetween the lines, so that you arrive at a possible answer. Don’tread more than twice.After finishing tough questions, start answering questions withconfusing answers in the same manner. If you follow these threesteps you can spend time wisely, while attending a reading test.Avoid wasting time by going after tips for reading, when you arenot getting desired results.There are only two things that can improve your OET readingscore:1. Efficient management of time2. Practicing more and more reading sample tests.

WORK HARD, SCORE MORE!

Practice Test 1READING SUB-TEST – QUESTION PAPER: PART A

TIME: 15 MINUTES

INSTRUCTIONS TO CANDIDATES:

DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.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 andthe Text Booklet. DO NOT remove OET material from the test room.Text AAspirin Resistance

Abstract

In the last few years, the concept of aspirin resistance has beenlargely emphasised in the medical literature, although its definition,mechanism, and specific guidelines for its management remainunclear. Aspirin displays good antithrombotic activity. Variouslaboratory parameters assessing the efficacy of aspirin likebleeding time, platelet reactivity, thromboxane-A2 (TX-A2)production, and measurement of platelet aggregation, have

confirmed the lack of its uniform effect on the platelets. Fewstudies have reported aspirin resistance to the tune of 5 - 45%.Various extrinsic and intrinsic factors influence the resistance.Numerous studies reveal that aspirin resistance can be overcome bycombining it with another antithrombotic agent, i.e., clopidogrel.Further, clopidogrel resistance has also been reported. So, much isexpected in the field of diagnostic tests in order to know the truepicture of aspirin resistance.

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Text BMechanisms of aspirin resistanceThe exact mechanisms are not clear:True aspirin resistance:The proposed factors for this type of resistance include:i. Decreased bioavailability of aspirin.ii. Accelerated platelet turnover introducing newly formed, non-aspirinated platelets into the blood stream.iii. Competition of aspirin with other NSAIDs (like ibuprofen)preventing aspirin access at Serine 530 of Cox-I.iv. Transcellular formation of TxA2 by aspirinated platelets fromPGH2 released by other blood cells or vascular cells.v. TxA2 production by aspirin insensitive Cox-2 in newly formedplatelets or other cells.vi. (Theoretical) presence of variant Cox-I which is less sensitive toaspirin inhibition.vii. Poor compliance by the patient.

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Text CAspirin dosage

According to the Antithrombotic Trialists’ Collaboration, dailydoses of aspirin (75 - 150 mg) are as effective as higher doses forprevention of thrombotic events and are associated with low risk ofbleeding. Bornstein et al in their study have shown that even 100mg of aspirin completely inhibits Cox-1 enzyme, thus furthersubstantiating the fact that patients with resistance establishedduring low dose aspirin therapy may respond to higher doses. Theresults of this study showed that aspirin in doses of 500 mg/daysignificantly prolonged the time between first and second stroke (p= 0.002) compared with lower doses. Helgason et al revealed thatan increase in the dose of aspirin to 625 that suboptimal reductionof urinary 11-dehydro TxB2 level during aspirin treatment isassociated with increased risk for future MI and cardiovasculardeath, thereby suggesting that “true aspirin resistance” may be aclinically relevant phenomenon. Inadequate inhibition of TxA2biosynthesis by aspirin can be seen in patients on ibuprofentherapy, because of competition of these 14 mg/day in five patientswho were aspirin resistant with 325 mg/day showed aspirinsensitivity. Another study has revealed that these patients remainedresistant with aspirin 1,300 mg. This shows that inadequate dosecannot explain aspirin resistance in all subjects.

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Text DManagement of aspirin resistance

Currently there are no specific guidelines for the management ofaspirin resistance. The first step is to enquire about the patient’scompliance. Regarding optimal aspirin dosing, it is controversial.No convincing data are available showing that the antithromboticeffect of aspirin is dose related. The meta-analysis by Anti-Thrombotic Trialist’s Collaboration refuted the claim that highdoses of aspirin (500 - 1,500 mg/day) were effective than lowdoses (75 - 150 mg/day). Other method to manage aspirinresistance is by addition of another antiplatelet agent – clopidogrel,because CAPRIE trial has shown greater benefit of combination ofaspirin and clopidogrel compared with aspirin alone. Thecombination of aspirin with clopidogrel is an ideal one sinceclopidogrel inhibits another pathway of platelet activation.However, till date, it is not clear whether the superiority of acombination of clopidogrel and aspirin over aspirin is due toclopidogrel compensation for aspirin non-responders. Resistance toeven clopidogrel has been reported, which is associated with anincreased risk of recurrent thrombotic events in patients with acuteMI.

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Part ATIME: 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 therelevant information.• Write your answers on the spaces provided in this QuestionPaper.• Answer all the questions within the 15-minute time limit.• Your answers should be correctly spelt.

QUESTIONS

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

In which text can you find information about1. what are the factors of true aspirin resistance? _____

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“TextA”

“TextB”

“TextC”

“TextD”

2. how much of aspirin completely inhibits Cox-1 enzyme? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

3. what will happen if aspirin compete with other NSAIDs? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

4. how the the true picture of aspirin resistance is revealed? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

5. what are the parameters for assessing the efficacy of aspirin?_____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

6. list the methods to manage aspirin resistance? _____Go “Text “Text “Text “Text

to A” B” C” D”

7. whether true aspirin resistance is a clinically relevantphenomenon? _____

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“TextA”

“TextB”

“TextC”

“TextD”

Questions 8-13

Answer each of the questions, 8-13, with a word or short phrase from one ofthe texts. Each answer may include words, numbers or both.

8. How much mg of aspirin is minimum required to completelyinhibit Cox-1 enzyme?

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“TextA”

“TextB”

“TextC”

“TextD”

9. Which patients show inadequate inhibition of TxA2 biosynthesis byaspirin?

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“TextA”

“TextB”

“TextC”

“TextD”

10. Name the antiplatelet agent used to manage aspirin resistance?Goto

“TextA”

“TextB”

“TextC”

“TextD”

11. What are responsible for transcellular formation of TxA2?Goto

“TextA”

“TextB”

“TextC”

“TextD”

12. What is the daily doses range of aspirin according to theAntithrombotic Trialists’Collaboration?

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“TextA”

“TextB”

“TextC”

“TextD”

13. Which trial has shown greater benefit of combination of aspirinand clopidogrel?

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“TextA”

“TextB”

“TextC”

“TextD”

Questions 14-20Complete each of the sentences, 14-20, with a word or short phrasefrom one of the texts. Each answer may include words, numbers orboth.14. Aspirin displays good _____ activity.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

15. Few studies have reported aspirin resistance to the tune of_____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

16. TxA2 may be produced by aspirin insensitive _____ in newlyformed platelets or other cells.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

17. Increase in the dose of aspirin to 625 is associated withincreased risk for future MI and _____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

18. Inadequate inhibition of TxA2 ______ by aspirin can be seen inpatients on ibuprofen therapy.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

19. The first step in management of aspirin resistance is to enquireabout the patient’s ______.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

20. The combination of _____ with clopidogrel is an ideal one.Goto

“TextA”

“TextB”

“TextC”

“TextD”

Answer Key

“Practice Test 1”

Practice Test 2READING SUB-TEST – QUESTION PAPER: PART B & C

TIME: 45 MINUTES


DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.You must answer Part B & C within the 45-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 45 minutes, hand in this Question Paper andthe Text Booklet. DO NOT remove OET material from the test room.

Part B

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

Anaesthetic MachinesThe anaesthetic machine (or anaesthesia machine in America) is used byanaesthesiologists and nurse anaesthetists to support the administration ofanaesthesia. The most common type of anaesthetic machine is thecontinuous-flow anaesthetic machine, which is designed to provide anaccurate and continuous supply of medical gases (such as oxygen and nitrousoxide), mixed with an accurate concentration of anaesthetic vapour (such as

halothane or isoflurane), and deliver this to the patient at a safe pressure andflow. Modern machines incorporate a ventilator, suction unit, and patientmonitoring devices.1. The manual is giving information aboutA. how to use anaesthetic machinesB. types of anaesthetic machinesC. an overview of anaesthetic machines

Autoclaves and Sterilizers

Sterilization is the killing of microorganisms that could harm patients. It canbe done by heat (steam, air, flame or boiling) or by chemical means.Autoclaves use high pressure steam and sterilizers use boiling water mixedwith chemicals to achieve this. Materials are placed inside the unit for acarefully specified length of time. Autoclaves achieve better sterilization thanboiling water sterilizers. Heat is delivered to water either by electricity orflame. This generates high temperature within the chamber. The autoclavealso contains high pressure when in use, hence the need for pressure controlvalves and safety valves. Users must be careful to check how long items needto be kept at the temperature reached.2. Why autoclaves are better than boiling water sterilizers?A. Heat is transferred to water by electricity or flameB. Autoclaves use high pressure steamC. 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 tracingsdisplayed and printed. Some ECG machines also provide preliminaryinterpretation of ECG recordings. There are 12 different types of recordingdisplayed depending upon the points from where the recordings are taken.Care must be taken to make the electrode sites clean of dirt before applyingelectrode 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 andreported on various benefits and limitations of these systems. Benefitsincluded increase in immunization rates, improved data collection, increasedstaff productivity, increased visitor satisfaction with services, improvedcommunication, quality of care, access to data, reduced medical errors, andmore 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 aboutA. pros and cons of electronic health recordsB. necessity of electronic health recordsC. demonstrated benefits of electronic health records

mHealth

The use of mobile technologies for data collection about individuals andinteractive information services are a part of a growing area of eHealth calledmHealth. The GOe published a volume on this subject in 2011 whichdocuments the uptake of mHealth worldwide by types of initiatives and mainbarriers to scale. Mobile technologies are emerging as a powerful tool forhealth information transfer including making patient information portable.Such technologies can be more fully utilized through electronic patientinformation 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 mHealthA. is a published volume on the GOe

B. is a powerful tool for information transferC. makes patient information portable

Systematized Nomenclature of Medicine (SNOMED)

SNOMED was designed to provide a comprehensive nomenclature of clinicalmedicine for the purpose of describing records of clinical care in humanmedicine. It is a multi-axial and hierarchical classification system. It is multi-axial in that any given clinical condition can be described through multipleaxes such as topography (anatomy), morphology, organisms such as bacteriaand 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 ofthe axes has a hierarchical tree that proceeds from general terms to morespecific ones. For example topography (anatomic) terms are first divided intomajor organs such as lung, heart, and then into the smaller components ofeach.

6. What does this extract from a handbook tell us about SystematizedNomenclature of Medicine?A. is a multi-axial and hierarchical classification systemB. is a comprehensive nomenclature of trial medicinesC. is used to described any clinical condition through axis

Answer Key“Practice Test 2”


TIME: 45 MINUTES



Part CIn this part of the test, there are two texts about different aspects ofhealthcare. Choose the answer (A, B, C or D) which you think fitsbest according to the text.

All life is connected Cancer in Humans and WildlifeWILDLIFE—HUMAN LINKS

Paragraph 1It may be that biologists, rather than physicians, will be the majorcontributors to the health of our wildlife caused by the combined action ofpesticides planet and its people. It was Rachel Carson, a biologist, whoresearched and wrote of the harm to wildlife caused by the combined action

of pesticides and radiation. In the tradition of the observant biologist is TheoColborn, who, with her colleagues, provided a significant breakthrough inunderstanding the hormonal effects of environmental contaminants. In July1991, a gathering of some of the world’s most astute, - scientists were held atthe Wingspread Conference Center in Wisconsin, where they defined thepattern of diverse endocrine malfunction seen throughout the animalkingdom. They revealed a gm“: picture of the Brave New World we shouldm rigorously seek not to leave as a legacy to our children.

Questions“Q1”“Q2”“Q3”“Q4”“Q5”“Q6”“Q7”“Q8”

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


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


Paragraph 4Xenoestrogens are an insidious enemy, but they have had help from powerfulallies: 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 showreproductive failure, growth retardation, life-threatening deformities, and

alterations in their brains and liver functions.” There is direct experimentalevidence for permanent [organizational] effects of gonadal steroids on thebrain as well as reproductive organs throughout life. This means thatoffspring whose brains have been altered are unable to function as had theirparents. They become different in ability or function.


Paragraph 5This means that the sea of hormonally active chemicals in which the fetusdevelops may change forever the health and function of the adult, and insome cases, may alter the course of an entire species. Worldwide there arereports of declining sperm counts and reduced ratio in births of male babies.Without the capacity to reproduce, a species ceases to exist. Extinction isforever; a species loss has never been reversed.


Paragraph 6The data derived from animal observations are unequivocal: breast andgenital cancers, _ ital abnormalities, interference with sexual development,and changes in reproductive behavior all expressions of a root cause. Apossible connection between women with breast cancer and those havingchildren with reversed sexual orientation is a question that bears study. Thisis n n. from science fiction, considering what we have learned from observingwildlife and the effects inappropriate hormonal influence upon the breast,brain, and reproductive organs. If an unequivocal answer were to emergefrom human observation, it could have a significant impact upon theprevailing political and economic landscape, and may finally settle the natureor nu issue of sexual orientation.


Paragraph 7SILENT SPRING-SILENT WOMEN Considering the accumulated knowledge linking chemical and radioactivecontamination environment with increasing breast cancer rates means wemust focus our energies and prevention. Early were the eloquent words andpleas for prevention from Rachel Carson. Her book, Silent Spring, originallypublished in 1962, while she herself was suffering from breast cancer, is stilla 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 wildanimals; increasing rates of leukemia in children; and chronicled thepesticides and chemicals known at that time to cause cancer. This was over30 years ago!


Paragraph 8Carson’s is a book for every citizen, for without understanding of ourcollective actions and permissions, we cannot govern democratically. InAustralia, a citizen is required to vote. In the United States, proclaimed bysome 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 registerand vote, few are sufficiently alert and/or educated to vote with intelligence,thought, and compassion. Requiring participation in the governance of one’sown country is not a bad idea. Requiring thoughtful voting may be moredifficult, especially when it comes to such issues as cancer, pesticide use,consumer products, nuclear radiation, toxic chemicals, and environmentaldestruction. Taking this thought one step further; this democracy could do farworse than to require reading of Silent Spring as a requirement to vote!Radical? Perhaps. But is the ongoing cancer epidemic any less radical?


Paragraph 9One successor to Ms. Carson has emerged in the person of SandraSteingraber, an ecologist, poet, and scientist. In her book, LivingDownstream, she writes eloquently of the connections betweenenvironmental contamination and cancer. Dr. Steingraber was diagnosed withbladder cancer at age 20, a highly unusual diagnosis in a woman, a youngwoman, a nonsmoker and nondrinker. She pursued the question, why? Sherealized a connection with our wild relations and she asks: Tell me, does theSt. Lawrence beluga drink too much alcohol and does the St. Lawrencebeluga 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 somehowimmune and that it is only the beluga whale that is being affected?


Paragraph 10The portion of Dr. Steingraber’s book that struck me most personally waswhen 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 onehas ever asked me about the environmental conditions where I grew up, eventhough bladder cancer in young women is highly unusual. I was once asked ifI 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 hasever shown interest in probing the possible causes of my disease-even when Ihave introduced the topic. From my conversations with other cancers,patients, I gather that such lack of curiosity in the medical community isusual.


Paragraph 11I take her words as an indictment of the medical and scientific establishment,whose point of view must be changed. Certainly the lack of curiosity amongphysicians, scientists, policymakers, and politicians has contributed to theepidemic of illness among humans and wildlife alike. An equally talentedwoman is Terry Tempest Williams, an ecologist and wildlife researcherwhose book, Refuge: An Unnatural History of Family and Place, tells thestory of her Utah family, whom she “labels “a clan of one—breastedwomen.” Ms. Williams contrasts the life-affirming awareness Great Salt Lakewildlife refuge against the erosion-of-being, as cancer takes away the womenin her family: her mother, her grandmothers, and six aunts. She writes: “Icannot 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 12Times are changing. It is becoming impossible to ignore the carnage ofendocrine-disruption chemicals, nuclear radiation, and chemical carcinogens,alone and in combination, invading nearly every family with cancer. Facingthis reality may be too much for some people, afraid to look, or afraid ofbeing the next victim. The story of cancer is not an easy one, and neither iscancer. But if we do not exert our efforts to prevent this disease, we doom ourchildren and grandchildren to repeat our collective errors. What does it taketo change from environmental destruction and random killing to affirmationof life? Can the protection of life for ourselves and our environment beaccomplished by women with breast cancer; the women at risk for breast

cancer; the families of breast cancer victims? Who should lead? If we citizenscan’t and don’t try, what are our alternatives?


QUESTIONSQ1. The author’s main contention is thata. wildlife all around the world is being linked to environmental pollutionb. fish, birds, seals and canaries are being exposed to toxic chemicalsc. humans need to understand the link between destroying the planet’swildlife, through exposure to toxic chemicals, and the destruction of theentire biosphere — which includes human life itself.d. humans need to understand the link between destroying the planet’swildlife, through exposure to toxic chemicals, and behavioural abnormalitiesacross all forms of life.

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Q2. The author states that in an environment of “hormonally activechemicals”a. males with higher sperm counts may result ‘b. more male babies are bornc. lower sperm count in males may result in a particular species being wipedout ‘d. males with more sperm count may result

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Q3. Dr Sandra Steingraber, ecologist, poet and scientist:a. realised that contracting bladder cancer was not due to her alcohol drinkingb. realised her bladder cancer was not due to her smokingc. believed her bladder cancer was due to environmental contaminationd. doctors, nurses and technicians were very interested in her unusual cancer

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Q4. The wildlife researcher, Terry Tempest Williams, sees the dichotomywhich exists in the Salt Lake wildlife refuge area:a. many women in her family have died from breast cancer after a nuclearfallout in Utahb. many men in her family have died from breast cancerc. her family have many one-breasted women — unusual for Utahd. such wide-spread cancer is probably due to environmental, not geneticcauses

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Q5. Animal observations show:a. changes in sexual maturity are not only due to a root causeb. genital abnormalities may be due to a root causec. inappropriate hormones adversely affect the development of breast, brainand reproductive organsd. humans are not similarly affected.

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Q6. The author puts forward several ideas about governance except for one ofthe following:a. People who participate in elections are not alert and educated enoughb. Unless the wants and needs of the population are known, it is difficult forpoliticians to govern democraticallyc. People being required to vote, to participate in the decision makingprocess, is a good idead. Reading Carson’s book, Silent Spring, should be made compulsory for allvoters.

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Q7. Rachel Carson’s book Silent Spring, written in 1962, revealed:a. more had to be done to prevent chemical contamination of the environmentb. there was a link between pesticides, chemicals and cancerc. chemicals were leading to an inability to reproduce leading to theeradication of entire species of insects, birds, fish and animalsd. all of the above

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Q8. Research about xenoestrogens revealsa. they are everywhereb. they are harmlessc. they are in our everyday foodsd. they are in our everyday foods and disrupt hormonal function

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TIME: 45 MINUTES




Does Tamiflu really work?Paragraph 1 The British Medical Journal (BMJ) was dominated in 2009 by a cluster ofarticles on oseltamivir (Tamiflu). Between them the articles conclude that theevidence that oseltamivir reduces complications in otherwise healthy peoplewith pandemic influenza is now uncertain and that we need a radical changein 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 tofacilitate the choices that doctors, patients, policy makers and others face inhealth care. Most Cochrane Reviews are based on randomized controlledtrials, but other types of evidence may also be taken into account, ifappropriate.


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


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


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


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


Paragraph 7 Where does this leave oseltamivir, on which governments around the worldhave spent billions of pounds? The papers in last years journal relate only toits use in healthy adults with influenza. But they say nothing about its use inpatients judged to be at high risk of complications- pregnant women, childrenunder 5, and those with underlying medical conditions; and uncertainty overits role in reducing complications in healthy adults still leaves it as a usefuldrug for reducing the duration of symptoms. However, as Peter Doshi pointsout on this outcome it has yet to be compared in head to head trials with non-steroidal inflammatory drugs or paracetamol. And given the drug’s knownside effects, the risk-benefit profile shifts considerably if we are talking onlyin terms of symptom relief.


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


QUESTIONSQ1. A cluster of articles on oseltamivir in the British Medical Journal

conclude__________a. complication are reduced in healthy people by oseltamivirb. the efficacy of Tamiflu in now in doubtc. complications from pandemic influenza are currently uncertaind. a series of articles supporting Tamiflu

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Q2. Cochrane Reviews are designed to __________a. set randomized controlled trials to specific valuesb. compile literature meta-analysisc. peer review articlesd. influence doctors choice of prescription

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Q3. According to the article, which one of the following statements aboutTamiflu is FALSE?a. The use of randomized controls is suspectb. The efficacy of Tamiflu is certainc. Oseltamivir induces complications in healthy peopled. Cochrane reviews are useful when examining the efficacy of Tamiflu

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Q4. According to the article, Cochrane Review Groups __________a. like to work for “consumers”.b. are being overhauled.c. use language suitable for expert to expert communication.d. evaluate a clinical effect better than individual studies.

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Q5. Which would make the best heading for paragraph 4?a. Analysis of 10 drug company trialsb. The stockpiling of Oseltamivirc. Risk of complications in healthy adults

d. Tamiflu claims fail verificationParagraphs“1”“2”“3”“4”“5”“6”“7”“8”

Q6. According to the article, which one of the following statements aboutRoche is TRUE?a. Full study reports were made freely available on the internetb. Patients were recruited through a double blind trialc. The identities and roles of researcher in the Roche trials are not fullyaccounted ford. Not all neuropsychiatric adverse events were reported

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Q7. Cochrane reviews should __________a. use a more complete analysisb. not be published until final data is availablec. be considered interim rather than definitive adviced. be superseded by a more reliable method of reporting results

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Q8. Which would make the best heading for paragraph 7?a. Risk-benefit profile of Tamiflub. Studies limited to healthy adultsc. High risk of complicationsd. Oseltamivir only for high risk patients

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TIME: 15 MINUTES


DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.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 andthe Text Booklet. DO NOT remove OET material from the test room.Text AMorgellons diseaself you have fatigue, skin lesions, aches and pains and a sensation that insectsare crawling around under your skin, you most probably have Morgellonsdisease. But this disease may actually not exist. Whether or not Morgellons isa real disease, no one knows. Something like the symptoms described above,supplemented by the appearance of strange fibres or filaments growing on orjust beneath the skin, was reported by the 17th-century physician ThomasBrowne. There were no other reported cases, and the disease seemed todisappear. Then, in 2002, the mother of a child with a skin ailmentchampioned its comeback. Her child, she insisted, had Morgellons.Delve into the medical literature, though, and Morgellons disease isfrequently described as “unexplained dermopathy” or “delusional parasitosis”- a psychiatric illness that results in people mistakenly believing their skin to

be infested with parasites. We may soon find out more. The US Centers forDisease Control and Prevention (CDC) is in the middle of a large, systematicstudy into Morgellons. The study aims to determine whether there is actuallya physiological basis to the disease. The CDC is keeping an open mind onMorgellons, says Michele Pearson, who is leading the study. “CDC hasapproached this as an unexplained condition,” she says.

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Text BCDC, Kaiser to study puzzling illnessThe Centers for Disease Control and Prevention and Kaiser Permanente‘sNorthern California Division of Research announced they are launching astudy to learn more about an unexplained skin condition called Morgellonsdisease. The CDC will identify patients with the condition in Kaiser‘sNorthern California health plan. The study is expected to take at least 12months. Reports of cases have been made in every state and 15 countries.Many reported cases have been clustered in California, Texas and Florida,according to the Mayo Clinic.

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Text CDelusional ParasitosisDelusional Parasitosis is an uncommon psychiatric disorder presented bypersons with an unremitting false belief that they are infested withectoparasites or infected with endoparasites. The delusion is usually long-standing and well integrated into the patient’s persona. Patients with thedisorder are predominantly older women, although younger people and mencan be affected. Most cases involve patient beliefs that the skin has beeninvaded by insects, but some involve delusions that internal parasites are thecause of their condition.

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Text DThe causes for the disorder are not clear, but sufferers are generally ofaverage or higher intelligence and are otherwise functional. Patients withdelusional parasitosis generally have a long history of visiting physiciansseeking information of their diagnosis and help with their condition. Thepatients have certain characteristics or exhibit behaviors that strongly suggestthe presence of the disorder. Moreover, these patients can be antagonistic andrelentless in their need to find someone who will agree with their self-diagnosis and help them. Because these delusional patients may seek helpfrom non-physician medical professionals, such as parasitologists, clinicalmicrobiologists, entomologists, or biologists, such individuals should beaware of this disorder. Delusional parasitosis can be treated withantipsychotic medication and psychiatric consultations but generally does notrespond well to such treatment.

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Part ATIME: 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 therelevant information.• Write your answers on the spaces provided in this QuestionPaper.• Answer all the questions within the 15-minute time limit.• Your answers should be correctly spelt.

QUESTIONS

Questions 1-7

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

In which text can you find information about1. what is the minimum expected time period for CDC’s study to learn moreabout Morgellons disease? _____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

2. what are the treatments for Morgellons disease? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

3. name the places where Morgellons disease reported so far? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

4. what is the aim for CDC’s study to learn more about Morgellons disease?_____

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“TextA”

“TextB”

“TextC”

“TextD”

5. which are the age groups predominantly affected by Morgellonsdisease? _____

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“TextB”

“TextC”

“TextD”

6. what is the current approach of CDC’s towards Morgellons disease?_____

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“TextB”

“TextC”

“TextD”

7. what are the other names of Morgellons disease? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

Questions 8-13


8. Who reported a medical condition similar to Morgellons diseasefor the first time?

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“TextA”

“TextB”

“TextC”

“TextD”

9. Name the person who leads CDC’s study to learn more about Morgellonsdisease?

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“TextB”

“TextC”

“TextD”

10. Name the type of medications used to treat Morgellons disease?Goto

“TextA”

“TextB”

“TextC”

“TextD”

11. How many countries reported Morgellons disease?Goto

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“TextB”

“TextC”

“TextD”

12. Name the type of illness under which the Morgellons disease isclassified?

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“TextD”

13. what is the popular delusion of the people affected by Morgellonsdisease?

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“TextA”

“TextB”

“TextC”

“TextD”

Questions 14-20Complete each of the sentences, 14-20, with a word or short phrasefrom one of the texts. Each answer may include words, numbers orboth.14. Morgellons disease is frequently described as _____ or “delusionalparasitosis”.

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“TextA”

“TextB”

“TextC”

“TextD”

15. Morgellons disease is a psychiatric illness that results in peoplemistakenly believing their skin to be infested with _____.

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“TextA”

“TextB”

“TextC”

“TextD”

16. Many reported cases have been clustered in California, Texas andFlorida, according to the _____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

17. The _____ will identify patients with the condition in Kaiser‘s NorthernCalifornia health plan.

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“TextA”

“TextB”

“TextC”

“TextD”

18. The delusion is usually long- standing and well integrated into thepatient’s _____.

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“TextA”

“TextB”

“TextC”

“TextD”

19. Patients with delusional parasitosis generally have a long history ofvisiting ______.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

20. Patients with delusional parasitosis can be antagonistic and ______.Goto

“TextA”

“TextB”

“TextC”

“TextD”



TIME: 45 MINUTES



Part B

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

Electronic Diagnostic EquipmentThere are many items of equipment in a hospital that use electronics foroperation. The maintenance of such equipment is a task for specialised andtrained staff. However, regular inspection and cleaning will help suchequipment last for a long time and deliver safe function. These are tasks thatthe equipment user can carry out and should be done regularly, as laid out onthe checklists on the next pages. The types of equipment that might be

included in this category are for instance audiometers, blood gas analyzers,cardiac monitors, cryoprobes, infusion pumps and stimulators. The steps inthis section can also be applied to most laboratory equipment, although itshould be noted that the WHO publication Maintenance Manual forLaboratory Equipment deals with these in much better detail.1. The type of equipment that might not be included in the category ofElectronic Diagnostic Equipment isA. cardiac analyzersB. stimulatorsC. audiometersElectrosurgical Units (ESU) and Cautery Machines

Electrosurgery is the application of a high-frequency electric current tobiological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue.Its benefits include the ability to make precise cuts with limited blood loss inhospital operating rooms or in outpatient procedures. Cautery, orelectrocautery, is the application of heat to tissue to achieve coagulation.Although both methods are sometimes referred to as surgical diathermy , thischapter avoids the term as it may be confused with therapeutic diathermy,which generates lower levels of heat within the body.2. What does this manual tell us about electrocautery?A. make precise cut with limited blood lossB. uses high-frequency electric currentC. application of heat to tissue to achieve coagulationEndoscopy

Endoscopy means looking inside the body using an endoscope, an instrumentused to examine the interior of a hollow organ or cavity of the body.Endoscopes are inserted directly into the organ. An endoscope can consist ofa rigid or flexible tube, a light delivery system (light source), an optical fibresystem, a lens system transmitting the image to the viewer, an eyepiece andoften an additional channel to allow entry of medical instruments, fluids ormanipulators. There are many different types of endoscopy, includingarthroscopy, bronchoscopy, colonoscopy, colposcopy, cystoscopy,laparoscopy and laryngoscopy.

3. What does this extract from a handbook tell us about endoscopes?A. are inserted directly into the organB. used to examine the exterior of a hollow organ or cavity of the bodyC. there are mainly 7 typesMessaging standards

Messaging is the electronic communication of health information from thepoint of collection or storage to a point of use. This can be a short distancesuch as within a clinic or larger distances across facilities or districts.Messages can be used to retrieve historical data as well as current data. Ahealth message includes health data that is expressed in a standardvocabulary. It may also include metadata about the definitions orenvironment of the data. The message itself is in a precisely defined formatso that it can be received by a computer program which will understand itsmeaning.4. The email is reminding staff that theA. health message should include health data expressed in a standardvocabularyB. health message should include metadata about the definitions orenvironment of the dataC. health message should be precise in any format to be received by acomputer programCommunication skills during medical examination

An appropriate contact with the patient requires applying professionalknowledge about psychological aspects of interpersonal relations. Whileexamining the patient, most doctors apply just the experience or abilities toestablish interpersonal contacts that have been acquired on a social level. Thisknowledge would definitely be insufficient in unusual and problematicsituations. For many years, clinical and social aspects of doctors’psychological education have been neglected. The ability of conversationshould be based on appropriate education, not only on personal intuition orown experience.5. The notice is giving information aboutA. necessity of communication based on appropriate psychological education

B. necessity of establishing interpersonal contacts with patientC. necessity of appropriate contact based on personal experienceLiver PalpationLiver palpation is performed with the right hand placed flat under right costalchest border, parallel to the long body axis, then applying pressure at thedepth of inspiration in an attempt to move under the costal border in the rightmiddle clavicular line and towards its right side. In normal conditions, thelower liver border is not touched. During the respiration, the lower liverborder is slightly moving down and upwards.If the liver edge can be detected on palpation, some additional features haveto be determined as there are various abnormalities related with specificdiseases.6. What must all staff involved in liver palpation do?A. should place right hand flat under right chestB. should apply pressure at the depth of aspirationC. should place left hand flat under right chest



TIME: 45 MINUTES




Tufts University faculty debunks common dental mythsParagraph 1Brushing, flossing, and twice-yearly dental check-ups are standard for oralhealth care, but there are more health benefits to taking care of your pearlywhites than most of us know. In a review article, a faculty member at TuftsUniversity School of Dental Medicine (TUSDM) debunks common dentalmyths and outlines how diet and nutrition affects oral health in children,teenagers, expectant mothers, adults and elders.


Paragraph 2Myth 1: The consequences of poor oral health are restricted to themouth Expectant mothers may not know that what they eat affects the toothdevelopment of the fetus. Poor nutrition during pregnancy may make theunborn child more likely to have tooth decay later in life. “Between the agesof 14 weeks to four months, deficiencies in calcium, vitamin D, vitamin A,protein and calories could result oral defects,” says Carole Palmer, EdD, RD,professor at TUSDM and head of the division of nutrition and oral healthpromotion in the department of public health and community service. Somedata also suggest that lack of adequate vitamin B6 or B12 could be a riskfactor for cleft lip and cleft palate formation


Paragraph 3In children, tooth decay is the most prevalent disease, about five times morecommon than childhood asthma. “If a child’s mouth hurts due to tooth decay,he/she is less likely to be able to concentrate at school and is more likely tobe foods that are easier to chew but that are less nutritious. Foods such asdonuts and pastries are often lower in nutritional quality and higher in sugarcontent than nutritious foods that require chewing, like fruits and vegetables,”says Palmer. Oral complications combined with poor diet can also contributeto cognitive and gr problems and can contribute to obesity


Paragraph 4Myth 2: More sugar means more tooth decay It isn’t the amount of sugar you eat; it is the amount of time that the sugar hascontact with the teeth. “Foods such as slowly-dissolving candies and soda arein the mouth for longer periods of time. This increases the amount of timeteeth are exposed to the acids formed by oral bacteria from the sugars,” saysPalmer.


Paragraph 5Some research shows that teens obtain about 40 percent of their carbohydrateintake from soft drinks. This constant beverage use increases the risk of toothdecay. Sugar-free carbonated drinks and acidic beverages, such as lemonade,are often considered safer for teeth than sugared beverages but can also

contribute to demineralization of tooth enamel if consumed regularly.Questions“Q1”“Q2”“Q3”“Q4”“Q5”“Q6”“Q7”“Q8”

Paragraph 6Myth 3: Losing baby teeth to tooth decay is okay

It is a common myth that losing baby teeth due to tooth decay is insignificantbecause baby teeth fall out anyway. Palmer notes that tooth decay in babyteeth can result in damage to the developing crowns of the permanent teethdeveloping below them. If baby teeth are lost prematurely, the permanentteeth may erupt mal-positioned and require orthodontics later on.


Paragraph 7Myth 4: Osteoporosis only affects the spine and hips

Osteoporosis may also lead to tooth loss. Teeth are held in the jaw by the facebone, which can also be affected by osteoporosis. “So, the jaw can also sufferthe consequences of a diet lacking essential nutrients such as calcium andvitamins D and K,” says Palmer. “The jawbone, gums, lips, and soft and hardpalates are constantly replenishing themselves throughout life. A good diet isrequired to keep the mouth and supporting structures in optimal shape.”


Paragraph 8Myth 5: Dentures improve a person’s diet If dentures don’t fit well, older adults are apt to eat foods that are easy tochew and low in nutritional quality, such as cakes or pastries. First, denturewearers should make sure that dentures are fitted properly. In the meantime,if they are having difficulty chewing or have mouth discomfort, they can stilleat nutritious foods by having cooked vegetables instead of raw, canned fruitsinstead of raw, and ground beef instead of steak. Also, they should drinkplenty of fluids or chew sugar-free gum to prevent dry mouth,” says Palmer.


Paragraph 9Myth 6: Dental decay is only a young person’s problemIn adults and elders, receding gums can result in root decay (decay along theroots of teeth). Commonly used drugs such as antidepressants, diuretics,antihistamines and sedatives increase the risk of tooth decay by reducing

saliva production. “Lack of saliva means that the mouth is cleansed moreslowly. This increases the risk of problems,” says Palmer. “In this case,drinking water frequently can help cleanse the mouth.”


Paragraph 10Adults and elders are more likely to have chronic health conditions, likediabetes, which are risk factors for periodontal disease (which begins with aninflammation of the gums and can lead to tooth loss). “Type 2 diabetespatients have twice the risk of developing periodontal disease of peoplewithout diabetes. Furthermore, periodontal disease exacerbates diabetesmellitus, so meticulous oral hygiene can help improve diabetes control,” saysPalmer.


QUESTIONSQ1. This article is abouta. how the nutritional needs of children, teenagers and expectant mothers hasan effect on oral healthb. how the oral health is affected by nutritional needs of children, teenagers,expectant mothers and other groups.c. how diet and nutritional needs of children, teenagers, mothers-to-be, andadults affects one’s oral healthd. disproving some long held beliefs

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Q2. Carole Palmer observes thata. pies and pastries have low food value and require more chewingb. lower nutritional quality food needs more chewingc. nutritious foods like fruits and vegetables have less sugar and require morechewingd. too much vitamin B6 or B12 could lead to problems with cleft palateformation

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Q3. According to Palmer

a. asthma is five times less common in childhood than tooth decayb. school kids with tooth decay pain may have concentration problems atschoolc. mouth and dental problems plus a poor diet can affect thinking abilities andbe a factor later on in obesityd. all of the above

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Q4. According to the article :a. it’s important to make sure you retain baby teethb. It’s important that teeth are not exposed for a long time to acids formed byoral bacteria as a result of eating sugary foodsc. it’s important to look after your baby teethd. it’s important that teeth are not exposed to acids formed by oral bacteriafrom sugary foods

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Q5. According to the article, baby teetha. are dispensableb. develop to help eat foodc. if lost prematurely, may result in poor development of permanent teethd. help with correct development of permanent teeth

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Q6. Dental health in older people requiresa. properly fitting denturesb. a calcium rich dietc. nutritious food containing vitamins D and Kd. all of the above

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Q7. The article says that Osteoporosisa. may prevent loss of teethb. may affect jaw bones

c. jaw bone health may be affected by chewing sugar-free gumd. none of the above

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Q8. Lack of salivaa. all of the followingb. results in mouth being cleansed more slowlyc. can be addressed by chewing sugar-free gumd. may increase the risk of tooth decay

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TIME: 45 MINUTES




Global Health Care WorkforceParagraph 1 Health care systems worldwide continue to be plagued by difficulties inrecruiting and retaining health workers, resulting in a shortage of health careprofessionals that is now considered a global crisis. However, although thegap between the need for health care workers and the supply is experiencedglobally, it widens disproportionately, so that the regions with the greatestneed have the fewest workers. For example sub-Saharan Africa and south-east Asia together have 53% of the global disease burden but only 15% of theworld’s health care workforce. Moreover, the shortage experienced by

countries that can least afford it is exacerbated by health worker migration tohigh-income countries. South Africa, for example, has fewer than 7 doctorsper 10,000 people, but reported in 2002 that 14% of the physicians who hadtrained there had emigrated to the US or to Canada.


Paragraph 2 And the problem is not going away as in the UK, US, Canada and Australia,23% C: to 28% of all physicians are international graduates. Efforts to reducemigration usually focus on reducing recruitment by high-income countries,and these efforts are gaining a higher profile. Improving the workingconditions in source countries has not received the same attention, however,even though this would help counter the factors that push health professionalsto seek better conditions elsewhere. It would also make work healthier forthose who remain in lo income countries, and thereby reduce occupationalconcerns such as injuries violence and stress, and exposure to biological,chemical and physical hazards.


Paragraph 3Although concerns about healthy work conditions exist to varying degreesaround the world, they are greatest in nations with few resources, andparticularly in Africa, where work conditions are the most challenging. It iswe] documented that health workers in low and middle-income countriesexperience fear and frustration when caring for patients with tuberculosis andblood—borne diseases, and that they do so often in difficult workenvironments. Health workers may also be ostracised by their owncommunities due to the ever present stigma associated with exposure. It isnow also well established that health workers are indeed at higher risk ofacquiring numerous infectious diseases.


Paragraph 4 International organizations are recognizing the importance of promoting andprotecting the health of the global health care workforce, which isconservatively estimated to be 59 million, and are undertaking constructiveinitiatives to do so. The World Health Organization (WHO) has explicitlyrecognized the need to improve the environment of health care workers inorder to increase retention and is promoting the use of workplace audit

checklists to help guide the reduction of infectious disease transmission inhealth care. WHO is also promoting the immunization of all health careworkers against hepatitis B, and, is working to move forward specificHealthy Hospital Initiatives, which include projects that involve bothinfection control and occupational health practitioners, and that trainpractitioners along with health and safety representatives in conductingworkplace inspections.


Paragraph 5 Canada and other countries that receive health care workers from lowresource settings compromise the workforce in the source country as theysupplement their own. The situation is inequitable and, over time, willundermine those low resources further, worsening the already challengingworking conditions and creating even more pressure for health care workersto emigrate. To offset this effect, high-income countries can reciprocate byimproving working conditions in source countries. British Columbia, whichattracts the highest number of South African physicians of all Canadianprovinces, has taken a step in this positive direction by sharing expertise inoccupational health and infectious p disease transmission control through thePelonomi Hospital project.


Paragraph 6 At the university level, researchers and practitioners can contribute to thisknowledge exchange by partnering with their colleagues in low-incomecountries. Such collaborations are essential. Also needed are intensifiedefforts to promote further integration of worker safety and patient safety. Toensure information systems being developed support this goal, we need topromote evidence based decision making and share our information withthose who can; benefit from it. That way, each region will not need to findmillions of dollars annually to design, implement and maintain separatesystems that could b easily shared and reproduced.


Paragraph 7 To achieve this aim, we need international collaboration in order to reachconsensus on a data dictionary and complete the programming of non-proprietary information systems such as OHASIS, which can be tailored to

different technological environments and made widely available usingCreative Commons licensing. Much of what needs to be done can beaccomplished with simple and effective solutions that benefit both patientsand workers. What it will take is commitment from high-income countries toassist in the development, refinement and implementation of these tools incollaboration with low-income countries. Such endeavours can be madepossible by making them a priority at the national funding level.


QUESTIONSQ1. The main idea presented in paragraph 1 is__________a. Recruiting health care workers is a problem in most countriesb. There is a shortage of health care workers in Sub-Saharan Africa andSoutheast Asiac. There are not enough health care Workers in places which have the highestneed for medical treatmentd. A significant number of South African doctors are migrating to the US andCanada

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Q2. The main point raised by the authors in paragraph 2 is that__________a. there are too many international graduates in UK, US, Canada andAustraliab. high income countries must reduce recruitment of overseas healprofessionalsc. more effort is required to improve work conditions in sourced. work conditions in poorer countries are dangerous

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Q3. According to paragraph 3 which of the following is false regardingconditions in low & middle income countries?a. Work conditions are most difficult in Africab. Health Workers fear exposure to contagious diseasesc. Health Workers feel frustration towards patients

d. Being exposed to infectious diseases may lead to shame within localcommunities.

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Q4. Regarding the size of the global health care workforce, we can inferparagraph 4 that__________a. there may be more than 59 million Workersb. there may be less than 59 million workersc. there are exactly 59 million Workersd. the number of health care workers in unknown

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Q5. According to paragraph 4, which of the following statements is trueregarding WHO?a. WHO realises that improvements in the working environment of healthcareworkers is necessaryb. WHO wants to increase immunisation rates of health care workers againsthepatitis Bc. WHO is advancing Healthy Hospital Initiatives including training andinfection controld. All of the above

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Q6. In paragraph 5 the authors infer that__________a. High-income countries have a responsibility to help build better workingconditions in low-income countriesb. High income countries should not recruit health professionals from low-income countriesc. The working conditions in low-income countries is improvingd. British Columbia has stopped recruiting South African doctors

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Q7. Which of the following is closest in meaning to the word reciprocate?a. helpb. give back

c. supportd. take back

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Q8. According to paragraph 6, which of the following statements is true?a. Researchers and medical practitioners in low & high income countries haveexpressed a desire to work togetherb. Improved safety of health workers and patients is a priorityc. Millions of dollars are needed to develop information systems that can beshared between countriesd. None of the above

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TIME: 15 MINUTES


DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.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 andthe Text Booklet. DO NOT remove OET material from the test room.Tuberculosis, AIDS, and Death among Substance Abusers on Welfare inNew York City

Text ABackground In New York City, the incidence of tuberculosis has more than doubledduring the past decade. We examined the incidence of tuberculosis and theacquired immunodeficiency syndrome (AIDS) and the rate of death from allcauses in a very-high-risk group —indigent subjects who abuse drugs,alcohol, or both. Methods In 2009 we began to study prospectively a cohort of welfare applicants andrecipients 18 to 64 years of age who abused drugs or alcohol. The incidencerates of tuberculosis, AIDS, and death for this group were ascertainedthrough vital records and New York City’s tuberculosis and AIDS registries.

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Text BResults The cohort was followed for eight years. Of the 858 subjects;

tuberculosis developed in 47 (5.5 percent),84 (9.8 percent) were given a diagnosis of AIDS, and

183 (21.3 percent) died. The rates of incidence per 100,000 person- years were744 for tuberculosis,1323 for AIDS, and2842 for death. In this group of welfare clients,the rate of newly diagnosed tuberculosis was 14.8 times that of theage matched general population of New York City;the rate of AIDS was 10.0 times as high;

the death rate was 5.2 times as high.no significant difference in the rate of new cases of tuberculosisbetween subjects with positive skin tests and those with negative skintests at examination in 2009.

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Text CDeaths in the cohort There were 183 deaths in the cohort during follow-up (21.3 percent) of thesubjects, a rate of 2842 deaths per 100,000 person-years, 5.2 times that of theage-matched general population.

Causes of death - Table 3

CAUSES OF DEATH IN THE STUDY GROUP

Causes of death No. of subjects(%)

Average Age at Death(years)

AIDS 66 (36.1%) 40

Infectious diseases 18 (9.8%) 43

Cirrhosis of the liver 16 (8.7%) 43

TB 11 (6%) 42

Coronary artery disease 10 (5.5%) 47

Pneumonia 9 (4.9%) 42

Cancer 8 (4.4%) 54

Overdose of non- narcoticsubstance

8 (4.4%) 42

Other heart disease 7 (3.8%) 43

Drug dependence 4 (2.2%) 37

Alcohol abuse 3 (1.6%) 43

Cerebrovascular disease 3 (1.6%) 47

Diabetes 3 (1.6%) 53

Upper gastrointestinal bleeding 3 (1.6%) 44

Wound 3 (1.6%) 47

Chronic renal failure 2(1.1%) 59

Respiratory arrest 2(1.1%) 46

Other 7 (3.8%) 48

Total 183 43

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Text DConclusions

Of the 47 subjects with tuberculosis, 21 (44.7 percent) died before theend of 2017;12 (57.1 percent) of those who died also had AIDS.Of 15 persons with both tuberculosis and AIDS, 12 (80.0 percent)died before the end of 2017 and 8 died before completing anti-TBtherapy.Of the 84 study subjects with AIDS, 68 (81.0 percent) died before theend of 2017.

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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 therelevant information.• Write your answers on the spaces provided in this QuestionPaper.• Answer all the questions within the 15-minute time limit.• Your answers should be correctly spelt.

QUESTIONS

Questions 1-7For 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 about1. what was the percentage of deaths caused by diabetes in the study group?_____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

2. what was the rate of incidence per 100,000 person per years fortuberculosis? _____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

3. name the city where the study was conducted? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

4. how the incidence rates of diseases and death for the study group wereascertained? _____

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“TextD”

5. how many died before the end of 2017 without completing anti-TBtherapy? _____

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“TextD”

6. what was the average age of subjects died due to other causes in the studygroup? _____

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“TextD”

7. how many years the cohort was followed? _____Goto

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“TextD”

Questions 8-13

Answer each of the questions, 8-13, with a word or short phrase from one ofthe texts. Each answer may include words, numbers or both.8. How many of the study subjects with only AIDS died before the end of

2017?Goto

“TextA”

“TextB”

“TextC”

“TextD”

9. In how many of the study subjects wound was the cause of death?Goto

“TextA”

“TextB”

“TextC”

“TextD”

10. What was the age limits of the study subjects?Goto

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“TextC”

“TextD”

11. When did the study begin?Goto

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“TextB”

“TextC”

“TextD”

12. What was the total number of deaths in the study group?Goto

“TextA”

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“TextD”

13. What was the percentage of deaths caused by respiratory arrest in thestudy group?

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“TextB”

“TextC”

“TextD”

Questions 14-20Complete each of the sentences, 14-20, with a word or short phrasefrom one of the texts. Each answer may include words, numbers orboth.14. The study shows that number of the incidence of tuberculosis inNew York City has more than _____ during the past decade.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

15. In conclusion, 12 of those who died had both AIDS and _____.Goto

“TextA”

“TextB”

“TextC”

“TextD”

16. In the cohort during follow-up of the subjects, rate of deaths was 5.2times that of the _____ general population..

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“TextB”

“TextC”

“TextD”

17. In the group of welfare clients, the rate of ____ was 10.0 times as high.Goto

“TextA”

“TextB”

“TextC”

“TextD”

18. The study was conducted among _____ who abuse drugs, alcohol,or both.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

19. ______ subjects died suffering from coronary artery disease.Goto

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“TextB”

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“TextD”

20. There were _____ subjects in the study group.Goto

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“TextB”

“TextC”

“TextD”



TIME: 45 MINUTES



Part B

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

Incubators for Infant

The general principle is that air is processed before it reaches baby.An electric fan draws room air through a bacterial filter whichremoves dust and bacteria. The filtered air flows over an electric

heating element. The filtered and heated air then passes over awater tank where it is moistened. It then flows on to the incubatorcanopy. The incubator canopy is slightly pressurized. This allowsexpired carbon dioxide to pass back into the room via the ventholes and most of the air to be re-circulated. It also preventsunfiltered air entering the system.1. The extract informs us that the incubatorsA. is likely to circulate most of the air again.B. may not work correctly in close proximity to some otherdevices.C. prevents filtered air entering the system.Nebulizers

A nebulizer is a device used to administer medication in the formof a mist inhaled into the lungs. Nebulizers are commonly used fortreatment of cystic fibrosis, asthma and other respiratory diseases.The reason for using a nebulizer for medicine to be administereddirectly to the lungs is that small aerosol droplets can penetrate intothe narrow branches of the lower airways. Large droplets would beabsorbed by the mouth cavity, where the clinical effect would below. The common technical principle for all nebulizers is to useoxygen, compressed air or ultrasonic power as means to break upmedical solutions or suspensions into small aerosol droplets.2. The notice is giving information aboutA. ways of checking that a nebulizer has been placed correctly.B. how the use of nebulizer is authorised.C. why nebulizer are being used.Oxygen Concentrators

Atmospheric air consists of approximately 80% nitrogen and 20%oxygen. An oxygen concentrator uses air as a source of oxygen byseparating these two components. It utilizes the property of zeolitegranules to selectively absorb nitrogen from compressed air.Atmospheric air is gathered, filtered and raised to a pressure of 20pounds per square inch (psi) by a compressor. The compressed airis then introduced into one of the canisters containing zeolitegranules where nitrogen is selectively absorbed leaving the residualoxygen available for patient use. After about 20 seconds the supplyof compressed air is automatically diverted to the second canisterwhere the process is repeated enabling the output of oxygen tocontinue uninterrupted.3. What does this manual tell us about zeolite granules?A. leave residual oxygen for patient useB. selectively absorb nitrogen from airC. absorb only nitrogen from compressed airArterial blood pressureThe arterial blood pressure (BP) is connected with the force, which is exertedby the blood volume on the walls of the arteries. The level of BP is dependenton two factors: the heart minute ejection volume and the elasticity of arterialwalls. Other factors affecting BP include: the volume and viscosity of theblood, body position and emotional state. The BP at the top of pulse wave(due to the constriction of heart ventricles) is called systolic BP, whereas therespective one during the diastole is called diastolic BP. The differencebetween systolic and diastolic BP is defined as amplitude or pulse pressure.4. Which is the main factor behind BP level?A. the heart minute rejection volumeB. volume and viscosity of the bloodC. elasticity of the arterial wallBasic Life Support

Basic Life Support means saving lives by maintaining airway, supplyingventilation (rescue breathing by blowing air to the victim’s mouth) andsupplying circulation (external cardiac massage – chest compressions)performed without additional equipment. It is the first step in cardio-pulmonary resuscitation (CPR) that should be initiated by bystanders andcontinued until qualified help arrives. Next step is Advanced Life Support(ALS), which is performed by medical services. People with cardiac arrest(CA) need immediate CPR. First aid means BLS that is started by witnessesbefore the emergency service arrival and is the key action in achieving patientsurvival.5. What does this manual tell us about cardio-pulmonary resuscitation?A. should be initiated by bystandersB. should be initiated immediately only for cardiac arrestC. should be performed by medical servicesTypes of surgical threadsMaterials, which the threads are made of, are divided into absorbable andnon- absorbable ones or natural and synthetic sutures. Non-absorbablesutures are applied on the skin and in septic wounds. Absorbable threads,depending on their structure are divided into monofilament, polifilament,braided, plaits, coated and uncoated ones. Time of their absorbing is variedand depends on material properties; it can take from 14 days to 6 months.Absorbing progresses due to enzymatic disintegration and hydrolysis.6. What does this extract from a handbook tell us about absorbable threads?A. absorbing progresses due to enzymatic integration and hydrolysisB. absorbing time is varied and depends on material propertiesC. are divided into monofilament, polifilament, braided, plaits and uncoatedones



TIME: 45 MINUTES




Targeting two important risk factors for cardiovascular disease andother major risk factors that can be lowered by modification, treatment

or controlParagraph 1(ARA) - It’s well known that the prevalence of diabetes is on the rise.According to the Centers for Disease Control and Prevention (CDC), about23.6 million, or nearly 8 percent of people in the United States, have diabetes,and 1.6 million new cases are diagnosed each year in people aged 20 andolder. Type 2 diabetes is the most common form, accounting for about 90 to

95 percent of those diagnosed, and occurs when the body either does notproduce enough insulin or does not respond to insulin.


Paragraph 2But something that many people may not know is that in addition to havingdiabetes, 70 percent of adults with type 2 diabetes also have high LDLcholesterol (LDL-C), the “bad” cholesterol that can cause build-up in thearteries, greatly increasing their risk for cardiovascular disease. Cholesterol isneeded for the body to function normally, but when there is too much LDL-Cin the bloodstream, it is deposited in arteries, including those of the heart,which can limit blood flow and lead to heart disease.


Paragraph 3The American Diabetes Association (ADA) and the American College ofCardiology (ACC) emphasize that it is critical to control both cholesterol andblood sugar Ievels. The ADA recommends that patients with type 2 diabetesaim for an A1C level which reflects your average blood sugar level for thepast two to three months, of less than 7 percent. The National CholesterolEducation Program (NCEP) ATP lll recommends that patients with type 2diabetes target an LDL-C goal of less than 100 mg/dL.


Paragraph 4Treating these two diseases can take a combination of efforts, including ahealthy diet and increased exercise. Medications are also sometimes needed.While there are many drugs approved by the U.S. Food and DrugAdministration (FDA) to treat type 2 diabetes and others available to lowerLDL-C, a drug called Welchol (colesevelam HCI) is the first and onlymedication approved as an adjunct to diet and exercise to reduce both A1C inadults with type 2 diabetes and LDL-C in adults with elevated cholesterol.Welchol addresses both of these chronic health conditions with onemedication and offers the convenience of two formulations, Welchol tabletsand Welchol for Oral Suspension. Welchol can be taken alone or with othercholesterol lowering medications known as statins and can be added to otheranti-diabetic medications (metformin, sulfonylureas, or insulin).


Paragraph 5

“For patients with type 2 diabetes and high LDL cholesterol, it is important tomanage both conditions,” said Yehuda Handelsman, MD, FACP, FACE,Medical Director of the Metabolic Institute of America in Tarzana, Calif.“Welchol reduces these two risk factors for cardiovascular disease in adultswith type 2 diabetes by significantly lowering A1C and LDL-C or ‘bad’cholesterol, providing a unique therapeutic option.” It is important to notethat the affect of Welchol on cardiovascular morbidity and mortality has notbeen determined.


Paragraph 6What are the major uncontrollable risk factors for coronary heartdisease? The American Heart Association has identified several risk factors forcoronary heart disease. Some of them can be modified, treated or controlled,and some can’t. The more risk factors a person has, the greater the chancethat he or she will develop heart disease. Also, the greater the level of eachrisk factor, the greater the risk. For example, a person with a total cholesterolof 300 mg/dL has a greater risk than someone with a total cholesterol of 240mg/dL, even though all people with a total cholesterol of 240 or higher areconsidered high risk.


Paragraph 7Increasing age — About 82% of people who die of coronary heart diseaseare 65 or older. Male sex (gender) — The lifetime risk of developing CHD after age 40 is49% for men and 32% for women. The incidence of CHD in women lagsbehind men I years for total CHD and by 20 years for more serious clinicalevents such as sudden death.


Paragraph 8Heredity (including Race) — Children of parents with heart disease aremore likely to develop it themselves. African Americans have more severehigh blood pressure than Caucasians and a higher risk of heart disease. Heartdisease is also higher among Mexican Americans, American Indians, nativeHawaiians and some Asian Americans. This is partly due to higher rates ofobesity and diabetes. Most people with a strong family history of heart

disease have one or more other risk factors. Just as you can’t control yourage, sex and race, you can’t control your family history. Therefore, it’s evenmore important to treat and control any other risk factors you have.


Paragraph 9Other major risk factors that can be lowered by modification, treatmentor controlTobacco smoke — Smokers’ risk of developing CHD is two to four timesthat nonsmokers‘. Smokers who have a heart attack are more likely to die anddie suddenly (within an hour) than nonsmokers. Cigarette smoking also actswith other risk factors to greatly increase the risk for coronary heart disease.People who smoke cigars or pipes seem to have a higher risk of death fromcoronary heart disease (and possibly stroke), but their risk isn’t as great ascigarette smokers‘. Constant exposure to other people’s smoke — calledenvironmental tobacco smoke, secondhand smoke or passive smoking —increases the risk of heart disease even for nonsmokers.


Paragraph 10High blood cholesterol levels — The risk of coronary heart disease rises asblood cholesterol levels increase. When other risk factors (such as high bloodpressure and tobacco smoke) are present, this risk increases even more. Aperson’s cholesterol level is also affected by age, sex, heredity and diet. High blood pressure — High blood pressure increases the heart’s workload,causing the heart to enlarge and weaken over time. It also increases the riskof stroke, heart attack, kidney failure and heart failure. When high bloodpressure exists with obesity, smoking, high blood cholesterol levels ordiabetes, the risk of heart attack or stroke increases several times.


Paragraph 11Physical inactivity — An inactive lifestyle is a risk factor for coronary heartdisease. Regular, moderate-to-vigorous physical activity is important inpreventing heart and blood vessel disease. Obesity and overweight — People who have excess body fat — especiallyif a lot of it is in the waist area — are more likely to develop heart diseaseand stroke even if they have no other risk factors. Excess weight increases thestrain on the heart, raises blood pressure and blood cholesterol and

triglyceride levels, and lowers HDL (good) cholesterol levels. It can alsomake diabetes more likely to develop. Many obese and overweight peoplehave difficulty losing weight. If you can lose as little as 10 to 20 pounds, youcan help lower your heart disease risk.


Paragraph 12Diabetes mellitus — Diabetes seriously increases the risk of developingcardiovascular disease. Even when glucose levels are under control, diabetesgreatly increases the risk of heart disease and stroke. From two-thirds to three—quarters people with diabetes die of some form of heart or blood vesseldisease.


Paragraph 13What other factors contribute to heart disease risk?Stress — Individual response to stress may be a contributing factor. Somescientists have noted a relationship between coronary heart disease risk andstress in a person’s life, their health behaviors and socioeconomic status.These factors may affect established risk factors. For example, people understress may overeat, start smoking or smoke more than they otherwise would.


Paragraph 14Excessive alcohol intake — Drinking too much alcohol can raise bloodpressure, cause heart failure and lead to stroke. It can contribute to hightriglycerides, cancer and other diseases, and produce irregular heartbeats. Italso contributes to obesity, alcoholism, suicide and accidents. The risk ofheart disease in people who drink moderate amounts of alcohol (an averageof one drink for women or two drinks for men per day) is lower than innondrinkers. One drink is defined as 1-1/2 fluid ounces (fl oz) of 80-proofspirits (such as bourbon, Scotch, vodka, gin, etc.), 1 fl oz of 100- proofspirits, 4 fl oz of wine, or 12 fl oz of beer. It’s not recommended thatnondrinkers start using alcohol or that drinkers increase their intake.


QUESTIONSQ1. According to paragraph 1 of the article states that__________a. Diabetes has stabilised

b. 1.6 million people aged 20 and older have diabetesc. Type 2 diabetes is the most commond. Type 2 diabetes occurs when there is an over-production of insulin

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Q2. In addition to having diabetes__________a. 30% of adult with Type 2 diabetes do not have high counts of low densitylipidsb. 70% of adults with Type 2 diabetes do have high counts of low densitylipidsc. Too many LDLs in the bloodstream go straight to the heartd. LDLs in the bloodstream cannot hinder blood flow

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Q3. According to the ADA and the ACC__________a. Both blood sugar levels and cholesterol levels need to be controlled ifdiabetes is avoidedb. Blood sugar levels need to be controlled if diabetes is to be avoidedc. ACA believes less than 7% average blood sugar level over a one monthperiod indicates diabetes riskd. The NCEP does not recommend Type 2 diabetics aim for less than 100mg/dL of low density lipids

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Q4. Welchol, a drug to lower the level of LDLs in the blood__________a. has not been approved by the U.S. FDAb. Welchol must be taken with other statinsc. Welchol should not be added to medications such as metformin,

sulfonylureas or insulin.d. Welchol needs to be taken together with a healthy diet and an exerciseprogram to reduce A1C in Type 2 diabetics and LDL-C in adults withelevated cholesterol levels.

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Q5. Welchol’s affect on cardiovascular morbidity and mortality...a. is supported by the evidenceb. has not been positively establishedc. has been positively establishedd. none of the above

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Q6. Some risk factors can be controlled, or lowered; some cannot becontrolled: such as advancing age, one’s gender, and one’s geneticinheritance. However, there are some major risk factors that can be lowered— by modifying one’s lifestyle - or by medical intervention.Risk factors such as__________a. high blood pressureb. high cholesterol levelsc. obesityd. all of the above

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Q7. The article states that stress __________a. causes overeating and/or habitual smokingb. does not interact with lifestyle and socioeconomic statusc. depends on how one reacts to it

d. may depend on how one reacts to it

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Q8. Alcohol contributes to heart failure and strokes;a. if you drink very less amountb. moderate alcohol intake leads to less risk of heart diseasec. but not contribute to high triglyceridesd. is not a factor in developing cancer

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TIME: 45 MINUTES




FluorideParagraph 1 Globalization has provoked changes in many facets of human life,particularly in diet. Trends in the development of dental caries in populationhave traditionally followed developmental patterns where, as economiesgrow and populations have access to a wider variety of food products as aresult 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 amore “western” diet, high in carbohydrates and refined sugars. Rapidglobalization of many economies has accelerated this process. These dietary

have a substantial impact on diseases such as diabetes and dental caries.Questions“Q1”“Q2”“Q3”“Q4”“Q5”“Q6”“Q7”“Q8”

Paragraph 2The cariogenic potential of diet emerges in areas where fluoridesupplementation is inadequate. Dental caries is a global health problem andhas a significant negative impact on quality of life, economic productivity,adult and children’s general health and development. Untreated dental cariesin pre-school children is associated with poorer quality of life, pain anddiscomfort, and difficulties in ingesting food that can result in failure to gainweight and impaired cognitive development. Since low-income countriescannot afford dental restorative treatment and in general the poor are mostvulnerable to the impacts of illness, they should be afforded a greater degreeof protection.


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


Paragraph 4More recently, the decline in dental caries amongst school children in Nepalhas been attributed to improved access to affordable fluoride toothpaste. Formany low-income nations, fluoride toothpaste is probably the only realisticpopulation strategy for the control and prevention of dental caries sincecheaper alternatives such as water or salt fluoridation are not feasible due topoor infrastructure and limited financial and technological resources. The useof topical fluoride e.g. in the form of varnish or gels for dental cariesprevention is similarly impractical since it relies on repeated applications of

fluoride by trained personnel on an individual basis and therefore in terms ofcost cannot be considered as part of a population based preventive strategy.


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


Paragraph 6 Taxes and tariffs on fluoride toothpaste can also significantly contribute tohigh prices, lower demand and inequity since they target the poor.Toothpastes are u; classified as a cosmetic product and as such often highlytaxed by governments. For example, various taxes such as excise tax, VAT,local taxes as well as taxation on the ingredients and packaging contribute to25% of the retail cost of toothpaste in Ne and India, and 50% of the retailprice in Burkina Faso. WHO continues to recommend the removal taxes andtariffs on fluoride toothpastes. Any lost revenue can be rest by higher taxeson sugar and high sugar containing foods, which are common risk factors fordental caries, coronary heart disease, diabetes and obesity.


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


Paragraph 8 In view of the current extremely inequitable use of fluoride throughoutcountries and regions, all efforts to make fluoride and fluoride toothpasteaffordable and accessible must be intensified. As a first step to addressing theissue of affordability of fluoride toothpaste in the poorer countries in-depthcountry studies should be undertaken to analyze the price of toothpaste in thecontext of the country economies.


QUESTIONSQ1. Which of the following would be the most appropriate heading for theparagraph 1?a. High sugar intake and increasing tooth decayb. Globalisation, dietary changes and declining dental healthc. Dietary changes in developing nationsd. Negative health effects of a western diet

Para-graphs

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Q2. Which of the following is not mentioned as a negative effect of untreateddental caries in pre-school children?a. Decreased mental alertnessb. Troubling chewing and swallowing foodc. Lower life qualityd. Reduced physical development

Para-graphs

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Q3. According to paragraph 3, which of the following statement is correct?a. Dental caries is the most contagious disease on earth.b. Fluoride in drinking water is effective but rarely usedc. 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.

Para-graphs

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Q4. Fluoride toothpaste is considered the most effective strategy to reducedental 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.

Para-graphs

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Q5. Which of the following is closest in meaning to the word impede?a. stopb. preventc. hinderd. postpone

Para-graphs

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Q6. Regarding the issue of taxation in paragraph 6 which of the followingstatements 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 isclassified as a cosmetic.d. WHO suggests taxing products with a high sugar content instead oftoothpastes.

Para- “1”“2”“3”“4”

graphs“5”“6”“7”“8”Q7. Which of the following is closest in meaning to the word advocacy?a. marketingb. demandc. developmentd. support

Para-graphs

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Q8. Statistics in paragraph 7 indicate that....a. local products can’t compete with global products and make a profit at thesame time.b. Philippine produced toothpaste is profitable while being less than half theprice of global brands.c. in Nepal, fluoride toothpaste is limited to imported products which are veryexpensived. toothpaste produced in the Philippines has a higher profit margin thaninternationally produced toothpaste.

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TIME: 15 MINUTES


DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.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 andthe Text Booklet. DO NOT remove OET material from the test room.Text AEconomy Class SyndromeInternational flights are suspected of contributing to the formation of DVT insusceptible people, although the research evidence is currently divided. Someairlines prefer to err on the side of caution and offer suggestions topassengers on how to reduce the risk of DVT. Suggestions include:

Wear loose clothesAvoid cigarettes and alcoholMove about the cabin whenever possibleDon’t sit with your legs crossedPerform leg and foot stretches and exercises while seated

Consult with your doctor before travelling

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Text BPrevious researchVenous thrombosis was first linked to air travel in 1954, and as air travel hasbecome more and more common, many case reports and case series havebeen published since. Several clinical studies have shown an associationbetween air travel and the risk of venous thrombosis. English researchersproposed, in a paper published in the Lancet, that flying directly increases aperson’s risk. The report found that in a series of individuals who diedsuddenly at Heathrow Airport, death occurred far more often in the arrivalthan in the departure area.Two similar studies reported that the risk of pulmonary embolism in airtravelers increased with the distance traveled. In terms of absolute risk, twostudies found similar results: one performed in New Zealand found afrequency of 1% of venous thrombosis in 878 individuals who had traveledby air for at least 10 hours. The other was a German study which foundvenous thrombotic events in 2.8% of 964 individuals who had traveled formore than 8 hours in an airplane. In contrast, a Dutch study found no linkbetween DVT and long distance travel of any kind.

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Text CSymptoms

Pain and tenderness in the legPain on extending the footTenderness in calf (the most important sign)

Swelling of the lower leg, ankle and footRedness in the leg

Bluish skin discolorationIncreased warmth in the leg

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Text DTravel-Related Venous Thrombosis: Results from a Large Population-Based Case ControlStudy Background

Recent studies have indicated an increased risk of venous thrombosis after airtravel. Nevertheless, questions on the magnitude of risk, the underlyingmechanism, and modifying factors remain unanswered. Methods We studied the effect of various modes of transport and duration of travel onthe risk of venous thrombosis in a large ongoing case-control study on riskfactors for venous thrombosis in an unselected population. We also assessedthe combined effect of travel in relation to body mass index, height, and oralcontraceptive use. Since March 2015, consecutive patients younger than 70years of age with a first venous thrombosis have been invited to participate inthe study, with their partners serving as matched control individuals.Information has been collected on acquired and genetic risk factors forvenous thrombosis. ResultsOf 1,906 patients, 233 had traveled for more than 4 hours in the 8 weekspreceding the event. Traveling in general was found to increase the risk ofvenous thrombosis. The risk of flying was similar to the risks of traveling bybus or train. The risk was highest in the first week after traveling. Travel bybus, or train led to a high relative risk of thrombosis in individuals with factorV Leiden, in those who had a body mass index of more than 30, those whowere more than 190 cm tall, and in those who used oral contraceptives. Forair travel these people shorter than 160 cm had an increased risk ofthrombosis after air travel as well. Conclusions

The risk of venous thrombosis after travel is moderately increased for allmodes of travel. Subgroups exist in which the risk is highly increased.

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Part ATIME: 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 therelevant information.• Write your answers on the spaces provided in this QuestionPaper.• Answer all the questions within the 15-minute time limit.• Your answers should be correctly spelt.

QUESTIONS

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

In which text can you find information about

1. what are the symptoms of DVT? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

2. how much risk of DVT is there in the first week after traveling? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

3. what is the most important sign of DVT? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

4. when did DVT was first linked to air travel? _____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

5. what are the safe practices to reduce the risk of DVT? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

6. which exercises reduce the risk of DVT? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

7. what were the conclusions of the Dutch study on DVT? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

Questions 8-13

Answer each of the questions, 8-13, with a word or short phrase from one ofthe texts. Each answer may include words, numbers or both.8. What is the type of skin discolouration seen in DVT patients?

Goto

“TextA”

“TextB”

“TextC”

“TextD”

9. What type of clothes reduce the risks of DVT?Goto

“TextA”

“TextB”

“TextC”

“TextD”

10. Which type of flights are more suspected of contributing to the formationof DVT?

Goto

“TextA”

“TextB”

“TextC”

“TextD”

11. Name the physical activity which was found to increase the risk ofDVT in general?

Goto

“TextA”

“TextB”

“TextC”

“TextD”

12. Which type of population was the subject for travel relatedDVT study?

Goto

“TextA”

“TextB”

“TextC”

“TextD”

13. Name the body part/s were tenderness was observed as a symptom of

DVT?Goto

“TextA”

“TextB”

“TextC”

“TextD”

Questions 14-20Complete each of the sentences, 14-20, with a word or short phrasefrom one of the texts. Each answer may include words, numbers orboth.14. The risk of flying was similar to the risks of traveling by _____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

15. Recent studies have indicated an increased risk of venous thrombosisafter _____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

16. _____ of the lower leg, ankle and foot is a symptom of DVT.Goto

“TextA”

“TextB”

“TextC”

“TextD”

17. Several _____ have shown an association between air travel and the riskof venous thrombosis.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

18. _____ in general was found to increase the risk of venous thrombosis.Goto

“TextA”

“TextB”

“TextC”

“TextD”

19. Venous thrombosis was first linked to air travel in ______.Goto

“TextA”

“TextB”

“TextC”

“TextD”

20. Some airlines offer _____ to passengers on how to reduce the risk ofDVT.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

Answer Key


TIME: 45 MINUTES



Part B


FlowmeterA flowmeter is an instrument used to measure the flow rate of aliquid or a gas. In healthcare facilities, gas flowmeters are used todeliver oxygen at a controlled rate either directly to patients orthrough medical devices. Oxygen flowmeters are used on oxygen

tanks and oxygen concentrators to measure the amount of oxygenreaching the patient or user. Sometimes bottles are fitted tohumidify the oxygen by bubbling it through water.1. The purpose of bottles that are fitted with flowmeter is toA. humidify the oxygen tanks by bubbling it through waterB. humidify the oxygen reaching the patient or userC. dehumidify the gas in the flowmeterPulse Oximeters: Non-invasive monitorsThe coloured substance in blood, haemoglobin, is carrier of oxygenand the absorption of light by haemoglobin varies with the amountof oxygenation. Two different kinds of light (one visible, oneinvisible) are directed through the skin from one side of a probe,and the amount transmitted is measured on the other side. Themachine converts the ratio of transmission of the two kinds of lightinto a % oxygenation. Pulse oximeter probes can be mounted onthe finger or ear lobe.2. What does this notes tell us about pulse oximeters?A. levels varies with amount of oxygenationB. converts percent of light into a % oxygenationC. probes can be mounted either on finger or earlobeMeasuring Patient Weight

Measuring patient weight is an important part of monitoring healthas well as calculating drug and radiation doses. It is therefore vitalthat scales continue to operate accurately. They can be used for allages of patient and therefore vary in the range of weights that aremeasured. They can be arranged for patients to stand on, or can beset up for weighing wheelchair bound patients. For infants, thepatient can be suspended in a sling below the scale or placed in a

weighing cot on top of the scale.

3. These notes are reminding staff that theA. importance of precise reading of scales to monitor health ofpatientB. infants should stand in a weighing cot on top of the scaleC. wheelchair bound patients should be suspended in a set upBreast ExaminationDetection of changes in the breast depends on routine medicalcheck-ups, especially by an oncologist, regular breast scanning andmammography, and women’s self-examination. If early detected, atumor is usually small, and the smaller it is, the less probability ofmetastases. Early detection considerably improves prognosis inwomen with breast cancer. Mammography enables detection ofbreast cancer at least one year ahead of its manifestations. Thesmallest clinically palpable tumor is about 1 cm in size.

4. The purpose of these notes about mammography is toA. help maximise awareness about its efficiencyB. give guidance on early detection and prognosisC. decrease probability of metastasesCatheterization

Regardless of the instrumental examination carried out in theurinary tract, it is obligatory to maintain perfectly sterileconditions, to apply analgesic and sedative drugs in order toalleviate patient’s suffering, and to use gel substances that facilitatethe introduction of the instrument into the urinary tract. Whileintroducing instruments into the bladder, it is necessary toremember about overcoming the resistance of the urethral sphincter

gently.

5. What must all staff involved in the catheterization process do?A. maintain perfect aseptic conditionsB. use non lubricant substancesC. inhibit analgesic and sedative drugsOphthalmoscopyDirect ophthalmoscopy is the most common method of examiningthe eye fundus. It provides a 15x magnified upright image of theretina. Ophthalmoscopy is much easier through a dilated pupil.Tropicamide 1% drops (0.5% for children) are recommended. Thepupil mydriasis starts 10 to 20 minutes after installation and lastsfor 6-8 hours. There is a small risk of angle closure glaucomacaused by mydriasis in eyes with shallow anterior chambers,particularly in elderly patients.

6. The guidelines establish that the healthcare professional shouldA. recommend 1% drops of Tropicamide for elderly patientsB. recommend 5% drops of Tropicamide for childrenC. recommend 10% drops of Tropicamide for elderly patients



TIME: 45 MINUTES




Is ADHD a valid diagnosis in adults?Paragraph 1 Attention deficit hyperactivity disorder (ADHD) is well established inchildhood, with 3.6% of children in the United Kingdom being affected.Most regions have child and adolescent mental health or paediatric servicesfor ADHD. Follow-up studies of children with ADHD find that 15% stillhave the full diagnosis at 25 years, and a further 50% are in partial remission,with some symptoms associated with clinical and psychosocial impairmentspersisting.


Paragraph 2 ADHD is a clinical syndrome defined in the Diagnostic and StatisticalManual of Mental Disorders, fourth edition, by high levels of hyperactive,impulsive, and inattentive behaviours in early childhood that persist overtime, pervade across situations, and lead to notable impairments. ADHD isthought to result from complex interactions between genetic andenvironmental factors.


Paragraph 3 Proof of validity. Using the Washington University diagnostic criteria, theNational Institute for Health and Clinical Excellence (NICE) reviewed thevalidity of the system used to diagnose ADHD in children and adults.


Paragraph 4 Symptoms of ADHD are reliably identifiable. The symptoms used to defineADHD are found to cluster together in both clinical and population samples.Studies in such samples also separate ADHD symptoms from conductproblems and neuro developmental traits. Twin studies show a distinctpattern of genetic and environmental influences on ADHD compared withconduct problems, and overlapping genetic influences between ADHD andneuro developmental disorders such as autism and specific readingdifficulties. Disorders that commonly, but not invariably, occur in adults withADHD include antisocial personality, substance misuse, and depression.


Paragraph 5 Symptoms of ADHD are continuously distributed throughout the population.As with anxiety and depression, most people have symptoms of ADHD atsome time. The disorder is diagnosed by the severity and persistence ofsymptoms, which are associated with high levels of impairment and risk fordeveloping co—occurring disorders. ADHD should not be diagnosed tojustify the use of stimulant drugs to enhance performance in the absence of awider range of impairments indicating a mental health disorder.


Paragraph 6 ADHD symptoms have been tracked from childhood through adolescence

into adult life. They are relatively stable over time with a variable outcome inwhich around two thirds show persistence of symptoms associated withimpairments. Current evidence defines the syndrome as being associated withacademic difficulties, impaired family relationships, social difficulties, andconduct problems. Cross sectional and longitudinal follow-up studies ofadults with ADHD have reported increased rates of antisocial behaviour, drugmisuse, mood and anxiety disorders, unemployment, poor work performance,lower educational performance, traffic violations, crashes, and criminalconvictions.


Paragraph 7 Several genetic, environmental, and neurobiological variables distinguishADHD from non-ADHD cases at group level, but are not sufficientlysensitive or specific to diagnose the syndrome. A family history of ADHD isthe strongest predictor—parents of children with ADHD and offspring ofadults with ADHD are at higher risk for the disorder. Heritability is around76%, and genetic associations have been identified. Consistently reportedassociations include structural and functional brain changes, andenvironmental factors (such as maternal stress during pregnancy and severeearly deprivation).


Paragraph 8 The effects of stimulants and atomoxetine on ADHD symptoms in adults aresimilar to those seen in children. Improvements in ADHD symptoms andmeasures of global function are greater in most studies than are reported indrug trials of depression. The longest controlled trial of stimulants in adultsshowed improvements in these response measures over six months.Stimulants may enhance cognitive ability in some people who do not haveADHD, although we are not aware of any placebo controlled trials of theeffects of stimulants on work or study related performance in healthypopulations. This should not, however, detract from their specific use toreduce symptoms and associated impairments in adults with ADHD.


Paragraph 9 Psychological treatments in the form of psychoeducation, cognitivebehavioural therapy, supportive coaching, or help with organising daily

activities are thought to be effective. Further research is needed because theevidence base is not strong enough to recommend the routine use of thesetreatments in clinical practice.


Paragraph 10 Conclusions. ADHD is an established childhood syndrome that often (inaround 65% of cases) persists into adult life. NICE guidelines are a milestonein the development of effective clinical services for adults with ADHD.Recognition of ADHD in primary care and referral to secondary or tertiarycare specialists will reduce the psychiatric and psychosocial morbidityassociated with ADHD in adults.


QUESTIONSQ1. The article reports what proportion of diagnosed children present withADHD in adulthood?a. Halfb. 3.6%c. A quarterd. 15%

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Q2. According to the article __________a. ADHD is triggered by genetic factorsb. ADHD is the result of environmental factorsc. both A and B.d. neither A nor B.

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Q3. According to the article symptoms __________a. vary across clinical and population samples.b. varies across situational factors.c. need to pervade across time and situations for a diagnosis to be made.d. are not reliably identifiable.

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Q4. Which co-occurring disorders does ADHD frequently present with?a. Antisocial personality disorder.b. Substance misuse.c. Depression.d. All of the above.

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Q5. According to the article, which one of the following statements aboutADHD is FALSE?a. The use of stimulants is justified in the absence of a wider range ofimpairments.b. Symptoms of ADHD are evenly prevalent throughout the population.c. The criteria for diagnosis measure the severity and persistence ofsymptoms.d. High levels of impairment and risk for developing co-occurring disordersare related with ADHD.

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Q6. Which heading would best describe paragraph 6?a. Symptoms associated with impairments.b. ADHD and outcomes in adulthood.c. Further definition of the syndrome.d. none of the above

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Q7. The strongest predictor of ADHD is__________a. Diagnostic and Statistical Manual of Mental Disorders, fourth edition.b. Social and academic impairment.c. Heritability.d. Family environment.

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Q8. The effectiveness of atomoxetine on ADHD symptoms is __________

a. less than described in drug trials of depression.b. greater when measured over six months.c. reduced in adults with ADHD.d. known to improve measures of global functioning.

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TIME: 45 MINUTES




Risks and Benefits of Hormone Replacement TherapyParagraph 1 Several recent large studies have provoked concern amongst both healthprofessionals and the general public regarding the safety of hormonereplacement therapy (HRT). This article provides a review of the currentliterature surrounding the risks and benefits of HRT in postmenopausalwomen, and how the data can be applied safely in everyday clinical practice.


Paragraph 2

Worldwide, approximately 47 million women will undergo the menopauseevery year for the next 20 years. The lack of circulating oestrogens whichoccurs during the transition to menopause presents a variety of symptomsincluding hot flushes, night sweats, mood disturbance and vaginal atrophy,and these can be distressing in almost 50% of women.


Paragraph 3 For many years, oestrogen alone or in combination with progestogens,otherwise known as hormone replacement therapy (HRT), has been thetreatment of choice for control of problematic menopausal symptoms and forthe prevention of osteoporosis. However, the use of HRT declined worldwidefollowing the publication of the first data from the Women’s Health Initiative(WHI) trial in 2002.


Paragraph 4 The results led to a surge in media interest surrounding HRT usage, with therevelation that there was an increased risk of breast cancer and, contrary toexpectation, coronary heart disease (CHD) in those postmenopausal womentaking oestrogen plus progestogen HRT. Following this, both the Heart andEstrogen/Progestin Replacement Study Follow-up (HERS II) and the MillionWomen Study published results which further reduced enthusiasm for HRTuse, showing increased risks of breast cancers and venous thromboembolism(VTE), and the absence of previously suggested cardioprotective effects inHRT users. The resulting fear of CHD and breast cancer in HRT users leftmany women with menopausal symptoms and few effective treatmentoptions.


Paragraph 5 Continued analysis of data relating to these studies has been aimed atunderstanding whether or not the risks associated with HRT are, in fact,limited to a subset of women. A recent publication from the InternationalMenopause Society has stated that HRT remains the first-line and mosteffective treatment for menopausal symptoms. In this article we examine theevidence that has contributed to common perceptions amongst healthprofessionals and women alike, and clarify the balance of risk and benefit tobe considered by women using HRT.


Paragraph 6 One of the key messages from the WHI in 2002 was that HRT should not beprescribed to prevent age-related chronic disease, in particular CHD. Thiswas contradictory to previous advice based on observational studies.However, recent subgroup analysis has shown that in healthy individualsusing HRT in the early postmenopausal years (age 50-59 years), there was noincreased CHD risk and HRT may potentially have a cardioprotective effect.


Paragraph 7 Recent WHI data has suggested that oestrogen-alone HRT in compliantwomen under 60 years of age delays the progression of atheromatous disease(as assessed by coronary arterial calcification). The Nurses Health Study, alarge observational study within the USA, demonstrated that the increase instroke risk appeared to be modest in younger women, with no significantincrease if used for less than five years.


Paragraph 8 Hormone replacement therapy is associated with beneficial effects on bonemineral density, prevention of osteoporosis and improvement in osteoarthriticsymptoms. The WHI clearly demonstrated that HRT was effective in theprevention of all fractures secondary to osteoporosis. The downturn in HRTprescribing related to the concern regarding vascular and breast cancer risksis expected to cause an increase in fracture risk, and it is predicted that in theUSA there will be a possible excess of 243,000 fractures per year in the nearfuture.


Paragraph 9 The WHI results published in 2002 led to a significant decline in patient andclinician confidence in the use of HRT. Further analysis of the data hasprompted a re-evaluation of this initial reaction, and recognition that manywomen may have been ‘denied’ treatment. Now is the time to responsiblyrestore confidence regarding the benefit of HRT in the treatment ofmenopausal symptoms when used judiciously. Hormone replacement therapyis undoubtedly effective in the treatment of vasomotor symptoms, andconfers protection against osteoporotic fractures.

Questions“Q1”“Q2”“Q3”“Q4”“Q5”“Q6”“Q7”“Q8”Paragraph 10 The oncologic risks are relatively well characterised and patients consideringHRT should be made aware of these. The cardiovascular risk of HRT inyounger women without overt vascular disease is less well defined andfurther work is required to address this important question. In the interim,decisions regarding HRT use should be made on a case—by—case basisfollowing informed discussion of the balance of risk and benefit. The lowestdose of hormone necessary to alleviate menopausal symptoms should beused, and the prescription reviewed on a regular basis.


QUESTIONSQ1. Which statement is the closest match to the description of the recentstudies in Paragraph1?a. They demand a prompt review of current HRT practices.b. They have shown that HRT can be used safely in clinical practice.c. They have decreased the confidence of doctors and the public in HRT.d. They have given menopausal women a new confidence to undergo HRT.

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Q2. Which statement is the closest match to the description of projectedmenopause figures in Paragraph 2?a. 47 international women will enter menopause annually for the next 20years.b. All women are likely to go through menopause if they live long enough.c. 47 million women globally will enter menopause each year for the next 20years.d. Most women will succumb to menopause if they do not undertake HRT.

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Q3. What cause does the article cite for the symptoms of menopause?a. Lack of circulationb. Agec. Low progesterone levels

d. Low circulating estrogen levelsParagraphs“1”“2”“3”“4”“5”“6”“7”“8”“9”“10”

Q4. What has been the effect of the 2002 WHI study?a. HRT has become less popular.b. HRT has increased in popularity as the treatment of choice for problematicmenopause symptoms.c. There has been an increase in combined estrogen and progesterone therapy.d. The women’s health initiative has since been established to investigateHRT.

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Q5. Why were many women left with menopausal symptoms and noeffective treatment?a. They were unable to afford HRT treatments.b. They were concerned about coronary heart disease and breast cancer.c. They were concerned about breast cancer and venous thromboembolism.d. They were concerned about breast cancer and the cardioprotective effects.

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Q6. Which of these statements is a TRUE summary of Paragraph 5?a. Surveys since WHI have attempted to find out if the WHI results arerepresentativeb. Results of past surveys are only valid for a subset of women, whether ornot the public is aware of this.c. The present study aims to show that HRT is safer than previously believed.d. Women should ask their doctors to clarify the balance of risks and benefitsof HRT

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Q7. Which study showed an increased risk of VTE?a. The Nurses Health Studyb. The Million Women Studyc. The Women‘s Health Initiative Study

d. The WISDOM StudyParagraphs“1”“2”“3”“4”“5”“6”“7”“8”“9”“10”

Q8. Which of the following does the article recommend HRT should NOT beused to treat’?a. Vasomotor symptomsb. Atheromatous diseasec. Age-related chronic diseased. Osteoarthritic symptoms

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TIME: 15 MINUTES


DO NOT open this Question Paper or the Text Booklet untilyou are told to do so. Write your answers on the spaces provided on this QuestionPaper.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 andthe Text Booklet. DO NOT remove OET material from the test room.Text ASTART ‘EM YOUNG — ‘CIGARETTE WITH YOUR MORNINGBREAST MILK?’US researchers have found altered sleep patterns amongst breastfed infants ofmothers who smoke. Julie Mannella from the Monell Chemical SensesCentre in Philadelphia recruited 15 breastfeeding mothers who smoked. Sleepand activity patterns in their babies, which were aged between two and sixmonths, were monitored on two occasions over a three-hour period after thechildren were fed. On both occasions the mothers were asked to abstain fromsmoking for 12 hours before the study, but on one of the two occasions theywere allowed to smoke just before they fed their babies. The women werealso asked to avoid caffeinated drinks during the study.

Text B

Tests on the milk from mothers who had recently smoked confirmed that thebabies were receiving a significant increase in nicotine dose, and the teamfound that the amount of sleep taken during the following three hours bythese babies fell from an average of 85 minutes to 53 minutes, a drop ofalmost 40%. This is probably due to the neuro-stimulatory effects of nicotine,which has been shown to inhibit regions of the brain which are concernedwith controlling sleep. It may also, suggests Manella, explain why neonatalnicotine exposure has been linked in the past with long-term behavioural andlearning deficits, since these could be the consequence of sleep disturbance.In light of these findings, mothers who smoke might want to considerplanning their smoking around their breastfeeding. Nicotine levels in milkpeak 30-60 minutes after smelting, but take three hours to return to baseline,so this might be feasible.

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Text CCigarette smokeWhat is in smoke?Scientific studies show that there can be around 4000 chemicals in cigarettesmoke. They can be breathed in by anyone near a smoker. They can also stickto clothes, hair, skin, walls and furniture.Some of these chemicals are:

tar - which has many chemicals in it some of which cause cancercarbon monoxide - reduces the oxygen in blood - so people candevelop heart diseasepoisons - including arsenic, ammonia and cyanide.

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Text DPassive smoking and respiratory function in very low birth weight

childrenAbstractAim

To determine if an adverse relationship exists between passive smoking andrespiratory function in very low birth weight (VLBW) children at 11 years ofage.SettingThe Royal Women’s Hospital. Melbourne.Patients154 consecutive surviving children of less than 1501 g birth weight bornduring the 18 months from 1 October 2006.MethodsRespiratory function of 120 of the 154 children (77.9%) at 11 years of agewas measured. Exposure to passive smoking was established by history; nochildren were known to be actively smoking. The relationships betweenvarious respiratory function variables and the estimated number of cigarettessmoked by household members per day were analysed by linear regressionResultsMost respiratory function variables reflecting airflow were significantlydiminished with increasing exposure to passive smoking. In addition,variables indicative of air-trapping rose significantly with increasingexposure to passive smoking.ConclusionsPassive smoking is associated with adverse respiratory function in survivingVLBW children at 11 years of age. Continued exposure to passive smoking,or active smoking, beyond 11 years may lead to further deterioration inrespiratory function in these children.

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Part ATIME: 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 QuestionPaper.• Answer all the questions within the 15-minute time limit.• Your answers should be correctly spelt.

QUESTIONS

Questions 1-7For each question, 1-7, decide which text (A, B, C or D) the informationcomes from. You may use any letter more than once.In which text can you find information about1. how many chemicals are there in cigarette smoke? _____

Goto

“TextA”

“TextB”

“TextC”

“TextD”

2. which chemical/s in cigarette smoke cause/s cancer? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

3. when does nicotine levels in breast milk reach at peak? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

4. How does exposure to passive smoking was established in the study?_____

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“TextA”

“TextB”

“TextC”

“TextD”

5. what happened to respiratory function variables reflecting airflow in thestudy? _____

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“TextA”

“TextB”

“TextC”

“TextD”

6. what are the side effects of neonatal nicotine exposure? _____Goto

“TextA”

“TextB”

“TextC”

“TextD”

7. what are the poisons in cigarette smoke? _____

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“TextA”

“TextB”

“TextC”

“TextD”

Questions 8-13


8. How much percentage does the sleep drop in the babies who hadsignificant nicotine dose?

Goto

“TextA”

“TextB”

“TextC”

“TextD”

9. How much percentage of children at 11 years of age was measured forrespiratory function?

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“TextA”

“TextB”

“TextC”

“TextD”

10. What was the maximum birth weight of babies who were considered forthe study?

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“TextA”

“TextB”

“TextC”

“TextD”

11. Which chemical component in cigarette smoke reduces theoxygen in blood?

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“TextA”

“TextB”

“TextC”

“TextD”

12. Who recruited subjects for the study conducted by MonellChemical Senses Centre?

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“TextA”

“TextB”

“TextC”

“TextD”

13. Which chemical component in cigarette smoke is responsible forheart disease?

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“TextA”

“TextB”

“TextC”

“TextD”

Questions 14-20Complete each of the sentences, 14-20, with a word or short phrase

from one of the texts. Each answer may include words, numbers orboth.14. If children are continually exposed to active smoking, it can lead to_____ in respiratory function.

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“TextA”

“TextB”

“TextC”

“TextD”

15. Cigarette smoke can be breathed in by anyone near a _____.Goto

“TextA”

“TextB”

“TextC”

“TextD”

16. During the study some women were asked to avoid _____.Goto

“TextA”

“TextB”

“TextC”

“TextD”

17. _____ can also stick to clothes, hair, skin, walls and furniture.Goto

“TextA”

“TextB”

“TextC”

“TextD”

18. Variables indicative of _____ rose significantly with increasing exposureto passive smoking.

Goto

“TextA”

“TextB”

“TextC”

“TextD”

19. _____ of nicotine can inhibit regions of the brain which control sleep.Goto

“TextA”

“TextB”

“TextC”

“TextD”

20. The relationships between respiratory function variables and number ofcigarettes smoked per day were analysed by _____.

Goto

“TextA”

“TextB”

“TextC”

“TextD”



TIME: 45 MINUTES



Part B


B.P. sets: Functioning

The cuff on the arm is inflated until blood flow in the artery isblocked. As the cuff pressure is decreased slowly, the sounds ofblood flow starting again can be detected. The cuff pressure at this

point marks the high (systolic) pressure of the cycle. When flow isunobstructed and returns to normal, the sounds of blood flowdisappear. The cuff pressure at this point marks the low (diastolic)pressure.1. When should one note the diastolic pressure of patient?A. blood flow is limited to make the sound disappearB. blood flow is normal and the sound disappearC. blood flow is obstructed and the sound disappearAspirators

Suction is generated by a pump. This is normally an electricallypowered motor, but manually powered versions are also oftenfound. The pump generates a suction that draws air from a bottle.The reduced pressure in this bottle then draws the fluid from thepatient via a tube. The fluid remains in the bottle until disposal ispossible. A valve prevents fluid from passing into the motor itself.

2. The purpose of bottle in aspirator is toA. deliver suction that draws airB. draw the fluid from the patientC. keep pressure stable if valve prevents fluid

Operating Theatre and Delivery Tables

Where the table has movement, this will be enabled by unlocking acatch or brake to allow positioning. Wheels have brakes on the rimor axle of the wheel, while locks for moving sections will normallybe levers on the main table frame. Care should be taken that theuser knows which lever applies to the movement required, as injuryto the patient or user may otherwise result. The table will be set at

the correct height for patient transfer from a trolley then adjustedfor best access for the procedure.

3. The email is reminding user that theA. importance of lever for the required movementsB. locks of moving wheels are on main table frameC. table should be set at correct height of the patientMethods of reporting hospital infection

A mass outbreak of a hospital infection, which can result in severeinjury or death, must be reported without delay, by telephone, faxor e-mail to the local public health protection authority (usually tothe regional hygiene departments). The following cases are subjectto the reporting of hospital infections:• Severe injury, as a result of hospital infection• A mass outbreak• An infection that led to the death of a patient

4. The guidelines establish that the healthcare professional shouldA. report a mass outbreak of hospital infection immediatelyB. report severe injury, as a result of hospital infection with delayC. report an infection that led to the death of a patient onlyAdmission and treatment in medical and social care facilities

Hygiene requirements for the admission and treatment of patientsat medical inpatient facilities, day care and outpatient care facilitiesare set out in the operating rules of each healthcare provider, andalways take into consideration the nature and scope of activity, andthe type of healthcare provided. The receiving healthcareprofessional at the healthcare facility such as an inpatient facility,

day care or social care facility, records anamnesis information thatis significant in terms of the potential occurrence of hospitalinfection, including travel and epidemiological anamnesis, orconducts an examination of the overall health of the individual.

5. This guideline extract says that hygiene requirements areA. determined by the healthcare professionalB. implemented by the healthcare providerC. written in the operating rules of the facilitiesTreatment of used contagious and surgical linen

The healthcare provider and the laundry contractually agree on asystem for classifying and labelling containers according to thecontent (e.g. in colour or numerical) and the procedure in terms ofthe quantity, deadlines and handling is documented. Linen is sortedat the place of use but it is not counted. The linen is not to beshaken before placing into the containers in the ward. It is sortedinto bags according to the degree of soiling, type of material andcolour.

6. The purpose of this email is toA. report on a rise in used contagious and surgical linen inhealthcare facilityB. explain the background to a change healthcare provider and thelaundry contractC. remind staff about procedures for treatment of used contagiousand surgical linen

Answer Key


TIME: 45 MINUTES




Pancreatic Islet TransplantationParagraph 1The pancreas, an organ about the size of a hand, is located behind the lowerpart of the stomach. It makes insulin and enzymes that help the body digestand use food. Spread all over the pancreas are clusters of cells called theislets of Langerhans. Islets are made up of two types of cells: alpha cells,which make glucagon, a hormone that raises the level of glucose (sugar) inthe blood, and beta cells, which make insulin.


Paragraph 2Islet Functions Insulin is a hormone that helps the body use glucose f energy. If your betacells do not produce enough insulin, diabetes will develop. In type 1 diabetes,the insulin shortage is caused by an autoimmune process in which the body’simmune system destroys the beta cells.


Paragraph 3Islet TransplantationIn an experimental procedure called islet transplantation, islets are taken froma donor pancreas and transferred into another person. Once implanted, thebeta cells in these is begin to make and release insulin. Researchers hope that;transplantation will help people with type 1 diabetes live without dailyinjections of insulin.


Paragraph 4Research Developments Scientists have made many advances in islet transplantation recent years.Since reporting their findings in the June issue of the New England Journal ofMedicine, researchers the University of Alberta in Edmonton, Canada, havecontinued to use a procedure called the Edmonton protocol to transplantpancreatic islets into people with type 1 diabetes. According to the ImmuneTolerance Network (ITN), as of June 2003, about 50 percent of the patientshave remained insulin—free up to g 1 year after receiving a transplant.Researchers use specialized enzymes to remove islets from the pancreas of adeceased donor. Because the islets are fragile, transplantation occurs soonafter they are removed.


Paragraph 5During the transplant, the surgeon uses ultrasound to guide placement of asmall plastic tube (catheter) through the upper abdomen and into the liver.The islets are then injected through the catheter into the liver. The patient willreceive a local anesthetic. If a patient cannot tolerate local anesthesia, thesurgeon may use general anesthesia and do the transplant through a smallincision. Possible risks include bleeding or blood clots. It takes time for thecells to attach to new blood vessels and begin releasing insulin. The doctor

will order many tests to check blood glucose levels after the transplant, andinsulin may be needed until control is achieved.


Paragraph 6Transplantation: Benefits, Risks, and Obstacles The goal of islet transplantation is to infuse enough islets to control the bloodglucose level without insulin injections. For an average—size person (70 kg),a typical transplant requires about 1 million islets, extracted from two donorpancreases. Because good control of blood glucose can slow or prevent theprogression of complications associated with diabetes, such as nerve or eyedamage, a successful transplant may reduce the risk of these complications.But a transplant recipient will need to take immunosuppressive drugs thatstop the immune system from rejecting the transplanted islets.


Paragraph 7Researchers are trying to find new approaches that will allow successfultransplantation without the use of immunosuppressant drugs, thus eliminatingthe side effects that may accompany their long—term use. Rejection is thebiggest problem with any transplant. The immune system is programmed todestroy bacteria, viruses, and tissue it recognizes as “foreign,” includingtransplanted islets. Immunosuppressive drugs are needed to keep thetransplanted islets functioning.


Paragraph 8Immunosuppressive Drugs The Edmonton protocol uses a combination of immunosuppressive drugs,also called antirejection drugs, including daclixrm (Zenapax), sirolimus(Rapamune), and tacrolimus (Prograf). Dacliximab is given intravenouslyright after the transplant and then discontinued. Sirolimus and tacrolimus, thetwo drugs that keep the immune system from destroying the transplantedislets, must be taken for life.


Paragraph 9These drugs have significant side effects and their long—term effects are stillnot known. Immediate side effects of immunosuppressive drugs may includemouth sores and gastrointestinal problems, such as stomach upset or diarrhea.

Patients may also have increased blood cholesterol levels, decreased whiteblood cell counts, decreased kidney function, and increased susceptibility tobacterial and viral infections. Taking immunosuppressive drugs increases therisk of tumors and cancer as well.


Paragraph 10Researchers do not fully know what long—term effects this procedure mayhave. Also, although the early results of the Edmonton protocol are veryencouraging, more research is needed to answer questions about how long theislets will survive and how often the transplantation procedure will besuccessful. Before the introduction of the Edmonton Protocol, few islet celltransplants were successful. The new protocol improved greatly on theseoutcomes, primarily by increasing the number of transplanted cells andmodifying the number and dosages of immunosuppressants. Of the 267transplants performed worldwide from 1990 to 1999, only 8 percent of thepeople receiving them were free of insulin treatments one year after thetransplant. The CITR’s second annual report, published in July 2005,presented data on 138 patients. At six months after patients’ final infusions,67 percent did not need to take insulin treatments. At one year, 58 percentremained insulin independent. The recipients who still needed insulintreatment after one year experienced an average reduction of 69 percent intheir daily insulin needs.


Paragraph 11A major obstacle to widespread use of islet transplantation will be theshortage of islet cells. The supply available from deceased donors will beenough for only a small percentage of those with type 1 diabetes. However,researchers are pursuing avenues for alternative sources, such as creating isletcells from other types of cells. New technologies could then be m employedto grow islet cells in the laboratory.


QUESTIONSQ1. The pancreas isa) in the handb) in the stomach

c) above the stomachd) behind the lower part of the stomach

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Q2. What is the main purpose of insulin?a) It is a hormoneb) to destroy beta cellsc) to assist in energy productiond) to stimulate the auto immune process

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Q3. According the article, is islet transplantation common practice?a) Yes, it’s frequently usedb) No, it’s still being trialedc) Not stated in the articled) Yes, but only in Canada

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Q4. What is the Edmonton Protocol?a) A trade agreementb) The journal of Alberta Universityc) A way to transplant pancreatic isletsd) Not stated in the article

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Q5. What’s the source of the pancreatic islets that are in the transplantoperation?a) They are donated by relativesb) They come from people who have recently diedc) They are grown in a laboratoryd) They come from foetal tissue

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Q6. Which one of the sentences below is true?

a) A local anaesthetic is preferred where possible.b) A general anaesthetic is preferred where possible.c) A general anaesthetic is too risky due to the possibility of blood clots andbleeding.d) An anaesthetic is not necessary if ultrasound is used

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Q7. How soon after the operation can the patient abandon insulin injections?a) Immediatelyb) After about two weeksc) When the blood glucose levels are satisfactoryd) After the first year

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Q8. How many islets are required per patient?a) About a millionb) 70 kgc) Whatever is available is usedd) it depends on the size of the patient

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TIME: 45 MINUTES



Part CIn this part of the test, there are two texts about different aspects ofhealthcare. Choose the answer (A, B, C or D) which you think fitsbest according to the text.Seasonal Influenza Vaccination and the H1N1 VirusParagraph 1As the novel pandemic influenza A (H1N1) virus spread around the world inlate spring 2009 with a well-matched pandemic vaccine not immediatelyavailable, the question of partial protection afforded by seasonal influenzavaccine arose. Coverage of the seasonal influenza vaccine had reached 30%-40% in the general population in 2008-09 in the US and Canada, followingrecent expansion of vaccine recommendations.


Paragraph 2Unexpected Findings in a Sentinel Surveillance System The spring 2009 pandemic wave was the perfect opportunity to address theassociation between seasonal trivalent inactivated influenza vaccine (TIV)and risk of pandemic illness. In an issue of PLoS Medicine, DanutaSkowronski and colleagues report the unexpected results of a series ofCanadian epidemiological studies suggesting a counterproductive effect ofthe vaccine. The findings are based on Canada’s unique near-real-timesentinel system for monitoring influenza vaccine effectiveness. Patients withinfluenza-like illness who presented to a network of participating physicianswere tested for influenza virus by RT-PCR, and information ondemographics, clinical outcomes, and vaccine status was collected.


Paragraph 3In this sentinel system, vaccine effectiveness may be measured by comparingvaccination status among influenza-positive “case” patients with influenzanegative “control” patients. This approach has produced accurate measures ofvaccine effectiveness for TIV in the past, with estimates of protection inhealthy adults higher when the vaccine is well-matched with circulatinginfluenza strains and lower for mismatched seasons. The sentinel system wasexpanded to continue during April to July 2009, as the H1N1 virus defiedinfluenza seasonality and rapidly became dominant over seasonal influenzaviruses in Canada.


Paragraph 4Additional Analyses and Proposed Biological MechanismsThe Canadian sentinel study showed that receipt of TIV in the previousseason (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 andgeography. The investigators were prudent and conducted multiple sensitivityanalyses to attempt to explain their perplexing findings, importantly, TIVremained protective against seasonal influenza viruses circulating in Aprilthrough May 2009, with an effectiveness estimated at 56%, suggesting thatthe system had not suddenly become flawed. TIV appeared as a risk factor inpeople under 50, but not in seniors—although senior estimates wereimprecise due to lower rates of pandemic illness in that age group.

Interestingly, if vaccine were truly a risk factor in younger adults, seniorsmay have fared better because their immune response to vaccination is lessrigorous.


Paragraph 5Potential Biases and Findings from Other CountriesThe Canadian authors provided a full description of their study populationand carefully compared vaccine coverage and prevalence of comorbidities incontrols with national or province-level age-specific estimates—the best cando short of a randomized study. In parallel, profound bias in observationalstudies of vaccine effectiveness does exist, as was amply documented inseveral cohort studies overestimating the mortality benefits of seasonalinfluenza vaccination in seniors.


Paragraph 6Given the uncertainty associated with observational studies, we belie wouldbe premature to conclude that TIV increased the risk of 2009 pandemicillness, especially in light of six other contemporaneous observational studiesin civilian populations that have produced highly conflicting results. We notethe large spread of vaccine effectiveness estimates in those studies; indeed,four of the studies set in the US an Australia did not show any associationwhereas two Mexican studies suggested a protective effect of 35%-73%.


Paragraph 7Policy Implications and a Way Forward

The alleged association between seasonal vaccination and 2009 H1N1remains an open question, given the conflicting evidence from availableresearch. Canadian health authorities debated whether to postpone seasonalvaccination in the autumn of 2009 until after a second pandemic wave hadoccurred, but decided to follow normal vaccine recommendations insteadbecause of concern about a resurgence of seasonal influenza viruses duringthe 2009-10 season.


Paragraph 8This illustrates the difficulty of making policy decisions in the midst of a

public health crisis, when officials must rely on limited and possibly biasedevidence from observational data, even in the best possible scenario of awell-established sentinel monitoring system already in place. What happensnext? Given the timeliness of the Canadian sentinel system, data on theassociation between seasonal TIV and risk of H1N1 illness during the autumn2009 pandemic wave will become available very soon, and will be crucial inconfirming or refuting the earlier Canadian results.


Paragraph 9In addition, evidence may be gained from disease patterns during the autumn2009 pandemic wave in other countries and from immunological studiescharacterizing the baseline immunological status of vaccinated andunvaccinated populations. Overall, this perplexing experience in Canadateaches us how to best react to disparate and conflicting studies and can aid inpreparing for the next public health crisis.


QUESTIONSQ1. The question of partial protection against H1N1 arose__________a. before spring 2009b. during Spring 2009c. after spring 2009d. during 2008-09

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Q2. 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 counterproductived. the inactivated influenza vaccine has proven to be ineffective.

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Q3. 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.

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Q4. Which one of the following is closest in meaning to the word prudent?a. anxiousb. cautiousc. busyd. confused

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Q5. 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 peoplec. the vaccination was no longer effective.d. the risk of H1N1 seemed to be higher among people who received the TIVvaccination.

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Q6. Which of the following sentences best summarises the writers’ opinionregarding the uncertainty associated with observational studies?a. More studies are needed to determine whether TIV increased the risk of the2009 pandemic illness.b. It is too early to tell whether the risk of catching the 2009 pandemic illnessincreased due to TIV.c. The Australian and Mexican studies prove that there is no associationbetween TIV and increased risk of catching the 2009 pandemic illness.d. Civilian populations are less at risk of catching the 2009 pandemic illness.

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Q7. Which one of the following is closest in meaning to the word alleged?a. reportedb. likely

c. suspectedd. possible

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Q8. Canadian health authorities did not postpone the Autumn 2009 seasonalvaccination 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 thevaccine.c. the sentinel monitoring system was well established.d. observational data may have been biased.

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Answer KeyPractice Test 11. B2. C3. B4. A5. A6. D7. C8. 100 mg9. ibuprofen therapy patients10. clopidogrel11. aspirinated platelets12. 75 - 150 mg13. CAPRIE14. antithrombotic15. 5 - 45%`16. Cox-217. cardiovascular death18. biosynthesis19. compliance20. aspirin

“Practice Test 2”Practice Test 21. C2. B3. B

4. A5. C6. A

“Practice Test 3”Practice Test 31. C2. C3. C4. D5. C6. A7. D8. D

“Practice Test 4”Practice Test 41. B2. B3. B4. D5. D6. A7. C8. A

“Practice Test 5”Practice Test 51. B2. D

3. B4. A5. C6. A7. A8. Thomas Browne9. Michele Pearson10. antipsychotic11. 1512. psychiatric illness13. infested by parasites14. unexplained dermopathy15. parasites16. Mayo Clinic17. CDC18. persona19. physicians20. relentless

“Practice Test 6”Practice Test 61. A2. C3. A4. A5. A6. B

“Practice Test 7”Practice Test 7

1. C2. C3. D4. B5. C6. D7. B8. A

“Practice Test 8”Practice Test 81. C2. C3. C4. A5. D6. A7. B8. B

“Practice Test 9”Practice Test 91. C2. B3. A4. A5. D6. C7. B8. 689. 3

10. 18 to 64 years11. 200912. 18313. 1.1%14. doubled15. tuberculosis16. age-matched17. AIDS18. indigent subjects19. 1020. 858

“Practice Test 10”Practice Test 101. A2. C3. C4. C5. A6. B

“Practice Test 11”Practice Test 111. C2. B3. A4. D5. B6. D7. D8. B

“Practice Test 12”Practice Test 121. B2. A3. C4. C5. C6. D7. D8. B

“Practice Test 13”Practice Test 131. C2. D3. C4. B5. A6. A7. B8. bluish9. loose10. international flights11. traveling12. large13. calf and leg14. bus or train15. air travel.16. swelling17. clinical studies18. traveling

19. 195420. suggestions

“Practice Test 14”Practice Test 141. B2. C3. A4. A5. A6. A

“Practice Test 15”Practice Test 151. D2. C3. C4. D5. A6. B7. C8. D

“Practice Test 16”Practice Test 16

1. C2. C3. D4. B5. C

6. D7. B8. C

“Practice Test 17”Practice Test 171. C2. C3. B4. D5. D6. B7. C8. almost 40%9. 77.9%10. 1500g11. carbon monoxide12. Julie Mannella13. carbon monoxide14. deterioration15. smoker16. caffeinated drinks17. cigarette smoke18. air-trapping19. neuro-stimulatory effects20. linear regression

“Practice Test 18”Practice Test 181. B2. B3. A

4. A5. C6. C

“Practice Test 19”Practice Test 191. D2. C5. B4. C5. B6. A7. C8. D

“Practice Test 20”Practice Test 201. B2. A3. D4. B5. D6. B7. C8. A

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BYMAGGIE RYAN

VOL. 1 (OET 2.0 Reading Books by Maggie Ryan)

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