READING TEST 10
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.
Text A
Cytokines
Cytokines are messengers secreted by various cell types in the body in response to
a wide variety of physiological stimulus. Cytokines aid in normal physiological
processes such as growth, differentiation, hematopoiesis, as well as several
inflammatory and immune responses. The cytokines as present in minimal levels in
hepatic circulation during normal physiological status and are necessary for hepatic
homeostasis. However, the cytokines have been observed to play an active role in
mediating the inflammatory progression of NAFLD as characterized by apoptotic
and necrotic lesion in liver leading to fibrosis. The cytokines involved in hepatic
inflammation, are categorized under several subfamilies – Tumor necrosis factor-α
(TNF-α), Tumor growth factor β (TGF-β), Interleukins and chemokines.
Text B
Tumor Necrosis Factor α
TNF-α is a pro-inflammatory cytokine secreted by several cell types such as
neutrophils, macrophages, T and B lymphocytes, endothelial cells, mast cells,
fibroblasts etc. In liver, hepatocytes and Kupffer cells are the major contributors of
TNF- α. TNF-α plays a central role in the initiation of inflammatory cascade and
its progression from steatosis to steatohepatitis. Experiments with mice models for
obesity have shown the importance of TNF-α in NAFLD, where anti- TNF-α drug
therapy showed promising results. Increased free fatty acid level in obesity
stimulates the hepatocytes to secrete TNF-α, which elicits the free fatty acid
induced expression of inflammatory genes. A positive correlation has been
observed between TNF-α level in serum and degree of fibrosis in patients with
NAFLD. A study with pentoxifylline - an inhibitor of TNF-α has shown
suppressive effect on elevation of serum transaminases and triglycerides in
experimental NAFLD induced rats. The study also demonstrated that NAFLD
induced TNF-α expression stimulates endoplasmic reticulum stress, which further
mediate the progression of steatosis to fibrosis. c-Jun N-terminal Kinase 1 (JNK1)
a stress activated protein kinase is activated by TNF-α which leads to initiation of
an autocrine/paracrine loop resulting in enhanced TNF- α production in liver. TNF-
α activates inhibitory kappa b kinase β (IKKβ) which phosphorylates IKB resulting
in the translocation of NFκB into nucleus.
Text C
Transforming growth factor β
TGF-β is a cytokine secreted by hepatocytes and Kupffer cells in response to
degradation changes in liver. TGF-β activates the resting stellate cells by
transforming them into active myofibroblasts, which secrete extracellular matrix
protein to initiate the fibrosis process. Earlier studies have shown up regulated
expression of TGF-β following experimentally induced hepatic damage such as in
CCl4 poisoning. Elevated TGF-β mRNA expression levels have been found in
patients with liver fibrosis. Earlier studies have shown that TGF-β is an early
marker for the progression of steatohepatitis. Hence, detection of TGF-β level
would be helpful in marking NASH stage of NAFLD. Studies have observed
polymorphisms in TGF-β1 gene in obese NAFLD patients with advanced stages of
hepatic fibrosis. Xiao and Ho have recently reported that administration of
Epigallocatechin gallate (EGCG) reduced hepatic severity in NAFLD by
suppression of TGF/SMAD pathway. Studies with TGF-β receptor II deficient
mice showed protective effect against experimentally induced NAFLD with
methionine and choline deficient (MCD) diet, which was mediated through smad2
activation.
Text D
Interleukins
Interleukin-6 is a proinflammatory cytokine which has been implicated in
metabolic syndrome. IL-6 also plays several other functions such as inducer of
immune response, hematopoiesis and oncogenesis. Certain studies have reported
IL-6 to be antihepatotoxic and mediate hepatic regeneration after partial
hepatectomy in mice. IL-6 has also been considered to reduce hepatic oxidative
stress and to curtail mitochondrial dysfunction. However, studies have reported the
role of IL-6 as an acute phase inflammatory mediator leading to secretion of
inflammatory serum proteins. Hence, the possibility of its role in pathogenesis of
NAFLD cannot be ignored. A positive correlation has been found in patients with
NASH and circulating IL-6 level. Studies with IL-6 knockout mice models have
shown reduced severity when subjected to experimental NAFLD. Yamaguchi et al,
has shown that inhibition of IL-6 receptor with Tocilizumab, enhanced hepatic
steatosis but protected against extensive hepatic damage in MCD diet induced
NASH. Recently, Hamirani et al, have observed a positive correlation between C
reactive protein (CRP) and IL-6 levels and increased liver fat accumulation in
NAFLD patients as verified with CT-scans.
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 once.
In which text can you find information about;
1. Biological cell that synthesizes the extracellular matrix and collagen.
Answer _____________
2. Arranged in a radiating pattern like that of a star.
Answer _____________
3 .Production or formation, development, and differentiation of blood cells.Answer
____________
4 .Evokes a specific functional reaction in an organ or tissue.
Answer ______________
5. Hepatoprotection in most of the cases d.
Answer ______________
6. Impairment of the normal processes of synthesis and elimination of triglyceride
fat.
Answer _____________
7. The tendency towards a relatively stable equilibrium between interdependent
elements, especially as maintained by physiological processes.
Answer _____________
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 What plays an active role in mediating the inflammatory progression of NAFLD
Answer _____________
9 What is the term used to indicate the thickening and scarring of connective
tissue?
Answer ______________
10 What does the TNF-α level in serum indicate in patients with NAFLD?
Answer ______________
11 What reduced the hepatic severity in NAFLD patients?
Answer ______________
12 What does IL-6 secrete, as an acute phase inflammatory mediator?
Answer ______________
13 What is known to be enhancing or contributing more to TNF- α?
Answer______________
14 What is the terms used to show the derivative, which decreases the viscosity of
blood?
Answer ______________
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. _____________ relates to a hormone which has effect only in the vicinity of
the gland secreting it.
16. It can be said that disturbances in the normal functioning of the ER often lead
to cell ____________ response.
17. ___________ also plays is reported to initiate immune response.
18. ____________ delivered results as expected
19. _____________ is characterized by inflammation of the liver with concurrent
fat accumulation in liver.
20 . _____________ denotes a cell-produced substance that has an effect on the
cell by which it is secreted
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.
Questions 7-6
1 The given notice talks about;
US Death Rate with respect to maternity cases.
Scope and importance.
How to deal with preventable mortality?
Variety of challenges by Obstetricians and Gynecologists
The biggest challenge lies in managing the care of patients of all ages from puberty
through menopause and beyond; treating both acute and chronic health conditions;
and of course, managing risk through the pregnancy and childbirth process. The
United States has a higher ratio of maternal deaths than at least 40 other countries,
even though it spends more money per capita on maternity care than any other. The
lack of a comprehensive, confidential system of ascertainment of maternal death
designed to record and analyse every maternal death continues to subject U.S.
women to the unnecessary risk of preventable mortality. Maternal deaths must be
reviewed to make motherhood safer.
The status of maternal deaths in the United States was part of a larger report on the
global, regional, and national levels and causes of maternal mortality from 1990-
2015. The findings suggest that only 16 countries will achieve a target of a 75%
reduction in the maternal mortality ratio (or number of maternal deaths per 100,000
live births) by 2017.
2 As per the case study, pick the right statement;
The baby was born with the infection.
The infection surfaced itself when the child turns 1 year 6 months.
The child was normal at the age of 1 year and 6 months.
Case Study
The mother of the other patient was a white 30-year-old housewife. This was her
second pregnancy, it was planned and there had been an ovarian infection during
prenatal and she had been carrying twins, but one fetus had died. Delivery was
vaginal, birth weight was 1,260 g, gestational age was 30 weeks, SNAPE-PE was 0
and sex was male. The child presented petechiae at birth and persistent tachypnea
for several days. At 1 year and 6 months he was still excreting CMV in urine, had
normal neurological development for his corrected age and his sight and hearing
examination findings were normal.
3 Pick the right statement;
Improper care during pregnancy can lead to complications.
Continous examination is necessary to thwart complications.
Major complications will always lead to death.
Complications
Some complications are common to every expecting mother while others can be
specific to limited expecting females only. According to the statistics, it is found
that 90% of the females in some or the other stages of pregnancy have
knowledgeable complications. While some difficulties are easy on the body like
mild nausea and morning sickness but other complications like asthma, diabetes,
thyroid diseases and hypertension necessities to be taken care of under the
excellent guidance of gynecologists and obstetrics. Some of the medical
complications develop to be fatal to the fetus as well as the mother. Women
suffering from other medical problems like HIV, Urinary Tract Infections, Ectopic
Pregnancies and it’s should go for immunization and medical assistance from time
to time to keep the intensity of the complications under control. Some of the
medical complications like Diabetes and Hypertension are so chronic that continue
to persist in the body even after the liberation of the baby. Shunning smoking,
drinking alcohol and maintaining a healthy lifestyle decreases the chances of
having complications in pregnancy.
4 The notice gives information about;
Indications of splenectomy.
Percentage of disease conditions.
Various conditions, which arise due to Splenectomy.
ELECTIVE SPLENECTOMY
ITP : 57 %
Congenital spherocytosis : 12 %
Hemolytic anemia : 10 %
Hodgkin’s disease : 5 %
AIDS―related thrombocytopenia : 3 %
Lymphoma : 3 %
Leukemia: 2.5 %
Others (sarcomas, splenic metastases,…)
2. SPLENECTOMY IN EMERGENCY:
Trauma
5 According to Markov model:
Screening for NASH in Primary Care shall be simple.
Screening for NASH in Diabetic Care or Clinics shall be simple.
Use of ultrasound is not fully recommended.
Screening For NAFLD
A recent, cost-effective analysis using a Markov model suggested that screening
for NASH in individuals with diabetes is not cost-effective at present, because of
disutility associated with available treatment. Given that liver biochemistries can
be normal in patients with NAFLD, they may not be sufficiently sensitive to serve
as screening tests, whereas liver ultrasound or TE are potentially more sensitive,
but their utility as screening tools is unproven. Some experts recently have called
for “vigilance” for chronic liver disease (CLD) in patients with type 2 diabetes, but
not routine screening.
6 Pick the incorrect statement;
Bil (cut-off): Bil<1.5; 1.5 ≤ Bil ≤ 2.5; Bil>2.5; scores 1, 2, 3
respectively.
Alb (cut-off):Alb>3.5; 2.5 ≤ Alb ≤ 3.5; Alb<2.5; scores 1, 2, 3
respectively.
Platelets (cut-off):Plt<100; 100 ≤ Plt ≤ 150; Plt ≥150; scores 1, 2, 3
respectively
Liver index and its relationship to patient survival
Score
1 2 3
GGTP (IU/ml) <100 100 - 200 >200
Total Bilirubin (mg/dl) <1.5 1.5 - 2.5 >2.5
Albumin (g/dl) >3.5 2.5 - 3.5 <2.5
Platelets (x109/l) <100 100 - 150 >150
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: Brain Imaging Technologies
Brain imaging has greatly advanced in the last 20 years, due to a better
understanding of the electromagnetic spectrum and radiofrequency waves, in
relation to protons in individual molecules within the cells of the brain. New
technologies allow non-invasive spatial mapping, (morphology), and observations
of processes within the brain during set tasks. By sequencing scanned sections of
the brain, activity between neurons in different parts of the brain can be observed
and monitored. More recent technologies using a higher frequency resolution can
identify the distribution of individual metabolites (large complex molecules), and
pharmaceutical drugs. There are a number of scanning techniques, their purpose
and limitations are described below.
A computerised tomography (CT) scans use X-rays to show the structure of the
brain, with details such as blood perfusion, (plates a and b); the resultant images
are two dimensional and of comparatively low resolution, however, the quality has
been much improved since 1998. With improved technology, the single section has
now become as multisection and the speed has increased eight times, giving well-
defined 3-D pictures. A CT scan may reveal underdeveloped parts of the brain or
sites of injury from impact, tumours, lesions or infection. Before a CT scan, the
patient may drink but is asked not to eat for four hours beforehand, and not to take
strenuous exercise. A CT brain scan, the preferable scanning method by doctors,
will take about 30 minutes and the patient must lie still for the duration.
An MRI scanner uses a strong magnetic field and radio waves to create pictures of
the tissues and other structures inside the brain, on a computer. The magnetic field
aligns the protons (positively charged particles) in hydrogen atoms, like tiny
magnets. Short bursts of radio waves are then sent to knock the protons out of
position, and as they realign, (relaxation time), they emit radio signals which are
detected by a receiving device in the scanner. The signals emitted from different
tissues vary, and can, therefore, be distinguished in the computer picture. An MRI
scanner can create clear detailed pictures of the structure of the brain and detect
any abnormalities or tumours. Sometimes a dye, or tracer, such as gadolinium may
be introduced via a vein in the arm, to improve contrast in the image. Images can
be enhanced by differences in the strength of the nuclear magnetic resonance
signal recovered from different locations in the brain.
Functional magnetic resonance imaging (fMRI) can show which part of the brain is
active, or functioning, in response to the patient performing a given task, by
recording the movement of blood flow. All atoms and molecules have magnetic
resonance, emitting tiny radio wave signals with movement, because they contain
protons. Different molecules have different magnetic resonance and two
components of blood are tracked to observe brain activity. Haemoglobin in the
blood carries oxygen; oxyhaemoglobin, around the brain and when it is used up, it
becomes deoxyhaemoglobin. Where the oxygen is being ‘used up’ shows the site
of activity in the brain. The picture is made by monitoring the ratio of the tiny
wave frequencies between these two states whilst the patient carries out a task, e.g.
tapping a finger, which highlights the area of the brain functioning to carry out this
task.
Positron emission tomography (PET) scanning produces a three-dimensional
image of functional processes in the brain, (not just the structure). PET is a nuclear
medicine imaging technique, which requires the patient to receive a small injection
of radioactive material (a sugar tracer; fluorodeoxyglucose), into the bloodstream.
The radioactive material causes the production of gamma-rays, these are a form of
electromagnetic radiation like X-rays, but of higher energy. The radioactive
material is transported around the body and into the brain. A ring of detectors
outside the head is used to detect pairs of gamma rays emitted indirectly by the
positron-emitting radionuclide (tracer), in each part of the brain under examination.
The single photon emission computed tomography records the signals from gamma
rays, (singly, rather than when the emissions are opposite at 180º), using two or
more synchronised gamma cameras, and the multiple 2-D images are computed,
tomographically reconstructed, to 3-D. A section may be examined from several
angles, but is slightly less clear than a PET image. A SPECT scanner is less
expensive than a PET scanner and uses longer-lived, more easily obtained
radioisotopes.
Text 1: Questions 7-14
7 According to paragraph 1, technology;
Has made it easier to detect what is going on in a person’s brain
Helps define how neurons act and multiply
Makes the mapping of the brain a very simple task
Can help identify how big complex parts are distributed
8 According to paragraph 2, what is true about CT?
It works on the principles of X-rays
It provides two-dimensional images
It can help identify which parts of the brain are developed and which are not
It will always just take half an hour
9 The word “itty-bitty― in paragraph 3 may means;
Effective
Gigantic
Small
Strong
10 According to paragraph 3, what is not true about an MRI?
During the scan, the tissues produce different signals and thus easily get
identified.
Dye may be used to improve the quality of the image produced by the scan.
Protons emit radio signals.
The receiving device collects the emitted protons.
11 According to paragraph 4, a fMRI scan;
Produces more efficient images of the brain than an MRI.
Can detect which parts of the brain are active during movement.
Obtains the picture by closely analysing the frequencies of the emitted waves.
Not given
12 According to paragraph 5, a PET is;
An advanced technique like an MRI.
A non-magnetic technique for the detection of brain functioning.
A technique in which a patient is given a radioactive material injection.
Much more powerful than other techniques.
13 According to paragraph 6, what is true about a SPECT?
It produces quality images like an MRI
It is similar to a PET in imaging
It relies on gamma rays for detection
Not given
14 According to the information provided, which technique is considered the best
of all by doctors?
MRI
fMRI
PET
SPECT
Text 2: A safer way to detect heart disease
Researchers have used a specialized type of MRI to detect 88% of cases of
coronary artery disease in a group of patients with chest pain. The results suggest
that the imaging technique can detect heart disease as accurately as conventional
methods, but with much less risk. Coronary artery disease is the most common
form of heart disease and the leading cause of death in the United States. It occurs
when fat and calcium accumulate in the arteries that supply blood to the heart.
Over time, less blood reaches the heart and heart muscle dies. If the plaque blocks
the arteries completely, a heart attack occurs.
Currently, the best way to detect the disease is through a coronary angiography. A
physician threads a tube into the heart, releases a dye, and uses X-ray images to
look for decreased blood flow. But there’s a small risk in this procedure that the
tube will pierce an artery, resulting in bleeding, or else scrape plaque from artery
walls, which, once the chunks of plaque are in the bloodstream, can lead to a heart
attack or stroke. Other, noninvasive tests such as cardiac ultrasounds are less risky,
but not as accurate. Ultrasound images can be poor in patients with other
conditions such as obesity, requiring doctors to resort to invasive tests.
While an MRI allows doctors to image the body using magnets and radio waves,
until recently it could not produce clear images of dynamically voyaging objects,
such as a beating heart. In the past two years, though, stronger magnets, more
powerful computers, and new software have improved MRI scanning. “Recent
developments allow us to acquire images of the heart in motion,” says Ricardo
Cury, director of clinical cardiac MRI at Massachusetts General Hospital in Boston
and leader of the study. Doctors can now watch the heart beating in real-time and
the images are now sharp. “It’s like opening up the heart and looking at it directly,”
says Renato Santos, a cardiologist at Wake Forest University Baptist Medical
Center. “Until recently, MRI was a research tool,” says Santos. “Now it’s really a
clinical tool…ready for prime time.”
Cury combined two cardiac MRI tests to improve the technique’s ability to
diagnose coronary artery disease. In his study, published in the July issue of
Radiology, researchers at MGH, Harvard Medical School, and Beneficencia
Portuguesa Hospital in Sao Paulo, Brazil, examined 46 patients. They began with
an MRI stress test, injecting a harmless dye and medicine that stresses the heart. As
the heart pumped, they used MRI to look for decreased blood flow or evidence that
the heart was working abnormally. Next, they examined still MRI images of the
heart for damaged areas or evidence of prior heart attacks. If patients were
abnormal in one or both tests, the doctors deduced blocked arteries.
Cury’s results reinforce those of an earlier, unrelated study in which researchers at
Duke University used the same techniques to successfully diagnose coronary artery
disease in 100 patients. The results are good news for patients. The MRI exam is
short and painless. By using it to triage people with chest pain but actually without
any disease, physicians might save such patients from unnecessary invasive
procedures. In cases where the heart disease is evident, MRI can help
doctorsdecide what to do next, for instance, whether surgery to clear or bypass a
blocked artery is necessary. After surgery, doctors can use MRI to monitor arteries
for future blockages noninvasively. Cury says that the 12 percent of cases
misdiagnosed in his study are less than other noninvasive tests, and in certain cases
artifacts of the study’s design. He adds that MRI’s accuracy will increase as
doctors learn to make better diagnoses from MRI images. “Obviously 100% is
ideal,” says Santos. “I think MRI is going to get us closer to that than our
traditional methods.”
Text 2: Questions 15-22
15 Paragraph 1 talks more about;
A breakthrough in imaging.
How heart diseases can be detected.
How new techniques are more efficient than traditional techniques.
How a heart attack occurs.
16 According to paragraph 1, a simple cause of a heart attack is;
Heart doesn’t receive enough blood.
Fat gets deposited in arteries.
Arteries carry less blood to the heart.
All of these
17 What risk is mentioned in paragraph 2?
The tube may puncture the artery.
The tube can cut off plaque.
The artery walls may release more plaque into the bloodstream.
All of these
18 Paragraph 2 talks more specifically about;
Techniques that are risky.
Why conventional techniques should not be used.
How expensive techniques are.
How risky CA can be.
19 According to paragraph 3, what is true about MRI scanning?
MRI scans in previous years were less effective.
It was not possible to capture motion-based images.
MRI scans of the new generation are more effective with power imaging
qualities.
use of powerful computers and software have made MRI scanning more
effective.
20 According to paragraph 3, what is possible with MRI now?
It is easy to see the heart, live in action
It is easy to track heart beating
It is easy to get more quality-based images
All of these
21 According to paragraph 4, which one of the following statements is true?
Cury led a team of doctors and researchers at MGH.
Cury detected blocked arteries.
The team of doctors compared 46 case studies.
Researchers began with the stress testing.
22 In paragraph 5, the word “triage― may mean;
To help
To examine
To show
To provide comfort
