TEXT A

Dengue: virus, fever and mosquitoes

Dengue fever is a viral disease spread only by certain mosquitoes – mostly Aedes aegypti or
“dengue mosquitoes” which are common in tropical areas around the world.

There are four types of the dengue virus that cause dengue fever – Dengue Type 1, 2, 3 and 4.
People become immune to a particular type of dengue virus once they’ve had it, but can still get
sick from the other types of dengue if exposed. Catching different types of dengue, an even
year apart, increases the risk of developing severe dengue. Severe dengue causes bleeding
and shock, and can be life threatening.

Dengue mosquitoes only live and breed around humans and buildings, and not in bush or
rural areas. They bite during the day – mainly mornings and evenings. Dengue mosquitoes
are not born with dengue virus in them, but if one bites a sick person having the virus in their
blood, that mosquito can pass it on to another human after about a week. This time gap for
the virus to multiply in the mosquito means that only elderly female mosquitoes transmit
dengue fever. The mosquitoes remain infectious for life, and can infect several people.
Dengue does not spread directly from person to person

TEXT B

Signs and Symptoms

Classic dengue fever, or “break bone fever,” is characterised by acute onset of high fever 3–14
days after the bite of an infected mosquito. Symptoms include frontal headache, retro-orbital
pain, myalgias, arthralgias, hemorrhagic manifestations, rash, and low white blood cell count.
The patient also may complain of weight loss and nausea. Acute symptoms, when present,
usually last about 1 week, but weakness, malaise, and weight loss may persist for several
weeks. A high proportion of dengue infections produce no symptoms or minimal symptoms,
especially in children and those with no previous history of having a dengue infection.
TEXT C

Steps to take when seeing a suspected case of dengue fever

Step 1: Notify your nearest Public Health Unit immediately upon clinical suspicion.
Step 2: Take a comprehensive travel history and determine whether the case was acquired
overseas or locally.
Step 3: Note the date of onset of symptoms to identify the correct diagnostic test, as suitable
laboratory tests depend on when the blood sample is collected during the illness.
 Another useful test is full blood count. Cases often have leucopenia and/or
thrombocytopenia.
The table below shows which test to order at which stage of illness:
NSI
TEST TYPE PCR IgM IgG
ELISA

Days after onset of From day 5 From day 8

0-5 days 0-9 days
symptoms onwards onwards
Stage 4: Provide personal protection advice.
 The patient should stay in screened accommodation and have someone stay home to
look after them.
 The patient should use personal insect repellent particularly during daylight hours to
avoid mosquito bites.
 All household members should use personal insect repellent during daylight hours.
 Advise family members or associates of the case who develop a fever to present
immediately for diagnosis.

TEXT D

Prior to discharge:

 Tell patients to drink plenty of fluids and get plenty of rest.

 Tell patients to take antipyretics to control their temperature. Children with dengue are at
risk for febrile seizures during the febrile phase of illness.
 Warn patients to avoid aspirin and anti-inflammatory medications because they increase
the risk of haemorrhage.
 Monitor your patients’ hydration status during the febrile phase of illness. Educate
patients and parents about the signs of dehydration and have them monitor their urine
output.
 Assess hemodynamic status frequently by checking the patient’s heart rate, capillary
refill, pulse pressure, blood pressure, and urine output. If patients cannot tolerate fluids
orally, they may need IV fluids.
 Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.
 Continue to monitor your patients closely during defervescence. The critical phase of
dengue begins with defervescence and lasts 24–48 hours.
 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.
 Your answers should be correctly spelt.

DENGUE FEVER : Questions

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 can you find information about

1. the different types of dengue virus? ---------------------------

2. how fever presents in patients? ---------------------------

3. how dengue fever is transmitted? ---------------------------

4. the stages at which to conduct tests for dengue fever? --------------------------

5. monitoring and assessing a patient’s condition? ---------------------------

6. what advice to give patients to avoid mosquito bites? ---------------------------

7. advice for patients regarding medication? ----------------------------

Questions 8-14

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

8. How long after being bitten by an infected mosquito does high fever occur?
----------------------------------------------------------------------------------------------
 9. What might patients with dengue fever complain of?
---------------------------------------------------------------------------------------------
10. Which test should only be ordered 5 days after symptoms appear?
---------------------------------------------------------------------------------------------
11. What other test is also useful when checking for dengue fever?
---------------------------------------------------------------------------------------------
12. Who is at risk of seizures during the febrile stage of dengue?
----------------------------------------------------------------------------------------------
13. What takes places in the most lethal cases of dengue?
-----------------------------------------------------------------------------------------------
14. How long does the most serious stage of dengue last?
-----------------------------------------------------------------------------------------------

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, numbers or both.

15. Dengue fever does not spread ----------------------------------------------------------

16. In many ------------------------------------------------------------------------------- dengue

infections cause almost no symptoms.

17. Within three days of symptoms beginning a PCR or -----------------------------------

---------------------------------------- can be ordered.

18. To avoid haemorrhage patients mustn’t take anti-inflammatory medications or

-------------------------------------------------------------------------------------------

19. Advise patients be cared for by someone at home in ---------------------------------

-------------------------------------- accommodation.

20. Patients must be made aware of the need to check their ----------------------------

----------------------------------.
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. Which type of hazard does the workplace extract relate to?

Ⓐ Chemical agents.

Ⓑ Biological agents.

Ⓒ Physical agents.

Extract from Workplace Policy Document: Hazard Assessment

Hazards to Look for When Inspecting Hospitals

Examples of typical hazards include bacteria, viruses, fungi, and other living
organisms that can cause acute and chronic infections by entering the body through
ingestion, inhalation or breaks in the skin. They also include exposure to blood or
other body fluids or to clients or patients with infectious diseases (e.g., MRSA,
staph, HIV, HBV, HCV, influenza, tuberculosis). Hospital workers can be exposed to
blood borne pathogens from blood and other potentially infectious materials if not
following universal precautions.
2. The policy extract is explaining

Ⓐ Why to make a LAM submission.

Ⓑ How to make a LAM submission.

Ⓒ Where to make a LAM submission.

Requesting a change to the list of approved medicines (LAM)

Any hospital staff member can request a change to the list of approved medicines
(LAM). It is expected that applications for changes will include input from a senior
prescriber. Changes should be requested by completing either the standard or, in
limited circumstances, a minor submission form. A standard submission form is
available online or from your local pharmacy department. A minor submission form
can be obtained through contacting the relevant Secretariat. Staffs are also
encouraged to flag potential issues regarding the use of medicines or
pharmaceuticals in writing, with evidence attached. Requests from pharmaceutical
manufacturers or their agents will not be accepted.
3. What point do the guidelines make about leadership for doctors?

Ⓐ The role of a doctor should go beyond practising medicine.

Ⓑ Doctors are the most important clinician in a health care setting.

Ⓒ There could be harsh penalties for doctors who don’t improve their
skills.

Guidelines: Leadership and Management for all Doctors

This guidance sets out the wider management and leadership responsibilities of
doctors in the workplace. The principles in this guidance apply to all doctors,
whether they work directly with patients or have a formal management role.

Being a good doctor means more than simply being a good clinician. In their day-to-
day role doctors can provide leadership to their colleagues and vision for the
organisations in which they work and for the profession as a whole. However,
unless doctors are willing to contribute to improving the quality of services and to
speak up when things are wrong, patient care is likely to suffer. You must be
prepared to explain and justify your decisions and actions. Serious or persistent
failure to follow this guidance will put your registration, and so you’re right to
practice medicine, at risk.
4. The purpose of this memo to staff is to

Ⓐ State the potential risks to patients who smoke electronic cigarettes.

Ⓑ Provide information about the substances used in electronic

cigarettes.

Ⓒ Advise that no position has yet been reached about electronic

cigarettes

Memo to staff: Electronic Cigarettes

Electronic cigarettes (e-cigarettes) are battery operated devices that heat a liquid
(called ‘e-liquid’) to produce a vapour that users inhale. Although the composition of
this liquid varies, it typically contains a range of chemicals, including solvents and
flavouring agents, and may or may not contain nicotine.

Electronic cigarettes are a topic of contention among public health and tobacco-
control advocates, some of whom argue they don’t pose the same dangers to
smokers as traditional cigarettes. Others, however, argue that electronic cigarettes
should not be promoted as a lower threat option for smokers when their long-term
safety is unknown.
5. As a result of an update in favour of patient-centeredness what is going to
happen?

Ⓐ There will be a greater focus on hospital wait times.

Ⓑ More staff will be required to undertake training.

Ⓒ New standards of practice will be developed.

Patient-centered Interdisciplinary Goal Setting in Rehabilitation Services

Although goal setting is fundamental to rehabilitation practice and optimal patient

outcomes, it typically varies in the practices taught across different health
professions, and the preparedness of rehabilitation clinicians to undertake it.
Patient-centeredness has been shown to improve patient care experiences and
create value for public services through increasing the quality and safety of health
care.

Hospital pressures to facilitate discharge and decrease length of stay have been
identified by staff as barriers to implementing patient-centered goal setting practice.
This has resulted in goal setting often being hospital driven rather than patient
driven. Furthermore, staff has recently expressed a lack of strategies or tools to
implement patient-centered principles in care processes such as goal setting. There
is therefore a need to enable rehabilitation services to improve goal setting models
and patient engagement in health care related goals and decisions.

.
6. According to the procedure, when inserting a catheter clinicians should

Ⓐ Only use a catheter once.

Ⓑ Carefully follow all guidelines.

Ⓒ Ensure the patient isn’t left alone.

Catheter Insertion Procedure

Where possible, use a two clinician buddy system to carry out the procedure. The
patient’s ethical, religious and cultural beliefs and personal history should be
considered when appointing clinicians to perform a catheterisation. A chaperone may
also be required to observe the procedure.

It is recommended that the patient’s genital area be washed with soap and water
prior to catheterisation. If unable to insert a catheter after two attempts (includes
changing to a different catheter size), seek further assistance from a senior clinician.
A new catheter should be used for each attempt.
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: Restless Leg Syndrome

The relatively common neurologic movement disorder known as restless legs

syndrome (RLS) is poorly understood. Patients describe uncomfortable sensations in
their legs that often are worse at night, having a huge impact on their ability to sleep
and overall quality of life. Experts now speculate that patients with RLS, like those
with unrelieved chronic pain, might feel hopeless, leading to suicidal thoughts and
actions. The risk correlates with history of depression, and is independent of the
severity of restless leg symptoms and demographic factors.

Although evaluating restless legs syndrome and finding effective treatments is

challenging, a recent study suggests that it’s important to assess not only the impact
of RLS on the patient’s life, but also the presence of suicidal thoughts. People with
severe RLS are more likely to plan and attempt suicide than people without it, even
after controlling for depression, according to new research. “Lifetime suicidal ideation
and attempts are very prevalent among people with restless legs syndrome and
seem to be independent of demographic factors and depression and seem to be
associated with severity of restless legs,” said Brian Koo, MD, director of the Yale
Center for Restless Legs Syndrome, Yale University, New Haven, Connecticut.

Until now, RLS and its potential relationship with suicide had not been studied in any
depth. The Yale team investigated the frequency of lifetime suicidal behaviour in 198
patients with severe RLS and 164 controls. All participants completed the Suicidal
Behaviour Questionnaire-revised (SBQ-R) and the Brief Lifetime Depression Scale.
RLS and controls were similar in age (mean age, 51), income, and gender.
Compared with controls, patients with RLS were more often white (96% vs 88%),
less often had higher education (84% vs 96%), were more often married (72% vs
60%), and were less often employed or retired (80% vs 90%). Significantly more
patients with RLS than controls were at high suicide risk (SBQ-R score ≥7) and had
lifetime suicidal thoughts or behaviour, independent of depression history.
“Mood and anxiety disorders are highly comorbid in RLS patients,” noted John W.
Winkelman, MD, PhD, from Harvard Medical School and Massachusetts General
Hospital, Boston.”My feeling is that the suicidal ideation, or even plan or intent, and
even some who have followed through, is the same thing you see in patients with
chronic pain. In many respects, RLS is a chronic pain disorder. And if you have
chronic pain, for which you feel there is no appropriate treatment and your physician
may not understand what you have, or may not know how to treat it appropriately, it
can lead you to feeling hopeless, and I think pain and hopelessness can lead to
those kinds of thoughts,” Winkelman said.

One such case is Lisa, a 45-year-old married woman who came to see a psychiatrist
initially for depressive symptoms. During the initial evaluation, she complained of
difficulty in falling asleep and other depressive symptoms such as low mood,
difficulty with concentration, poor appetite, and low energy along with daytime
fatigue. Depression was diagnosed. A selective serotonin reuptake inhibitor (SSRI)
was prescribed on an as-needed basis, and the patient was advised to take a nightly
dose of diphenhydramine to help her sleep. Three days later—after staying up nearly
all night—Lisa called her doctor in despair and complained of worsening insomnia.
On more detailed questioning about the insomnia, Lisa revealed that for the past 2
years, she has experienced leg discomfort when she gets into bed. She is so
uncomfortable that she needs to walk or ride on her exercise bike past 2 or 3 am
until the discomfort subsides. While not painful, this leg discomfort sometimes
prevents her from relaxing and watching television because she just “has to move”
her legs.

Lisa describes a deep uncomfortable sensation that feels like “bugs crawling in her
legs:’ she also reveals that her mother used to suffer from similar night-time leg
restlessness. Lisa’s leg discomfort became more intense and was lasting most of the
night. After secondary causes of RLS, such as iron deficiency anaemia, pregnancy,
uraemia, and neuropathy were ruled out, SSRI and diphenhydramine therapy were
stopped. Low-dose dopamine agonist therapy was started, after which the symptoms
subsided. However, despite resolution of the RLS symptoms, her depressive
symptoms continued. This only serves to further reinforce the need to investigate
and treat any associated mood or anxiety disorders in conjunction with RLS
symptoms.
Text 1: Questions 7-14

7. The writer suggests that restless legs syndrome (RLS)

Ⓐ Is impossible to cure.

Ⓑ Could lead to depression.

Ⓒ Doesn’t occur during the day.

Ⓓ May relate to pain management.

8. Dr Brian Koo suggests it’s important for clinicians to treat any suicidal thoughts
because

Ⓐ Older people are more likely to suffer from RLS.

Ⓑ The effects of RLS can be better identified.

Ⓒ It makes managing RLS much easier.

Ⓓ RLS is a mental health condition.

9. What did the Yale team learn from their investigations?

Ⓐ Some people in the control group had previously suffered from RLS.

Ⓑ The likelihood of someone developing RLS depends on various

factors.

Ⓒ Answers to the questionnaires didn’t provide a lot of useful data

about RLS.

Ⓓ A person with RLS is more likely to attempt suicide than someone

without it.
10. The expression ‘followed through’ refers to

Ⓐ RLS patients who have attempted suicide.

Ⓑ The relationship between RLS and pain.

Ⓒ A time when RLS has been resolved.

Ⓓ Management of RLS by the doctor.

11. John Winkelman’s comments in the fourth paragraph show his

Ⓐ Concern that a lot of doctors have never heard of RLS.

Ⓑ Belief that RLS relates to many other health conditions.

Ⓒ Frustration that too many people with RLS commit suicide.

Ⓓ Understanding of the situation facing a lot of RLS sufferers.

12. The case involving Lisa highlights that

Ⓐ Some patients don’t follow the recommended advice for RLS.

Ⓑ Regular exercise is recommended for people with RLS.

Ⓒ Sleep problems and exhaustion could indicate RLS.

Ⓓ Medication is important in the treatment of RLS.

13. In the final paragraph, the writer suggests Lisa’s treatment was changed
because

Ⓐ A new diagnosis was made.

Ⓑ She no longer had depression.

Ⓒ SSRI medication wasn’t working for her.

Ⓓ She developed a range of new symptoms.

14. What does the word ‘this’ in the final paragraph refer to?

Ⓐ Low-dose dopamine agonist therapy.

Ⓑ The differences between therapies.

Ⓒ The end of her RLS symptoms.

Ⓓ Lisa’s unresolved depression.

Text 2: Statins- How Safe Are They?

Heart disease is the leading cause of death in the U.S and statins are a commonly
prescribed medicine that helps to lower harmful levels of LDL cholesterol in the blood
and mitigate the risks of cardiovascular disease, including heart attack and stroke.
Trials have consistently demonstrated a clear correlation between reducing LDL
cholesterol with statins and a decrease in cardiovascular risk. So it may appear
puzzling that uncertainty over statins still remains.

As the body of evidence evaluating statins has expanded, so too have the
indications for the drug. Guidelines released in 2013 by the American College of
Cardiology (ACC) and the American Heart Association (AHA) recommended that
statin therapy might be beneficial for people with cardiovascular disease, people who
have high LDL cholesterol levels, people aged 40 to 75 years with diabetes and high
LDL levels and people aged 40 to 75 years without diabetes, but with high LDL
cholesterol levels and a predicted 10-year risk of cardiovascular disease of 7.5
percent or higher. However, experts questioned the 2013 guidelines, arguing that a
7.5 percent threshold seemed too low.

In 2015, two research teams examined the 7.5 percent threshold and published their
findings. The first paper, led by Dr. Udo Hoffmann at Massachusetts General
Hospital and Harvard Medical School – both in Boston - found that compared with
guidelines published in 2004, the 2013 guidelines were more accurate at identifying
individuals at a greater risk of cardiovascular disease. They estimated that by
adopting the 2013 guidelines, between 41,000 and 63,000 cardiovascular events
would be prevented over 10 years compared with previous guidelines. The second
paper, led by Drs. Ankur Pandya and Thomas A. Gaziano at the Harvard T.H. Chan
School of Public Health - also in Boston - assessed the cost-effectiveness of the 10-
year cardiovascular disease threshold. The researchers concluded that the risk
threshold of 7.5 percent or higher had an acceptable cost-effectiveness profile.

As a result of the expansion of the groups reported to benefit from statins, suspicions
have been raised about the pharmaceutical industry and of the prescribing
healthcare professionals. Alarm bells started ringing that people were being
overmedicated and put at risk of adverse effects. Statins are generally considered to
be safe and well tolerated. However, as with any medication, statins may have
negative effects in some people. “We know that statins can prevent a significant
number of heart attacks and strokes. We know there is a small increase in the risk of
diabetes, and at high doses there is a very small increase in myopathy, but overall
the benefits greatly outweigh the harms,” says Peter Sever, professor of clinical
pharmacology and therapeutics at Imperial College London. “Widespread claims of
high rates of statin intolerance still prevent too many people from taking an
affordable, safe, and potentially life-saving medication.”

Some people, however, believe heart disease is better treated by other means, such
as diet. A study found those who had a diet rich in vegetables, nuts, fish and oils,
such as a Mediterranean-style diet were a third less likely to die early, compared with
those who ate larger quantities of red meat, such as beef, and butter. Sir David
Nicholson, former chief executive of the National Health Service (NHS) in the UK,
entered the debate over statins when he said he had stopped taking them as part of
his medication for diabetes. “If a lifestyle change works then why would you take the
statin? The trouble is that they give you a statin straightaway, so you don’t know
what is working,” he said.

While a heart-healthy diet, regular physical activity, and maintaining a healthy weight
are all components that may help to reduce cholesterol and lower the risk of heart
disease and stroke, certain factors are unable to be influenced - such as genetics. In
some people, lifestyle changes alone are not enough to lower cholesterol. According
to a study published in the Journal of the American Medical Association, from 1969
to 2013, deaths from heart disease fell by 68 percent, and there were 77 percent
fewer deaths from stroke. There may be a link between the rise in statin use and the
fall of deaths connected to cardiovascular disease. However, the progress made
could be attributed to the “cumulative effect of better prevention, diagnosis, and
treatment,” says Wayne D. Rosamond, Ph.D., professor of epidemiology at the
University of North Carolina in Chapel Hill.

The mounting research appears to overturn debate around statins and aims to
reassure doctors and patients that the risks of not taking statins - heart attack or
stroke - far outweigh concerns about side effects associated with the drug. Serious
side effects are rare, and study authors seem to agree that the substantial proven
benefits of statins have been compromised by “serious misrepresentations of the
evidence for its safety.”
Text 2: Questions 15-22

15. The writer suggests that uncertainty over the use of statins is puzzling because

Ⓐ No other medication is used as often to treat cardiovascular

disease.

Ⓑ Heart disease kills large numbers of people in the United States.

Ⓒ Extensive studies have been conducted about their use.

Ⓓ They are so effective in lowering LDL cholesterol.

16. In the second paragraph, what do we learn about the guidelines released in
2013?

Ⓐ They were seen as worse than the previous guidelines.

Ⓑ They recommended the use of statins for anyone with high LDL
levels.

Ⓒ They contained a lot of advice that health professionals didn’t agree

with.

Ⓓ They suggested a connection between heart disease and other

conditions.

17. The research papers written in 2015 concluded that the 7.5 percent threshold
would

Ⓐ Focus more on patient health than the previous guidelines.

Ⓑ Result in lower treatment costs for most patients.

Ⓒ Reduce the amount of cardiovascular disease.

Ⓓ Take many years to implement.

18. The writer uses the phrase ‘alarm bells started ringing’ to indicate

Ⓐ Some health professionals have been overprescribing statins.

Ⓑ The numbers of people taking statins has grown too quickly.

Ⓒ There are too many risks associated with taking statins.

Ⓓ Research into the use of statins has cost too much.

19. What concerns does Peter Sever have about statins in the fourth paragraph?

Ⓐ They aren’t being promoted as widely as they should be.

Ⓑ They are linked to several other health conditions.

Ⓒ They are too expensive for some patients.

Ⓓ They aren’t being used enough.

20. Sir David Nicholson’s comments show that he believes statins

Ⓐ Should only be prescribed after other options have been tried.

Ⓑ Aren’t as effective as diet in improving a person’s health.

Ⓒ Only work after you have been taking them for a while.

Ⓓ Don’t work as an effective treatment for diabetes.

21. In the sixth paragraph, Wayne D. Rosamond attributes a reduction in deaths from
heart attack and stroke to

Ⓐ A combination of different factors that work together.

Ⓑ The rise in medications that treat heart disease.

Ⓒ A person’s family history and background.

Ⓓ Improved diet and regular exercise.

22. The benefits of statins are described as having been ‘compromised’ because

Ⓐ Their benefits are too few in number.

Ⓑ A lot more research needs to be done.

Ⓒ There is still a lot of debate around their use.

Ⓓ Too many lies have been told about their effects.