R000006

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

TIME: 45 MINUTES

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 Part B

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

1. According to the policy document, what should be assessed at the clinic?

A the anticipated longevity of the pacemaker battery

B whether a different type of pacemaker would be more suitable

C reasons for delaying referral of the pacemaker wearer to the implant surgeon

Pacemaker Follow-up Clinic

Objectives:
1. To optimise the pacing system according to the individual patient needs whilst maximising
generator life.
2. To identify any abnormalities in the pacemaker system and complications of the therapy in
order to ensure prompt treatment.
3. To assess battery status to predict end-of-life of the pulse generator in order to permit timely
elective generator replacement.
Suggested appointments schedule:

- Yearly for pacemakers implanted for less than 7-10 years, depending on the manufacturers
recommendation
- 6 monthly for implants exceeding 7-10 years.
- 3-6 monthly for devices that show decline in battery life.
- At Cardiac Physiologist’s discretion for devices that require closer monitoring, e.g.
programming/lead issues.

The implant centre need only be contacted when seeking additional advice or when making a referral to
the implanting physician.
2. What does this memo about dental anaesthesia tell nurses in the orthodontics department?

A As a precaution, Prilocaine is used in low concentrations for all patients.

B There may be circumstances when a higher dose of Lidocaine should be used.

C One formulation of Mepivacaine is most suitable for patients with high blood pressure.

Memo

To: dental nurses

Subject: Information for dental nurses regarding dental anaesthesia

Lidocaine is used in dental local anaesthetics in this orthodontics department. Lidocaine 2% combined with

adrenaline (1 in 80 000 or 12.5 micrograms/mL) is a safe and effective preparation, and therefore no justification

exists for stronger concentrations of adrenaline. Other local anaesthetics we keep in stock are Articaine

and Mepivacaine, purchased in cartridges suitable for dental use. Mepivacaine is available with or without

adrenaline, whereas Articaine is available only with adrenaline. In patients with severe hypertension, the use

of adrenaline in a local anaesthetic may be hazardous. For these patients, where Mepivacaine is unavailable,

Prilocaine can be used. However, there is some evidence that it can cause coronary vasoconstriction when used

at high doses. Common practice is therefore to limit the dose administered to patients with hypertension.
3. The purpose of the email is to emphasise to staff the need to ensure that

A sufficient blood transfusion leaflets are available for patients to pick up.

B patients fully understand one consequence of having a blood transfusion.

C aftercare for blood transfusion patients is carried out by specific personnel.

From: Head of department

To: All ward staff

Subject: Blood transfusions

This is to bring an incident in the mobile blood-donation clinic to your attention. A potential

donor was unaware that he couldn’t donate blood because he’d recently had a blood

transfusion. In light of this, please ensure that verbal and written information is provided

to patients about to undergo a transfusion. This should always include the reason for

transfusion, risks, benefits, alternatives, and subsequent ineligibility to be blood donors.

‘Will I need a Blood Transfusion’ leaflets are available in all ward areas or from the

Transfusion Laboratory and should be given directly to patients. A ‘Following your Blood

Transfusion’ leaflet is available to give to patients leaving hospital shortly after their

transfusion. Consent for transfusion must be documented by the prescriber in the patient’s

notes, and the person administering the blood must sign the yellow transfusion form.
4. This update explains that the new defibrillator sign

A consists of more pictures but fewer written instructions for using the AED.

B provides a strong visual cue as to how the AED should be used.

C emphasises clearly who the AED should not be used on.

Resuscitation Council: update on Automated External Defibrillators (AEDs)

All AEDs will now be displayed with new signage. The lightning bolt icon is replaced with an ECG heart

trace, and the description of the device is changed to ‘Defibrillator – Heart Restarter’. Such changes

aim to encourage wider use of the AED, and in trials respondents have overwhelmingly said that, in

an emergency, they would feel more inclined to use a device displaying this icon. Note also that a

supine person has been added with the suggested placement of the defibrillator pads, to reinforce

what the user needs to do without having to read lengthy explanations in a critical situation. The sign

remains consistent with government guidelines and reinforces the key message about Public Access

Defibrillation, i.e. that no prior medical training is needed by the user and that it is for an unconscious

person not breathing normally.

5. According to the guidelines, medical staff who are considering the withholding of treatment should

A consult senior colleagues.

B put their concerns in writing.

C inform the patient immediately.

Extract from the guidelines: Withholding of treatment from violent or abusive patients

The decision to withhold treatment must balance the risk to the patient if treatment is withdrawn, the
organisation's obligation to provide healthcare and the potential danger to staff. The decision must not
be taken without having fully discussed the issue with the Local Security Manager Specialist (LSMS).
A final written warning should always be sent prior to making any decision to withhold treatment. This
letter should be drafted by the LSMS and signed by the Executive Director. Any decision to withhold
treatment must be based on a proper clinical assessment and the advice of the patient’s GP/Independent
Practitioner or a senior member of the medical team on a case-by-case basis. Under no circumstances
should it be implied to a patient that treatment may be withheld without appropriate discussions taking
place. The withholding of treatment should always be seen as a last resort.
6. What is the email to paediatric staff explaining?

A The radiologist should be contacted directly to book hip ultrasound appointments.

B If a physiotherapy appointment is necessary, this will be made prior to discharge.

C A hip ultrasound may be needed even when a dislocated hip isn’t apparent

From: Carol Scott, Radiologist

To: Paediatric staff

Subject: Procedure for referring babies with Developmental Dysplasia of the Hip to

appropriate services

Any baby born with a dislocated or dislocatable hip should be referred urgently for an

ultrasound scan at 1-2 weeks of age. To book a hip ultrasound, send a written referral to

the Orthopaedic booking office, specifying ‘baby hip ultrasound clinic’.

The Paediatric Orthopaedic Physiotherapy team don’t need to be informed of babies with

dislocated or dislocatable hips as I will refer on as/when required.

Babies presenting with any of the risk factors for Hip Dysplasia in the attachment to this

email should be referred for a hip ultrasound scan at 6 weeks of age.

Babies requiring physiotherapy won’t normally be seen on the ward by the Physiotherapy

team, but an outpatient appointment will be offered within 2 weeks.

 Part C

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

Text 1: Temporo-mandibular Joint Disorder

TMD is a set of heterogeneous musculoskeletal conditions involving the temporo-mandibular joint (TMJ) and/or
the masticatory muscles. Up to 33% of the population has had at least one TMD symptom, with 5-10% requiring
treatment. Common symptoms include limited jaw movement, joint clicking, popping or crackling, and facial pain.
Once TMD becomes chronic, it can be debilitating, with comorbidities such as teeth grinding, depression, IBS and
fatigue that greatly reduce an individual’s quality of life. The multi-faceted nature of the disease means that the
underlying mechanism of TMD often remains unclear.

Conservative treatments – warm compresses, behavioral therapy, oral appliances, and drugs such as anti-
inflammatories – are commonly used to treat TMDs, and in many cases reduce pain to tolerable levels. So, it is
only once these therapies have been exhausted that a physician should suggest to a chronic TMD sufferer the
possibility of trying Botox injections into the masseter and temporalis (chewing) muscles. In addition to its well-
publicized cosmetic uses, Botox has been approved by the FDA for painful conditions potentially related to TMD,
such as cervical dystonia and migraine, although as yet Botox is not FDA-approved for use in TMD. When doctors
offer it, patients should be aware this is off-label use. The FDA has not evaluated the safety or efficacy of this
powerful toxin for TMD treatment.

Botox (or Botulinum toxin) is a toxin secreted by a bacterium called Clostridium botulinum, known to inhibit skeletal
muscle. In one study, Botox injections were used to cure jaw hypertension (and its consequent teeth-grinding)
in one of the four pairs of masticatory muscles known as the LP muscle. In a further study, Botox was used to
counteract jaw sounds, with no recurrence in the year following injections. And in yet another study, injections of
Botox for patients with cartilage displacement resulted in pain relief and the return of the normal movement of the
mandible.

But before we ask whether Botox can reduce TMD pain, we need to question the safety of using it in this way.
Injected into muscles, Botox causes partial paralysis, and this changes the forces that cause normal stress on
the temporo-mandibular joint. These forces are necessary for maintaining the usual process of breakdown and
regrowth of bone. If temporo-mandibular joint paralysis changes bone remodeling, injecting Botox into the chewing
muscles might cause unique and unknown problems. To investigate this, Dr Susan Herring at the University of
Washington in Seattle examined the effect of injecting Botox into the jaw muscles of rabbits. She observed that
this resulted in an osteoporotic condition in the temporo-mandibular joint of rabbits, raising concerns that long-term
Botox use might be unhealthy.
While Herring’s findings caused consternation, it was unclear if results from a rabbit study had any useful
connection to humans. With the cooperation of the TMJ Association, Dr Karen Raphael at New York University
posted an online survey on the Association's website in order to identify the definitive answer, by comparing
women who had received temporo-mandibular joint injections with a similar group of TMD patients who had not.
Sixteen women underwent specialized radiological imaging, and abnormally low bone density was found in the
temporo-mandibular joint of all those treated with Botox but in none of those who had not received Botox, indicating
conclusively the need for more research into the safety of Botox for TMD pain.

In an evidence-based review, Ihde et al. evaluated the effect of Botox on chronic facial pain. They noticed
adverse effects including muscle paralysis in a number of patients, but four weeks after treatment 91% of patients
expressed improvement in facial pain. Emara et al. assessed the use of Botox for treating jaw clicking in six
patients, and an electromyogram (EMG) was used to determine precisely where to inject. They concluded that
Botox eliminated clicking in all but one case, and during the subsequent three to four months, recurrence was
seen in only one other patient. Unlike Ihde et al., negative secondary effects were not reported. Later, von Lindren
evaluated the effect of Botox injections on reducing maxillofacial muscle pain, again employing EMG while injecting
into muscles that were difficult to access. Continued pain was reported in 80% of patients, dropping only to 50%
three months after injection.

I wish to single out Dr Raphael’s informative report about studies showing how Botox injections cause decreased
bone density in the temporo-mandibular joint. Patients and clinicians should understand there are other reasons to
be cautious about such injections, including the risk of so-called disuse atrophy (wasting or loss of muscle tissue),
resulting in disfiguration on the side of the head. Some patients may develop an immune response to Botox which
blocks its action and renders injections ineffective. Finally, Botox is used to treat symptoms of myofascial pain but
not the cause, which seems to me an illogical way to approach the situation.
Text 1: Questions 7-14

7. What challenge is referred to in the first paragraph?

A pinpointing the root cause of a patient’s TMD

B misdiagnosing TMD for another medical condition

C making provision for the large number of TMD sufferers

D deciding which TMD patients need intervention and which don’t

8. In the second paragraph, the writer argues that

A Botox interventions are started too early.

B Botox should be a last resort for chronic TMD pain.

C Botox is best used in combination with non-invasive measures.

D Botox may be unpopular with patients because of how it is administered.

9. The phrase off-label use in the second paragraph refers to the fact that

A the FDA doesn’t endorse the use of Botox in cosmetic procedures.

B Botox is a non-standard approach to relieving pain in TMD patients.

C the FDA is concerned that Botox aggravates certain long-term conditions.

D higher doses of Botox are used for TMD than for cervical dystonia and migraines.

10. In the third paragraph, what is suggested about studies involving Botox?

A Their follow-up periods were too short to be reliable.

B The claims of long-term cures were greatly exaggerated.

C There were positive outcomes in treating several conditions.

D They aimed to reduce pain by improving mobility of the joint.

11. What point is made about the jaw in the fourth paragraph?

A Humans suffer from jaw osteoporosis just like other animals.

B A degree of pressure on the temporo-mandibular joint is normal.

C Damage to masticatory muscles has devastating consequences.

D Many temporo-mandibular disorders inhibit the process of bone regrowth.

12. In the fifth paragraph, the phrase ‘the definitive answer’ refers to

A whether Dr Herring’s findings were of relevance to medicine/physicians.

B why non-recipients of Botox also displayed low bone density in the jaw.

C what further research the radiologists urgently needed to carry out.

D how to select the most reliable trial group for Dr Raphael’s study.

13. What did the investigations referred to in the sixth paragraph have in common?

A a more carefully targeted injection site

B the observation of certain side effects

C a reduction in the dosage of Botox

D variable rates of success

14. In the final paragraph, the writer expresses the view that

A it is likely that Botox could adversely affect the immune system.

B Dr Rafael’s report deserved further consideration and discussion.

C facial disfigurement is a rare side effect of having a TMJ disorder.

D TMD sufferers would be unwise to ignore reservations about Botox.

Text 2: Fasting

The practice of fasting - abstaining from food and non-water beverages - has been known for years to be an
effective non-pharmacological strategy for counteracting some of the most entrenched modern ailments, from
cardiovascular disease and cancer to diabetes and diminishing cognition. However, because the evidence for this
came mainly from studies in rats and mice, rather than in humans, intermittent fasting remained an interesting, but
somewhat fringe, field of research and was largely ignored by the medical community. That has changed, however,
with the publication of some small but promising investigations showing positive outcomes in human patients.

When patients enter a fasting state, they deplete the stores of glucose in their livers and convert to using fat-
derived ketone bodies. Depending on their physical output during the fasting period, they may enter a ketogenic
state within hours. Advocates of fasting as a dietary intervention will probably have little difficulty explaining why
there might be benefits to substituting ketones for glucose, and the many negative health effects caused when
glucose is poorly regulated. However, they may find it more difficult to overcome the common belief that fasting
slows down metabolic rates - so when a patient's body is compensating for lack of food in this manner, doesn't this
simply offset or limit any advantages to be gained? In fact, this long-standing assumption began to change toward
the end of the 20th century, when research emerged indicating that fasting for durations of a few days actually has
the opposite effect, and increases metabolic rates.

The full spectrum of physiological mechanisms contributing to this increase in metabolic rates during early food
restriction is complex, involving factors such as circadian rhythm and increased levels of the fat-burning hormone
norepinephrine. However, the benefits of fasting are borne out by clinical studies of metabolic outcomes, 16 of
which were highlighted in a recent review. Although primarily consisting of cohorts of less than 50 patients, they
nonetheless show different fasting regimens produced notable decreases in glucoregulatory markers, lipids,
inflammatory markers, and weight.

Another, possibly more surprising, benefit of fasting is its ability to enhance cognition and brain function. Research
has provided abundant animal data showing that fasting-related ketogenic states lead to cellular and molecular
adaptions in the brain that confer such benefits as resistance to stress, injury, and disease. Here, too, there is a
compelling evolutionary explanation. Ketones are an exceptional energy source for the brain, more so than the
unreliable fluctuations of glucose. It seems probable that mammals who excelled at surviving long periods of food
deprivation were likely to develop optimal brain function in that state.
Fasting can also play a role in the management of breast cancer. Clinical research suggests that its positive impact
may depend not just on whether people abstain from eating, but also when. In a 2015 epidemiologic analysis of
women participating in the 2009-2010 US National Health and Nutrition Examination Survey, researchers were
able to show, for the first time, that longer night-time fasting duration was significantly associated with improved
glycaemic regulation, and thereby reduced risk for breast cancer. In a study the following year, researchers
looked at over 2400 patients who were in remission from early-stage breast cancer. In those who self-reported
nightly fasting of less than 13 hours, there was a statistically significant 36% increase of the risk for breast cancer
recurrence compared with those whose nightly fasting lasted more than 13 hours.

The popularity of fasting diets is also increasing amongst the general public. This may be because of the prevailing
consensus that there is something fundamentally wrong with the modern diet. Although human bodies retain
the ability to get by quite capably for long periods in a ketogenic state, most people live in societies where the
predominant eating schedule – three meals a day with some snacking on top – means that their bodies rarely have
to do so. As humans evolved over millennia to function in one way (hunter-gatherer systems defined by periodic
food scarcity) but have been wrenched into another system in a relatively short period, it takes only a small
mental leap to see how this may play a role in the contemporary crisis of food-related illnesses, including the
'obesity epidemic'.

All the researchers interviewed for this article agree that the data supporting intermittent fasting as a clinical
intervention are currently limited to a few indications, and are derived from relatively small studies. It is difficult to
know the true benefits of this treatment, much less the adverse events that could accompany its application. They
caution against the adoption of fasting in such populations as frail and elderly persons, hypoglycaemic patients,
and children and adolescents. There is nonetheless a justifiable excitement that a simple, nonpharmacologic
intervention could have a notable impact for patients with life-threatening conditions.
Text 2: Questions 15-22

15. In the first paragraph, what point does the writer make about fasting?

A It is a preferable form of treatment to using drugs.

B The reasons why it is beneficial are well documented.

C Claims made about it are now beginning to be verified.

D There is little justification for overlooking its importance.

16. In the second paragraph, what does the writer say is often misunderstood?

A how the duration of fasting influences outcomes

B how fasting can help control glucose levels

C how ketones are produced during fasting

D how metabolism is affected by fasting

17. In the third paragraph, the word 'they' refers to

A cohorts

B patients

C clinical studies

D metabolic outcomes

18. What does the writer suggest about the evolution of animals in the fourth paragraph?

A Certain mental attributes improved the chance of withstanding illness.

B Those with reduced access to nourishment became more intelligent.

C Those with faculties dulled by starvation would be more likely to die.

D Species with less stamina would tend to have slower reactions.

19. The two breast cancer studies mentioned investigated the impact of

A fasting for prolonged periods every night.

B fasting at different times of the day and night.

C night-time fasting after early-stage breast cancer.

D night-time fasting during treatment for breast cancer.

20. According to the writer, fasting diets are popular because people

A prefer not to have regular meals.

B suspect that the way they eat is unnatural.

C no longer trust the quality of the food they eat.

D are convinced that this is the best way to lose weight.

21. In the sixth paragraph, the phrase 'it takes only a small mental leap' is used

A to illustrate a point that the writer has made.

B to justify the writer's reluctance to take sides in a debate.

C to demonstrate the writer's agreement with a point of view.

D to explain why the writer believes an argument is misleading.

22. In the final paragraph, the writer is

A challenging some accepted opinions about fasting.

B warning that fasting may have negative consequences.

C stressing the need for some further research into fasting.

D admitting that the advantages of fasting may be overrated.

END OF READING TEST

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