Reading 44

44 Dry Eye Syndrome

Part A – Text Booklet

Text A

Dry eye syndrome is caused by a chronic lack of sufficient lubrication and moisture on the surface of the eyes. Consequences of dry eyes range from subtle but constant eye irritation to significant inflammation and even scarring of the front surface of the eye. In addition to being called dry eye syndrome, dry eye disease, or simply “dry eye,” alternative medical terms used to describe dry eyes include:

• Keratitis sicca. Generally used to describe dryness and inflammation of the cornea.
• Keratoconjunctivitis sicca. Used to describe dry eye that affects both the cornea and the conjunctiva.
• Dysfunctional tear syndrome. Used to emphasize that inadequate quality of tears can be just as important as inadequate quantity.

Reflex Tears

Dry eyes can actually cause eyes to water. This can happen when eyes are irritated. It’s similar to tear production that is triggered when something gets in your eyes. They are called reflex tears. Reflex tears (the watery type that are produced in response to injury, irritation, or emotion) don’t have the lubricating qualities necessary to prevent dry eyes. Tear film is made of water, oil, and mucus, all of which are important for maintaining good eye health. The cornea, which covers the front of the eye, needs tears continuously to protect it against infection.

Text B

An adequate and consistent layer of tears on the surface of the eye is essential to keep your eyes healthy, comfortable and seeing well. Tears bathe the eye’s surface to keep it moist and wash away dust, debris and microorganisms that could damage the cornea that lead to an eye infection. A normal tear film consists of three important components:

• An oily (lipid) component.
• A watery (aqueous) component.
• A mucous-like (mucin) component.

Each component of the tear film serves a critical purpose. For example, tear lipids help keep the tear film from evaporating too quickly and increase lubrication, while mucin helps anchor and spread the tears across the surface of the eye.

Each tear component is produced by different glands on or near the eye:

• The oily component is produced by meibomian glands in the eyelids.
• The watery component is produced by lacrimal glands located behind the outer aspect of the upper eyelids.
• The mucin component is produced by goblet cells in the conjunctiva that covers the white of the eye (sclera).

A problem with any of these sources of tear film components can result in tear instability and dry eyes, and there are different categories of dry eyes, depending on which component is affected.

For example, if the meibomian glands don’t produce or secrete enough oil (meibum), the tear film may evaporate too quickly — a condition called “evaporative dry eye.” The underlying condition — called meibomian gland dysfunction — is now recognized as a significant factor in many cases of dry eye syndrome.

Text C

Type of Evaluation	Test
Tear secretion	Schirmer I, John’s Test, Cotton Thread Test, Dye Clearance Test, Fluorophotometry.
Tear stability	Invasive TBUT – Non-invasive TBUT (T-BUT – Tear Breakup Time).
Tear film integrity, epithelial integrity	Rose Bengal Staining
Physical features	Osmolality, PH, Ferring evaporation rate
Chemistry	Electrolytes, Protein (Lysozyme lactoferrin)
Histology	Impression cytology, Lacrimal gland biopsy, minor salivary gland biopsy.

Text D

Medication

Prescription medication used to treat dry eyes include:

Drugs to reduce eyelid inflammation. Inflammation along the edge of your eyelids can keep oil glands from secreting oil into your tears. Your doctor may recommend antibiotics to reduce inflammation. Antibiotics for dry eyes are usually taken by mouth, though some are used as eyedrops or ointments.

Eyedrops to control cornea inflammation. Inflammation on the surface of your eyes (cornea) may be controlled with prescription eyedrops that contain the immune-suppressing medication cyclosporine (Restasis) or corticosteroids. Corticosteroids are not ideal for long-term use due to possible side effects.

Eye inserts that work like artificial tears. If you have moderate to severe dry eye symptoms and artificial tears don’t help, another option may be a tiny eye insert that looks like a clear grain of rice. Once a day, you place the hydroxypropyl cellulose (Lacrisert) insert between your lower eyelid and your eyeball. The insert dissolves slowly, releasing a substance that’s used in eyedrops to lubricate your eye.

Tear-stimulating drugs. Drugs called cholinergics (pilocarpine, cevimeline) help increase tear production. These drugs are available as pills, gel or eyedrops. Possible side effects include sweating.

Eyedrops made from your own blood. These are called autologous blood serum drops. They may be an option if you have severe dry eye symptoms that don’t respond to any other treatment. To make these eyedrops, a sample of your blood is processed to remove the red blood cells and then mixed with a salt solution.

Part A | Answer Booklet

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. Procedure for medicine intake.
2. Symptoms found during assessment.
3. Providing conformity of syndrome.
4. Administering the prescribed medicine.
5. Triggering of reflex tears.
6. Performing detection mechanism.
7. Why tears are produced.

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.

1. Why does cornea of the eye need tears continuously?
2. Tears stability can be confirmed with?
3. What need to be taken in order to reduce eyelid?
4. What will be produced by Meibomian glands?
5. When can you determine if Reflex Tears are caused?
6. What kind of syndrome it is, when there is lack of adequate quality of tears?
7. What is recently identified in causing dry eye syndrome?

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.

1. Tear-stimulating drugs are prescribed by doctors for tears _______________________.
2. Lysozome and Lactoferins are used in _______________________ type of evaluation.
3. _______________________ helps in preventing tear film from evaporation.
4. Mucin component for covering white of the eye is produced by ________________.
5. Lacrimal glands producing the watery component located in the _____________ eyelid.
6. ______________ are not ideal eye drops used for dry eye syndrome treatment.

End of Part A | You have to Submit the 2 Booklets Immediately.

• Once you have submitted the 2 Booklets, you will not be allowed to modify your answers.
• Double-check your answers before submitting. 

Part B | 6 Extracts | 6 Questions

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. The manual extract tells that:

1. LMS should reduce the problems of healthcare.
2. IT people will be employed more in the hospitals.
3. Healthcare HRs should play a pivotal role in hospital management.

Manual Extract:

The healthcare industry may be the most risk-heavy and compliance-intensive sector of the economy. With the potential (ability) for life-changing impact on patients and the need to manage sensitive patient data—the stakes don’t get much higher. Regulations cover everything from equipment and facilities to processes and supplies. Adding to the compliance challenge: Everyone from radiologists to IT people must have certifications. Healthcare HR departments must meet compliance challenges with tools that offer streamlined, trackable methods for delivering the necessary learning—and ensuring that staff obtain the required certifications. Here’s how a Learning Management System (LMS) for healthcare can help reduce the administrative burden, centralize learning materials and improve tracking of data.

2. What does this manual extract emphasize?

1. The importance of ethics committees in hospitals.
2. The role played by the surrogate decision maker involved in surgery.
3. The importance of shared decision making between patient-surgeon.

Manual Extract:

Patient-Centred Informed Consent in Surgical Practice

To review the medical, ethical (moral), and legal basis of the doctrine of informed consent for surgery and its complications, particularly for an incapacitated (impaired) patient who requires a surrogate decision maker; to discuss the elasticity (flexibility) of the consent doctrine, whether surgical consent encompasses (includes) consent for surgical complications, and emphasize the importance of communication and shared decision making in the context of the patient-surgeon relationship; and to discuss patient and surrogate refusal of treatment, standards of surrogate decision making, barriers (obstacles) to effective communication, the role of the hospital ethics committee in resolving (solving) disputes (arguments) over treatment, and how to reconceptualize surgical consent in the context of patient-centered medicine.

3. The instructions provided to the medical staff shows that:

1. Lack of sufficient medical staff to take care of the patients.
2. Failure of Emergency departments in hospitals contributed to discharge of patients in less than 30 days.
3. Medical staff is advised to provide proactive care and follow up.

Instructions:

Patients with more complicated physical and/or mental illnesses are at increased risk of potentially serious, even fatal (causing death), exacerbations (worsening) and complications. They may benefit from more intensive follow-up and management than (what) can be done through repeated office visits. Many patients being discharged from the hospital or Emergency Department fit this description. Evidence suggests that well-organized care management by a nurse or other health professional can reduce patients’ risk of deterioration and readmission, and the associated health care costs. One-half of patients readmitted to hospitals within 30 days of discharge have not seen a community provider.

4. What does this manual extract tell about medical instruments catalogue?

1. It may be helpful for guiding the one who does not have adequate knowledge about medical equipment.
2. It covers the full range of medical instruments in use.
3. Its purpose is to provide technical support for all levels.

Manual extract – Guidelines for Procurement

Procurement (agencies that buy and arrange) agencies and health facilities are required to prepare appropriate technical specifications and descriptions (catalogue) of medical instruments or equipment whenever they conduct tenders or prepare purchase orders. In order to accomplish this task effectively, knowledge of the type, nature and specific characteristics of the instruments is essential. The main purpose of this catalogue is, therefore, to provide technical guidance for procurement of medical instruments / equipment by procurement agencies and health facilities. It is also hoped that this catalogue can serve as a useful teaching aid for health personnel training institutions. The catalogue is divided into thirteen sections based on the areas of use of the instruments/equipment or departments. Attempts have been made to illustrate each instrument/equipment in picture followed by a catalogue number, specification/description and use (wherever it is relevant). Some sections (e.g. diagnostics) are incomplete in terms of coverage and will be treated separately in the future. At the end, an index (list) is included for ease (easiness) of reference. The catalogue has a general nature and focuses on commonly used instruments/equipment; it can be used by any level of health facility or procurement agency by extracting information pertinent to its level. As it is the first attempt of its kind, the catalogue needs improvement and updating from time to time.

5. What does this extract from a handbook tell us about physician employment?

1. Large employment of physicians are being done by Small hospitals.
2. The rise of employment for physicians in hospitals would cost more.
3. Paying for most productive physicians is not difficult, but to find them is difficult.

Extract from a handbook:

The healthcare industry saw a wave of physician employment by hospitals back in the 1990s, and hospitals are again pursuing (searching for) employment of physicians as a core (fundamental) strategy. Employing physicians tends to work in a fee-for-service environment and should also work as hospitals move forward into an ACO managed-care type of environment. The downside to a physician employment strategy is that it is expensive for the hospital, and there are increasing anecdotal discussions about the losses per physician that systems suffer as they employ physicians in larger numbers. Here, the average productivity of the employed physicians seems to be declining. Initially, as hospitals began to again employ physicians, there had been great focus on hiring the most productive physicians. Now it seems as though many hospitals have an “all in” strategy and have hired with less focus on the most productive physicians. Thus, the average productivity per physician has regressed to a more average level.

6. This manual extract emphasizes:

1. the importance of ethics committees in hospitals.
2. the role played by the surrogate decision maker involved in surgery.
3. the importance of shared decision making between patient-surgeon.

Manual extract:

Patient-Centred Informed Consent in Surgical Practice

To review the medical, ethical, and legal basis of the doctrine of informed consent for surgery and its complications, particularly for an incapacitated patient who requires a surrogate decision maker; to discuss the elasticity of the consent doctrine, whether surgical consent encompasses consent for surgical complications, and emphasize the importance of communication and shared decision making in the context of the patient-surgeon relationship; and to discuss patient and surrogate refusal of treatment, standards of surrogate decision making, barriers to effective communication, the role of the hospital ethics committee in resolving disputes over treatment, and how to reconceptualize surgical consent in the context of patient-centred medicine.

End of Part B

Part C, Text: 01 Teenage years risky for sports injuries

Adolescence is a vulnerable time for sports injuries and some young athletes are being pushed too hard, the author of a new report says. The years around puberty aren’t just a peak time for pimples and mood swings; it’s also when rapid changes in bones and muscle leave teens at increased risk of injuries when they play sport. And this is bad news. Not only are injured young athletes predisposed to health problems like arthritis later in life, but the experience can also lead them to drop out of sport altogether and perhaps begin the downward spiral to being a couch potato.

It’s something coaches need to recognise and they may need to reduce the volume of training for certain teens, says paediatric sports medicine specialist Dr Carolyn Broderick. “I think some coaches are overtraining adolescents at this vulnerable age. There isn’t a ‘one size fits all’. Some children can cope with a higher training volume than others. It needs to be monitored. A player who gets one overuse injury after another for example needs to have their training load reduced.”

Broderick is a senior author of a new report which highlights for the first time just how common such injuries are among the young. They make up 5 per cent of all GP visits in children, but this jumps to 10 per cent during adolescence, the report led by researchers from the George Institute for Global Health and the University of Sydney found. All up, 880,000 children and teens see a GP for a musculoskeletal injury each year, it estimates. And after about age 10, more boys than girls are affected.

Prior to puberty, sports injuries are very uncommon, says Broderick, who is also the medical director of the Australian team for the 2014 Youth Olympic Games. But “the incredible change” in muscles and bones around puberty is a key reason the injury rate jumps at this time. This vulnerable phase actually starts a bit before puberty – around 10 in girls and around 12 in boys, Broderick says. The rapid increase in the length of bones at this time seems to come at the expense of bone strength, increasing the odds (chances) of fractures. “Because the bones are growing at a great rate, then the muscles tend to be a bit tight too. It’s a time of inflexibility.”

This tightness in muscles means there is an increased pulling force on the growth plate of bones (where muscles are attached), which can cause pain and inflammation. This is the basis of the common condition called Sever’s disease, which affects the heel of the foot, and Osgood-Schlatter disease, which affects the knee. As well, the growth in weight and muscle bulk of teens, particularly in boys, makes contact and collision sports more likely to result in injury – especially when there is a mismatch in the size and weight of opposing players. (This may be a reason for the higher injury rate of teenage boys.)

“The main problem we have in this generation is getting children and adolescents to be active,” says Broderick, “We want them to play sport, but we need to make it as safe as it can be.” Around 8 percent of teens drop out of sport each year because of injury, and this may mean they miss out on the health benefits exercise can bring like boosted self-confidence, stronger bones, a healthier weight, and reduced risk of diabetes and heart disease later in life.

Dr David Hunter, an arthritis specialist at Sydney’s Royal North Shore Hospital, says sporting injuries in childhood are responsible for 20 to 30 per cent of osteoarthritis cases in adults, some of whom are as young as 30. He was part of a group pushing for injury prevention exercises to become standard in training offered for youth sports across Australia.

While this has not yet happened, the Australian Sports Commission (ASC) is currently introducing a module on injury prevention in courses offered to coaches who become certified through the commission, he said. However, rugby league is the only sport which has ruled that its coaches must receive ASC accreditation, he said. Coaches from other sports may choose to but it is not compulsory. “It’s one small step in the right direction, but there’s still a lot of steps to go,” he said. Children were better off waiting until about age 15, before specialising and training hard in a single sport, he said. “Kids specialise too early and train too hard before their bodies have a chance to properly mature. They’re often doing in excess of 20 hours a week of activity and their fatiguing and getting overuse injuries as a result.” Parents also needed to be sure to tell coaches if their kids were getting overloaded through sport played both in and out of schools and suggest pulling back a bit in training.

Questions 7-14

7. What would be the reason that the author considered young athletes are highly prone to sport injuries?

1. the addictive nature of continuous sport activities.
2. the impact of sports exercises during events.
3. several factors may contribute to sport injuries.
4. increasing trends of dangerous sport events

8. As per the sports medicine specialist Dr Carolyn Broderick, who he thinks are primarily responsible for relieving stress of sport persons?

1. Coaches.
2. Medical specialists.
3. Event organisers.
4. Sportsperson.

9. What was significant about Georges institute research report?

1. Most of the younger people are not prone to fractures.
2. Teenage boys are most affected than girls.
3. Most adolescents are prone to sports injuries in their age after 23 years.
4. The report doesn’t cover all aspects of the study

10. The phrase “the incredible change” in the fourth paragraph illustrates

1. The increased susceptibility of youth to sport injuries through physical change.
2. The Number of people with sports injuries has been decreasing in recent times.
3. The policymakers need to review the athlete’s health policy.
4. The athletes view on the sports injuries changed

11. What might be a reason for the higher injury rate in teenage boys?

1. Growth plates of bone.
2. Size and weight mismatch of opposite players.
3. Strength muscles.
4. Increased pulling speed

12. What do you understand from Broderick’s statement in the sixth paragraph?

1. He was frustrated over the statements issued by the parents.
2. He projected a good formula for healthy sporting.
3. He advised the parents let their child play.
4. He suggested the all athletes to follow healthy diet

13. Which league made their coaches compulsorily ASC accredited?

1. Cricket council.
2. Football association.
3. Rugby league.
4. ASC Champions league

14. The word ‘It’s’ defines:

1. Accreditation process.
2. Rugby league.
3. Australian Sports Commission
4. Training

Part C, Text 2

Lean body mass can be estimated using imaging studies, anthropometry such as mid-arm muscle circumference, or equations based on serum creatinine. Serum creatinine has been shown to correlate closely with muscle mass, especially in dialysis patients, and equations have been created that use serum creatinine and certain demographic data to estimate lean body mass.

In a study in 535 adult hemodialysis patients whose body fat was directly measured with near-infrared interactance, low baseline body fat percentage and fat loss over time were independently associated with higher mortality even after adjustment for demographics and surrogates of muscle mass and inflammation, whereas a tendency toward a worse quality of life was seen with a higher body fat percentage. In a cohort of 742 hemodialysis patients comprising 391 males and 351 females who were separately divided into 4 quartiles of near-infrared interactance − measured lean body mass and fat mass, the highest versus lowest quartiles of fat mass and lean body mass were strongly associated with lower mortality in women, whereas the highest versus lowest quartiles of fat mass and percentage fat but not of lean body mass were associated with greater survival in men.

Cubic spline survival analyses showed greater survival with higher fat mass percentage and higher “fat mass minus lean body mass percentiles” in both sexes, whereas a higher lean body mass was protective in women. This study suggested that the survival advantage of fat mass was superior to that of lean body mass. There are, however, other studies suggesting that both higher lean body mass and BMI are related to greater survival in hemodialysis patients. In a large cohort of 117,683 hemodialysis patients, higher estimated lean body mass, defined by creatinine-based equations, was linearly associated with lower mortality.

Compared with the reference group (48.4 to <50.5 kg), patients with the lowest estimated lean body mass (<41.3 kg) had a 1.4-fold higher risk of mortality. A similar linear association was seen among patients with BMI < 35 kg/m2 and in non-Hispanic Caucasian and African American subgroups. However, higher estimated lean body mass was not associated with improved survival in Hispanic patients or those with BMI > 35 kg/m2. 

To better examine the role of different types of fat, a landmark study was conducted by Italian colleagues led by Zoccali et al. in a prospective cohort of 537 dialysis patients, in whom waist circumference was used as surrogate of intra-abdominal or visceral (truncal) fat. In this study, each 10-cm increase in waist circumference was associated with 10% and 37% higher all-cause and cardiovascular death.

To determine whether dry weight gain accompanied by an increase in muscle mass is associated with a survival benefit in a nationally representative 5-year cohort of 121,762 maintenance hemodialysis patients, 3-month averaged serum creatinine levels and their changes over time were used as muscle mass and as muscle mass change, respectively. Dry weight loss or gain over time exhibited a graded association with higher rates of mortality or survival, respectively, as did changes in serum creatinine level over time. Among a sub-cohort of 50,831 patients who survived the first 6 months, those who lost weight but had an increased serum creatinine level had a greater survival rate than those who gained weight but had a decreased creatinine level. These data suggest that there is a superiority of lean body mass to fat mass, in that larger body size with more muscle mass was associated with better survival, whereas a discordant muscle gain with weight loss over time conferred greater survival benefit as compared with weight gain while losing muscle.

Additional analyses of the same cohort using more sophisticated analytic techniques confirmed the superiority of muscle mass while overall weight gain or loss maintained parallel associations with survival and mortality, respectively. A decline in muscle mass appeared to be a stronger predictor of mortality than weight loss. These studies suggest that a considerable proportion of the obesity paradox in dialysis patients might be explained by the survival benefits of greater muscle mass.

In a large epidemiologic study by Beddhu et al., 24-hour urinary creatinine excretion was used as a measure of muscle mass in 70,028 patients who initiated hemodialysis in the US over 5 years (January 1995 to December 1999), and the outcomes of hemodialysis patients with high BMI and normal or high muscle mass (inferred low body fat) and high BMI and low muscle mass (inferred high body fat) were compared. The investigators found that patients with high BMI (>25 kg/m2) had 15% lower hazard of death, but that patients who had more muscle mass had even greater survival, whereas patents with high BMI but lower muscle mass had a 14% to 19% higher all-cause and cardiovascular mortality.

According to the authors’ interpretation of their data, the protective effect conferred by high BMI is limited to higher muscle mass, as patients with higher BMI with inferred high body fat exhibited increased and not decreased mortality. Hence, given the commonality of the muscle mass superiority despite mixed data about fat, controlled trials of muscle-enhancing interventions in patients receiving dialysis are warranted.

Questions | Reading Part C, Text 2

15. According to the paragraph, which three criteria are included in the equations?

1. Gender, Height, Weight.
2. Place, Muscle mass, Lean body mass.
3. Age, Gender, Body measurement.
4. Age, Gender, Place.

16. What is not correct about the cohort study?

1. All participants had shared characteristics.
2. The study was participated more men than women.
3. Only the female participants were divided into 4 quartiles.
4. Men have a predominance of fat mass.

17. The study suggested that:

1. Predominance of lean body mass is healthy.
2. Predominance of fat mass is healthy. 
3. Both higher lean body mass and BMI are related to greater survival in hemodialysis patients. 
4. Presence of lean body mass and fat mass is rare but is most ideal for men and women.

18. According to the paragraph:

1. It is better to maintain lean body mass between 48.4 to not above 50.5 kg.
2. Up to 50.5 kg of lean body mass stands safe.
3. Mortality is high in people with very low lean body mass.
4. If the lean body mass is above 50.5 kg, some groups of people have better survival.

19. In the cohort study among 537 patients:

1. Intra-abdominal fat was used as measurement.
2. Visceral fat was used as measurement.
3. Waist circumference was used as measurement.
4. Truncal fat was used as a measurement. 

20. The cohort was conducted to see the association:

1. Between dry weight gain and an increase in muscle mass.
2. Dry weight gain followed by an increase in muscle mass.
3. Increase in muscle mass followed by dry weight gain.
4. Between serum creatinine levels and their changes over time.

21. The expression, “obesity paradox” explains:

1. The contradiction that exists between lean body mass and muscle mass.
2. The conflict that exists between lean body mass and body fat.
3. The Inconsistency that exists about healthy body and unhealthy body.
4. The puzzle about body mass index and weight gain.

22. Which statement is not correct about the Beddhu and associates’ study?

1. Hemodialysis patients with high BMI and normal or high muscle mass were compared.
2. Hemodialysis patients with high BMI and normal or low body fat were compared.
3. Hemodialysis patients with high BMI and low muscle mass were compared.
4. Hemodialysis patients with low BMI and normal or low body fat were compared.

End of Reading 44 | Answers?