TEST-8

Gallstones
PART A
TEXT 1
Gallstones (Cholelithiasis) are hardened deposits of digestive fluid that can form in
the gallbladder. The stones can be the size of a grain of sand or a golf ball. Gallstones
do not cause problems in approximately 70% of cases. Problems occur if a stone, or
stones, becomes trapped in the cystic duct or the common bile duct tract that carries
the digestive fluids from the gallbladder to the bowel. There are no single causes of
gallstones but they are more common in women, overweight people and those with
a family history of gallstones.
Biliary colic is a sudden, intense abdominal pain and fever that usually lasts between
one and five hours. It occurs when a stone moves into the cystic duct (neck of the
gallbladder) leading to obstruction.
Cholangitis (inflammation of the bile ducts) occurs when a bile duct becomes blocked
by a gallstone and the bile becomes infected. This causes pain, fever, jaundice and
rigors.
Cholecystitis (inflammation of the gallbladder) is a common complication from
gallstones. It can cause persistent pain, fever, nausea and vomiting.
Jaundice develops if a gallstone blocks a bile duct leading to the bowel. This means
trapped bile enters the person’s bloodstream instead of the digestive system.
Jaundice is painless but can cause itchiness. Bile pigments cause the persons skin and
eyes to turn yellow and their urine may also turn orange or brown.

TEXT 2
Clinical assessment
• Take a thorough family history
• Ask about lifestyle activities including exercise, diet and recent weight loss

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 Take symptom history including:
1.
• onset of symptoms
• a link between symptoms and eating
presence of a fever?
• severity and duration of symptoms
• any symptom relievers or antagonists
• Perform abdominal examination including Murphy’s test Diagnostic tests include:
• plain abdominal x-ray
• ultrasound scan – the most common diagnostic test for gallstones
• endoscopy
• magnetic resonance imaging (MRI)
• cholangiography
• CT Scan
• endoscopic retrograde cholangiopancreatography (ERCP) –
conclusive test if diagnosis unclear in other tests and can include removal of
gallstones during the procedure
• Blood tests may be performed to check:
• Liver function
•
• For infection

TEXT 3
Treatment for gallstones
Active monitoring for asymptomatic patients
Simple analgesia for biliary colic
- continue indefinitely if episodes mild and/or infrequent
- Surgical options are the preferred choice of treatment
Laparoscopic cholecystectomy (lap.choly) carried out to:
- remove the gallbladder and any stones in the cystic duct
- remove any stones seen in the bile ducts
Open abdominal surgery to remove gallbladder (cholecystectomy) if patient is:
- in last three months of pregnancy
- extremely overweight

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 - has atypical gallbladder or bile duct physiology
Non-surgical treatment options
Medication to dissolve calcium free gallstones
- rarely effective
- significant side effects
A well balanced diet
- to ease, not cure, symptoms
Lithotripsy
- rarely used for gallstones, but still widely used for kidney stones
- soundwaves that shatter the gallstones.
- suitable for people with small and soft stones
ERCP
- Can be used for diagnosis
- if stones are found, the bile duct is widened with a small incision or an electrically
heated wire
- stones are removed or left to pass naturally

TEXT 4
Ways to prevent gallstones
•Avoid eating too many foods with a high saturated fat content such as:
−meat pies
−sausages and fatty cuts of meat
−butter, ghee and lard
−cream
−hard cheeses
−cakes and biscuits
−food containing coconut or palm oil
•Drinking small amounts of alcohol may also help reduce risk of gallstones
•Gradual weight loss if obese
- there's evidence that low-calorie, rapid-weight-loss diets can disrupt the bile
Ways to prevent gallstones
•Avoid eating too many foods with a high saturated fat content such as:
−meat pies
−sausages and fatty cuts of meat
−butter, ghee and lard
−cream
−hard cheeses

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 −cakes and biscuits
−food containing coconut or palm oil
•Drinking small amounts of alcohol may also help reduce risk of gallstones
•Gradual weight loss if obese
- there's evidence that low-calorie, rapid-weight-loss diets can disrupt the
bile chemistry and increase the risk of developing gallstoneschemistry and
increase the risk of developing gallstones

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 How gallstones are confirmed?___________________

2 The signs a person has jaundice?___________________

3 What type of food to avoid to prevent gallstones? ___________________

4 The surgical options available for ladies with gallstones in their third
trimester?___________________

5 Biliary colic? ____________________

6 Pharmaceutical options for managing gallstones? ___________________

7 Key evidence that suggests gallstones that can be captured when taking the
patients history? ___________________

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 type of cheese should be avoided to reduce the risk of developing
gallstones? ____________________

9 What test is usually carried out to check for gall stones? ____________________

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10 If a person has cholecystitis, what past of their body is affected?
____________________

11 The gallbladder and what else might be removed during a laparoscopic

cholecystectomy? ____________________

12 Diets that are low calorie, leading to what, should be avoided?

____________________

13 A blood test may be taken from a person suspected of having gallstones to check
the functioning of which organ? ____________________

14 Which non-surgical treatment is now mostly used to treat kidney stones?

____________________

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 In approximately____________________of cases, people with gallstones are
asymptomatic

16 Low intake of____________________can keep the risk of developing gallstones

low.

17 During surgery, if gallstones are found, the bile duct is expanded with a minor cut
or an____________________

18 A person may appear yellow if a gallstone occludes

a____________________connecting to the bowel.

19 During the clinical assessment of a patient presenting with possible gallstones, an

abdominal examination is carried out including____________________

20 Cholelithiasis are solid lumps of____________________that can grow in the

gallbladder.

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 PART B
TEXT 1
Focus: wound/infection control. New solutions for wound healing

Treating skin tissue damaged by burns and other trauma, diabetes or vascular
disease is a major challenge and a burden on healthcare systems. Several advanced
skin graft treatments exist but they are costly, come with risks such as host rejection,
excessive scarring and potentially disease transmission, and are limited to treating
shallow wounds where formation of blood vessels is less important. The emergence
of 3D printing tools and techniques, biofabrication of tissue materials from
biologically compatible materials offers the possibility of not only reducing
availability and cost of treatment issues, but also the prospect of treating deep
wounds comprising several tissue layers. The layered fabrication method could also
accommodate the use of wound healing proteins, stem cells and anti-inflammatory
drugs during the printing process, as well as creating more complex tissue structures
that could eventually include vascular networks that facilitate oxygen and nutrient
exchange to hair follicles and sweat glands. Even though the biological complexities
of human skin are relatively well understood, appropriate repair mechanisms are
scarce and often costly.

Question
1) In this article what might eventually be made on a 3D printer?
a) Skin with its various layers, components and blood supply
b) Skin including nerve cells, stem cells and sweat follicles
c) Skin, with muscles, tendon and blood vessels

TEXT 2
Therapeutic Objectives in the Elderly

When treatments are very likely to achieve benefits and very unlikely to have adverse effects,
decisions are relatively easy. However, assessing the relative importance of these quality of life
factors to each patient is important when treatments may have discordant effects. For
example, aggressive cancer therapy may prolong life but have severe adverse effects (e.g.,

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chronic nausea and vomiting, mouth ulcers) that greatly reduce quality of life. In this case, the
patient’s preference for quality vs duration of life and tolerance for risk and uncertainty help
guide the decision whether to attempt cure, prolongation of life, or palliation. The patient’s
perspective on quality of life may also affect treatment decisions when different treatments
(e.g., surgical vs drug treatment of severe angina or osteoarthritis) may have different
efficacies, toxicities, or both. Practitioners can help patients understand the expected
consequences of various treatments, enabling patients to make more informed decisions.

Questions 1-6
2) What three options are generally available for discussion when a person
is faced with making a decision about what treatment pathway to take
for their illness?
a) Modifying their lifestyle to deal with the illness, accepting that they cannot be
cured, taking all treatment options available.
b) Managing the side effects of treatment, consider declining treatment, revising
their expectations of whether they will be cured
c) Extending life-expectancy, treating the symptoms to lessen their effect,
remedying the condition

TEXT 3
Treatment or management of chronic kidney disease

Early CKD is usually asymptomatic and must be actively sought to be recognised.

Kidney function is measured by the glomerular filtration rate (GFR), which is the
amount of blood the kidneys clear of waste products in one minute. As GFR cannot
be measured directly, current practice is to estimate GFR (eGFR) by applying a
formula that includes age, gender and creatinine levels in the blood. Kidney function
can also be tested by measuring the levels of albuminuria (type of protein) in the
urine, but this testing requires follow-up, as CKD is diagnosed where albuminuria is
seen to be persistent in the urine for at least three months.

General practitioners (GPs) are the usual source of initial assessment and diagnosis
of CKD and have a variety of options available for treating the condition, including
the ordering of imaging and pathology tests, prescribing of medications and, where
necessary, referral to a specialist. Best practice management of CKD utilises a

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collaborative effort, involving at least the individual and their GP, but also including
practice nurses and/or allied health professionals as appropriate.

Questions 1-6
3) Why does a urine test to check for Chronic Kidney Disease have to be
followed up on?
a) The urine test has to be compared with the blood test results so a formula can
be applied to confirm CKD
b) The urine is tested for a protein that has to be present for 90 days to confirm
CKD.
c) The urine test has to be repeated to ensure the results are accurate before
CKD can be confirmed.

TEXT 4
Position Statement on Medicinal Cannabis

It is the position of the NSW Nurses and Midwives’ Association that:

Access to cannabis for therapeutic purposes should be supported where patients, in

consultation with their treating health professionals, receive some benefit or
symptoms are alleviated. Clinical trials should be conducted to develop the evidence
base. Approved pharmaceutical cannabis products should be accessible and
affordable. A legal framework must be established so that patients or their carers
who are in possession of cannabis for personal, therapeutic purposes should have a
complete legal defence from arrest or prosecution. A legal framework must be
established so that approved cannabis products can be developed and sold for the
purposes of therapeutic use. Cannabis misuse should be approached primarily as a
health issue rather than a criminal issue and we support an appropriate harm-
reduction response.

Questions 1-6

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4) What is the NSW Nurses and Midwives Association stance regarding
carers found in possession of cannabis?
a) Carers should be protected from legal action against them
b) Carers should be arrested and prosecuted
c) Carers should be referred to health professionals

TEXT 5
Memo to all staff re: Mandatory FONT requirements bulletin

Completion of all components of the FONT program is mandatory for all NSW Health
maternity clinicians (including Obstetricians, General Practitioner Obstetricians,
Trainees in Obstetric Medicine, Registered Midwives and midwifery students).

This is to occur in three yearly cycles and will consist of:

• 16 hours to complete the online K2MS Perinatal Training Programs (once

every three years) which includes:
o Fetal Monitoring Training System (including 15 Cardiotocograph (CTG)
‘Training Simulator’ cases)
o Maternity Crisis Management Training System
• 2½ hours to complete two (2) K2MS - Fetal Monitoring Training System
‘Training Simulator’ CTG case studies (every year within the cycle where the
entire Fetal Monitoring Training System is not completed)

• 16 hours to complete both face-to-face education sessions (once every three

years)

o Fetal Welfare Assessment (‘F’)

o Obstetric emergencies and Neonatal resuscitation Training (ONT’).

Chief Executives of Local Health Districts – are responsible for:

• Supporting:

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 o FONT Facilitators to provide the face-to-face sessions
o Maternity clinicians to complete the mandatory FONT requirements

• Monitoring FONT completion compliance.

Information relating to the granting of Recognition of Prior Learning (RPL) will be

available in the FONT Curriculum. The changes outlined in this Information Bulletin
will be incorporated into relevant NSW Ministry of Health Policy Directives during
2013.

Questions 1-6
5) How much cardiotocograph training is must be completed to complete
the FONT programme?
a) Two face to face training sessions and fifteen case studies every three years
b) Sixteen hours online training every three years and two and half hours
annually
c) Two case studies and fifteen simulator cases every three years

TEXT 6
Choice of meter for the individual with diabetes

The choice of a blood glucose meter for the person with diabetes will depend on a
variety of factors including ease of use, size and portability, type of strip (e.g.
canister, individual foil-wrapped strip or strip-free), amount of blood required,
suitability for alternate site testing and other additional features such as memory
and download capability, alarms and back lights. Individuals with sight or dexterity
problems will need a meter that accommodates these issues. Many people with type
1 diabetes use more than one blood glucose meter, and may require a meter to
measure blood ketone levels, a smart meter that assists in insulin bolus calculations
or a meter that relays blood glucose levels to their insulin pump. Capillary blood
samples are best taken from the side of the finger, but avoiding close proximity to
the nail bed, particularly when blood glucose levels are changing rapidly. Some blood
glucose meters allow the measurement of glucose levels from small samples of blood
from the forearm and other sites.

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Questions 1-6
1) Where is the best place to take blood from to monitor blood glucose
levels?
a) Near the nail bed
b) The side of the finger
c) The forearm

PART C
TEXT 1
Cancer, of course, is not new. Throughout the ages societies have defined and dealt
with it variously. Ancient Greeks employed the term to describe tumors: mass,
burden. It is an apt translation of what cancer does inside of our bodies. In Emperor
of All Maladies Siddhartha Mukherjee travels to the root of onkos.

Nek is an Indo-European term that represents an active form of “load.” It means to

carry, to move the burden from one place to the next, to bear something across a
long distance and bring it to a new place. It is an image that captures not just the
cancer cell’s capacity to travel—metastasis—but also Atossa’s journey, the long arc
of scientific discovery—and embedded in that journey, the animus, so inextricably
human, to outwit, to outlive and survive.As Atul Gawande recently expressed in
conversation with musician Andrew Bird—Bird asked the doctor how cancer forms,
given a severe bout his wife had recently undergone—we all grow cancer cells every
day. Fortunately, our bodies are designed to not let them metastasize. Then a
mutant gets through, our body under attack.

Certain cancers are genetic—my testicular cancer two years ago is one such case,
given a childhood condition that predisposed me to it. Yet many are environmental.
More importantly, where genetics and environment meet is either a breeding
ground or defense system for cancer. Cigarettes have always been the former, like
letting streptococcal bacteria loose in a sauna.

A recent study published in Science reminds us just how dangerous cigarettes are. It
turns out that hundreds of DNA cells are in danger of mutation in what scientists
believe is impactful enough to leave an “archaeological record.Smoking a pack a day
leads to the following number of potential mutations every single year 150 in the

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lungs; 97 in the larynx or voice box; 23 in the mouth; 18 in the bladder; six in the
liver. Each mutation increases the risk of cells becoming cancerous.

Every cigarette contains at least 60 carcinogens, which is why six million people die
because of cigarette-related (and thus avoidable) cancers every year. Tobacco has
been implicated in 17 types of cancer. While the researchers remind us that smoking
is “mechanistically complex,” and there are multiple factors when considering
cancer, they conclude: Although we cannot exclude roles for covariate behaviors of
smokers or differences in the biology of cancers arising in smokers compared with
nonsmokers, smoking itself is most plausibly the cause of these differences.

Forty-five percent of American adults puffed tobacco 60 years ago. This is partly the
result of the hundreds of millions of dollars manufacturers were pouring into
advertising. The 1955 introduction of the Marlboro Man increased sales by whopping
5,000 percent over eight months. Peak consumption hit in the early sixties, with sales
of nearly $5 billion in America alone.

It’s been a long, slow withdrawal. In 1956, Richard Doll and Bradford Hill began
questioning the role of cigarettes in lung cancer. Today we view the Mad Men-esque
nonchalance of lighting up as a romantic throwback to a better time. Yet since
January 1, 1971, cigarette ads have been banned on television. That decade marked
a profound turn in our understanding of just how dangerous cigarettes are.

Still, addictions persist. While Utah is just over 12 percent smokers, and California in
second at 15 percent, Kentucky leads the charge with 30.2 percent of its population.
West Virginia and Mississippi follow closely behind. That means over 1.3 million
people still smoke in Kentucky. Even though that state doubles the percentage of
California smokers, around 5.8 million people still light up on the west coast.

Mukherjee, whose brilliant book on cancer is lucid and frightening, has spent a lot of
time in cancer wards around the world. In one passage he describes a fraction of the
devastation: “An ebullient, immaculately dressed young advertising executive who
first started smoking to calm his nerves had to have his jawbone sliced off to remove
an invasive tongue cancer. A grandmother who taught her grandchildren to smoke
and then shared cigarettes with them was diagnosed with esophageal cancer. A
priest with terminal lung cancer swore that smoking was the only vice that he had
never been able to overcome. He then describes that even while going through this,
many patients refuse to surrender their vice: “I could smell the acrid whiff of tobacco
on their clothes as they signed the consent forms for chemotherapy.

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Questions 7-14

7) What point does the writer make about the term the Ancient Greeks
used for cancer?
a) That it is a suitable translation that reflects the way in which cancer behaves
b) That it is an appropriate description of the outcomes of cancer.
c) That it describes precisely the root of the disease.
d) That the word cannot describe the disease properly.

8) How does the author describe cancer in terms of its Indo-European

implication?
a) As a carrier
b) As a load
c) As a journey
d) As a discovery

9) Which of the following can be a cause of cancer?

a) Environment
b) Breeding
c) Childhood conditions
d) Streptococcal bacteria

10) What does “the former” refer to in third Paragraph?

a) Genetics
b) Environment
c) A Breeding ground
d) A Defense system

11) Why do cigarettes cause cancer?

a) They can cause mutations in DNA cells.

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 b) They cause mutations in the organs of the body.
c) They turn cells into cancerous tissues.
d) They increase the risk for lung, larynx, mouth, bladder, and liver cancer.

12) When considering cancer, scientists

a) Are not sure that it is caused by smoking because cancers are complex
b) Are sure that smoking causes cancer
c) Believe that smoking is the most likely cause for cancer in smokers as opposed
to nonsmokers
d) Believe that smoking is the most likely cause for differences that are visible in
the cancers that occur in smokers compared to nonsmokers
13) What happened in the seventies?
a) New ways of advertising
b) A different attitude towards smokers
c) A Decrease in sales of cigarettes
d) People began to view cigarettes as a health hazard

14) What does Mukherjee say about smokers who got cancer?
a) He is worried about them.
b) He is disgusted by them.
c) He was disgusted by the smell of tobacco on their clothes.
d) He knows that many of them haven’t quit smoking.

TEXT 2
According to the National Institutes of Health, we spend about 26 years of our life
asleep, one-third of the total. The latest research states that between 6.4 and 7.5
hours of sleep per night is ideal for most people. But some need more and others
less. A contingent out there, mostly women, who do surprisingly well on just six
hours.There is even some data to suggest that a slim minority, around three percent
of the population, thrive on just three hours sleep per night, with no ill effects. Of
course, most people need much more. Even though in general, Americans are getting
far less sleep today than in the past.

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Cutting out needful rest could damage your health, long-term. A recent study
showed that sleep is essential to clearing the brain of toxins that build up over the
course of the day. It also helps in memory formation and allows other organs to
repair themselves. Our professional lives and our natural cycles don’t always mesh.
Often, they are at odds. What if you are insanely busy, like ten times the norm? Say
you are going to medical school, earning your PhD, or are trying to get a business off
the ground. There may not be enough hours in the day for what you have to do. One
thing you can do is rearrange your sleep cycle to give yourself more time.

Paleoanthropologists espouse that our ancestors probably didn’t sleep for seven
hours at a clip, as it would make them easy prey. Instead, they probably slept at
different periods throughout the day and night, and you can too.What we consider a
“normal” sleep cycle is called monophasic. This is sleeping for one long period
throughout the night. In some Southern European and Latin American countries, the
style is biphasic. They sleep five to six hours per night, with a 60-90 minute siesta
during midday. There is a historical precedent too. Before the advent of artificial
light, most people slept in two chunks each night of four hours each, with an hour of
wakefulness in-between. That’s also a biphasic system.

Then there is polyphasic sleep. This is sleeping for different periods and amounts of
time throughout the day. Certain paragons of history slept this way including
Leonardo Da Vinci, Nikola Tesla, Franz Kafka, Winston Churchill, and Thomas Edison,
among others. The idea gained popularity in the 1970’s and 80’s among the scientific
community. Buckminster Fuller, a famous American inventor, architect, and
philosopher of the 1900’s, championed this kind of slumber. So what’s the science
behind this radical system? Unfortunately, no long-term research has been
conducted, yet. One 2007 study, published in the Journal of Sleep Research, found
that most animals sleep on a polyphasic schedule, rather getting their sleep all at
once. This also begs the question, how much sleep does the human brain need to
function properly? The answer is unknown.

Sleep is broken into three cycles. There is light sleep, deep sleep, and rapid eye
movement (REM) sleep. The last one is considered the most important and restful of
phases. We don’t stay in any one phase for long. Instead, we cycle through these
constantly throughout the night. So with polyphasic sleep, the idea is to experience
these three phases in shorter amounts of time, and wake up rested.

We don't know the exact purpose of these phases. Sleep is still something of a
mystery. Without a good understanding, it’s difficult to quantify the impact a
polyphasic schedule has. One question is whether such a schedule allows for enough

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REM sleep. Polyphasic practitioners say they are able to enter the REM phase
quickly, more so than with a monophasic style. Jost, for example, claimed he could
enter REM sleep immediately. This quick entry into the REM state is known as
“repartitioning.” The deprivation of sleep may help the body enter REM quickly, as
an adaptation.

Questions 15-22
15) In first paragraph, the author
a) Introduces the phases of sleep
b) Introduces general facts about sleep
c) Discusses the amount of time people sleep.
d) Discusses the period of time when people sleep.

16) The author uses the word “contingent” in the first Paragraph to refer to
the women as:
a) An exception
b) A group
c) Resilient.
d) Brave.

17) What does the author imply when he/she says that our professional
lives and natural cycles are at odds?
a) That they are in congruence.
b) That they are in conflict.
c) That they correspond to one another.
d) That they cannot be compared.

18) What does the author suggest about our ancestors?

a) That they had monophasic sleep.
b) That they didn’t sleep for 7 hours.
c) That they didn’t have monophasic sleep.
d) That they had biphasic sleep.

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19) What is a siesta?
a) A long afternoon sleep.
b) A 60-90 minute afternoon sleep.
c) A 60-90 minute sleep which follows a regular 5-6 hour sleep.
d) Part of the biphasic sleeping schedule in Latin America.

20) What do scientists suggest about sleep in fourth paragraph?

a) That in order to be successful you need to have polyphasic sleep.
b) They can’t explain why many animals have polyphasic sleep.
c) They have no answers about what proper sleep is as no studies have been
carried out
d) They have no specific answers about the amount of sleep we require?

21) What does the author say about the way we sleep in fifth paragraph?
a) That we all experience polyphasic sleep.
b) That we all sleep in cycles.
c) We cycle when we go to sleep
d) That polyphasic sleep makes us feel rested.

22) Why are some scientists skeptical about the success of polyphasic
sleep?
a) Because they believe that it does not allow for enough REM sleep.
b) Because they believe that it allows people to enter the REM phase more
quickly
c) They suspect that it may not allow for enough REM sleep.
d) They don’t believe that the repartitioning phase can be achieved.

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