READING 1

PART A

TEXT A
Maternal microbiota

The maternal microbiota of pregnancy also appears to affect fetal development from
afar .prior to birth; the maternal microbiota is separated from the developing fetus by
both physical barriers of the placenta and chorioamniotic sac and immunological
barriers that are established at the maternal –fetal interface.Nevertheless,data from
animal studies indicate that the composition and metabolic function of the maternal
microbiota are reflected in fetal immune development .Deciphering the impact of the
maternal microbiota during gestation on long term childhood development has proven
challenging owing to the inherent coupling of the gestational effects of the maternal
microbiota with its role in establishing the early life microbiota in offspring. Ⓒ OET
Medcity

TEXT B
Fetal immune development and maternal microbiota

Fortunately a clever model system has been developed to circumvent these limitations
by making use of transient colonization strategy to generate “gestation-only
“colonization in mice. Transiently colonizing pregnant mice with a mutant strain of
Escherichia-coli that is unable to survive and replicate in vivo has enabled transient
gastrointestinal colonization with these bacteria during gestation ,followed by a return
to germ-free status prior to delivery. With this model fetal development occurs in the
presence of maternal microbiota ,yet pups are born germ free and never encounter
microbes directly.Outside the gastrointestinal tract ,pups born to gestationally colonized
dams displayed reduced splenic cytokine production in response to bacterial endotoxin
compared to germ -free counterparts .This proved that normal fetal immune
development is critically dependent on long distance signals received from the maternal
microbiota ,which functions to prepare the gut epithelium and mucosal immune system
is the developing offspring for the onslaught of microbial exposure experienced at birth.
 TEXT C
Although much has been learned about the maternal microbiota in pregnancy and early
life, many fundamental questions remain. It is unclear if this information can be used to
prevent and treat childhood illnesses.To do so, are live microbial therapeutics
needed,or will specific bacterial products or metabolites suffice(and if so,which
one)?further research is needed to determine whether there is a “normal “maternal and
early- life microbiota that should be universally strived for ,or whether microbial
therapeutic require individualization .in addition ,what are the the ethical
considerations of issues of consent and the potential for unexpected adverse effects?to
answer these (and other)outstanding questions ,studies must vmove beyond
observational correlations to define casual relationships,including the cellular and
molecular mechanisms that mediate microbiota –host interactions in pregnancy and
early life. Ⓒ OET Medcity

TEXT D
QUESTIONS 1-7

For each question, 1-7 decide which text (A, B, C, OR D) the information comes
from .you may use any letter more than one

1. Evidence for reflection in fetal immune development

2. Effect of maternal microbiota in early life colonization

3. A model that breaks the limitations

4. The need for future study regarding Impact of maternal

microbiota in pregnancy

5. Influence of maternal microbiota in pregnancy

6. Neurodevelopmental disorders as an effect of the maternal

Microbiota in early life

7. Information regarding maternal microbiota which is unclear ___________

Questions 8-13

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

8. Why studies should move far off from observational correlations

9. One of the barriers which separates maternal microbiota from the fetus

10. What does depend on signals received from the maternal microbiota ?

11. What does regulate the susceptibility to childhood illness?

_________________________
12. Why is it difficult to break the impact of maternal microbiota on childhood
development?

13. What needs to be included when defining causal relationship?

14. Characteristics of E.coli, which is used on mice

Questions 15-20

Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

15. Antimicrobial is present in breast milk

16. ,the maternal microbiota is separated from developing fetus

17. Splenic cytokine production is reduced in response to bacterial

compared to germ free counterparts
18. What are the considerations of therapeutic modifications?
19. Childhood illness can vertically transmit _ pathologies

20. Fetal development occurs in the presence of a

Ⓒ OET Medcity
 PART B
GENE EDITING

A new form of gene therapy termed genetic editing or gene targeting has become
possible owing to advances in genetic engineering technology. The intent of genetic
editing is to alter the DNA code in cells with single base-pair specificity, and thus it can
be considered to be an ultimate form of precision therapy. For the past two decades,
genome editing has been a powerful tool for basic science research. The importance of
genome editing as a research tool was recognized in 2007 by the award of the Nobel
Prize in Physiology or Medicine to Smithies, Capecchi, and Evans. Ⓒ OET Medcity

1) What is the purpose of this guideline?

a) Explains what is gene editing
b) Importance of future research on genome editing
c) The aim of gene targeting

DISCRIMINATING LUNG PRIMARY TUMORS AND METASTASES

Pulmonary metastases of head and neck squamous cell carcinoma (HNSC) are currently
difficult to distinguish from primary lung squamous cell carcinomas
(LUSCs).Differentiating these tumor types has important clinical implications ,as
whether the lung tumor is primary or has spread can affect the treatment options
offered to a patient .Here , Jurmeister developed a machine learning algorithm that
exploits the differential DNA methylation observed in primary LUSC and metastasized
HNSC tumors in the lung .Their method was able to discriminate between these two
tumor types with high accuracy across multiple cohorts , suggesting its potential as a
clinical diagnostic tool.

2) What the extract says about Jurmeister’s method?

a) It is beneficial to learn the algorithm ,which exploits the differential DNA
methyation
b) Method can differentiate primary LUSC and metastasized HNSC tumors with
accuracy.
c) It was unable to discriminate between two tumor types
 MICROBIOME

Early childhood is a critical stage for the foundation and development of both the
microbiome and host. Early-life antibiotic exposure, cesarean section, and formula
feeding could disrupt microbiome establishment and adversely affect health later in life.
We profiled microbial development during the first 2 years of life in a cohort of 43 U.S.
infants and formula feeding. These exposures contributed to altered establishment of
maternal bacteria, delayed microbiome development, and altered alpha-diversity. These
finding illustrate the complexity of early–life microbiome development and its sensitivity
to perturbation. Ⓒ OET Medcity

3) What could disturb the microbiome development?

a) Altered establishment of maternal bacteria
b) Formula feeding
c) Host and antibiotic exposures

WAR OF NERVE

Cancer is adept at exploiting the body’s normal functions by stimulating the growth of
new blood vessels that nourish a tumor ,for example or harnessing protective
mechanisms of the immune system .Recent studies have revealed a long-overlooked
accomplice in cancer’s growth and spread :peripheral nerves that branch through our
bodies and regulate our organs .Those nerves churn out molecules that appear to aid
the growth of cancer cells , and they alter surrounding tissue in ways that can make it
more hospitable to cancer . To some experts, these basic discoveries help explain a
controversial link between chronic stress and cancer progression .The work has also
prompted several clinical trials testing whether blocking nerve signaling slows tumors ‘
spread.

4) What will happen if nerves churn out molecules?

a) That may appear to encourage the growth of cancer cells
b) Molecules change the neighboring tissue and can make more susceptible to
cancer.
c) It regulates body organs
 Hard work meets the path of least resistance

Transcatheter aortic valve replacement (TAVR) is a treatment for patient with aortic
stenosis (narrow aortic valve) that reduces the transvalvular pressure gradient;
however, only some patients experience improved quality of life after the procedure. To
understand how valvular,ventricular and systemic vascular conditions contribute to
improvements after TAVR ,Ben –Assa et al.studied 70 patients undergoing the
procedure. Patients with lower preprocedural vascular impedance and higher left
ventricular stroke work had greater improvements in quality of life after TAVR.this
suggests that analyzing valve,ventricle,and arterial system hemodynamic could identify
patients likely to benefit from TAVR and inform timing of intervention. Ⓒ OET Medcity

5) According to this extract, what is the outcome of TAVR?

A) Most patients had greater quality of life after the procedure.

B) Patient with lower vascular impedance only had higher left ventricular stroke

C) Only a few patients had improved quality of life after TAVR.

Risk factors predicting operative mortality in perforated peptic ulcer disease.

Following the introduction of H2-blockers and proton pump inhibitors, there has been a
sharp decrease in elective peptic ulcer surgery. However, emergency operations for
complications such as perforation are on the rise. This study was undertaken to review
the factors which determine mortality following emergency surgery for peptic ulcer
perforation. A prospective study of all patients who underwent surgery at our institute
for peptic ulcer perforation between September 1999 and August 2001 was carried out.
One hundred seventy-four patients underwent surgery for perforated peptic ulcer. Risk
of death was related to age more than 60 years, shock at presentation, delay more than
24 hours prior to surgery and size of perforation more than 5 mm. Perforated peptic
ulcer disease remains a frequent clinical problem associated with a significant
postoperative mortality. Ⓒ OET Medcity
6) According to the extract

a) Surgery is the option for peptic ulcer

b) Study shows emergency operation following perforation
c) Death due to surgery depends on different factors.
 PART C
MICROBIOTA IN CHILDHOOD

Paragraph 1

INTRODUCTION

The establishment of stable microbial communities within the gastrointestinal tract

closely parallels host growth and immune system development and thus could play an
important role in directing host development. Delayed or altered establishment of the
intestinal microbiota in childhood , termed microbiota immaturity ,has been associated
with diarrhea in Bangladeshi children .The causes of these microbiota disturbances and
their consequences in other populations have not been established, but they may be
linked to host development.

Paragraph 2

Antibiotic use during childhood is prevalent in most parts of the world, but the effect on
maturation of microbiota and human health are poorly characterized. The average U.S.
child receives about three courses of antibiotic by the age of 2 and 10 courses by the
age of 10. Antibiotics directly perturb the intestinal microbiota, leading to altered
compositional states in children and adults, but the consequences of these changes on
host physiology are not well understood. Antibiotic exposure in children has been
associated with increased risk of obesity, diabetes, inflammatory bowel disease, asthma,
and allergies. We have shown previously that antibiotic exposure leads to increased
adiposity in mice, that early-life exposures lead to prolonged effects on host metabolic
characteristics, and that the disturbed intestinal microbiota mediates these host effects.

Paragraph 3

Other disturbances, including birth mode and infant diet, also affect the intestinal
microbiota during early life and are associated with later-in-life adiposity and other
clinical effects. Cesarean delivery has been associated with asthma, allergies, type 1
diabetes, and obesity, possibly because of diminished exposure to maternal microbes
during birth. Formula feeding similarly disrupts the intestinal microbiota and may impair
immune development and normal metabolism. Ⓒ OET Medcity
 Paragraph 4

Although the impacts of antibiotic exposures on intestinal dysbiosis in adults are well
characterized, less attention has been given to their effects on microbiota development
during early childhood . We hypothesized that antibiotics and other early disturbances
may alter microbiome establishment during early life , potentially explaining
associations with emerging health issues .We examined the intestinal microbiota to
model its development over 2 years of life in a cohort of 43 healthy urban U.S. infants.
We then assessed the effects of birth mode, infant nutrition, and antibiotic exposures
on intestinal microbiota development

Paragraph 5

RESULTS

From the 53 mothers who initially enrolled in this study, a total of 43 infants were
enrolled for follow-up until 2 years of age. Stool samples were collected from these
infants; stool samples, vaginal swabs, and rectal swabs were collected from their
mothers’ prepartum and postpartum .In the first month of life, stools were dominated
by facultative aerobic enterobacteiaceae before yielding to strict anaerobes-principally
Bifidobacterium, Bacterroides, and Clostridium. These taxa were gradually displaced
between months 6 and 24 by a diverse mixture of clostridiales, roughly corresponding to
the introduction and increased use of solid foods in these infants. However, even among
infants who received no antibiotics in the first 6 months of life, those differing by birth
mode and predominant diet showed substantial early differences. During the first 2
years of life, microbiome was characterized by a period of gradual succession of taxa.
Although the infant microbiota began to resemble an adult’s microbiota at about 2
years of age, it had not yet achieved an adult-like state, characterized by different
alternative states that exist in quasi-equilibrium. Hence, we focused on the trajectory of
microbiota development in children in the context of early disturbances. Ⓒ OET
Medcity

7. Which statement is the closest match to the description in the first paragraph?

a) Stable microbial communities are established in Bangladesh

b) Microbiome in intestine regulates immune system development
c) Causes of microbiota disturbances has been established
 d) Consequences from microbiota is linked to host development

8. Microbiota immaturity is

a) An intestinal microbiome
b) Delayed alteration of the intestinal microbiota
c) A childhood intestinal disorder
d) Retarded development of intestinal microbiot

9. What is the average course of antibiotic received by a U.S. child, in paragraph 2?

a) 2 courses by the age of 3

b) 10 courses at the age of 10
c) About three courses within 2 years
d) 3 or 10 courses by 10 years

10. What can be lead to adiposity in mice?

a) Previous antibiotic exposure

b) Excessive use of antibiotics
c) Exposure to antibiotic and obesity
d) None of the above

11. In paragraph 3, diminished exposure to maternal microbes can be a reason for

a) Cesarean delivery
b) Formula feeding
c) Adiposity and asthma
d) Obesity

12. Which one of the following is closest in meaning to the word dysbiosis?

a) Changes
b) Imbalance
c) Disorders
d) Improves

13. In paragraph 5, who were the actual subjects of the study?

a) Children above 2 years

 b) Prepartum mothers only
c) 43 infants
d) 53 mothers

14. Which heading would best suit to paragraph 5?

a) Growth of enterobacteriaceae in children

b) Factors influencing antibiotics
c) A study involving infant microbiota
d) A comparative study of mothers and infants microbiota
 ANTICANCER DRUGS
Paragraph 1

Cancer drug developers may be missing their molecular targets –and never knowing it.
Many recent drugs take aim at specific cell proteins that drive the growth of tumors .The
strategy has had marked successes, such as the leukemia drug Gleevec . But a study now
finds that numerous candidate anticancer drugs still kill tumor cells after the genome
editor CRISPR was used to eliminate their presumed targets .that suggests the drugs
thwart cancer by interacting with different molecule than intended.

The study points to problems with an older lab tool for silencing genes that has been
used to identify leads for such drugs. The results also hint that the drugs in question,
most of which are in clinical trials, and perhaps others could be optimized to work even
better by pinning down their true mechanism. Ⓒ OET Medcity

Paragraph 2

“The work is very well done and it’s a great public service. I hope people talk about it. I
don’t find any of it surprising, unfortunately, “says William Kaelin of the Dana –Farber
Cancer Institute in Boston,who has written about why promising preclinical findings are
often not reproducible, or fail to lead to drugs.

Leads for many recent targeted drugs emerged from experiments in which cancer cells
were dosed with RNA strands that disrupt the natural RNAs that convey a gene’s protein
building instructions. After using this RNA (RNAi) method to zero in on genes essential to
the growth of cancer cells, researchers screened libraries of molecules to find
compounds that block the gene’s protein.

Paragraph 3

A few years ago, cancer biologist Jason Sheltzer of Cold Spring Harbor Laboratory in New
York and colleagues used CRISPR’s gene disabling skills, instead of RNAi, to prevent the
manufacture of a well established growth protein,called MELK,in cancer cells .Several
companies at the time Were developing MELK inhibitors as anticancer agents. But to
the group’s surprise, the MELK –deficient cells kept growing. Yet a drug though to be
aimed at MELK still stopped growth of the cells, suggesting its true target was not that
protein.
 Paragraph 4

That work spurred Sheltzer’s lab to collect examples of other drugs that target proteins
found largely with RNAi.H is group ultimately homed in on 10 drugs aimed at six
proteins whose roles range from driving cell proliferation to controlling cancer gene
activity .When the scientists used CRISPR to knock out the genes for those proteins in
various cancer cell lines, the cells kept growing, suggesting the originally RNAi assay was
misleading. Yet, when the team gave the relevant drug to cancer cells now missing the
target protein, they still died –apparently through some other mechanism. “Many of the
previous results were replicable, but the interpretation was,” Sheltze says.

Paragrapgh 5

The researchers found a clue to the real mechanism for a drug, now in preclinical
testing,that supposedly blocks a protein called PBK, which aids cell division .By
identifying cells that developed resistance to the drug ,known as OTS964, and
sequencing them for mutations that confer that trait, the lab showed the drug instead
blocks the proteinCDK11,which plays a different role in cell proliferation . Sheltzer calls
this result “exciting because inhibitors of other CDKs work well against breast cancer,
and targeting this one could be a new option. Ⓒ OET Medcity

Paragraph 6

The developer of drug on Sheltzer’s list that reportedly activates a protein called
caspase-3 that commands cells to self-destruct questioned the study. Chemist Paul
Hergenrother of the University of Illinois in Urbana, notes that the drug also activates a
related protein with a similar function. So, Sheltzer’s group would have had to knock out
the genes for both proteins to eliminate the drug’s effects on cancer cells, Hergenrother
say. Another caveat that Sheltezer’s group acknowledges is that some of the drugs’
reported protein targets could influence cancer growth indirectly within the body, for
example by spurring other cells to secrete molecules that nurture a growing tumor.

Paragraph 7

Paragraph 7But the new study has made other cancer researchers generally skeptical of
RNAi screening to identify potential cancer drugs. That work,it now seems ,was “riddled
with falsehoods,” says Traver Hart of MD Anderson Cancer Center in Houston, Texas,
who now screens for new drug leads with CRISPR. Those results should be checked with
multiple techniques because CRISPR can have off-target effects too, Kaelin says.”You
have to assume the downstream effects you’re measuring are off target until you prove
otherwise.

Paragraph 8

Sheltzer doesn’t think his group’s result cast doubt on the targeted cancer drugs already
on the market, as most have other compelling evidence they’re hitting the right protein.
But for the 10 candidate drugs studied by his lab ,as well as others in development, it’s
important to find out how they work so physicians can match patients to the best drug
and fulfill the promise of precision medicine, Sheltzer says.Paul Workman of the
Institute of Cancer Research in London agrees:”it clearly helps enormously the true.

15) According to paragraph 1 which of the following statement is correct?

a) The strategy had remarkable success

b) Anticancer drugs eliminate targets by killing tumor cells.
c) Cancer drugs prevent cancer through interaction with different molecules.
d) Cancer drugs only kills intended tumor cells.

16) What William Kaelin says about the work?

a) It was not surprising.
b) A public service
c) Findings are not reproducible
d) It was well but fails to lead to drugs

17) Regarding MELK in paragraph 6 which of the following statement is most correct?
a) Gene disabling skills were used to prevent manufacture of MELK
b) MELK is a cancer cell
c) It is manufactured growth protein
d) It stopped the growth of targeted protein only.

18) What the phrase ‘knock out the gene’ in 4th paragraph indicates?
a) Behold the genes
b) Remove the genes from cancer cell protein
c) Eliminate the gene through CRISPR
d) Limit the genes for proteins.

19) Why Sheltzer thinks preclinical testing result as exciting?

a) Other CDKs inhibitors prevent breast cancer.
b) Drugs block the all protein.
c) Inhibitors of CDKs other than CDK 11 effective against breast cancer.
d) Because mutations that converse the traits. Ⓒ OET Medcity

20) What the paragraph 6 says about?

a) A drug which activates only caspase -3
b) A list of drugs activates related protein with a similar function
c) A drug activates caspase -3 and a related protein with similar function
d) Drugs on Sheltzer’s list, influences the cancer growth.

21) What the phrase “riddle with falsehoods “means in paragraph 7?

a) False to solve
b) Misinterpretation of drugs
c) A false intervention
d) An unclear result

22) Paul Workman agreed to?

a) It clearly helps enormously
b) Promise to fulfill precision medicine
c) It is important to know drug works
d) Physician will match patients to the best drug
READING 2
PART A
Health effects of environmental noise pollution

TEXT A
It might be tempting to think that noise isn’t a serious health issue, after all, it’s just
noise. It won’t kill us … right? Well, maybe. Exposure to prolonged or excessive noise
has been shown to cause a range of health problems ranging from stress, poor
concentration, productivity losses in the workplace, and communication difficulties and
fatigue from lack of sleep, to more serious issues such as cardiovascular disease,
cognitive impairment, tinnitus and hearing loss. In 2011 the World Health Organization
(WHO) released a report titled ‘Burden of disease from environmental noise’. This study
collated data from various large-scale epidemiological studies of environmental noise in
Western Europe, collected over a 10-year period. The studies analysed environmental
noise from planes, trains and vehicles, as well as other city sources, and then looked at
links to health conditions such as cardiovascular disease, sleep disturbance, tinnitus,
cognitive impairment in children, and annoyance. The WHO team used the information
to calculate the disability-adjusted life-years or DALYs—basically the healthy years of
life―lost to ‘unwanted’ human-induced dissonance. Their results might surprise you.

TEXT B

Exposure to prolonged or excessive noise has been shown to cause a range of

health problems
They found that at least one million healthy years of life are lost each year in Europe
alone due to noise pollution (and this figure does not include noise from industrial
workplaces). The authors concluded that ‘there is overwhelming evidence that exposure
to environmental noise has adverse effects on the health of the population’ and ranked
traffic noise second among environmental threats to public health (the first being air
pollution). The authors also noted that while other forms of pollution are decreasing,
noise pollution is increasing. Interestingly, it may be the sounds we aren’t even aware
we’re hearing that are affecting us the most, in particular, those we ‘hear’ when we’re
asleep. The human ear is extremely sensitive, and it never rests. So even when you sleep
your ears are working, picking up and transmitting sounds that are filtered and
interpreted by different parts of the brain. It’s a permanently open auditory channel. So,
although you may not be aware of it, background noises of traffic, aircraft or music
coming from a neighbour are still being processed, and your body is reacting to them in
different ways via the nerves that travel to all parts of the body and the hormones
released by the brain. Ⓒ OET Medcity

TEXT C
HEALTH PROBLEMS RELATED TO PROLONGED EXCESSIVE EXPOSURE TO NOISE
Research has shown that people living near airports or busy roads have a higher
incidence of headaches, take more sleeping pills and sedatives, are more prone to minor
accidents, and are more likely to seek psychiatric treatment.
1. interrupted sleep
2. effects of tiredness
3. impaired judgement and weakened psychomotor skills
4. impaired memory and creativity
But there is another, more serious outcome. Even if you don’t wake up, it appears that
continual noise sets off the body’s acute stress response, which raises blood pressure
and heart rate, potentially mobilising a state of hyperarousal. It is this response that can
lead to cardiovascular disease and other health issues.

TEXT D

Continual noise sets off the body’s acute stress response

A study undertaken by Dr Orfeu Buxton, a sleep expert at Harvard University, monitored
the brain activity of healthy volunteers, who were played 10-second sound clips of
different types of noise as they slept. The brainwaves of volunteers were found to spike
in jagged, wake-like patterns of neural activity when each clip was played. This particular
study was focusing on noises heard in a hospital environment—including talking, phones
ringing, doors closing, machinery, toilets flushing, and city traffic, among others—but
many of the sounds tested are ones we would also hear in an urban environment.
Sound is an important and valuable part of everyday life. But when sound becomes
noise, it can negatively affect our mental and physical health. The realities of modern
life mean the noises created in our world are not going to suddenly fall silent. Instead,
we need to recognise that noise pollution is a serious health concern worthy of our
attention, and find realistic and sustainable ways to manage and reduce it—starting
with banning those rubbish truck pickups in the middle of the night!

Ⓒ OET Medcity
QUESTIONS 1-7
For each question, 1-7 decide which text (A,B,C,OR D)the information comes
from .you may use any letter more than one

In which text can you find information about

1) Noise is one of the main environmental threats to public health _____________

2) Most sensitive organ in the human body _____________
3) Description of study _____________
4) Study conducted regarding the effect of hospital noises _____________
5) Study conducted in particular area _____________
6) Consequences of increased noise _____________
7) Evidence for health of population and increased noise _____________

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

8) An organ which is continuously working?

9) What leads to a state of hyperarousal?

10) Main environmental issue that affects the health?

11) What is the effect of noise in the children?

12) Due to noise pollution how many healthy year of life looses in each year?

13) What is the end result of excessive high noise?

Questions 14-20
Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

14) Continuous noise leaves the body’s response

15) leads to lack of sleep
16) filters and interprets the sounds
17) People lives noisy roads requires for sleep.
18) increases blood pressure
19) is an sleep expert
20) used the information to calculate DALYS.
 PART B

EFFECTS OF INFLAMMATION

Inflammation alters bone marrow hematopoiesis to favor the production of innate

immune effector cells at the expense of lymphoid cells and erythrocytes. Furthermore,
proinflammatory cytokines inhibit steady-state erythropoiesis, which leads to the
development of anemia in disease with chronic inflammation. Acute anemia or hypoxic
stress induces stress erythropoiesis, which generates a wave of new erythrocytes to
maintain erythroid homeostasis until stedy state erythropoiesis can resume. Although
hypoxia-dependent signaling is a key component of stress erythropoiesis, we found that
inflammation also induced stress erythropoiesis in the absence of hypoxia.

1) Acute anemia will

a) Results in stress erythropoiesis
b) Create new form of erythrocytes
c) Maintain erythroid hemostasis

CATHETERS

A catheter is a thin tube made from medical grade materials serving a broad range of
functions. Catheters are medical devices that can be inserted in the body to treat
diseases or perform a surgical procedure. By modifying the material or adjusting the
way catheters are manufactured, it is possible to tailor catheters for cardiovascular,
urological, gastrointestinal, neurovascular, and ophthalmic applications. Catheters can
be inserted into a body cavity, duct, or vessel. Functionally, they allow drainage,
administration of fluids or gases, access by surgical instruments, and also perform a
wide variety of other tasks depending on the type of catheter.[1] The process of inserting
a catheter is "catheterization". In most uses, a catheter is a thin, flexible tube ("soft"
catheter) though catheters are available in varying levels of stiffness depending on the
application. A catheter left inside the body, either temporarily or permanently, may be
referred to as an "indwelling catheter" (for example, a peripherally inserted central
catheter). A permanently inserted catheter may be referred to as a "permcath"
(originally a trademark)

2) According to paragraph, catheters

a) Penetrate the body to treat disease or perform procedures

b) Perform variety of functions
c) Are flexible tubes

HEPARIN

Heparin includes unfractionated heparin (UFH) and low-molecular-weight heparin

(LMWH) products. They produce their anticoagulation effects by binding to
antithrombin (AT, formerly called AT III, also known as heparin cofactor I) rather than by
binding directly to coagulation factors. Binding of heparin to AT converts AT from a slow
to a rapid inactivator of coagulation factors (for example, thrombin [factor IIa], factor
Xa). Neither UFH nor LMWH crosses the placenta; however, it's important to note that
multiple-dose vials may contain benzyl alcohol, which does cross the placenta and may
cause fetal harm. As a result, pregnant women should be given preservative-free
preparations. Ⓒ OET Medcity

3) Heparin,
a) Comprises of LWMH and UFH
b) Directly attach to the coagulation factor
c) Contain benzyl alcohol, so it cannot give to pregnant woman

Eczema
A genetic mutation that impairs the skin barrier means that skin is easily penetrated by
irritants, allergens and bacteria, and constant vigilance is required to offset
exacerbations. Immunological and inflammatory processes and reduced moisturising
factors confound the issue. Topical preparations need to be altered according to the
fluctuating skin condition; making eczema care seems complex (National Institute for
Health and Clinical Excellence (NICE). Children and parents suffer distress with the
manifestations causing interrupted sleep and reduced quality of life (QOL). About 9% of
severe cases experiencing recurring infection require hospitalization . QOL is further
diminished by the costs of treatments and the time taken to undertake them. For some
parents, concurrent food allergy and the fear that their child's eczema will progress to
asthma and/or hay fever create an additional burden. This progression is termed the
‘allergic march’, where the clinical manifestation of allergic disease changes as one
grows older. Primarily a condition of children, eczema is more often continuing through
adolescence to adulthood making timely, effective eczema education by nurses, more
important than ever.

4) Paragraph says about

a) How eczema occur

b) Management and burden of care
c) How eczema affects children

Interventions Used by Nurse Preceptors to Develop Critical Thinking of

New Graduate Nurses
Heath care complexity and patient acuity necessitate competent nurses with critical
thinking abilities. However, these skill sets are less developed among newly hired
graduate nurses. The overall purpose of this systematic review was to examine
interventions/strategies implemented by preceptors in healthcare organizations to
promote critical thinking of new graduate nurses . A systematic search of the literature
resulted in 602 citations, with nine studies meeting the inclusion criteria. Educational
interventions were varied and will be described in this article. Preceptor education was
a key component in the studies reviewed. Ⓒ OET Medcity

5) What is the key component in the reviewed studies?

a) 602 citation
b) Preceptors in health care organization
c) Preceptor education

ACUTE PAIN AND ACUPUNCTURE

Back pain is a major economic burden in the UK, with increasing numbers of patients
seeking complementary therapies, such as acupuncture, as a means to supplement
traditional medical treatments. Studies to date have produced conflicting results
relating to the efficacy of acupuncture and thus this systematic review will provide a
concise summary of the clinical scenario in Western countries. A search of various
electronic databases identified 11 articles consisting of three case studies, five
randomized controlled trials, and two cross-over trials. Systematic examination of these
articles did not provide definitive evidence to support or refute the use of acupuncture
in the treatment of low back pain. In an era of increasing demands of evidence –based
practice and professional accountability, the absence of irrefutable scientific evidence
places nurses and medics in a vulnerable position.

6) What was the result relating to the efficacy of acupuncture?

a) Lack of evidence to support efficacy of acupuncture

b) 11 articles consisting of these case studies
c) Studies to date have produced conflicting result.
 PART C

VACCINE TO PREVENT HIV ACQUISITION

Paragraph 1
The need for a vaccine to prevent HIV-1 acquisition remains evident, especially in the
most burdened region of southern Africa, which is dominated by clade C infections.
Although the rollout of treatment and prevention programs has contributed to efforts
to stem the epidemic, in 2017 alone, there were an estimated 800,000 new infections
and 19.6 million people living with HIV in east and southern Africa . In the Republic of
South Africa (RSA), the country with the largest HIV burden, the epidemic is generalized
with heterosexual intercourse being the main mode of transmission.

Paragraph 2
RV144 was the first vaccine clinical trial to demonstrate any efficacy for preventing HIV-
1 acquisition . Although estimated vaccine efficacy was as high as 60% at month 12, it
waned thereafter to 31.2% by month 42 . Conducted in Thailand, with the clade B HIV-1
strain, CRF01_AE predominating, RV144 evaluated a heterologous prime-boost
combination vaccination regimen. Four injections (months 0, 1, 3, and 6) were given of
ALVAC-HIV (vCP1521), a canarypox vector expressing envelope (Env) (clade E), group-
specific antigen (Gag) (clade B), and protease (Pro) (clade B). In addition, two booster
injections (months 3 and 6) were administered of alum-adjuvanted AIDSVAX B/E, a
bivalent HIV glycoprotein 120 (gp120). The vaccine regimen induced HIV-specific
humoral and cellular immune responses, some of which were found to be associated
with reduced HIV infection risk, and included the following: the binding of plasma
immunoglobulin G (IgG) antibodies to the variable 1 and 2 (V1V2) regions of gp120, the
binding of IgA antibodies to Env, the avidity of IgG antibodies for Env in vaccinees with
low IgA, antibody-dependent cellular cytotoxicity (ADCC) in vaccinees with low IgA, and
the magnitude and polyfunctionality of Env-specific CD4+ T cells. Ⓒ OET Medcity

Paragraph 3
Despite evidence of vaccine efficacy, neutralizing antibodies against circulating tier 2
HIV-1 strains from Thailand were undetectable in the RV144 trial, suggesting that the
modest efficacy was largely attributed to non-neutralizing antibody effector functions 1.
In addition, virus sequence analyses and host genetic studies of RV144 revealed the
interplay of vaccine-elicited responses, infecting viruses, and host factors. A genomic
sieve analysis comparing breakthrough HIV-1 sequences between the infected vaccine
and infected placebo groups, focusing on the V1V2 region of Env, identified two sites in
the V2 loop associated with efficacy at amino acid positions 169 and 181. . A follow-up
sieve analysis also identified potential immune pressure in the V3 loop of the HIV-1 Env .
Host genetic analyses identified associations of human leukocyte antigen (HLA) and FcγR
polymorphisms with immune response correlates of risk and/or vaccine efficacy,
suggesting that host factors may influence vaccine immunogenicity and efficacy.

Paragraph 4
All of these studies investigating potential correlates of vaccine efficacy in RV144
involved a retrospective evaluation of HIV-infected and uninfected persons who
received the vaccine (i.e., case-control studies) or genetic sieve analyses comparing
breakthrough HIV infections between vaccine and placebo recipients. To evaluate
prospectively whether these same immune response correlates of risk could be elicited
in South Africans, we conducted a study immunizing with the RV144 regimen containing
clades B and E inserts in RSA where clade C dominates. In particular, we compared the
magnitude and frequency of responses seen in South Africans to the Thai RV144
participants, as it pertains to the correlates of infection risk and potential cross-clade
immune responses associated with these correlates. This study was a precursor to an
adapted regimen, involving the subtype C ALVAC–HIV-1 and bivalent subtype C
gp120/MF59 HIV-1 vaccine regimen HVTN (HIV Vaccine Trials Network) 100, conducted
in RSA to inform the advancement to efficacy testing . Our results provide critical
insights about the potential extension of this vaccine approach to other regions of the
world as well as the identification of non-neutralizing functional antibodies that are
elicited by this vaccine regimen.

Paragraph 5
Findings in this study demonstrate that the immune responses associated with reduced
risk of HIV-1 infection in the RV144 trial can be elicited, and often at greater frequency
and magnitude, among HIV-1–seronegative South Africans. This was seen, irrespective
of sex, age, and locale, in both Env-specific antibody and CD4+ T cell responses. In
addition, the RV144 vaccine regimen, although designed for the Southeast Asian clade
A/E epidemic, elicited substantial cross-clade immune responses to antibodies and T cell
antigens derived from the predominantly clade C epidemic in sub-Saharan Africa,
indicative of this regimen’s potential for global coverage. We demonstrate several
interesting functional antibody responses associated with protection of infection in both
NHP and human vaccine trials, including high frequencies of ADCP, ADCC, and
CD40L+CD4+ T cell responses to HIV-1 Env.
 Paragraph 6
Our data are encouraging because several other HIV vaccine studies have demonstrated
a differential effect of sex and BMI on vaccine-induced immune responses. In South
Africa, the HVTN 503/Phambili study demonstrated an inverse relationship of MRK Ad5
HIV-1 gag/pol/nef vaccine–induced CD4+ T cell immune response with BMI: Overweight
and obese participants had more muted responses compared to participants with
low/normal BMI . In contrast, there were no negative effects of BMI on vaccine-induced
CD4+ T cell immune responses or on IgG binding antibody responses in HVTN 097. As
BMI data were not collected in RV144, a limitation of our study was our inability to
compare the impact of BMI on immune responses across the two studies. Of the 100
participants enrolled in HVTN 097, only 15% of the cohort had a BMI > 31, reducing the
generalizability of our finding. Given the regional differences, BMI assessments in RV144
would have provided valuable insights in the role that body mass plays on vaccine-
induced immune responses. Ⓒ OET Medcity

Paragraph 7
Notably, HVTN 097 showed cellular responses to vaccination to be similar in both sexes.
There have been inconsistent results for CD4+ T cell responses by sex in studies of a
recombinant pox vector, NYVAC-C, where some studies have demonstrated no
differences by sex, whereas in another study, females were more likely to be
responders, as compared to males .The observation that South Africans had stronger
immune responses than Thais may be due to an interplay between race, ethnicity,
genetic factors, pathogen exposure, the microbiome, or factors such as smoking or
alcohol use that have affected immune responses to other vaccines

7) Writer suggest that in South Africa HIV infection spread widely due to

a) Lack of vaccine to prevent HIV -

b) Clade C infections
c) Generalized heterosexual relations
d) Heterosexual intercourse.

8) What is the estimated efficacy of vaccine in one year?

a) 31.2%
b) 60%
c) more than 60%
d) around 31.5%

9) RV144 vaccine induces

a) hormonal and cellular immune responses

b) Immunoglobulin G antibodies
c) Ig A antibodies
d) HIV specific hormonal and cellular immune response

10) What the paragraph 3 says about?

a) Different analysis on vaccine efficacy

b) A genome sieve analysis
c) Host genetic studies
d) Studies on vaccine immunogenicity

11) In paragraph 4,the word retrospective indicates

a) Backdated
b) Looking back
c) Reasoning
d) Study on HIV infection

12) What does the word “This”in the 5 th paragraph refers to?

a) immune responses
b) reduced risk of HIV -1infection
c) HIV-1 seronegativity
d) RV144 trial
13) In paragraph 6 what was the constraint of their study?
a) Impact of BMI on immune response in two studies was unable to compare.
b) Lack of reliability across the studies
c) RV144 provided valuable insights that BMI plays an important role in vaccine induced
immune responses.
d) Due to generalizability of their findings Ⓒ OET Medcity

14) What the writer highlight in paragraph 7?

a) Gender difference in CD4 T cell response
b) Cellular response to vaccination
c) Factors affect the immune response
d) A study on South Africans

EFFECTIVENESS OF VARIOUS POSTPARTUM DEPRESSION TREATMENTS

Paragraph 1

Postpartum depression is seen in approximately 13% of women who have recently given
birth; unfortunately, it often remains untreated. Important causes for undertreatment
of this disorder are providers’ and patients’ lack of information about the effectiveness
of various treatments, and their concerns about the impact of treatment on nursing
infants. This article presents research-based evidence on the benefits of various
treatments for postpartum depression and their potential risks to nursing infants. The
medical literature on postpartum depression treatment was reviewed by searching
MEDLINE and Current Contents using such key terms as “postpartum depression,”
“treatment,” “therapy,” “psychotherapy,” and “breastfeeding.”

Paragraph 2

There is evidence that postpartum depression improves with antidepressant drug

therapy, estrogen, individual psychotherapy, nurse home visits, and possibly group
therapy. Of the more frequently studied antidepressant drugs in breastfeeding women,
paroxetine, sertraline, and nortriptyline have not been found to have adverse effects on
infants. Fluoxetine, however, should be avoided in breastfeeding women. By
administering effective treatment to women with postpartum depression, we can
positively impact the lives of mothers, their infants, and other family members.

Paragraph 3

Postpartum depression, observed in approximately 13% of women who have recently

given birth. It is classified as a major depressive disorder and as such is characterized by
a variety of mental and physical symptoms that produce significant distress and
detrimental changes in life functions. According to the postpartum onset modifier of
major depressive disorder, depressive symptoms begin within the first 4 weeks after
delivery; however, it has been shown that women continue to remain at risk for mental
disorders even several months after delivery.

Paragraph 4

Postpartum depression is distinguishable from other postpartum mental disorders. The

transient “postpartum blues” occur in a majority of mothers at some time within the
first 2 weeks after delivery and are characterized by dysphoria, mood lability, crying,
anxiety, insomnia, poor appetite, and irritability.3 The more serious but relatively rare
postpartum psychosis (prevalence of 0.1%–0.2%),is associated with such symptoms as
loose thought associations, hallucinations, delusions, and disorganized or catatonic
behavior. Ⓒ OET Medcity

Paragraph 5

Although the consequences of postpartum depression are usually not as severe as those
of postpartum psychosis, they can have a significant, negative impact on the lives of not
only mothers but also other family members. Mothers themselves might experience
physical, marital, parental, social, and vocational difficulties. Their depression can, in
some cases, also adversely affect their infants; studies have noted associations between
maternal depression and impaired maternal-infant interactions, cognitive and emotional
development, and anxiety and lower self-esteem.

Paragraph 6

Given the potential serious consequences of postpartum depression, it is imperative

that health professionals caring for mothers of infants appropriately manage this
disorder. A common barrier to providing adequate care is failure to recognize the
problem in the first place. Therefore, the US Preventive Services Task Force has recently
recommended that adults be screened for depression in clinical practices that have
systems in place to assure accurate diagnosis, effective treatment, and follow-up. In a
study of 342 women, use of the Edinburgh Postnatal Depression Scale (EPDS) to screen
for depression at approximately 6 weeks postpartum improved the rate of depression
diagnosis from 3.7% to 10.7%. Although the EPDS is the most commonly used screening
tool for postpartum depression in research studies, the Task Force suggests that
screening with a simple 2-question tool, developed by Whooley et al (1997), may be as
effective as longer instruments. The tool includes these questions: “Over the past 2
weeks, have you felt down, depressed, or hopeless?” and“Over the past 2 weeks, have
you felt little interest or pleasure in doing things?” A positive response to either
question indicates a positive screen and should be followed by an expanded history to
confirm the diagnosis of depression.

Paragraph 7

Once the diagnosis of postpartum depression has been established, it should be treated
using methods similar to those used for non-postpartum major depressive disorder.
These consist of patient education regarding depression, including the biologic basis of
depression, treatment options, therapeutic and adverse effects of antidepressant drugs,
desired duration of treatment (usually several months or longer), and the need for a
healthy lifestyle and social support and the selection of an active treatment modality
(usually antidepressant medication and/or psychotherapy) through shared decision
making between the patient and provider. Notably, the treatment of depression in the
postpartum period may be more challenging than in other stages of life. Patients and
physicians often have concerns about the use of psychotropic medications in
breastfeeding women and, related to this, questions about other viable treatment
options for breastfeeding women. Therefore, the purpose of this article is to review
empirically based information about the effectiveness of various pharmacologic and
nonpharmacological treatment modalities for postpartum depression and
antidepressant drug effects on nursing infants.

Paragraph 8

Numerous studies have found antidepressant drugs to be effective in treating general

depression. Although newer antidepressants [eg, selective serotonin reuptake inhibitors
(SSRIs)] are as efficacious as the older tricyclic antidepressants (TCAs), the SSRIs are the
drugs of choice for treating depressive disorders because of their greater tolerability
and their relative safety if taken in overdose.Common side effects for TCAs include
anticholinergic effects, weight gain, sedation, and orthostatic hypotension, whereas
adverse effects for SSRIs include nausea, anorexia, diarrhea, headache, anxiety,
nervousness, insomnia, drowsiness, sexual dysfunction, and increased sweating.

15) What the writer says about the cause of unclear treatment in first paragraph?
a) Women who have recently given birth, lack information about the impact of various
medication on infants
b) They concerns more about nursing infants
c) Health care providers and patients know the evidence of various treatments for
postpartum depression
d) Efficacy of treatment modalities unawareness among professional patient on the
efficacy of treatment modalities.

16) What are the various ways to improve post partum depression?
a)Drug therapy
b) Estrogen, physiotherapy
c) Antidepressant drug and group therapy
d) Paroxetine and fluoxetine

17) In second paragraph which antidepressant is contraindicated during breast feeding

a) paroxetine and fluoxetine
b) sertraline and nortriptyline
c) nortriptyline and paroxetine
d) None of the above

18) Postpartum blues indicates

a) Baby blues
b) Postpartum depression
c) Extreme irritability
d) Catatonic behavior Ⓒ OET Medcity
19) According to paragraph 5 what are the adverse effect of postpartum depression on
infants
a) Depression
b) impaired cognitive and emotional development
c) Social, physical and vocational difficulties.
d) Depression and anxiety

20) According to paragraph 6 what the US Preventive Services Task Force suggests to
prevent postpartum depression?

a) Realize the problem in first place

b) Screening in clinical practice
c) Do accurate diagnosis, treatment and follow up.
d) Solve all barriers

21) In paragraph 7 “these “indicates

a) Treatment for non postpartum depressive disorder
b) Treatment for postpartum depression
c) Various methods to treat depressive patient
d) Non of the above

22) Select suitable heading for paragraph 8

a) Antidepressants v/s general depression
b) Efficacy of antidepressants
c) Side effects of antidepressants
d) Qualities of antidepressants
READING 3
PART A
Ectopic pregnancy
TEXT A
Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside
the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding.
Fewer than 50 percent of affected women have both of these symptoms. The pain may
be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding
into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting,
or shock. With very rare exceptions the fetus is unable to survive.
 Risk factors for ectopic pregnancy include
 Pelvic inflammatory disease, often due to chlamydia infection
 Tobacco smoking
 Prior tubal surgery
 History of infertility
 Use of assisted reproductive technology
 Those who have previous history ectopic pregnancy
 Previous exposure to DES
 Endometriosis
 Tubal ligation
Most ectopic pregnancies (90%) occur in the fallopian tube, which are known as tubal
pregnancies Implantation can also occur on the cervix, ovaries, or within the abdomen.
Detection of ectopic pregnancy is typically by blood tests for human chorionic
gonadotropin (hCG) and ultrasound. This may require testing on more than one
occasion Ⓒ OET Medcity
 TEXT B

Signs and symptoms

Up to 10% of women with ectopic pregnancy have no symptoms, and one third have no
medical signs. In many cases the symptoms have low specificity, and can be similar to
those of other genitourinary and gastrointestinal disorders, such as
appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or
urinary tract infection. Clinical presentation of ectopic pregnancy occurs at a mean ofweeks
after the last normal menstrual period, with a range of four to eight weeks. Later
presentations are more common in communities deprived of modern diagnostic ability.
Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in
varying amounts), sudden lower abdominal pain, pelvic pain, a tender cervix, an adnexal
mass, or adnexal tenderness. In the absence of ultrasound or hCG assessment,
heavy vaginal bleeding may lead to a misdiagnosis of miscarriage. Nausea, vomiting and
diarrhea are more rare symptoms of ectopic pregnancy.

TEXT C

Complications
The most common complication is rupture with internal bleeding which may lead to
hypovolemic shock. Death from rupture is the leading cause of death in the first
trimester of the pregnancy. Rupture of an ectopic pregnancy can lead to abdominal
distension, tenderness, peritonism and hypovolemic shock. A woman with ectopic
pregnancy may be excessively mobile with upright posturing, in order to decrease
intrapelvic blood flow, which can lead to swelling of the abdominal cavity and cause
additional pain.

Causes
There are a number of risk factors for ectopic pregnancies. However, in as many as one
third to one half no risk factors can be identified. Risk factors include: pelvic
inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure
to diethylstilbestrol (DES), tubal surgery, intrauterine surgery (e.g. D&C), smoking,
previous ectopic pregnancy, endometriosis, and tubal ligation. A previous
induced abortion does not appear to increase the risk. The intrauterine device (IUD)
does not increase the risk of ectopic pregnancy, but with an IUD if pregnancy occurs it is
more likely to be ectopic than intrauterine. The risk of ectopic pregnancy after
chlamydia infection is low. The exact mechanism through which chlamydia increases
the risk of ectopic pregnancy is uncertain, though some research suggests that the
infection can affect the structure of Fallopian tubes.
 Text D
Treatment
Unfortunately, the fetus (the developing embryo) cannot be saved in an ectopic
pregnancy. Treatment is usually needed to remove the pregnancy before it grows too
large
The main treatment options are;
 Expectant management –your condition is carefully monitored to see whether
treatment is necessary
 Medication – a medicine called methotrexate is used to stop the pregnancy
growing.
 Surgery –surgery is used to remove the pregnancy, usually along with the
affected fallopian tube.
These options each have advantages and disadvantages that your doctor will discuss
with you. They’ll recommend what they think is the most suitable option for you,
depending on factors such as your symptoms ,the size of the fetus and the level of
pregnancy hormone (human chorionic gonadotropin or hCG)in your blood.

Ⓒ OET Medcity

QUESTIONS 1-7
For each question, 1-7 decide which text (A,B,C,OR D)the information comes
from .you may use any letter more than one

In which text can you find information about?

1) Different sites of implantation in pregnancy?

2) Treatment usually requires to terminate pregnancy?

3) Characteristics of pain in ectopic pregnancy?

4) Cause of death during a certain period of pregnancy?

 5) Percentage of women with ectopic pregnancy who are asymptomatic?

6) Causes of ectopic pregnancy?

7) Unusual manifestations of ectopic pregnancy?

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

8) What is the most common complication noted when embryo attaches outside
the uterus?

9) What is the percentage of ectopic pregnancies which occurs in the fallopian

tube?

10) A medication which used to cease the gestation

11) What can cause abnormal enlargement of the abdominal cavity?

12) What is the percent of woman who have both abdominal pain and vaginal
bleeding?

13) Which management requires careful monitoring of the condition?

14) Which sign in ectopic pregnancy can present in varying amount?

 Questions 15-20
Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

15) of an ectopic pregnancy may cause hypovolemic shock

16) Woman with ectopic pregnancy are asymptomatic and _have no
medical signs
17) Detection of ectopic pregnancy may require testing more than .
18) The use of technology is a risk for ectopic pregnancy.
19) will suggest the most appropriate treatment option.
20) Massive vaginal bleeding may misdiagnose in the absence of HCG assessment
or
 PART B

TRENDS IN ONCOLOGY NURSING

As a result of the growing number of anticancer agents delivered orally and the shift of
responsibility from inpatient to outpatient settings, patients are increasingly expected
to control their treatment by themselves. Since patients generally stay at home during
therapy, the completion of the therapy depends on whether or not the patients
themselves adhere to the treatment regimen. A research that evaluated whether or not
nursing intervention improved patients' QOL using treatment adherence as the outcome
indicator is currently attracting attention. Ⓒ OET Medcity

1) What the manual says about?

a) Changes in the field of cancer treatment
b) Role of nursing intervention in cancer treatment
c) Importance of patient in cancer treatment.

NUCLEAR MEDICINE

In Nuclear Medicine Departments (NMDs), nurses care for patients undergoing

diagnostic or therapeutic treatments. This involves patient preparation, administering
radioactive and non-radioactive medications, explaining the procedure, comforting and
ensuring patient safety. These nurses are vulnerable to the damaging effects of ionizing
radiation. However, they can reduce the risks of radiation by using different principles of
radiation protection such as ALARA and the 10-day-rule. In addition, they may use the
principles of time, distance, and shielding as well as various monitoring devices such as
Geiger Muller (GM) counter and Thermoluminescent Dosimeters (TLDs). ALARA refers to
As Low as Reasonably Achievable, in other words, to receive the maximum benefits by
using the minimum of radiation dose to avoid its risks. The 10-day-rule on the other
hand recommends that in women of child bearing age, non-urgent examinations that
involve pelvic radiation should be limited to the first 10 days of the menstrual cycle.
Time refers to the length of exposure to radiation, in that short exposures will produce
less radiation dose. Distance refers to the distance between an individual and the
radiation source. Increase in distance can result in dose reduction. Shielding refers to
both fixed protective barriers and personal protective equipment such as lead aprons.
Ⓒ OET Medcity

2) How nurses should reduce damaging effect of ionizing radiation?

a) By using different principles of radiation protection such as ALARA and the 10 day
rule.
b) By administering radioactive medicines.
c) Should maintain less distances between individual and radiation sources.

Nurse Involvement in End-of-Life Decision Making.

In the critical care setting, nurses often feel the stress of working with patients and
family members who are facing end-of-life decisions. Traditionally, the responsibility for
end-of-life discussion belongs to the physician. Nurses often feel ill-prepared and
awkward in addressing the topic with the patient and family. As patient advocates,
nurses should be more actively involved with facilitating end-of-life decision-making
process for critically ill patients and their families. Advocating for patients is an ethical
imperative for nurses

3) Who is the main person involved in end of life discussion

a) physician
b) Nurse
c) Both physician and nurse.

Patient safety is one of the nation's most pressing health care challenges, which are in
the domain of clinical risk management; in fact clinical risk management is a principal
element of clinical governance. In other words, besides error detection capabilities,
establishing effective clinical risk management depends on institutionalizing the culture
of error reporting based on trust. Reducing the probability of clinical risks in hospitals is
very important to improve: Health care quality, having effective hospital staff and
patients relationship, patient satisfaction and also to limit complaints on medical errors
and nursing care. Ⓒ OET Medcity

4) The passage says about

a) Importance of patient care

b) Risks in patient care
c) Methods to reduce clinical risks

ERRORS IN ICU CARE

It is determined that most of potential errors have low discovery number showing that
the ICU nurses are familiar with potential errors of cares and will discover their causes
immediately. It is noteworthy, nursing failure and neglect is not the only causes of ICU
potential errors, there are many factors caused errors such as patients’ sensitivity,
patient with complex conditions and underlying disease, lack or malfunction of
equipment, negligence and malpractice of physicians and other personnel, lack of
proper training to the nurses, fatigue due to sensitivity and high volume of workload in
ICU. Team members also proposed some actions to control and eliminate each of
detected clinical errors. Ⓒ OET Medcity

5) Why the possible errors are less common now?

a) ICU nurses find the errors and solutions immediately

b) ICU nurses are able to find the causes of potential errors
c) Find other factors which leads to potential errors.

CODE OF ETHICS

As a main general conceptual background of the National code, the patients are not
considered as only people who receive the nursing care, and others including the
patients’ family and healthy people in the society are considered in the plans and
services. Another essence of the Code is that the individual dignity should be respected,
regardless of who is receiving the care, or from which nationality, ethnicity, religion,
culture, socio-economic class, gender, etc the patient/client is. Meanwhile, under the
provisions of the National Code, nurses must recognize and respect cultural sensitivity in
everyday practice, even in this era of globalization. Ⓒ OET Medcity

6) How individual dignity should be respected in code of ethics?

a) Nurses must recognize and respect cultural sensitivity in everyday practice

b) Patient and family requires appropriate nursing care as per code of ethics
c) Care in regardless of ethnicity, religion, culture, socioeconomic class, gender and
nationality.
 PART C

CRITICAL ROLE OF NURSE IN ANTIMICROBIAL STEWARDSHIP

Paragraph 1

The emergence and worldwide spread of antimicrobial resistance presents a global

health crisis that both the US Centers for Disease Control and Prevention (CDC) and the
World Health Organization (WHO) have labeled a grave threat to human health . The
“perfect storm” of widespread antibiotic use, pharmaceutical industry retreat from new
antibiotic development, and spread of antibiotic resistant organisms, combined with
rapid, accessible international travel has captured the attention of healthcare
professionals, national governments, the media, and the public at large. The main
immediately available strategy to address this problem is the utilization of currently
available antibiotics and resources in the most judicious manner to achieve the best
clinical results, while limiting the development and propagation of multi-drug resistant
microorganisms. Ⓒ OET Medcity

Paragraph 2

Antimicrobial stewardship is such a programmatic approach to the thoughtful use of

antibiotics. It is hoped that education of all healthcare providers, as well as the general
public, about the rationale for antimicrobial stewardship will lead to a restraint in the
use of antibiotics that was felt to be unnecessary in an earlier time when antibiotics
were regarded as abundant and effective “miracle drugs.” Although conceptual
guidelines for the ideal use of antibiotics were published in 1988, and warnings
regarding resistance to antibiotics were promulgated as far back as 1939 and 1945,
formal antimicrobial stewardship programs (ASPs) have developed only in the last 15
years . The major currently recognized stakeholders in ASPs include pharmacy,
infectious diseases, infection prevention, and microbiology professionals, with
administrative (including financial and regulatory) support. The sector currently absent
from the formal organizational chart is nursing.

Paragraph 3

Repeatedly, in guidelines for the development of ASPs, broad-based, multidisciplinary

involvement is highlighted as an essential feature to achieve the goals of antimicrobial
stewardship. Brief mention of including staff nurses is made in these recommendations,
but is limited to at most 3 or 4 sentences. In 2 articles from the United Kingdom and
from Australia and in the Institute for Health Improvement/Centers for Disease Control
and Prevention (IHI/CDC) Antibiotic Stewardship Driver Diagram and Change Package,
comment is made about nursing functions. However, in the latter, the itemized
secondary drivers are not explicitly assigned or attributed to nurses, and in the 2
infection control journal articles, the interventions are described as “should be
implemented” or “could impact” antimicrobial stewardship efforts. We assert that staff
nurses are already participating in these activities, albeit not in an acknowledged or
integrated fashion. Because of this exclusion, they cannot contribute most effectively to
the diverse goals of ASPs. The unintentional mischaracterization of the participation of
nurses in ASPs as only potential rather than actual has the additional unintended
consequence of divorcing nursing from those very activities that nurses need to
understand as critical attributes of antimicrobial stewardship.

Paragraph 4

The dichotomy between the omission of nurses from formal ASP guidelines and the
reality of daily nursing practice becomes obvious if one examines a stepwise progression
through a typical inpatient hospital admission. On arrival at the hospital emergency
department, a patient is triaged and placed on appropriate precautions. This triage
function is actually made by the emergency department triage nurse or by the admitting
staff nurse. That decision may be reviewed or modified later by an infection
preventionist, sometimes guided by microbiology results, but the immediate
determination regarding necessary isolation is an established staff nursing judgment.

Paragraph 5

Next, medication allergy history is assessed, either by the triage or admitting nurse. A
label of penicillin “allergy” has been documented to be associated with increased
antibiotic costs, increased selection of antibiotic resistant microbes, and increased
length of stay and hospital costs . These subsequent consequences are traditionally
linked to pharmacy, microbiology, case management, and fiscally to administration, but
the identification and documentation of a medication allergy history is a well-accepted
staff nurse responsibility. Nurses therefore need to be taught the difference between a
true allergy and the adverse events that would not preclude the use of certain classes of
antibiotics. As many electronic medical record systems preserve the past history of a
patient's medication usage, the nurse's review of past safe (or not) receipt of cross-
related antibiotics (eg, cephalosporins in a patient with a history of alleged penicillin
allergy) could become a useful component of “medication allergy reconciliation.”
 Paragraph 6

Timely antibiotic ordering and administration, regarded as a Joint Commission National

Quality Core Measure and identified as Centers for Medicare and Medicaid Services
(CMS) performance measure, is typically viewed purely as a physician prescribing event.
But it is the staff nurse who receives the order for antibiotics, submits the order to the
pharmacy, administers the medication, records its dose and timing, and monitors the
effects of treatment and adverse events. Likewise, collection and submission of
specimens for culture are almost universally performed by nurses. This underscores the
need for nurses to be educated about how to obtain appropriate specimens for culture
and then to send such specimens by protocol in suitable clinical settings without
awaiting a physician order. Ⓒ OET Medcity

7) What does the paragraph 1 says about?

a) Future actions needed to solve a serious problem
b) Highlight an instantly obtainable solution for a serious threat
c) Immediate actions needed to address the antimicrobial assistance
d) Explains the seriousness of antimicrobial resistance

8) What does the phrase “miracle days “indicates?

a) Drugs which elicit a dramatic response in a patient’s condition

b) Plentiful and effective drugs which are newly discovered
c) Antibiotics which produce wonderful effect on patients
d) Abundantly available effective drugs

9) In paragraph 2, when commenting on the popularity of ASPs, these were actually

making know in

a) 1988
b) 1939 and 1945
c) 1945
d) Last 15 years

10) According to paragraph 3, what is the limitation of recommendation which states

regarding inclusion of staff nurses?
a) Limited to fewer than 3 or 4 sentences
b) Guideline was just about 3 sentences
c) Restricted to maximum 3 or one sentence more than that
d) Extended to at most 3 or 4 sentences

11) Why microbiology results are using triaging the patient?

a) Triage function may be based on microbiology results.
b) Sometimes triaged patients are reviewed on the basis of these results.
c) For necessary isolation purpose
d) To modify the triage decision which made by the nurses.

12) When assessing medication allergy, why is it important to label penicillin

hypersensitivity?
a) It is documented in relation to various factors
b) Mainly it is associated with antibiotic costs
c) To reduce the total expenses of a hospital stay
d) It is related to pharmacy, microbiology, case management and administration

13) In paragraph 5, what does the word “reconciliation “means?

a) Restoration of patient’s medication allergic history
b) Harmonization of patient’s medication allergy
c) Consistent history of medication allergy
d) Review of past allergic history

14) In the final paragraph what the writer says about the need for nurses education?
a) It is important to follow the protocol in clinical setting
b) Need to educate regarding proper specimen collection and following procedures to
send specimen for culture
c) Education needed for collection and submission of culture, these are almost
universally performed
 ADHERENCE AND HEALTH CARE COSTS

Paragraph 1

Medication non-adherence is an important public health consideration, affecting health

outcomes and overall health care costs. This review considers the most recent
developments in adherence research with a focus on the impact of medication
adherence on health care costs in the US health system. We describe the magnitude of
the non-adherence problem and related costs, with an extensive discussion of the
mechanisms underlying the impact of non-adherence on costs. Specifically, we
summarize the impact of non-adherence on health care costs in several chronic
diseases, such as diabetes and asthma. A brief analysis of existing research study
designs, along with suggestions for future research focus, is provided. Finally, given the
ongoing changes in the US health care system, we also address some of the most
relevant and current trends in health care, including pharmacist-led medication therapy
management and electronic (e)-prescribing. Ⓒ OET Medcity

Paragraph 2

Patients are considered adherent to medications when they take prescribed agents at
doses and times recommended by a health care provider and agreed to buy the patient.
As the health care community adopts the concepts of patient centeredness and
activation, it is moving away from the term “compliance”, which implies patient
passivity in following the prescriber’s recommendations. Medication persistence is the
length of time from initiation to discontinuation of therapy.

Paragraph 3

Adherence may be measured indirectly or directly as shown in . Two indirect adherence

metrics used in research and administrative work are the medication possession ratio
(MPR) and the proportion of days covered (PDC). MPR is calculated as the total number
of days supplied, divided by the number of days between the first and last refills; while
PDC is calculated as the total number of days supplied during an interval, divided by the
total number of days during that interval. An MPR of 80% is often used as the cut off
between adherence and nonadherence based on its ability to predict hospitalizations
across selected high prevalence chronic diseases. These measures rely on pharmacy
claims data, which does not account for the use of free drug samples, can miss coverage
through a different insurance plans, and is insensitive to therapy changes. Insurance
claims data also do not assess whether patients time doses, or use delivery devices,
correctly. These protocols are important in conditions like COPD and asthma, where the
way a patient uses inhaled therapy can also affect outcomes significantly.

Paragraph 4

In clinical settings, adherence may be indirectly assessed using patient recall. Because
patients may significantly overestimate adherence during self-reports, patient recall is
more effectively interpreted when combined with a validated questionnaire to assess
adherence barriers. Other methods such as pill counting and reviewing pill bottles
against medication lists may provide important clinician insights and an opportunity for
patient education. Bidirectional electronic (e)-prescribing interfaces which provide
clinicians data on medication refill intervals at the time of care, are available in settings
with electronic medical records. Electronic and mechanical dose counters provide
estimates of adherence that can be reviewed during clinician visits; these may also
improve adherence by providing patient reminders. Finally, clinicians may assume
patients are adherent with medications when therapeutic goals are achieved. Like
claims data, clinical setting measures lack the ability to verify doses are taken but
require less time and expense to implement, compared to directly measured
adherence.Direct methods, including observed therapy, and blood or urine drug and
metabolite concentrations are most commonly used in research when therapy involves
high risk medications, or when public health needs merit the additional costs,
invasiveness, and resources required to implement them. Ⓒ OET Medcity

Paragraph 5

Optimizing expenditures and outcomes

In 2010 spending for prescription drugs in the US was US$259 billion. Considering the
prevalent rates of nonadherence, drug-related expenses could increase substantially if
adherence improved. Medication nonadherence is widespread and varied by disease,
patient characteristics, and insurance coverage, with nonadherence rates ranging from
25% to 50%. In the US, nearly half of all adults have at least one chronic disease28 and
the percentage of Americans taking at least one prescription drug increased from 38% in
the period 1988–1994 to 49% in the period 2007–2010; during the same time the
number of adults taking three or more prescription drugs doubled. Prescription
medication use will increase as the population ages. Based on these statistics, increasing
adherence from current levels could increase medication expenses by billions of dollars.

Paragraph 6

Strategies to enhance adherence should consider the impact on overall health care
costs, weighing increased drug expenditures against savings from improved outcomes.
The majority of the costs attributed to medication nonadherence result from avoidable
hospitalization. Additional direct costs are incurred by progression of controllable
disease with: increased service utilization at physician offices, emergency rooms, and
urgent care and treatment facilities such as nursing homes, hospice, or dialysis centers;
avoidable pharmacy costs related to therapy intensification as co morbid conditions
develop; and diagnostic testing that could be avoided by controlling the primary illness.

Paragraph 7

Because the adverse consequences of most chronic illnesses may not present for years,
it is argued that additional expenditure to increase medication adherence might not be
economically attractive to payers. Even in illnesses where total health care costs are
lower in adherent patients, savings might reflect the impact of patient characteristics,
other than adherence, that make them healthier overall than non-adherers. If this were
true, investing resources in activating “unhealthy non-adherers” might not be cost
effective. However, as discussed in our review, there is substantial evidence that the
long term costs of poor outcomes exceed costs of medications in much chronic illnesses.
In contrast, increasing adherence in mild illness may not save costs. If the cost of the
medication is relatively high, while the baseline rate of hospitalizations and emergency
department visits is low (eg, mild asthma or early human immunodeficiency infection),
total health care costs may increase with better adherence. In cases like these, using
low-cost generic medications and targeting higher severity patients may shift the
balance towards cost savings.

Paragraph 8

Increasing adherence in patients with higher acuity may be a better investment,

especially when rates of hospitalization are high. An estimated 10% of hospitalizations in
older adults may be caused by medication non-adherence. To prevent admissions and
readmissions, payers and hospitals have implemented programs to improve medication
adherence after discharge.
15) Which of the following statements best matches the information in the first
paragraph?
a) A study which relates healthcare cost and non-adherence.
b) Medication adherence health outcomes and health care cost
c) Emphasize on the need for future research studies.
d) Describing the current trends and related cost.

16) Why do the health care committee moving away from the term compliance?
a) They focus more on the concepts patient activation.
b) There is more appropriate word to describe patient centered care.
c) It indicated patient’s inactivity in obeying prescriber’s recommendations.
d) They espouse the patient centeredness and activation concepts.

17) According to paragraph 3, pharmacy claims data is not responsible

for
a) Therapy changes and insurance plans.
b) Utilization of free drug samples.
c) Cut off between adherence and non-adherence.
d) MPR’s ability to predict hospitalizations among selected high prevalence chronic
disease.

18) What is the advantage of indirect assessment of adherence compared to direct

methods?
a) Patient recall is more effectively interpreted
b) Less laborious and cost effective to execute.
c) Replenish intervals at the time of care.
d) Direct method requires additional costs and resources to implement.

19) The main idea presented in paragraph 5 is

a) Increasing rates of non-adherence and expenses.
b) Research on medication adherence and increased number of prescribed medications.
c) Enhancement in adherence could significantly increase the medication expenses.
d) Medication expenses could improve the drug adherence.

20) Attribution of costs to the drug non-adherence is due to _

a) Additional direct costs.
b) Progression of controllable disease.
c) Unnecessary hospitalization.
d) Avoidable hospital admissions.

21) What is the relation between medication cost and rate of hospitalization?
a) Total health care cost will increase.
b) Cost of medication exceeds proportion of hospitalization.
c) These are inversely proportional to each other.
d) Rate of hospitalization and emergency department visit is low.

22) The word “acuity” in paragraph 8 indicates -

a) Keenness
b) Knowledge
c) Clarity
d) Attitude
READING 4
PART A

PLASMODIUM FALCIPARUM
TEXT A
Plasmodium falciparum malaria parasites produce a repertoire of plant-like volatile
compounds. These compounds may represent interspecies chemical signals, or
semiophores, that modulate the attraction of vector mosquitoes to hosts. Among the
parasite-specific compounds we identified, terpenes are bioavailable molecules that
readily pass through membranes and partition into alveolar gas in the lung. Terpenes,
likely from dietary sources, have previously been identified in exhaled breath samples of
humans. Upon malaria parasite infection, parasite-produced terpenes are likely to be
detected outside infected individuals, since the total number of parasites in a typical
infected human well exceeds the number sampled in culture in such studies.

TEXT B

Previous studies have suggested that P. falciparum infection of Anopheles spp.

mosquitoes may reduce fitness and alter feeding behaviors. Over time, selective
pressures might enrich for mosquitoes with a decreased tendency to feed from malaria
parasite-infected individuals. Therefore, any chemical signals that increase attraction of
mosquitoes to infected individuals must be difficult to select against and resistant to
evolutionary pressures. This hypothesis is consistent with the finding that malaria
infection increases production of typical mammalian host odorants. Our studies suggest
an additional strategy by P. falciparum for overcoming selection against biting infected
hosts, in which the malaria parasite compensates by imitating the volatile components
of plants preferred by Anopheles spp. The parasite thus hijacks a highly selected
signaling response that is necessary for mosquito nectar feeding behavior and survival.
Since Plasmodium infection increases nectar attraction in Anopheles , the parasite
appears to facilitate transmission both by generating a mosquito chemoattractant and
by sensitizing the mosquito to detect this signal. Interruption of parasite-mediated
volatile signaling to mosquitoes will be a potent means of blocking this critical step in
the malaria life cycle. Ⓒ OET Medcity

TEXT C

P. falciparum has well-characterized biosynthetic machinery to produce isoprenoid

building blocks and prenyl diphosphates . In other systems, such as plants, terpenes are
produced by terpene synthases, which generate terpenes by catalyzing intramolecular
cyclization of prenyl diphosphate substrates . This promiscuous reaction typically
produces a variety of chemically related terpene variants from a single enzyme, a
cardinal feature of this enzyme class . Consistent with this product diversity, the large
protein family of terpene synthases (Pfam 01397) exhibits remarkable sequence
diversity. Our studies strongly suggest that terpenes are produced de novo in
P. falciparum, since chemical inhibition of parasite-specific isoprenoid biosynthesis
reduces terpene production. No unambiguous terpene synthase ortholog is present in
P. falciparum, based on domain or phylogenetic analyses, but is likely to be represented
among the nearly one-half of the parasite genes that remain unannotated. The diversity
of terpenes present in P. falciparum-conditioned gas suggests that there is at least one
monoterpene and one sesquiterpene synthase.

TEXT D

Here, we have reported a repertoire of volatile organic compounds that are specific to
P. falciparum-infected cultures. These compounds are not likely to represent all possible
malaria parasite-specific volatiles, because our conservative data filtering necessarily
excluded compounds that are parasite specific but exhibit significant biological
variability. The volatile fingerprint of P. falciparum represents not only a target for the
development of inhibitors that will interrupt malaria transmission, but also an untapped
strategy for malaria diagnostics. The parasite-specific compounds we have identified
may represent volatile biomarkers of malaria infection. Ongoing studies will establish
the presence and identity of these compounds in human P. falciparum infection
 QUESTIONS 1-7

For each question, 1-7 decide which text (A, B, C, OR D) the information comes
from .you may use any letter more than one

1. Evidence for factors affects production of terpene?

2. Total number of parasites in an infected human that is greater than number of

parasites in culture sample?

3. P falciparum represents untapped strategy for malaria diagnosis?

4. Mosquito requires some factors for survival?

5. Compounds which are constructed by parasites?

6. Basic quality of enzyme?

7. Study mention about malaria life cycle?

Questions 8-14

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

8. Which compounds are not likely to represent all possible malaria parasites?
 9. Identify a substance which forms alveolar gas

10. What is exhibited by the conservative data filtering

11. Why parasites sensitizing the mosquitoes?

12. What help to facilitate transmission?

13. What is produced from a single enzyme?

14. What increases typical mammalian host odorant production?

Questions 15-20

Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

15) compounds represent interspecies chemical signals

16) Terpenes have identified in each breath sample and

17) Mosquitoes may reduce and alter behaviours

18) increases the attraction of mosquitoes to infected individual

19) produces prenyl diphosphate

20) obstruct malaria transmission

 PART B
synaesthesia
In a variety of synaesthesia, photisms result from affect-laden stimuli as emotional
words, or faces of familiar people. For R, who participated in this study, the sight of a
familiar person triggers a mental image of “a human silhouette filled with colour”.
Subjective descriptions of synaesthetic experiences induced by the visual perception of
people’s figures and faces show similarities with the reports of those who claim to
possess the ability to see the aura. It has been proposed that the purported auric
perception may be easily explained by the presence of a specific subtype of cross-modal
perception. We analyse the subjective reports of four synaesthetes who experience
colours in response to human faces and figures. These reports are compared with
descriptions of alleged auric phenomena found in the literature and with claims made
by experts in esoteric spheres. The discrepancies found suggest that both phenomena
are phenomenologically and behaviourally dissimilar. Ⓒ OET Medcity

1) According to paragraph synaesthesia is

a) The production of a sense impression relating to one sense or part of the body by
stimulation of another sense or part of the body.
b) It is the visual perception of people’s figures and faces with similarities.
c) she experiences bright color in response tohuman faces and figures.

Autism spectrum disorder (ASD) affects 1 in 150 children and has been gaining national
attention over the past decade. Given the prevalence of this disorder, there is a high
probability that pediatric nurses will care for a child with ASD, regardless of the setting
in which they work. Children with ASD traverse the primary care outpatient setting,
schools, subspecialty clinics, and inpatient units. A basic understanding of the current
issues regarding prevalence and etiology, coupled with knowledge of the core features
of ASD, will help pediatric nurses in all settings and at various practice levels better care
for these children.

2) Main idea of this extract is

a) care of child with ASD in various settings

b) ASD is common among children
c) Autism in children

CHEMOTHERAPY

Chemotherapy is associated with multiple, often distressing, side effects. The negative
impact of these on quality of life is widely recognized. Typically, these side effects are
experienced at home, in the absence of professional assistance. Consequently,
chemotherapy that includes ambulatory treatments forces patients to actively self-
manage their symptoms. However, few patients seem to be able to do so adequately.
Performance of symptom self-management strategies is generally poor. Also, patients
sub-optimally report their symptoms to healthcare professionals. Patients report lacking
knowledge and experience, and report high levels of unmet needs in relation to self-
care support. Evidence suggests that greater symptom burden is associated with poorer
self-care. Ⓒ OET Medcity

3) According to extract patient who receives chemotherapy experiences negative impact

or side effects

a) Due to absence of professional assistance

b) Many symptoms are associated to poor self care
c) Patient partially reports their symptom to health care professional.

Children with cleft lip and/or palate have numerous problems including nutritional
deficiencies, modified front teeth, delay or change in speech development, and otitis
media. Feeding infants with cleft lip and/or palate is a challenging care process and
educating parents to establish successful feeding is one of the important tasks of
nursing.The complexity of feeding infants with cleft lip and/or palate depends on the
type of deformity and the severity. Nutritional problems can affect weight gain during
infancy and can have different effects based on the gender of the child. When children
are facing a serious problem, they cannot normally adapt to their surroundings, and
therefore, they become powerless in obtaining acceptable social behaviors and develop
behavioral problems. One of the most common behavioral problems in children is
nutritional problems,which are observed in 25–50% of healthy infants. This reflects the
significance and importance of this problem in this age group. Although some nutritional
problems are normal and transient, 3–10% of children showed severe problems, which
if untreated, placed them at risk of developmental and behavioral problems, as well as
growth retardation. Ⓒ OET Medcity

4) What does the passage says about

a) Problems for the carer to manage the children with cleft lip and palate
b) Difficulties for the children to adapt acceptable social behavior.
c) Issues and health problems for children

NOISE IN THE OPERATION THEATER : INTENSITY AND SOURCES

In hospital settings, the staff and patient alike are also exposed to a barrage of sound. In
the OT and the recovery room, the doors and equipment together with the conversation
among staff were the major sources of noise. These can be controlled to a considerable
extent by better acoustic design of the areas , better designing of the equipment as also
its maintenance, together with education, a greater sensitivity and awareness of the
staff towards the problem, and the need to control noise.

5) Which among the following is not mentioned in the paragraph?

a) Patients are exposed to a barrage of sound

b) Patients have greater sensitivity and awareness towards the barrage of sound
c) Intensity of noise could be controlled with considerable changes in the hospital infra
structure.

Digging Deep for Malaria Parasites

Malaria remains a major public health problem in developing countries. The
pathogenesis of the most deadly of human malaria parasites, Plasmodium falciparum, is
related to the ability of infected red blood cells to sequester in the microvasculature of
deep tissues. Using an existing tissue collection from malaria autopsy cases, Joice et al.
now reveal that P. falciparum transmission stages sequester in the hematopoietic
system of the human bone marrow. This finding suggests that new mechanisms may be
involved in the sequestration of these transmission stages and that the hematopoietic
system may be a major site of formation, development, and maturation of malaria
transmission stages. Ⓒ OET Medcity

6) Extract says about

a) complication of plasmodium falciparum
b) Relation between haematopoietic system and malarial transmission stages.
c) Transmission stages in the haematopoietic system of human bone marrow.
 PART C
ANIMAL MODELS OF ALLERGIC AND INFLAMMATORY CONJUNCTIVITIS

Paragraph 1

Allergic eye diseases are complex inflammatory conditions of the conjunctiva with an
increasing prevalence and incidence. The diseases are often concomitant with other
allergic diseases such as allergic rhinitis, atopic dermatitis and allergic asthma. Despite
the disabling and prominent symptoms of ocular allergies, they are less well studied and
further insights into the molecular basics are still required. To establish new therapeutic
approaches and assess immunological mechanisms, animal models of ocular allergies
have been developed in the past years. The major forms of allergic ocular diseases,
seasonal and perennial allergic conjunctivitis, vernal and atopic keratoconjunctivitis and
giant papillary conjunctivitis, each have different pathophysiological and immunological
components. In contrast to these distinct entities, the current animal models are based
on the sensitization against a small number of allergens such as ovalbumin, ragweed
pollen or major cat allergens and consecutive challenge. Different animal species have
been used so far. Starting with guinea‐pig models of allergic conjunctivitis to assess
pharmacological aspects, new models including rats and mice have been developed
which mimic major features of ocular allergy. The presently preferred species for the
investigation of the immunological basis of the disease is represented by murine models
of allergic conjunctivitis. In the future, combined ocular, nasal and aerosolic challenges
with allergens may provide a model of allergy that encompasses simultaneously the
target organs eye, nose and airways with conjunctivitis, rhinitis and asthma.

Paragraph 2

Numerous recent reports have demonstrated an increase in the prevalence and

incidence of allergic conditions during the past years which affect approximately 25% of
the general population . Whereas a large amount of studies have focused on the
pathophysiology of allergic rhinitis and asthma over the past years, ocular allergies are
less well studied. However, allergic diseases affecting the eye are very common and
pediatric studies have shown that within distinct cohorts, up to 32% of allergic children
have an ocular allergy as the primary manifestation of allergy . Allergic eye diseases such
as allergic conjunctivitis commonly present with the symptoms of itchy, watery, red,
sore and swollen eyes, but not pain. Ⓒ OET Medcity

Paragraph 3

In contrast to the large amount of experimental studies on allergic asthma and the
detailed knowledge that exists on mediators of allergic airway inflammation, there are
few experimental studies using models of allergic eye diseases. Detailed reviews to
assess the pathophysiology and immunology of ocular allergies have been limited. This
review hopefully fills this void to provide the clinical and translational researcher in the
area of ocular allergy.

Paragraph 4

Allergic conjunctivitis is commonly based on an IgE‐mediated hypersensitivity reaction.

Furthermore, allergic conjunctivitis may be divided into subgroups depending on the
duration of the symptoms. Basing on the WHO document ‘Allergic Rhinitis and its
Impact on Asthma’ (ARIA) and guidelines of the EAACI, allergic conjunctivitis should be
divided into intermittent allergic conjunctivitis (IAC), formerly termed seasonal allergic
conjunctivitis and persistent allergic conjunctivitis (PAC) formerly termed perennial
allergic conjunctivitis. They display the most common forms of ocular allergic diseases
caused by direct exposure of the conjunctiva to allergens. The old terms ‘seasonal’ and
‘perennial’ are not useful in zones where climatic seasons are perennial and therefore,
intermittent or persistent should be used to describe these forms of conjunctivitis. Both
forms of allergic conjunctivitis are IgE mast cell‐mediated hypersensitivity reactions to
aeroallergens such as ragweed or grass pollen after they come into contact with the
conjunctival surface. Next to the clinical symptoms of allergic conjunctivitis that often
includes a milky or pink conjunctiva with vascular congestion, elevated tear fluid and
serum levels for IgE are often found. In contrast to intermittent allergic conjunctivitis,
which is more common and seasonal and mainly evoked by allergens such as grass
pollens or ragweed, the persistent form is considered to be a variant of IgE‐mediated
allergic conjunctivitis which persists through the seasons. It is often caused by dust
mites or animal dander and more likely than intermittent allergic conjunctivitis
associated with other forms of persistent allergies such as persistent allergic rhinitis.
Further causes of persistent allergic conjunctivitis are exposures to work‐related
allergens that make this condition an important occupational disease.
 Paragraph 5

Differences between the two forms can be found by analysis of specific IgE. In this
respect, patients suffering from PAC in contrast to IAC have been reported to have
elevated house dust‐specific IgE serum levels, 89%vs 43% respectively. In addition,
house dust‐specific IgE levels in the tear fluid were found in 78% of PAC patients versus
none of the IAC patients. Further differences can be found in the cellular infiltrate in the
conjunctiva exemplified by the presence of eosinophils in 25–84% of patients with PAC
and in 43% of IAC patients. A large variety of mast cell and eosinophil mediators such as
major basic protein or adhesion molecules have also been identified in tear fluid and
conjunctival tissues .

Paragraph 6

Atopic keratoconjunctivitis (AKC), in contrast to IAC and PAC, has not been clearly
associated with allergens. AKC may lead to blindness and is a chronic process, usually
related to a history of atopic dermatitis or allergic asthma, which commonly involves the
lower tarsal conjunctiva and can involve the cornea. Clinical symptoms such as itching
eyelid eczema, burning and tearing tend to be more severe than that in IAC or PAC.
Histopathologically, a conjunctival inflammatory cell influx containing mast cells,
eosinophils and lymphocytes can be detected and increased tissue levels of interleukin
(IL)‐2, IL‐3, IL‐4 and IL‐5 were found. IL‐5 tear fluid levels in particular may be a marker
for the more chronic proliferative forms of ocular allergy. Ⓒ OET Medcity

Paragraph 7

In general, ocular allergies encompass a broad spectrum starting from seasonal allergic
conjunctivitis to severe types such as vernal keratoconjunctivitis. These different types
share common pathophysiological findings such as mast cell infiltration but also differ to
a major extend concerning clinical symptoms, prognosis and immunological background.
In contrast to this diversity, the presently known models of allergic eye diseases are
limited to a selected number of species and antigens and cellular mechanisms.
7) One of the distinctions in different form of allergic or inflammatory conjunctivitis is
a) Variation in major allergens
b) Different animal germs have been used for studies
c) Components of the disordered physiological process.
d)Immunological components and allergens

8) The term ‘‘concomitant” in the first paragraph is used to denote

a) Doubtful
b) Unrelated
c) Attendant
d )Uncertain

9) What are the symptoms of allergic conjunctivitis?

a) Red and puffy eyes
b) Pruritic eye and soreness and redding of eyes
c) Weepy and pruritic eyes
d) Swollen eyes with pain

10) What is the main idea of paragraph 3?

a) The details of the review are null and void
b) Studies on ocular allergy exceeds the number of experimented studies on asthma
c) Studies on ocular allergies are finite but reviews in the area are valid
d) There is limited number of studies on allergies. However, studies on allergic eye
disease are hopefully fills the area of research

11) In paragraph 4 “this” refers to

a)Persistent allergic rhinitis
b) Long lasting conjunctivitis
c) Perpetual hypersensitive conjunctivitis
d) None of the above

12) How the distinction between PAC and IAC are found?
a) Only through the analysis of IgE specific antibody
b) Through elevated serum level
c) Presence of eosinophils and mast cells
d) Elevated cellular infiltrate and specific IgE

13) What is not mentioned in paragraph 6?

a) AKC associated with atopic dermatitis and allergic asthma can lead to blindness
b) IAC or PAC is less severe than itching eyelid eczema
c) AKC is correlated with allergens
d) IL-5 tear level can be a maker for chronic proliferative forms of ocular allergy

14) What is true about final paragraph?

a) Seasonal allergic conjunctivitis is one of the minor ocular allergies
b) Various kinds of ocular allergies shows common pathophysiological and
immunological background
c) Available models of allergic eye disease are profound
d) Allergic conjunctivitis leads to severe kerato conjunctiviti

PARACETAMOL OVERDOSE

Paragraph 1

Paracetamol is an effective analgesic and antipyretic. It is well tolerated and, at the

recommended dose, is generally safe for healthy people. However, overdose or
repeated supra‐therapeutic use can cause hepatotoxicity and death. In many countries,
paracetamol is the drug most frequently involved in overdoses, and it is the most
frequent cause of acute liver failure in the Western world. Australian poisons centres
received 13 322 calls regarding paracetamol in 2015’ United States poisons centres
received more than 100 000 paracetamol‐related calls and recorded 313 deaths in
2016, while in the United Kingdom at least 80 000 people present to hospital with
paracetamol overdoses each year, and there are 150–250 deaths. Ⓒ OET Medcity

Paragraph 2

The gold standard treatment for paracetamol overdose is acetylcysteine. However,

adverse outcomes in patients with massive paracetamol overdoses, despite early
administration of acetylcysteine, have recently been reported.In the wake of increasing
numbers of overdoses, liver transplantations, and deaths, and evidence that
paracetamol overdose is often impulsive (taking medications already in the
home),paracetamol pack sizes have been restricted in the UK since 1998\ to 8 g for
non‐pharmacy sales and to 16 g for pharmacy sales (formerly: 50 g). The approach
appeared effective, as the number of large paracetamol‐related overdoses, liver unit
admissions, and suicide deaths in England and Wales subsequently declined. However,
these changes were not seen in Scotland,and the effectiveness of the measure has been
questioned.In 2009, the availability of non‐prescription paracetamol was restricted in
Germany to a maximum 10 g, and it can be purchased only in pharmacies.Most western
European countries have similar restrictions.

Paragraph 3

Paracetamol is the substance most frequently involved in overdoses in Australia. It is

available outside pharmacies in packs of twenty 500 mg tablets (10 g), and from
pharmacies as 100 × 500 mg (50 g) tablet packs and 96 × 665 mg (about 64 g) modified
release (MR) tablet packs; there is no legal limit to the number of packs that can be
purchased. Australian data on paracetamol overdose, including overdose size, liver
injury, and deaths, are limited. We therefore examined the numbers of paracetamol
overdose‐related hospital admissions and deaths in Australia since 2007–08, and the
overdose size in intentional paracetamol overdoses since 2004.

Paragraph 4

Our retrospective study focused on intentional paracetamol overdoses. Paracetamol

overdose was defined as consuming a quantity that exceeded appropriate therapeutic
levels, intentional overdose as knowingly consuming excessive amounts of single
ingredient paracetamol preparations (eg, for self‐harm or manipulative
purposes).Demographic information and data on liver injury and in‐hospital deaths were
obtained from the Australian Institute of Health and Welfare (AIHW) National Hospital
Morbidity Database (NHMD), a national database of person‐level records for hospital
admissions to public and private hospitals. The NHMD does not record the drug
amounts ingested, so overdose size information was obtained from the New South
Wales Poisons Information Centre (NSWPIC) database. NSWPIC is the largest poisons
information centre in Australia, receiving about half the 205 000 poisons‐related calls
made each year in Australia; it takes calls from health care professionals and members
of the public in NSW (65% of calls) and interstate.\ As the NHMD captures death data
only for in‐hospital deaths, these data were examined in conjunction with data from the
National Coronial Information System (NCIS), the national database for all reportable
deaths in Australia, managed by the Victorian Department of Justice and Community
Safety. Ⓒ OET Medcity

Paragraph 5

These three sources provide complementary data that together deliver a detailed
picture of paracetamol overdose in Australia. Paracetamol overdoses were identified as
admissions in the NHMD with the relevant paracetamol poisoning code, exposures in
the NSWPIC database coded with “paracetamol”, and deaths recorded in the NCIS
attributable to paracetamol overdose after manual review.We found that the annual
number of paracetamol‐related hospital admissions (annual increase, 3.8%) and the
incidence of paracetamol‐related liver injury (annual increase, 7.7%) grew more rapidly
in Australia during 2007–08 to 2016–17 than the national population (mean annual
increase, 2004–2017, 1.6%), as did the number of paracetamol‐related calls to NSWPIC
during 2004–2017 (3.3%). The number of paracetamol‐related deaths, however,
remained fairly constant.

Paragraph 6

Most paracetamol overdoses involved women (about 70%); the median age of patients
in the NSWPIC database was 18 years (IQR, 16–28 years). The median age in cases of
fatal overdoses recorded in the NCIS was higher (53 years; IQR, 41–66 years), perhaps
reflecting greater suicidal intent in overdoses by older people or the presence of
comorbid conditions that increase the risk of liver injury. Admissions to hospital with
paracetamol poisoning and liver injury increased at twice the rate of all
paracetamol‐related admissions (7.7% v 3.3% per year). This is consistent with NSWPIC
data that indicated a significant increase in overdose size and an increased proportion of
overdoses with MR paracetamol, which was implicated in 9.5% of overdoses during
2009–2017 but in 33% of fatal overdoses during 2009–2017 for which the formulation
was documented. The overall number of paracetamol‐related deaths was fairly
consistent across the study period; improved treatment guidelines may explain the
apparent drop in the case fatality rate.

Paragraph 7

Paracetamol pack sizes and availability differ markedly between countries. In Australia,
sales of 20‐tablet packs (10 g) are unrestricted; larger packs (50 g) have been available in
pharmacies under Schedule 2, which does not require a pharmacist to be involved in the
sale. In the US,\ Canada,\ and Russia paracetamol is available without restriction,
including from non‐pharmacy retailers. In 2018, 14 of 21 surveyed European countries
had pharmacy pack size restrictions (range, 8–30 g); most European countries do not
permit non‐pharmacy sales, and the rates of poisons centre calls regarding paracetamol
are lower in these states A comparison of French and British data suggested that greater
availability of paracetamol was associated with its increased use in overdoses and
suicide. Ⓒ OET Medcity

15) According to paragraph 1 reason for paracetamol overdose in the Western world
a) Increased dose can be tolerated
b) It is an effective analgesic.
c) Recommended dose is safe for healthy people.
d) Repeated use by the people

16) What was the benefit when paracetamol amount decreased to 16g for the
pharmacy sale in UK?
a) Impulsive doses reduced
b) Declined suicidal death
c) Massive effectiveness noted
d) Other European country also adopted these restrictions.

17) Paragraph says that amount of paracetamol available in pharmacy.

a) 50gm modified release tablet packs
b) 20 pack of 500gm tablets
c) No limit number of packs.
d) 50gm tablet pack

18) AIWH gives information regarding

a) Hospital admission to both private and public hospital due to liver injury
b) Characteristics of human population and date on liver injury
c) Amount of drug ingested
d) Death of people due to poison after conjunction with NCIS

19) What are the main sources which give information regarding paracetamol overdose
in Australia
a) AIHW, NHMD and NSWPIC
b) NSWPIC, NCIS, Victorian Department of Justice and Community Safety
c) NCIS, Victorian Department of Justice and Community Safety and NHMD
d) All of the above.

20) Increased number of admission due to paracetamol related in the year

a) 2007-2008
b) 2004-2017
c) 2008-2016
d) 2016-2017

21) According to NSWPIC data

a) There is 7.7% increase in the paracetamol related admission to the hospital
b) Life threatening overdose was documented
c) Unmarkable increase in overdose size
d) Action registered for overdose
22) According to paragraph 7, study says
a) Over dose of paracetamol was due to its availability
b) Most of the countries get paracetamol without restriction
c) Maximum sale in Australia is 20 tablet packs
d) European countries require consent for non pharmacy sale.
READING 5
PART A
Health effects of tobacco
TEXT A
Tobacco use has predominantly negative effects on human health and concern
about health effects of tobacco has a long history. Research has focused primarily on
cigarette tobacco smoking. Tobacco smoke contains more than 70 chemicals that cause
cancer. Tobacco also contains nicotine, which is a highly addictive psychoactive drug.
When tobacco is smoked, nicotine causes physical and psychological
dependency. Cigarettes sold in underdeveloped countries tend to have higher tar
content, and are less likely to be filtered, potentially increasing vulnerability to tobacco
smoking related disease in these regions. Tobacco use is the single greatest cause of
preventable death globally. As many as half of people who use tobacco die from
complications of tobacco use. The World Health Organization (WHO) estimates that
each year tobacco causes about 6 million deaths (about 10% of all deaths) with 600,000
of these occurring in non smokers due to second hand smoke. In the 20th century
tobacco is estimated to have caused 100 million deaths. Similarly, the United
States Centers for Disease Control and Prevention describes tobacco use as "the single
most important preventable risk to human health in developed countries and an
important cause of premature death worldwide." Currently, the number of premature
deaths in the U.S. from tobacco use per year outnumber the number of workers
employed in the tobacco industry 4 to 1. According to a 2014 review in the New England
Journal of Medicine, tobacco will, if current smoking patterns persist, kill about 1 billion
people in the 21st century, half of them before the age of 70. Ⓒ OET Medcity

TEXT B
Tobacco use leads most commonly to diseases affecting the heart, liver and lungs.
Smoking is a major risk factor for heart attacks, strokes, chronic obstructive pulmonary
disease (COPD) (including emphysema and chronic bronchitis), and
several cancers (particularly lung cancer, cancers of the larynx and mouth, bladder
cancer, and pancreatic cancer). It also causes peripheral arterial disease and high blood
pressure. The effects depend on the number of years that a person smokes and on how
much the person smokes. Starting smoking earlier in life and smoking cigarettes higher
in tar increases the risk of these diseases. Also, environmental tobacco smoke,
or secondhand smoke, has been shown to cause adverse health effects in people of all
ages. Tobacco use is a significant factor in miscarriages among pregnant smokers, and it
contributes to a number of other health problems of the fetus such as premature
birth, low birth weight, and increases by 1.4 to 3 times the chance of sudden infant
death syndrome (SIDS) Incidence of erectile dysfunction is approximately 85 percent
higher in male smokers compared to non-smokers. Several countries have taken
measures to control the consumption of tobacco with usage and sales restrictions as
well as warning messages printed on packaging. Additionally, smoke-free laws that ban
smoking in public places such as workplaces, theaters, and bars and restaurants reduce
exposure to secondhand smoke and help some people who smoke to quit, without
negative economic effects on restaurants or bars Tobacco taxes that increase the price
are also effective, especially in developing countries.

TEXT C
The idea that tobacco use caused some diseases, including mouth cancers, was initially,
in the late 1700s and the 1800s, widely accepted by the medical community. In the
1880s, automation slashed the cost of cigarettes, and use expanded. From the 1890s
onwards, associations of tobacco use with cancers and vascular disease were regularly
reported; a metaanalysis citing 167 other works was published in 1930, and concluded
that tobacco use caused cancer. Increasingly solid observational evidence was published
throughout the 1930s, and in 1938, Science published a Smoking is the cause of about 5
million deaths per year. This makes it the most common cause of preventable early
death. One study found that male and female smokers lose on average of 13.2 and 14.5
years of life, respectively. Another found a loss of life of 6.8 years Each cigarette that is
smoked is estimated to shorten life by an average of 11 minutes. At least half of all
lifelong smokers die earlier as a result of smoking. Smokers are three times as likely to
die before the age of 60 or 70 as non-smokers.

TEXT D
In the United States, cigarette smoking and exposure to tobacco smoke accounts for
roughly one in five, or at least 443,000 premature deaths annually. To put this into
context, ABC's Peter Jennings (who would later die at 67 from complications of lung
cancer due to his life-long smoking habit) famously reported that in the US alone,
tobacco kills the equivalent of three jumbo jets full of people crashing every day, with
no survivors. On a worldwide basis, this equates to a single jumbo jet every hour. A 2015
study found that about 17% of mortality due to cigarette smoking in the United States is
due to diseases other than those usually believed to be related. It is estimated that
there are between 1 and 1.4 deaths per million cigarettes smoked. In fact, cigarette
factories are the most deadly factories in the history of the world See the below chart
detailing the highest-producing cigarette factories, and their estimated deaths caused
annually due to the health detriments of cigarettes. Ⓒ OET Medcity

QUESTIONS 1-7
For each question, 1-7 decide which text (A, B, C, OR D) the information comes
from .you may use any letter more than one

1) Disease caused by tobacco?

2) Study calculated death in US

3) Factors that promote the cigarette smoking?

4) Warning regarding effect in future?

5) Study illustrate effect of smoking in both male and female

6) Passive smokers face effects of smoking irrespective of their age

7) Primary focus of research

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

8) Number of chemicals present in the tobacco that causes cancer

9) How many may die by passive smoking in each year stated by WHO?

10) One of the factors that increases the effect of smoking

11) Name the person who died due to smoking

12) Number of chemicals present in the tobacco

13) In which year cost of the cigarette was reduced?

14) Mention two diseases that that affect the lungs

Questions 15-20
Complete each of the sentences, 14-20 with a word or a short phrase from one
of the texts. Each answer may include words, number or both.

15) is an example for psychoactive drug

16) People die mainly due to
17) control the smoking in public places
18) One cigarette will reduce the life by an average of
19) smoking will increase the risk of diseases
20) are able to cause death
 PART B

Alcoholism, Drug Abuse, and Gambling

Patients in an alcoholism and drug dependency treatment facility were questioned

about their gambling behavior in order to find out what percentage of them were
abusing alcohol and/or drugs and gambling. In order to do this, a pathological gambling
signs index was constructed according to a modification of DSM III criteria and validated
using independent procedures. Out of 458 patients interviewed, 40 (9%) were
diagnosed as pathological gamblers and an additional 47 (10%) showed signs of
problematic gambling. These patients showed clear signs of emotional, financial, family
and occupational disruption, and illegal behavior in connection with their gambling
which compound the disruption induced by alcohol and/or drugs. Ⓒ OET Medcity

1) The manual says that pathological gambling signs index was

a)To identify the proportion of patients gambling behavior

b) Based on DSM III criteria and independent procedures
c) Found patients with various disturbances and illeginuate conduct in relation with
their gambling.

PERIOPERATIVE CONSIDERATION IN THE MANAGEMENT OF OSA

The domain of the perioperative clinician is expanding ,as more surgery on complex
patients with OSA is performed in smaller and regional facilities. This narrative review is
targeted at clinicians involved in the perioperative care of patients with suspected or
confirmed OSA who undergo procedures under conscious sedation or under general
anaesthesia. It highlights periopertive considerations of OSA, including changes in sleep
architecture and physiology, and the salient features that can predictably exacerbate
previously stable OSA in the postoperative setting. The scope of this review does not
encompass the intraoperative management of these patients.

2) The review providing information about

a) OSA and regional facilities
b) Clinicians involved in the perioperative care of OSA
c) OSA perioperative considerations including various factors.
It is better to be safe than to be sorry. So the standard operative procedure for OT
etiquette is to be followed precisely to minimize the risk of random inappropriate
practice. A checklist for potential hazards to be prepared and followed up through
meetings at a regular interval for the betterment. Well-designed plans and staff
education will prepare the healthcare personnel to reduce the probability of unwanted
incidents and permit safe, efficient, effective, and high standards of care to all patients
at all times thus controlling hazards in OT. Ⓒ OET Medcity

3) Paragraph says about

a) Control of hazards in operation theatre

b) Importance of standard protocol in OT
c) Types of etiquette followed in OT

HOSPITAL – ACQUIRED INFECTIONS

Hospital-Acquired Infections (HAI)are one of the most frequently-encountered adverse

events in providing care and constitute a major public health issue that impacts
morbidity, mortality and quality of life. There are many patient and institution-related
factors responsible for the high rates of HAI in intensive care units. Patient-related
factors include patient’s age, immunity status, chronic illnesses, nutritional status,
medications (especially antibiotics) and exposure to catheterization procedures. On the
other hand, institution-related factors include high number of patients receiving care in
spite of inadequate number of healthcare workers, the architectural structure of the
unit, underestimating hand hygiene, disinfection and sterilization practices and not
complying with isolation measures. The treatment costs and rates of mortality of
infections acquired in intensive care units are substantially high. Thus, monitoring and
controlling infections is of great importance. Intensive care nurses have important
duties and responsibilities in this regard.

4)Hospital acquired infection

a) Do not occur in isolation unit

b) Mainly due to invasive procedures
c) Depends on several factors
 Use of personal protective equipment in nursing practice

A comprehensive understanding of infection prevention and control is essential for

nurses when seeking to protect themselves, patients, colleagues and the general public
from the transmission of infection. Personal protective equipment (PPE) – such as
gloves, aprons and/or gowns, and eye protection – is an important aspect of infection
prevention and control for all healthcare staff, including nurses. Its use requires
effective assessment, an understanding of the suitability of various types of PPE in
various clinical scenarios, and appropriate application.
Understanding the role of PPE will enable nurses to use it appropriately and reduce
unnecessary cost, while ensuring that the nurse-patient relationship remains central to
care. Ⓒ OET Medcity

5) What is the significance of PPE in patient care?

a) Help to maintain nurse patient relationship as a core of care.
b) Prevent transmission of infection
c) Prevent infection.

DVT: INITIAL ANTICOAGULATION

Warfarin is a vitamin K antagonist that acts by inhibiting the synthesis of vitamin K-

dependent clotting factors, which include Factors II, VII, IX, and X, and the anticoagulant
proteins C and S. Warfarin has a narrow therapeutic window; therapy is monitored by
the prothrombin time (PT) and international normalized ratio (INR). Warfarin can't be
administered by itself initially for DVT because the full anticoagulant effect of warfarin
doesn't occur until 2 to 3 days of drug administration. Usually heparin or fondaparinux is
given along with warfarin for at least 5 days. Expect to adjust the warfarin dose until the
INR is therapeutic (2 to 3, with a target of 2.5) for at least 2 days in a row, when the
heparin can be stopped.

6) Extract says

a)Warfarin is the primary treatment modality for DVT.

b)Warfarin can be given with heparin
c)Warfarin inhibits vitamin k synthesis.
 NIPAH VIRUS INFECTION

Paragraph1
Nipah virus, a paramyxovirus related to Hendra virus, first emerged in Malaysia in 1998.
Clinical presentation ranges from asymptomatic infection to fatal encephalitis. In early
March 1999, virologists from the University of Malaya had isolated a virus from
cerebrospinal fluid of an encephalitis patient. Vero cells inoculated with cerebrospinal
fluid specimens from three fatal cases of encephalitis developed syncytia. Electron
microscopic (EM) studies of the virus demonstrated features characteristic of a virus
belonging to the family Paramyxoviridae. The name, Nipah virus, was proposed because
the first isolate was made from clinical material from a fatal human case from Kampung
Sungai Nipah.Malaysia has had no more cases since 1999, but outbreaks continue to
occur in Bangladesh and India. In the Malaysia-Singapore outbreak, transmission
occurred primarily through contact with pigs, whereas in Bangladesh and India, it is
associated with ingestion of contaminated date palm sap and human-to-human
transmission. Bats are the main reservoir for this virus, which can cause disease in
humans and animals. There are currently no effective therapeutics, and supportive care
and prevention are the mainstays of management. Ⓒ OET Medcity

Paragraph 2

In the Malaysian outbreak, there were reports of person-to-person transmission,

especially in families of affected index cases. In a study of >300 health care workers
(HCWs) in the 3 hospitals that had looked after 80% of encephalitis patients, there were
no reports of any serious illness, encephalitis, or hospital admissions among any HCW or
pathology worker. However, 3 nurses who had cared for outbreak-related encephalitis
patients had second serum samples that were positive for Nipah virus IgG antibodies.
Although the authors concluded that these were false positives because they had no
symptoms of encephalitis and blood samples showed no IgM response and were
negative for anti-Nipah virus neutralizing antibodies, one was a staff nurse who also had
magnetic resonance imaging (MRI) changes similar to those seen in acute NiV. Since she
had cared for the infected patients but had no previous contact with pigs, it is likely that
she had an asymptomatic or mild NiV infection.The situation was very different in
Bangladesh and India, where several outbreaks have resulted from person-to-person
transmission. About half of the cases identified in Bangladesh between 2001 and 2007
involved human-to-human transmission. The clearest illustration of person-to-person
transmission occurred during the Faridpur outbreak in 2004, where the chain of
transmission eventually involved 5 generations and affected 34.
 Paragraph 3

The incubation period in humans ranged from 4 days to 2 months, with more than 90%
at 2 weeks or less. Patients presented with fever, headache, dizziness, and vomiting,
which developed into a picture of severe encephalitis. Many patients had a reduced
level of consciousness and prominent signs of brainstem dysfunction, including
abnormal doll's eye reflex, pupillary reflexes, vasomotor changes, seizures, and
myoclonic jerks. Neurological involvement was diverse and multifocal, including aseptic
meningitis, diffuse encephalitis, and focal brainstem involvement. Cerebellar signs were
relatively common.
A unique and interesting feature of NiV infection was the development of relapse and
late-onset encephalitis, some of which occurred months or years after the acute illness:
In Tan's series of 160 cases who survived the initial encephalitis, 12 (7.5%) suffered
relapses (which occurred after recovery from acute encephalitis), while there were 3
(3.4%) cases who had late-onset encephalitis (where initial infection did not cause
neurological manifestation. The longest delay in the onset of late-onset encephalitis was
11 year.

Paragraph 4

In another series, a significant proportion developed psychiatric features, including

depression and personality changes, while others had deficits in attention, verbal,
and/or visual memory. There were also differences in neurological manifestations.
Segmental myoclonus was prominent in the Malaysian cases, but it was not commonly
seen in Bangladesh and India. A study on 22 patients who survived NiV showed that
almost a third had persistent neurologic and cognitive dysfunction. Almost all of them
had disabling chronic fatigue syndrome, and more than half had behavioral and
neuropsychiatric changes, similar to those in the Malaysian and Singapore cases.
Though Nipah virus infection was well established as having effects on the nervous
system, involvement of other organ systems was seen to various degrees. In the
Malaysian series, respiratory involvement was described in 14 to 29% of cases, although
it was unclear if this was part of initial presentation or was secondary to aspiration or
ventilator-associated pneumonia. In Singapore, 2 out of the 11 patients had only
respiratory symptoms and no encephalitis, while the remaining patients had
encephalitis. Cases in Bangladesh and India had higher rates of respiratory involvement,
comprising half to two thirds of cases, with some of them developing acute respiratory
distress syndrome. This difference may be related to differences between the 2 strains,
as discussed later. Ⓒ OET Medcity
 Paragraph 5

In the Malaysian outbreak, MRI scans brain patterns revealed extensive involvement of
the cortex, temporal lobe, and pons. Patients who relapsed or had late onset
encephalitis also had multiple areas of patchy and confluent cortical involvement.
In patients in the Singapore outbreak, the MRI brain pattern was different, with multiple
small (less than 1 cm in maximum diameter), bilateral abnormalities within the
subcortical and deep white matter and some lesions enhanced after contrast media
injection; other areas involved included the cerebral cortex, brainstem, and corpus
callosum. Most of these lesions were detected by diffusion-weighted (DW) MRI, a pulse
sequence that has been widely used to detect ischemic stroke and cerebral infarction.
This pattern of tiny DW abnormalities followed by T1 hyperintensities was distinctly
different from the characteristic features of herpesvirus and Japanese encephalitis, and
it may be consistent with virus-associated microangiopathy and subsequent ischemic
microinfarction.

Paragraph 6
Treatment measures were largely supportive and consisted of anticonvulsants,
treatment of secondary infection, mechanical ventilation, and rehabilitation. With
nothing known at the outset of the outbreak in Malaysia, empirical treatment was
started with ribavirin, chosen for its broad-spectrum activity against DNA and RNA
viruses and ability to cross the blood-brain barrier. As treatment options are limited,
focus on NiV management should be on prevention. Preventive strategies include
interventions to prevent farm animals from acquiring NiV by eating fruit contaminated
by bats. Farms should be designed to reduce overcrowding to avoid rapid spread of
disease between animals and should not be near fruit trees that attract bats.

Paragraph 7

Consumption of contaminated sap should be avoided. However, efforts to reduce fresh

sap consumption in general would be unpopular, as they go against social and cultural
norms. Other, more acceptable methods would include physical barriers to prevent bats
from accessing and contaminating sap.A number of vaccine candidates has been found
to be capable of complete protection against NiV disease in preclinical studies of small
animal and nonhuman primate models. Candidate vaccines using a vesicular stomatitis
virus vector are the most advanced, having demonstrated protection in hamsters,
ferrets, and African green monkeys. Vaccination programs would also have to cover
livestock animals, too, e.g., pigs, and perhaps horses in certain areas where NiV is
endemic.
 Paragraph 8
While WHO has declared NiV to be a priority pathogen, pharmaceutical companies may
be reluctant to fund trials in underdeveloped countries that can ill afford medications or
vaccines. Fortunately, a new international coalition of governments and pharmaceutical
companies called the Coalition for Epidemic Preparedness Innovations (CEPI) was
formed in January 2017 to develop safe, effective, and affordable vaccines for diseases
with pandemic potential, such as NiV.NiV emerged as a new virus exactly 20 years ago,
causing severe morbidity and mortality in both humans and animals and destroyed the
pig-farming industry in Malaysia, and it continues to cause outbreaks in Bangladesh and
India. As the reservoir host Pteropus bat is widespread, and NiV has been found in bats
in various countries, the potential for outbreaks to occur in new regions remains
significant. Ⓒ OET Medcity

7) According to paragraph 1 how did they realized the nature of virus?

a) Isolated viruses from infected patient’s CSF

b) Cells obtained from kidney injected to CSF of diseased patient which developed to
syncytia.
c) Through a electron microscopic study
d) Both B&C

8) In second paragraph why the author state that the result was false positive?
a) They were asymptomatic for encephalitis
b) IgG-IgM response were negative
c) MRI showed symptoms of acute NiV
d) One of staff nurses had NiV infection

9) In myoclonic jerk, patient experience

a)Brief loss of consciousness and jerking movement
c) Sudden involuntary muscle spasm
d) None of the above

10) According to paragraph 4 which is true?

a) Segmental myoclonus was common in India
b) Most of the patient suffered from persistent neurologic and cognitive dysfunction
c) Nipah viruses affect other organs in higher degree
d) Inclusion of respiratory symptom is not clear

11) According to paragraph 5, MRI shows

a) Involvement of all brain parts
b) Patches on brain whose condition is worsened
c) Deep white matter and subcortical area show multiple small lesions
d)ischemic stroke and cerebral infarction

12) Why did empirical treatment start during outbreak in Malaysia?

a) Virus has ability to cross the blood brain barrier
b) Due to limited treatment options
c) It require more preventive measures
d) Ribavirin has broad spectrum activity with DNA &RNA

13) What is the best method to prevent spread of infection according to paragraph 7?
a) Avoid ingestion of contaminated sap
b) Prevent bats from contaminating the fruits using physical barriers
c) Use available vaccine
d) None of the above

14) Which of the following statement is suitable for paragraph 8

a) Strategies to manage NiV
b)NiV and prevention
c) Control of NiV
d) Measures to prevent NiV
 Clindamycin promotes phagocytosis and intracellular killing of
periodontopathogenic bacteria by crevicular granulocytes: an in vitro
study

Paragraph 1

Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans are the most

important species in subgingival plaque samples obtained from patients with
progressive forms of periodontitis. Rapidly progressive periodontitis is associated with P.
gingivalis, which produces connective tissue destructive enzymes.
A.actinomycetemcomitans is often seen in localized juvenile periodontitis. In cases of
periodontitis it usually produces a leucotoxin which is able to impair polymorph nuclear
granulocytes. Polymorphonuclear neutrophil granulocytes (PMNs) play a key role in
defence against bacterial infections. The ability of specific bacterial pathogens to initiate
periodontal diseases depends on their evasion of PMN defences or the presence of host
neutrophils that are dysfunctional.

Paragraph 2

In dentistry, antimicrobial chemotherapy, e.g. metronidazole, doxycycline and

clindamycin, is an effective adjunct in the treatment of patients with progressive
periodontal disease. Besides their bacteriostatic or bactericidal effects antibiotics can
interact directly with cells of the immune system. Clindamycin has very lowminimal
inhibitory concentrations (MICs) for obligate anaerobes such as P. gingivalis, Prevotella
intermedia and Fusobacterium nucleatum. In contrast, the capnophilic species A.
actinomycetemcomitans exhibits resistance to this drug. In general clindamycin has a
positive immunomodulating effect. Moreover, an enhancement of phagocytosis has
been reported. However, there have not been studies concerning the influence of
clindamycin on phagocytosis by gingival crevicular PMNs in cases of periodontitis, in
which the function of the granulocytes often seems to be altered. Ⓒ OET Medcity

Paragraph 3

A study conducted on in vitro effect of subinhibitory concentrations of clindamycin on

the phagocytosis and intracellular killing of P. gingivalis and A.
actinomycetemcomitans by granulocytes obtained from the gingival sulci has been
assessed.Twenty-four patients with progressive forms of periodontitis with rapidly
progressive periodontitis (RPP), eight with localized juvenile periodontitis (LJP) and 12
with non-progressive adult periodontitis (AP)] participated in the trial. Thirteen
periodontally healthy subjects served as controls. All subjects selected for the study
were systemically healthy. None of them had received antibiotics in the previous 6
months. The diseased sites were characterized by assessment of clinical and
radiographic parameters. In addition this diagnosis was confirmed by micro-biological
cultivation of subgingival plaque samples.

Paragraph 4

Patients selected for the study suffered from different forms of periodontitis. The
microbiological results showed that P. gingivalis comprised a high percentage of cfu in
subgingival plaque samples collected from patients with both progressive forms of
periodontitis (RPP and LJP), while A. actinomycetemcomitans was detected in a high
number only in LJP patients. These microbiological findings confirm that relevant species
were used for the phagocytosis assay.The fluorochrome PMN phagocytosis and killing
assay described by Smith & Rommel and Pantazis & Knik was used to determine the
effect of a subinhibitory concentration of clindamycin on the phagocytosing and killing
properties of granulocytes obtained from the gingival sulci. The endpoint concentration
of clindamycin in the cell suspension chosen in our test system was near the MIC for P.
gingivalis and much lower than the MIC for the A. actinomycetemcomitans strain tested.
The bactericidal effect of the antibiotic can be excluded as the time of exposure to
bacteria was only 30 min and, in the periodontitis group, the number of granulocytes
with viable P. gingivalis after addition of clindamycin was not significantly reduced.
Comparisons between each periodontitis group and the controls showed an increased
phagocytosis in RPP patients as response to the inflammation. This result was due to the
higher number of phagocytes containing P. gingivalis and A. actinomycetemcomitans.
However, significant differences between the controls and the periodontitis groups
were observed when comparing the granulocytes with a high phagocytosing and
intracellular killing capacity.

Paragraph 5

Observations clearly confirmed a positive immunomodulating effect of clindamycin on

phagocytosis by crevicular PMNs collected from both patients with periodontitis and
periodontally healthy subjects. Treatment of neutrophils with clindamycin resulted in an
increased number of phagocytosing cells in both periodontitis and control groups,
regardless of whether P. gingivalis or A. actinomycetemcomitans was the test strain.
Moreover, the percentage of granulocytes with more than 10 ingested bacteria (both
for P. gingivalis and A. actinomycetemcomitans) was enhanced in all groups
studied.Nevertheless, differences were observed between the periodontitis patients
and periodontally healthy controls. An enhancement of the intracellular killing of P.
gingivalis or A. actinomycetemcomitans after the addition of clindamycin was found
only in controls. The lack of any enhancement in bactericidal activity of crevicular PMNs
from periodontitis patients suggests that these cells have an intrinsic deficiency.

Paragraph 6

The enhancement of opsonophagocytosis by clindamycin is known. Incubation of

granulocytes with clindamycin caused an increase in the proportion of granulocytes
bearing Fc receptors, but the adhesion of non-opsonized Staphylococcus aureus was
decreased after addition of this antibiotic. Clindamycin is highly concentrated in the
cytoplasm of the granulocytes.This high concentration in PMNs may promote the
bactericidal effect on susceptible species in the cells even if the serum concentration is
subinhibitory. Differing effects on intracellular killing have been described. Some
authors found an enhancement of intracellular killing, also of resistant species, while
other studies have reported that there was no influence or an inhibition of the
respiratory burst. Ⓒ OET Medcity

Paragraph 7

Clindamycin therapy is an effective means of treating periodontal disease due to

obligate anaerobic bacilli such as P. gingivalis and P. intermedia. These species are
sufficiently susceptible to this antibiotic. The use of locally applied clindamycin gel
inserted into periodontal pockets was beneficial in the treatment of advanced
periodontitis by eliminating and preventing early recolonization of
periodontopathogenic species and might avoid known side effects of systemic
administration, such as antibioticassociated pseudomembranous enterocolitis. The
enhancement of phagocytosis against periodontopathogenic species is a useful side
effect in periodontitis patients, although a promoting effect on intracellular killing was
found only in healthy subjects. Other positive effects of clindamycin are the ability to
penetrate into bone and the negative influence on the formation of
biofilms. However, A. actinomycetemcomitans is also an important species in
periodontitis, especially in LJP and exhibits resistance to clindamycin. Further in
vivo studies are therefore necessary to find out if the improvement in phagocytosis
alone justifies the use of clindamycin in such cases.

15) What is true about the first paragraph?

a) Host neutrophils are dysfunctional

b) Tissue destructive enzymes are produced in progressive periodontitis
c) Juvenile periodontitis is a common platform for growth of
A.actinomycetemcomitans
d) None of the above

16) Which is the best suited statement for paragraph 2?

a) There are reports supporting the effect of clindamycine on phagocytosis

b) Other than bactericidal effects, clindamycine is an efficacious adjuvant
c) Binding action over p.gingivalis by clindamycine has very slow MICs
d) Various drugs and its effect on periodontal disease

17) What is right about the study subjects in paragraph 3?

a) There were total 57 study subject with periodontitis

b) All the selected subjects were healthy
c) Patients with progressive peridontitis were 3 times more than subjects with LPJ
d) None of them had treated with antibiotics previously

18) Why does the flurochrome PMN was introduced?

a) To find out effect of clindamycine on the phagocytosing properties of

granulocytes
b) For intuit efficacy of a limited concentration of clindamycine on killing properties
of granulocytes
c) Not given
d) None of the above

19) Which of the following statement is Not True?

 a) Granulocytes with higher phagocytosing and intracellular killing ability were
observed in the comparison study
b) As a response to the inflammation, RPP patients showed increased phagocytosis
c) Comparison result was due to higher number of phagocytes containing
p.gingivals and A. actinomycetemcomitens
d) Comparison resulted in remarkable distinctions between the controls and
peridontitis group

20) The word closest in meaning intrinsic is

a) Acquired
b) Underlying
c) Built-in
d) Integral

21) According to paragraph 5 ,what was resulted in an increased number of

phagocytosing cell?

a) Clindamycine treatment of neutrophil

b) Treatment of peridontitis
c) Treatment for neutrophils with clindamycine
d) All of the above

22) What is mentioned in the final paragraph, as a positive effect of clindamycine?

a) Improving phagocytosis against periodontopathogenic species

b) Formation of biofilms
c) It can penetrate into bone
d) Eliminating and preventing early recolonization
READING 6
PART A

Text A

Transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure to

replace a narrowed aortic valve that fails to open properly (aortic valve stenosis).
Transcatheter aortic valve implantation is sometimes called transcatheter aortic
replacement (TAVR).

TAVI may be an option for people who are considered at intermediate or high risk of
complications from surgical aortic valve replacement. TAVI may also be indicated in
certain people who can’t undergo open-heart surgery. The decision to treat aortic
stenosis with TAVI is made after consultation with a multidisciplinary group of medical
and surgical heart specialists who together determine the best treatment option for
each individual. TAVI can relieve the signs and symptoms of aortic valve stenosis and
may improve survival in people who can’t undergo surgery or have a high risk of surgical
complications. Ⓒ OET Medcity

Why it’s done

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure to

replace the aortic valve in people with aortic valve stenosis.

Aortic valve stenosis – or aortic stenosis –occurs when the heart’s aortic valve narrows.
This narrowing prevents the valve from opening fully, which obstructs blood flow from
your heart into your aorta and onwards to the rest of your body. Aortic stenosis can
cause chest pain, fainting, fatigue, leg swelling and shortness of breath. It may also lead
to heart failure and sudden cardiac death.

Who benefits most from TAVI

TAVI may be an option if you have aortic stenosis that causes signs and symptoms. For
instance people who are candidates for TAVI may include those who are considered at
intermediate or high risk of complications from surgical aortic valve replacement.
Conditions that may increase the risk of surgical aortic valve replacement include lung
disease or kidney disease –which increases your risk of complications during surgical
aortic valve replacement.

TAVI may also be an option if you have an existing biological tissue valve that was
previously inserted to replace the aortic valve. But it’s not functioning well anymore.
Before TAVI you will need to tested and evaluated by a multidisciplinary team of heart
valve specialists doctors will evaluate your condition to determine the most appropriate
treatment.

TEXT B

MULTIPLE WAYS OF DELIVERING THE TAVI VALVE TO THE AORTIC VALVE POSITION:

1. TRANSFEMORAL
The delivery sheath is inserted into the femoral artery in the patient’s groin, and
the TAVI valve travels upwards through the artery to the aortic valve.

2. TRANSAPICAL
A 5-10cm horizontal incision is made on the left side of the chest below the
nipple line, which provides direct access to the heart. The delivery sheath is then
inserted in the apex of the heart and TAVI valve inserted.

3. TRANSAORTIC
A small incision at the top of the sternum (breast bone)is made and that the
delivery sheath is inserted in to the aorta(the large blood vessel that the aortic
valve is in). Ⓒ OET Medcity

The “heart team” will assess each patient and decide what is the best approach
to use. The transfemoral approach is the preferred because it is minimally
invasive. However it is sometimes not possible because of peripheral vascular
disease. A transapical or transaortic approach is then considered.
 TEXT C

OPEN ISSUES WITH TAVI AND HOW TO ADDRESS THEM

ISSUE HOW TO ADDRESS

Feasibility in lower-risk patients Randomised trials comparing TAVI
with SAVR

Device selection Randomized trails comparing

different TAVI devices

Bicuspid anatomy Specific Prosthesis design

Valve thrombosis Prospective trials evaluating the role

of anticoagulants

Durability Echocardiographic and 4D CT scan

Studies

Avoidance of annalus rupture Definition of maximal calcium load

Reduction of access site complications Specific vascular closure devices

Reduction of stroke rates Evaluation of protection devices/

antithrombotic therapy

SAVR = surgical aortic valve replacement; TAVI = transcatheter aortic valve

implantation.
 TEXT D

Recovery Period

Patients usually stay in the intensive care unit for 1-2 days for monitoring, and
then in the nursing unit for 6-7 days. Full recovery usually takes about ?2 months.
You surgeon will provide specific guidelines for your recovery and return to
activities.

Risks of the surgery

TAVI is generally reserved for patients that are considered too high- risk for
surgical aortic valve replacement. This is because it has been shown to be better
than medical therapy, and the risk of death is lower than surgery n high –risk
patients. However the risk of stroke is slightly higher in TAVI.
There are a number of other specific risks including a leak around the TAVI valve
(paravalvular regurgitation). Damage to the heart around the valve (aortic root
injury), kidney injury, arrhythmias and pacemaker implantation, bleeding and
possibly death. As with all invasive procedures there are also some general risks,
including wound infection, and reactions to the anesthetic. Ⓒ OET Medcity

Questions 1-7

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

In which text you can find information about

1. TAVI is performed in people with aortic valve stenosis. ___________

2. TAVI can be considered if previous insertion malfunctions ___________
3. Method to address specific vascular closure devices. ___________
4. Approach preferred because it is minimally invasive ____________
5. Issue that’s can be rectified by antithrombotic therapy ____________
6. Insertion of the delivery sheath in the apex of the heart ____________
7. Patients stay in the hospital during recovery period ____________

Questions 8-14

Answer each of the questions, 8-14, with a word or short phrase from one of the
text. Each answer may include words, numbers or both.

8. How is the comparative risk of death by TAVI with regard to surgery?

_________________________
9. What is observed to occur when the heart’s aortic valve narrows?
_________________________
10. Which are the conditions that increase the risk of surgical valve replacement?
_________________________
11. When is TAVI delivered by an incision on the left side of the chest?
_________________________
12. Which condition limits the effectiveness of the transfermoral approach?
_________________________
13. What risk is involved when a leak occurs around the TAVI valve?
_________________________
14. What risk is increased on administration of TAVI?
_________________________

Questions 15-20

Complete each of the sentences, 15-20, with a word or a short phrase from one
of the texts. Each answer may include words, numbers or both

15. There are risk involved in TAVI, as with all ………………..

16. Addressing valve thrombosis can be done by evaluating the role of …………….
17. A ………………. is expected within 2 months of the procedure .
18. Assessment of the approach for delivering TAVI valve is done by the
………………..
19. A ................... is addressed by trials comparing different TAVI devices.
20. A ...................... determines the best treatment options for each individual.
 PART B

Who do I choose to act as my health care representative?

Ensure that you choose an individual whom you trust and whom you feel
comfortable sharing your wishes. It is not necessary to choose a health care
representative who shares all your beliefs. However you should choose an
individual whom you are confident will respect your wishes and who will do
his/her best to get the type of health care treatment you want.

It is important to choose a health care representative who will be available when

required to make your health care decisions. There may come a time where you
require someone to remain by your bed side for long stretches of time to ensure
healthcare personnel follow your wishes. Under these circumstances it may not
be practical to have a representative who reside out of state. Ⓒ OET Medcity

You should discuss your heath care wishes with your health care representative
to ensure that he / she will be able to make decisions based on what you have
discussed and the information contained in the directive.

1. According to the directive, what should be the major concern while

choosing a healthcare representative?
a. One who mostly shares similar values and wishes
b. On who can exercise discretion during procedures
c. One who is available to discuss treatment options.

Tips For Planning Male Circumcision Services And Developing a Service

Support Reference Guide

In establishing the male circumcision services to be offered in a particular clinic,

the male circumcision team and clinic manager or supervisor should consider the
world Health Organisation’s minimum male circumcision package and optional
expanded packages in terms of the following.
 Onsite capacity ( that is ,skills, training and experience ) to provide a service.
 Availability of resources (that is, supplies and equipment) needed for a
service
 National policies on relevant and related issues (for ex, on tetanus toxoid
containing vaccination and legal age of consent for the procedure)
 Local needs (for example, high prevalence of tuberculosis and diabetes)
 Accessibility of referral facilities(dist hospital or other higher level of care);
specialist and other related services ( for eg HIV care and treatment)

Based on these considerations, the male circumcision team should design the
package of services they will offer (aside from education and counselling,
screening, provision of the procedure and follow up) and specifying the protocol
for each.

2) The instruction for male circumcision involves

a) Capacity of the team undertaking the procedure

b) Minimum procedural apparatus that is required on site

c) Assorted considerations that exhibits the wherewithal

Rapid diagnosis of Buruli ulcer now possible at district level health

facilities
Latest development marks important step towards early treatment of this
debilitating disease

An innovative diagnostic test developed by researcher at Harvard University that

can lead to rapid confirmation of Buruli ulcer in a patient. The test can detect
mycalactone, a toxin produced by the bacteria that causes tissue damage that
leads to buruli ulcer. The most important aspect of this new test-which is more
sensitive than microscopy – is that it can be carried out by technicians with
minimal training in district hospital laboratories. In 2010, the researchers made a
breakthrough by using boronate - assisted fluorescent thin– layer
chromatography to selectively detect mycalactone when visualized with
ultraviolet light. Further improvements have since optimized the method and
the reading o results. Clinical diagnosis of Buruli ulcer currently relies on will
 trained experienced health workers. Polymerase chain reaction- the most widely
used diagnostic test because of its high sensitivity- can be done only in reference
laboratories, remote from affected communities, results are available in a few
weeks. Ⓒ OET Medcity

3. The information sheet is dense on

a. New treatment available for BURULI ulcer
b. Recent developments in the diagnosis
c. Chemistry involved for clear detection

Cleaning the procedure room

Between procedures, the instrument trolley and the operating tabletop should
be disinfected. Any spillage on the floor contained with an absorbant material,
then mopped with clean water and detergent, and finally disinfected. At the end
of the operating day, all flat surfaces in the procedure room should be
thoroughly cleaned and disinfected, including the floor. A liquid disinfectant
should be used, the liquid should be diluted as recommended by the
manufacturer. There should be a periodic (weekly or monthly) thorough clean
when ceilings and walls are also cleaned, how often this is done will depend on
intensity of the rooms use and also whether the room is used only for a specific
operative procedure or for other types of surgery.

4.The procedure sheet articulates the process of cleaning by

a. Periodic cleansing of the exposed surface
b. Washing the surfaces depending on use
c. Disinfecting and mopping as per protocol

Guidelines on monitoring system

A monitoring system is a standardized method of data collection, data aggregation, data
analysis and feedback. Collecting information to track indicators requires the
collaboration of dedicated and knowledgable staff. Information, particularly sensitive
information, such as HIV test results, should be kept confidential by ensuring that there
are strict data security procedures, masking personal identifiers on records (paper and
electronic) as well as limiting access to these records to only those providers who need to
know the information. Health care providers need to know who is responsible for the
monitoring system record data accurately, completely and reliably and know how and
when report the information about the service or clients. Health care providers can also
help those responsible or the system by providing feedback on the system, that is, how
information is shared with providers, and how easy it is to complete form accurately and
reliably.
5. What must be ensured during information collection?
a. Discretion employed by the handlers
b. Secrecy of the private data collected
c. Responsible usage of monitoring systems

Safety Announcement
The health department is revising the prescription and over-the-counter (OTC)
labels for a class of drugs called proton pump inhibitors to include new safety
information about a possible increased risk of fractures of the hip, wrist an spine
with the use of these medications. Some studies found that those at greatest
risk for these fractures received high doses of proton pump inhibitors or used
them for one year or more. The majority o the studies evaluated individuals 50
yrs of age or older and the increased risk of fracture primarily was observed in
this age group. While the greatest increased risk of fractures in these studies
involved people who had been taking prescription proton pump inhibitors for
atleast one year or who had been taking high doses of the prescription
medications (not available over the counter), as a precaution. The “Drug Facts”
label on the OTC proton pump inhibitors (indicated for 14 days of continuous
use) also is being revised to include information about this risk. Ⓒ OET Medcity

6.What is a major concern in the study that triggers the announcement?

a. New data on the risk induced by proton pump inhibitors on over- the –
counter prescriptions.
b. New data on the risk induced by proton pump inhibitors in prolonged
usage in the elderly.
d. New data on the risk induced by proton pump which will be reflected in
the “Drug Facts”.
 PART C

Text 1: implications of mapping the human genome

The human genome project began in 1990, following initial co operation

between the Us Department of Energy and the Welcome Trust, a UK medical
charity China, Germany, France and Japan also became full partners in the
project. The objective was to generate a high quality reference DNA sequence
for the human genome. The genome represents the complete set of DNA in each
organism. In humans it is made up of 3.2 billion linked segments of DNA known
as base pairs. As the activity in every cell in every living organism is governed by
the DNA is its nucleus. It is clear that this project aimed to provide knowledge
about the most fundamental aspects of life. By reading the book of life, the
project was one of the most ambitious in human history.
At that time, the project was also seen as extremely ambitious in technical
terms. The laboratory techniques which were used to map the DNA were
complex and time consuming and depend on highly skilled laboratory staff. It
was clear that without new technologies and techniques it would not be possible
to achieve the stated objective by 2005, so as a first step major investments
were made in computer technology for data processing this marked the
beginning of a new scientific discipline of bioinformatics. Combining computing
and biology by 1998.a total of 200 million base pairs had been sequenced by the
project with less than half of the planned project time remaining. Just over 6% of
the genome had been mapped. Fortunately computers were becoming cheaper
and more powerful. Also by this time, significant investment had been made in
developing specialized electronic components which could directly analyze the
DNA without the need for human intervention consequently. There was an
enormous increase in the speed with which the genome could be mapped.

In June 2000 a rough draft of the human genome sequence was produced. This
converted 90% of the genome unlike the data produced by InterPro. A rival
private sector research project. the Human genome project data was freely
available to the public and could be used without any restrictions. While it was
possible to access the InterPro data without charge. It’s use for any purpose was
subject to license agreements. This gave rise to the major debates of the ethics
of commercializing genome research in this way. Although InterPro was the
main focus of these debates, it was not alone. Research carried out in November
2000 showed that drug and biotech companies government institutions and
universities had filed patents on 127000 human genes or partial human gene
sequences. By April 2003, a finished version of the human genome sequence
was available, along with much new knowledge .By coincidence or design. It was
exactly 50 years since Watson and Crick published their paper on the structure
of DNA. Which identified the letters of the genomic alphabet. The finished
version identified all of the estimated 25,000 human genes within the genome
less than one-third fewer than expected. Around half of them were linked to a
specific biological function. As a result of the project, we now know that there is
only 0.1% of a difference in DNA between humans. Specific gene sequences
have the associated with different diseases and disorders including breast
cancer, Muscle disease deafness and blindness. DNA based tests were among
the first commercial applications of the research, and several hundred have
been developed to date. Ⓒ OET Medcity

Many benefits have already emerged from this research and there will be many
more over the next decade. Researchers have already begun to correlate
variations in DNA with differences in results from medical interventions. This
should allow us to classify individuals in to sub groups based on their DNA profile
for whom drugs could be customized. A new discipline, pharmacogenomics is
developing around the study of these interactions. The knowledge should also
help tackle future pandemics and produce new developments in stem cell
technologies. While these benefits are truly worthwhile, there are a number of
key societal issues arising from the knowledge created by the Human Genome
Project. Perhaps the most important relates to the ownership of genetic
information, both at a societal and individual level. At a societal level we have
seen how InterPro sought to license genomic data to make money and while
questions have been raised regarding its right to do so, it is still free to pursue
commercial projects using the data .At the individual level, the issue of access to
and control of data about the genetic makeup of individuals is already extremely
important, given the susceptibility to many diseases has been linked to specific
genes which can be identified by testing. However, as more and more aspects of
what makes us human are linked to specific elements of DNA in our genes, the
 opportunity for misuse of this information becomes even greater. It may be that
thanks to the Human Genome Project we can now read ‘the book of life’ but as a
society it is not yet clear what use we will make of the knowledge we find there.

TEXT 1: QUESTIONS 7-14

7. What was the declared aim of the human genome project?

(A) Provide the most fundamental aspects of life

(B) Generate a reference sequence for human DNA
(C) Be known as the most ambitious project in history
(D) Map out the linking segments of DNA in humans

8. In the second paragraph what does ‘that’ refer to

(A) The initial phase of the genome projects

(B) The laboratory involved in the experiment
(C) The publishing of the book of life
(D) The time taken to finalize the project Ⓒ OET Medcity

9. What was the biggest impediment to the research?

(A) Compiling information received through mapping

(B) The time duration that was available for the research
(C) Investments required for precise, elaborate detailing
(D) Lack of available techniques for processing the data

10. How did the project achieve a reversal in the time taken?

(A) There was a sizeable investment in electronic components

 (B) Computers were becoming more efficient and capable

(C) Availability of technology without consistent human intervention

(D) Analysis of the genome with increased speed and precision

11. What according to paragraph 3, is a reason for debates?

(A) The use of human genome data for ethical purpose

(B) The rise of private sector entities in research process

(C) Restrictions on the use of data produced by private firms

(D) Patents filed by institutions including government ones

12. What scientific breakthrough does gene mapping involve?

(A) Identification of genes linked to various disorders

(B) The development of hundreds of DNA based tests

(C) Recognizing the letters of genome alphabet

(D) Designing the course for rectifying genetic anomalies

13. In the final paragraph ‘whom’ is used to denote

(A) People identified with genetic mutations and variations

(B) Groups to which certain drugs are known to be effective

(C) Individuals with a greater affinity to certain medications

(D) Until which shows similar variations in genetic makeup

14. Why is the influence on genetic information crucial?

 (A) It can be used for vested interests

(B) Control over such data gives monopoly

(C) Licensing might be offered on preference

(D) Existing knowledge may not be foolproof

TEXT 2: HEALTH FOR ALL GIRLS IS CRITICAL FOR THE HEALTH OF WOMEN

Proper nutrition is a key determinant of health, both in childhood and beyond. The
nutritional status of girls is particularly important due to their future potential
reproductive role and the intergenerational repercussions of poor female nutrition.
Preventing child abuse and neglect and ensuring a supportive environment in early
childhood will help children to achieve optimal physical, social and emotional
development. These will also help avoid risky behaviors and a significant burden of
disease. Including mental health disorders and substance use later in life.

It is essential to address the health and development needs of adolescents if they are to
make a healthy transition to adulthood. Societies must tackle the factors that promote
potentially harmful behaviors in relation to sex. Tobacco and alcohol use, diet and
physical activity, as well as provide adolescents with the support they need to avoid
these harmful behaviors. In many high-income countries, adolescent girls are
increasingly using alcohol and tobacco and obesity is on the rise supporting adolescents.

To establish healthy habits in adolescence will bring major health benefits later in life
including reduced morality and disability due to cardiovascular diseases stroke and
cancers.

Because they tend to live longer than men, women represent a growing proportion of all
older people. Societies need to prepare now to prevent and manage the chronic health
problems often associated with old age. Establishing healthy habits at younger ages can
help women to live active and healthy lives until well into old age. Societies must also
prepare for the costs associated with the care of older women. Many high- income
countries currently direct large proportions of their social and health budgets to care for
the elderly. In low income settings, such care is often the responsibility of the
family, usually of it’s female members. Policies are needed in relation to health
financing, pension and tax reform, access to formal employment and associated pension
and social protection, and to the provision of residential and community care.

The reasons why healthy systems fail women are often complex and related to the
biases they face in society. However, these shortfalls can be understood and they can
should be challenged and changed. For example women face higher health costs than
men due to their greater use of health care yet they are more likely than their male
counterparts to be poor, unemployed or else engaged in part-time work or work in the
informal sector that offers no health benefits. One of the keys to improving women’s
health therefore, is the removal of financial barriers to health care. For instance where
there are user fees for maternal health services, households pay a substantial
proportion of the cost of facility-based services, and the expense of complicated
deliveries is often catastrophic. Evidence from several countries shows that removing
user fees for maternal health care, especially for deliveries can both stimulate demand
and lead to increased uptake of essential services. Removing financial barriers to care
must be accompanied by efforts to ensure that health services are appropriate
acceptable of high quality and responsive to the needs of girls and women.

Paradoxically, health systems are often unresponsive to the needs of women despite
the fact that women themselves are major contributors to health through their roles as
primary caregivers in the family and also as health-care providers in both the formal and
informal health sectors. The backbone of the health system. Women are nevertheless
rarely represented in executive or management-level positions, tending to be
concentrated in lower – paid jobs and exposed to greater occupational health risks. In
their roles as informal health – care provides at home or the community. Women are
often unsupported, unrecognized and unremunerated.

Women’s health is profoundly affected by the ways in which they are treated and the
status they are given by society as a whole. Where women continue to be discriminated
against or subjected to violence, their health suffers. Where they are excluded by law
from the ownership of land or property or from the right to divorce, their social and
physical vulnerability is increased. At its most extreme, social or cultural gender bias can
lead to violent death or female infanticide. Even where progress is being made there are
reasons to keep pushing for more. While there has been much progress in girl’s access
to education for example, there is still a male-female gap when it comes to secondary
education, access to employment and equal pay. Meanwhile, the greater economic
independence enjoyed by some women as a result of more widespread female
employment may have benefits for health, but globally, women are less well protected
in the workspace, both in terms of security and working conditions.
15. What message does the first paragraph convey?
a) Proper nutrition is necessary for women
b) Health of girl children is a social duty
c) Intense care must be given for full growth
d) A wholesome childhood for girls is a priority

16. What must be done to address damaging behavior?

a) Assist adolescence to engage in healthy habits
b) Educate the girls on avoiding harmful behavior
c) Society support groups must tackle such factors
d) Highlight occurrences happening in some countries

17. What does the third paragraph try to establish?

a) The need for policies to care for the elderly
b) Healthy habits that influences the health of elderly
c) Responsibility of the female members in a family
d) The funds required for the care of older women

18. In which context is the term biases used in paragraph four?

a) Gender roles
b) Physical limitations
c) Cognitive superiority
d) Complex physiology

19. In paragraph four, what is meant by the term catastrophic?

a) Extreme
b) Dangerous
c) Versatile
d) Powerful

20. According to paragraph five, women must be given

a) Essential support needed for primary care giving
b) Adequate renumeration for services performed
c) Required representation in all professional pursuits
d) Security from possible occupational health risks
21. Why does paragraph six highlight the need for more progress?
a) Women’s health is at increased risk when they are abused
b) Social and statutory inclusion is the need of the hour
c) Profound changes are made in the absence of gender bias
d) Protection and security at workplace is global concern

22. What does the passage advocate?

a) Safety of the girl child is paramount
b) Rights of women must always be respected
c) Considerations must be given for health
d) Progress of women is always all inclusive
READING 7
PART A

Acute Diarrhea

Text A

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

Definition: An abnormal looseness of the stool, changes in stool frequency, consistency,

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

Text B

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

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

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

TEXT C
 TEXT D

Treatment for diarrhea:

Always see your doctor if you experience serious symptoms. Babies and young children
with diarrhoea need prompt medical attention.
Treatment for diarrhoea depends on the cause, but may include:
Plenty of fluids to prevent dehydration
Oral rehydration drinks to replace lost salts and minerals. These drinks are available
from pharmacies. An alternative is one part unsweetened pure fruit juice diluted with
four parts of water. Ⓒ OET Medcity

Intravenous replacement of fluids in severe cases

Medications such as antibiotics and anti-nausea drugs
Anti-diarrheal medications, but only on the advice of your doctor. If your diarrhea is
caused by infection, anti-diarrheal drugs may keep the infection inside your body for
longer
Treatment for any underlying condition, such as inflammatory bowel disease.
PART A
TIME: 15 minutes

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

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

ACUTE DIARRHEA

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

1. Causes of acute diarrhea ………………..

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

Questions 8-14

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

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

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

Questions 15-20

Complete each of the sentences, 15- 20, with a word or short phrase from one of the
texts. Each answer may include words, number or both. Your answers should be
correctly spelled

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

16. ---------------------- may keep the infection inside the body if diarrhea is caused by
an infection.
17. Acute diarrhea is leading cause of________________ in younger children
worldwide.
18. If diarrhea is severe or bloody, the GP may perform ______________
19. Anterior fontanelle of infants would be _____________in case moderate
dehydration.
20. It takes _______________to the pinched skin folds to disappear in case o severe
dehydration.
READING 8
PART A

Hemophilia

Text A

Hemophilia results from mutations at the factor VIII or IX loci on the X chromosome and
each occurs in mild, moderate, and severe forms.

A similar level of deficiency of factor VIII or IX results in clinically indistinguishable

disease because the end result is deficient activation of factor X by the factor Xase
complex (FVIIIa/FIXa/calcium and phospholipid).

Hemophilia A is an X-linked, recessive disorder caused by the deficiency of functional

plasma clotting factor VIII (FVIII), which may be inherited or arise from spontaneous
mutation.

Hemophilia B, or Christmas disease, is an inherited, X-linked, recessive disorder that

results in the deficiency of functional plasma coagulation factor IX.

Text B
Hemophilia A

Primary sites of factor VIII (FVIII) production are thought to be the vascular endothelium
in the liver and the reticuloendothelial system. Ⓒ OET Medcity

FVIII deficiency, dysfunctional FVIII, or FVIII inhibitors lead to the disruption of the
normal intrinsic coagulation cascade, resulting in excessive hemorrhage in response to
trauma and, in severe cases, spontaneous hemorrhage.

Human synovial cells synthesize high levels of tissue factor pathway inhibitor, resulting
in a higher degree of factor Xa (FXa) inhibition, which predisposes hemophilic joints to
bleed.

This effect may also account for the dramatic response of activated factor VII (FVIIa)
infusions in patients with acute hemarthroses and FVIII inhibitors.
Bleeding into a joint may lead to synovial inflammation, which predisposes the joint to
further bleeds; a joint that has had repeated bleeds (by one definition, at least 4 bleeds
within a 6-month period) is termed a target joint.

Approximately 30% of patients with severe hemophilia A develop alloantibody inhibitors

Hemophilia B

Factor IX deficiency, dysfunctional factor IX , or factor IX inhibitors lead to disruption of

the normal intrinsic coagulation cascade, resulting in spontaneous hemorrhage and/or
excessive hemorrhage in response to trauma.

Hemorrhage sites include joints (eg, knee, elbow), muscles, central nervous system
(CNS), GI system, genitourinary (GU) system, pulmonary system, and cardiovascular
system. Ⓒ OET Medcity

Factor IX, a vitamin K–dependent single-chain glycoprotein, is synthesized first by the

hepatocyte; the precursor protein undergoes extensive posttranslational modification
before being secreted into the blood.

The intrinsic system is initiated when factor XII is activated by contact with damaged
endothelium.

In the extrinsic system, the conversion of factor X to factor Xa involves tissue factor (TF),
or thromboplastin; factor VII; and calcium ions.

FVIII and FIX circulate in an inactive form; when activated, these 2 factors cooperate to
cleave and activate factor X, a key enzyme that controls the conversion of fibrinogen
tofibrin.

Therefore, the lack of either of these factors may significantly impair clot formation and,
as a consequence, result in clinical bleeding.

Statistics and Incidences:

Hemophilia is slowly progressing among pediatric patients in all parts of the globe.

X-linked recessive inheritance | Genetics Home Reference

Hemophilia A is the most common X-linked genetic disease and the second most
common factor deficiency after von Willebrand disease (vWD).
The worldwide incidence of hemophilia A is approximately 1 case per 5000 males, with
approximately one-third of affected individuals not having a family history of the
disorder.

In the United States, the prevalence of hemophilia A is 20.6 cases per 100,000 males; in
2016, the number of people in the United States with hemophilia was estimated to be
about 20,000.

Hemophilia A occurs in all races and ethnic groups.

Because hemophilia is an X-linked, recessive condition, it occurs predominantly in

males; females usually are asymptomatic carriers. Ⓒ OET Medcity

The incidence of hemophilia B is estimated to be approximately 1 case per 25,000-

30,000 male births.

The prevalence of hemophilia B is 5.3 cases per 100,000 male individuals, with 44% of
those having severe disease.

Hemophilia B is much less common than hemophilia A. Of all hemophilia cases, 80-85%
are hemophilia A, 14% are hemophilia B, and the remainder are various other clotting
abnormalities.

Hemophilia B occurs in all races and ethnic groups.

Text C
 Text D

Medical Management

The treatment of hemophilia may involve prophylaxis, management of bleeding

episodes, treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of
hemophilia synovitis.

Ryan White was an American hemophiliac who was infected with HIV from a
contaminated blood treatment (factor VIII).

Prehospital care. Rapid transport to definitive care is the mainstay of prehospital care;
prehospital care providers should apply aggressive hemostatic techniques, assist
patients capable of self-administered factor therapy, and gather focused historical data
if the patient is unable to communicate. Ⓒ OET Medcity

Emergency department care. Use aggressive hemostatic techniques; correct

coagulopathy immediately; include a diagnostic workup for hemorrhage, but never
delay indicated coagulation correction pending diagnostic testing; acute joint bleeding
and expanding, large hematomas require adequate factor replacement for a prolonged
period until the bleed begins to resolve, as evidenced by clinical and/or objective
methods; life-threatening bleeding episodes are generally initially treated with FVIII
levels of approximately 100%, until the clinicalsituation warrants a gradual reduction in
dosage.

Factor VIII and FIX concentrates. Various FVIII and FIX concentrates are available to
treat hemophilia A and B; besides improved hemostasis, continuous infusion decreases
the amount of factor used, which can result in significant savings; obtain factor level
assays daily before each infusion to establish a stable pattern of replacement regarding
the dose and frequency of administration.

Desmopressin.Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin

(DDAVP), is considered the treatment of choice for mild and moderate hemophilia A;
DDAVP stimulates a transient increase in plasma FVIII levels; DDAVP may result in
sufficient hemostasis to stop a bleeding episode or to prepare patients for dental and
minor surgical procedures.
Management of bleeding Immobilization of the affected limb and the application of ice
packs are helpful in diminishing swelling and pain; early infusion upon the recognition of
initial symptoms of a joint bleed may often eliminate the need for a second infusion by
preventing the inflammatory reaction in the joint; prompt and adequate replacement
therapy is the key to preventing long-term complications. Ⓒ OET Medcity

PART A

TIME: 15 minutes

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

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

Hemophilia

1. The information regarding treatment of hemophilia is …………………..

2. Hemophilia A occurs in all the races and ethnic groups. …………………..
3. The information regarding frequency of bleeding sites in factor XIII deficiency.
…………………..
4. Information regarding usage of aggressive hemostatic techniques …………………..
5. The definition of hemophilia A …………………..
6. Information regarding the consequences of bleeding into joints …………………..
7. The incidence of hemophilia A is more than hemophila B …………………..

Questions 8-14

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

8. Which types of patients have slow progression of hemophilia?

…………………………………………………………
9. Which clotting factor is deficient in hemophilia A?
…………………………………………………………
 10. What is initiated when factor XII comes in contact with damaged endothelium?
…………………………………………………………
11. Who are the asymptomatic carriers in the case of hemophilia?
…………………………………………………………
12. Which is the least bleeding site in factor VIII deficiency cases?
………………………………………………………….
13. What is the treatment of choice for mild and moderate hemophilia A?
……………………………………………………………
14. Which is the most common factor deficiency disorder around the globe?
……………………………………………………………..

Questions 15-20

Complete each of the sentences, 15- 20, with a word or short phrase from one of the
texts. Each answer may include words, number or both. Your answers should be
correctly spelled Ⓒ OET Medcity

15. Hemophilia B is also called as ………………….

16. A joint which has had repeated bleeds is called as ………………….
17. One third of patients with severe hemophilia A develop alloantibody
………………….
18. The incidence of hemophilia B is predicted to be nearly, one case per ……………….
births.
19. Hemophilia is an ..................... recessive disorder.
20. synthesize high levels of tissue factor pathway inhibitors, which
predisposes hemolytic joints to bleed.
Questions 1-7

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

1) Types of dry skin

2) Protective function of skin
3) Overactive epidermal turnover is one of the factors in dry skin
4) It is commonly seen in old age people
5) Define dry skin
6) Stratum corneum is flexible when its water content reaches particular level
7) Transepidermal waterloos stimulates the lipid synthesis
 MATERNAL MICROBIOTA

1. A
2. D
3. B
4. C
5. A
6. D
7. C

8. To define causal relationship

9. Physical barriers/immunological barriers
10. Fetal immune development
11. Maternal microbiota
12. Due to inherent coupling of gestational effect
13. Cellular and molecular mechanism
14. unable to survive and replicate in-vivo

15. Peptide
16. prior to birth
17. Endotoxin
18. Ethical
19. Dysbiosis mediated
20. Maternal microbiota

PART B

1. C
2. B
3. B
4. B
5. C
6. C
 PART C
7. B
8. D
9. C
10. D
11. A
12. B
13. C
14. C
15. C
16. B
17. A
18. C
19. C
20. C
21. A
22. A
READING 2
HEALTH EFFECTS OF ENVIRONMENTAL NOISE POLLUTION

1. B
2. B
3. A
4. D
5. A
6. C
7. B

8. Human ear
9. Continual noise
10. Air pollution
11. Cognitive impairment
12. At least one million
13. Sets off body’s acute stress response

14. Acute stress

15. Fatigue
16. Brain
17. Sleeping pills/sedatives
18. Continual noise
19. Dr Orfeu Buxton
20. The WHO team

PART B

1. C
2. B
3. A
4. B
5. C
6. C
 PART C
7. D
8. B
9. D
10. A
11. B
12. A
13. A
14. C
15. D
16. C
17. D
18. A
19. B
20. B
21. B
22. C
READING 3
ECTOPIC PREGNENCY

1. A
2. D
3. A
4. C
5. B
6. A
7. B

8. Rupture with internal bleeding

9.90%
10. Methotrextate
11. Decreased intra pelvic blood flow
12.Fewer than 50%
13. Expectant (management)
14. Vaginal bleeding

15. Rupture
16. one third
17. One occasion
18. Assisted reproductive
19. Doctor (your doctor)
20. Ultrasound

PART B
1. A
2. A
3. B
4. B
5. B
6. C
 PART C
7. B
8. A
9. D
10. C
11. D
12. A
13. A
14. B
15. A
16. D
17. B
18. B
19. C
20. C
21. C
22. A
READING 4

PLASMODIUM FALCIPARUM

1. C
2. A
3. D
4. B
5. A
6. C
7. B

8. Volatile organic compound

9. Terpenes
10. (Significant) biological variability
11. To facilitate transmission
12. Parasite
13. Terpene variants
14. Malarial infection

15. Plant like volatile

16. Dietary sources
17. Fitness and feeding
18. Chemical signals
19. P.Falciparum
20. Inhibitors

PART B

1. A
2. C
3. C
4. C
5. B
6. B
 PART C
7. C
8. C
9. A
10. C
11. D
12. D
13. C
14. A
15. C
16. B
17. D
18. B
19. C
20. D
21. D
22. A
READING 5

HEALTH EFFECTS OF TOBACCO

1. B
2. D
3. C
4. B
5. C
6. B
7. A

8.More than 70
9. 600000( 6 lakhs)
10. How much the person smokes/ no of years person smokes
11. Peter Jemings
12. 70
13.1880
14. Emphysema and chronic bronchitis

15. Nicotine
16. Complication of tobacco
17.Smoking Free laws
18.11 minutes
19. Early
20. Cigarette factories

PART B

1. C
2. B
3. A
4. C
5. C
6. C
 PART C
7. C
8. A
9. B
10. D
11. C
12. A
13. B
14. D
15. A
16. B
17. C
18. C
19. A
20. C
21. A
22. C
READING 6

TRANSCATHETER AORTC VALVE IMPLANTATION

1. A
2. A
3. C
4. B
5. C
6. B
7. D

8. Lower
9. Aortic valve stenosis
10. Lung or kidney disease
11. Transapical
12. Peripheral vascular disease
13. Paravalvular regurgitation
14. Stroke
15. Invasive procedures
16. Anticoagulants
17. Full recovery
18. Heart team
19. Device selection
20. Multidisciplinary group

PART B

1. B
2. C
3. B
4. C
5. A
6. B

PART C
7. B
8. A
9. D
10. C
11. C
12. A
13. B
14. A
15. D
16. A
17. A
18. A
19. B
20. C
21. B
22. D
READING 7

ACUTE DIARRHOEA

1. B
2. B
3. D
4. A
5. C
6. D
7. B

8. Rotavirus
9. Severe dehydration
10. 0ral rehydration drinks
11. See a doctor
12. Cramping, bloating, gas
13. No urine output/ anuria/ empty bladder
14. E.coli
15. Intravenous fluids
16. Anti diarrheal drugs
17. Mortality /death
18. Stool cultures/parasite exams /stool examination
19. Depressed
20. >2 seconds

PART B

1. A
2. C
3. A
4. C
5. B
6. C
 PART C

7. A
8. B
9. C
10. A
11. B
12. D
13. D
14. C
15. B
16. C
17. D
18. B
19. C
20. A
21. D
22. A
READING 8

HEMOPHILIA

1. D
2. B
3. C
4. D
5. A
6. B
7. B
8. Pediatric patient
9. Factor VIII
10. The intrinsic system
11. Females/Women
12. Renal
13. Desmopressin/Desmopressin vasopressin amlog/DDAVP
14. Von willebrand disease
15. Christmas disease
16. Target joint
17. Inhibitors hemophilia B
18. 25000-30000 male
19. X-linked
20. Human synovial cells

PART B

1. A
2. C
3. B
4. C
5. A
6. C
 PART C
7. B
8. D
9. C
10. A
11. A
12. C
13. D
14. B
15. D
16. A
17. D
18. B
19. C
20. A
21. B
22. C
READING 9

DRY SKIN

1. D
2. C
3. D
4. A
5. A
6. B
7. C

8. Internal keratin filaments

9. Harsh and brittle scaly surface
10. A lipid/major lipid of stratum corneum
11. Mild scaling or chafing
12. Desiccation
13. Water content
14. Water soluble hygroscopic substances
15. Smooth and supple
16. Congenital ectodermal defect
17. Water binding
18. Ceramides
19. on extensor surfaces
20. Constitutional

PART B

1. A
2. A
3. A
4. A
5. A
6. A
 PART C

7. C
8. D
9. D
10. A
11. B
12. B
13. A
14. D
15. A
16. D
17. D
18. C
19. A
20. B
21. B
22. A
READING 10

OPIOID DEPENDENCE

1. B
2. A
3. C
4. D
5. A
6. D
7. B
8. Pain intensity
9. Buprenorphine-naloxone
10. 1 to 3 days
11. If pain is not managed with non opioid medication
12. Urine drug screening
13. Alternative interests or pleasures
14. A single patch/one patch
15. Permit
16. Poorer outcome
17. Central features/features
18. Treatment agreement
19. Nonopioid agreement
20. 3 or more

PART B
1. C
2. C
3. A
4. A
5. B
6. C
 PART C

7. B
8. D
9. B
10. D
11. C
12. D
13. C
14. C
15. C
16. B
17. C
18. D
19. D
20. A
21. B
22. B