Question 1

Memo to: Department physicians and clinical staffSubject: Aseptic technique

Aseptic technique protects patients during invasive clinical procedures byemploying infection control measures that minimise, as far as practicably possible,the presence of pathogenic organisms. Good aseptic technique procedures helpprevent and control healthcare associated infections and must be preserved. Asyou are aware, the aim of every procedure should be to maintain asepsis at alltimes by protecting the key parts and key sites from contact contamination bymicroorganisms. This can be achieved through correct hand hygiene, a non-touchtechnique, glove use and ensuring asepsis and sterility of equipment. While theprinciples of aseptic technique remain constant for all procedures, the level ofpractice will change depending upon a standard risk assessment.

The purpose of this memo is to

provide staff information on appropriate methods.

notify staff of a possible change in standard procedure.

remind staff of the importance of following best practice.

PART B

A. B. C.

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Question 2

6.2 Thrombolysis for STEMI patientsPrimary percutaneous coronary intervention (PCI) is the treatment of choice forpatients presenting with an acute ST Elevation Myocardial Infarction (STEMI).However, if it is not possible to transfer the patient to the cardiac catheterlaboratory immediately, for whatever reason, then the need for thrombolysis to begiven should be considered. The admitting team must ask the primary PCIoperator if they are able to achieve the arrival in hospital to first balloon inflationtarget of 120 minutes. If not, then thrombolysis will be given on the advice of theprimary PCI operator without delay. Support for this may be given by CoronaryCare Unit (CCU) staff/Chest Pain Nurses depending on the patient’s location.Transfer the patient with resuscitation equipment to CCU immediately afterthrombolysis is administered.

The guidelines require those administering thrombolysis to

explore other options before proceeding.

contact the coronary care unit prior to transfer.

ensure support staff are readily available.

A.

B.

C.

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Question 3

Guidelines for the management ofimplants and foreign bodies during MRIscansImplantable devices or other foreign bodies may contraindicate MRI scanningand/or cause significant image artefacts. There is a growing number of medicaldevices and implants that are classified as ‘MRI conditional’, placing theresponsibility for safety on the operator. It should be stressed that safety at adefined field strength or for a specific MRI system is no guarantee of safety at ahigher (or lower) field strength, or a different MRI system at the same field strength.If there is any doubt as to the nature of a device then a scan should only proceedafter a careful assessment of the potential risks and benefits of the scan with thedevice in situ. The MRI Safety Expert can assist with identifying and quantifying therisks, but the decision to scan is a clinical one.

The guidelines specify that those performing an MRI on patients with implants orforeign bodies

should abandon the scan if unsure of the device.

have the final say in whether to scan a patient.

use a lower field strength for conditional items.

A.

B.

C.

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Question 4

Manual extract: Operation of AP14 ManualSyringe PumpPump ApplicationThe AP 14 syringe pump is simple to operate, reliable and is of general application. Itis suitable for various types of single-use syringes. BOLUS function enables quickand repeated delivery of bolus doses to the patient, with accurately establishedvolume and within a specified infusion time. The pump can operate withoutconnection to the mains, as it is automatically supplied by the internal battery incases, e. g. of mains failure. It also enables to continue the infusion when thepatient is being transported from one area of the hospital to another. Simplecasing, without any parts protruding from the front panel, facilitates maintenanceand disinfection.

The manual informs us that the AP14 syringe pump

should be disconnected in times of power outage.

facilitates easy cleaning by its smooth exterior.

has a unique patient transportation feature.

A.

B.

C.

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Question 5

Indwelling urinary cathetersUrethral, prostate or bladder neck injury resulting in false tracts, strictures andbleeding are related to traumatic urethral insertion. Traumatic injury is less likely tooccur with appropriate catheter selection, lubrication, correct patient positioningand insertion into a full bladder. Retention balloons should only be inflated insidethe bladder, which is indicated by urine return with IUC inserted to the hilt. If there isany uncertainty regarding catheter placement, the balloon should not be inflated.If the patient experiences pain with inflation, deflate the balloon immediately andreassess IUC position as this may indicate the catheter is outside the bladder. IUCsshould be used with caution in patients at risk of self-extraction, such as those withdementia or who are delirious. When available, ultrasonography is recommendedto evaluate bladder volumes and guide SPC insertions.

The notice on indwelling urinary catheters provides information about

the order for correct insertion.

optimal positioning of the patient.

how best to avoid harming patients.

A.

B.

C.

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Question 6

Delirium is an acute deterioration in cognition, often with altered arousal(drowsiness, stupor, or hyperactivity) and psychotic features (e.g. paranoia). Themain cognitive deficit in delirium is ‘inattention’, e.g. the patient is distractible,cannot consistently follow commands, and loses the thread during a verbalexchange. Delirium and dementia commonly co-exist, however, with the latterthere is a much slower deterioration in thinking, perceiving and understanding, andinattention is much less prominent. Because delirium is usually due to aninteraction between multiple predisposing and precipitating factors, managementshould be aimed at not just finding and treating the assumed cause, but alsooptimising all aspects of care.

This extract from a handbook says that patients with delirium experience

a similar cognitive decline as with dementia.

a loss of interest during conversations.

influences that may trigger the disorder.

A.

B.

C.

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Text 1: Shedding Light on ComplexRegional Pain Syndrome (CRPS)

Eleven years ago, Debbie had a routine bunion operation that changed her life. Instead of finding relief, her pain grew worse, until it was excruciating and constant. “I became disabled and had to stop working. My foot is permanently in an air cast and I walk with a cane. Most of the time the pain is a 10 out of 10,” she says. Debbie’s surgeon sent her to a pain specialist, who recommended a psychiatrist. “I knew the pain wasn’t in my head,” shesays, but the medical community didn’t believe her. It wasn’t until she met neurologist Anne Louise Oaklander that she finally received a diagnosis: Complex Regional PainSyndrome, or CRPS.

CRPS is a chronic pain condition that develops following trauma to a limb, such as surgery or a fracture. As Debbie learned, “this is a very controversial condition that not a lot of doctors understand,” says Oaklander. “Historically, the field of medicine has been very sceptical of patients with CRPS. On top of their illness, patients have had t

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_____________

___________

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As reflected in the original name for CRPS, Reflex Sympathetic Dystrophy, one of the earliest ideas about the biological underpinnings of the condition is the presence of dysfunction of the sympathetic nervous system, the network of neurons that governs the body’s automatic “fight or flight” response. Currently, researchers believe that such alterations are important in the initial generation and acute phase of CRPS. For example, studies suggest that in the tibial fracture model, sympathetic neurons release an immune system protein calledinterleukin-6 that stimulates inflammation and pain. Andreas Goebel, a clinician and painresearcher at the University of Liverpool, UK has identified a number of autoantibodies, which are immune system proteins directed against a person’s own tissues or organs, in the blood of people with chronic CRPS.

The first CRPS trial is underway, to evaluate the efficacy and safety of neridronate, a new bisphosphonate, which is a class of drugs already widely used to prevent and treatosteoporosis. This is a placebo- controlled clinical trial and has completed enrolment of 230 patients at 59 sites in the US and Europe. Debbie is one of the trial participants, and has received several intravenous infusions. Neither she nor Oaklander are aware as yet if she received neridronate or a placebo. “If this trial finds neridronate to be safe and effective and receives approval to be marketed for CRPS, it will be historic”, says Oaklander. “It’s only when there’s an approved drug that there’s advertising, which increases public awareness, and spurs doctors to learn more,” she adds. “I felt it

trial.” landmark a be could hisT trials. quality high deserves that disease medical real a is SRPC that world the to statement a makes it because trial this

in participate to important was

Page 300

7. In the first paragraph, the writer uses Debbie’s case to convey

The dangers of having even minor surgeryA lack of awareness of CRPS among the medical fraternity.The psychological causes of pain experienced by CRPS sufferers.That specialist attention is warranted in such instances

A. B. C. D.

8. What is meant by the phrase the tide is turning in the second paragraph?

Doctors now believe in the existence of CRPS.

Beneficial treatment is now more readily available.Recent investigations are indicating a cure is in sight.The medical community’s understanding is beginning to shift.

A.

B.

C.

D.

9. Evidence mentioned in the third paragraph has revealed

A. Possible reasons for the multitude of symptoms experienced.B. Better post-operative care of limbs is needed.C. Temperature patterns remain consistent throughout cases.D. Further research is required into the possible causes of pain.

10. What do we learn about CRPS in the fourth paragraph?

A.Patients respond very differently to available treatment.B. Professional diagnosis is necessary to see improvements.C. Profound psychological impacts are often reported.D. Amputation should only be performed when all else has failed.

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11. In the fifth paragraph, what point is made about the symptoms of CRPS?

A. The length and severity of CRPS are quite consistent.B. Pain is the dominant symptom for CRPS sufferers.C. CRPS presents itself in a diverse number of ways.

D. The average CRPS patient is very well understood.

12. What point is made about the sympathetic nervous system in the sixth paragraph?

A. It only affects CRPS in the very early stages.

B. It causes CRPS following a fractured tibia.C. It has a critical role from the outset of CRPS.D. It has less influence on CRPS than initially believed.

13. Anne Louise Oaklander values the trials highly because

A. Of the inclusion of the recently created neridronate.B. They may help validate the authenticity of CRPS.C. She gets to be a part of ground-breaking research.D. It is the first time a cohort of this size has been used.

14. The final paragraph mentions that confirmation has yet to be received regarding

A. Whether Debbie was given the neridronate infusion.B. The final number of participant enrolments for the trial.C. Having the backing of the entire medical community.

D. The approval for public advertising campaigns.

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Text 2: Antibiotic Resistance now a global threat to public health

In 1945, Alexander Fleming, the man who discovered the first antibiotic said in hisNobel Prize acceptance speech, “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant may easily under dose themselves and by exposing their microbes to non- lethal quantities of the drug, making them resistant." A recent report from the Centres for Disease Control and Prevention (CDC) revealed that more than 2 million people in the US alone become ill every year as a result of antibiotic-resistantinfections, and 23,000 die from such infections.

The World Health Organization (WHO) has recently published their first global report onthe issue, looking at data from 114 countries. WHO focused on determining the rate of antibiotic resistance to seven bacteria responsible for many common infections,including pneumonia, diarrhoea, urinary tract infections, gonorrhoea and sepsis. Theirfindings were worrying. Th

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______________

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Dr Charles Penn, coordinator of antimicrobial resistance at WHO, takes a slightly different viewpoint from his peers. "One of many reasons why antibiotic use is so high is that there is a poor understanding of the differences between bacteria, viruses and other pathogens, and also of the value of antibiotics," he said. "Too many antibiotics are prescribed for viral infections such as colds, flu and diarrhoea.

Unfortunately, these misconceptions arepublic often perpetuated by marketing andadvertising campaigns through the use of generic terms such as 'germs' and 'bugs.'It’s difficult to try and narrow down the blame to a single origin.”

Dr Penn noted that reliance on antibiotics for modern medical benefits hascontributed to drug resistance. "Surgery, cancer treatment, intensive care, transpla

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_________________

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16. In the second paragraph, what does the writer find particularly worrisome?

A.One particular antibiotic no longer provides resistance anywhereB. New borns are quickly becoming resistant to all antibioticsC. Resistance is at an all-time low for the most common infectionsD. Although treatment is available globally it is largely ineffective

17. What is meant by one of the pillars in the third paragraph?

A. An innovation that changed the healthcare industryB. A permanent fixture in the field of medicineC. An essential component of the medical systemD. A remedy that is among the greatest inventions

18. According to Dr Steve Solomon, what is ultimately responsible for antibiotic resistance?

A. Their everyday use for common diseasesB. The prescriber’s lack of experienceC. The increase in global demandD. The medical professional’s misuse

15. The writer quotes Alexander Fleming in the first paragraph to

A. Emphasise the impressive history of antibiotics.B. Reveal the ease at which people may purchase antibiotics.C. Compare current usage of medication to an earlier time.D. Show that his prediction of antibiotic resistance was accurate.

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20. In the sixth paragraph, Dr Penn gives examples of our dependence on antibiotics to

A. Stress that substitute medications are needed.B. Justify the need to change our habits.C. Show that it’s too late to reverse the damage.D. Highlight our lack of appreciation for current treatments.

21. In the final paragraph, Dr Penn makes the point that medical practitioners

A. Have depleted the supply of antibiotics through overuse.B. Were reluctant to take advice regarding antibiotics.C. Once believed there was an endless supply of antibiotics.

D. Are yet to understand the damage caused by their actions.

22. In the final paragraph, the phrase heeding the warning refers to

A. Prescribers being attentive to the problem.B. Doctors now issuing warnings to patients.C. The medical community regretting their carelessness.D. Practitioners looking ahead to a brighter future.

19. In the fifth paragraph, Dr Charles Penn argues that when it comes to antibiotic resistance

A. Increasing their cost would deter overuseB. The general public should be held responsibleC. Mass media plays a crucial role in its demand

D. More understanding is needed to overcome it

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1. C

2. B

3. A

4. D

5. A

6. C

7. B

8. major neurocognitive disorder

9. Alzheimer’s disease

10. executive function

11. specialist referral

12. psychiatric or psychogeriatric referral / psychogeriatric referral / psychiatricreferral / Psychiatric or psychogeriatric referral / Psychogeriatric referral /Psychiatric referral

13. learning and memory

14. every 12 months / once a year / once per year

15. delirium

16. ability to live independently

17. no / zero / 0

18. cognitive

19. recognition of emotions

E2language Reading Test IV- Answer

20. day to Day

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1-

C 2-

A 3-

B 4-

B 5-

C 6-

C

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Part

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7- B

8- D

9- A

10-C

11-C

12-C

13- B

14- A

15- D

16- A

17- C

18- D

19- C

20- B

21- C

22- A

C.1

_________________________________________________

C.2

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