Skin-lightening and tanning: Texts

SURVEY ON SKIN-LIGHTENING CREAMS

A British Skin Foundation survey found that fifteen per cent of dermatologists believe lightening creams are 'completely
unsafe' and four in five feel they are only safe when prescribed by a dermatologist.
"Many skin-lightening creams contain illegal compounds that can damage your health," says Indy Rihal of the British Skin
Foundation. "The most common compounds are high-dose steroids."
Although steroids can be useful in treating some skin diseases, such as psoriasis and eczema, this must take place under
the supervision of a skin specialist. "Unmonitored use of high-dose steroids can lead to many problems," says Rihal. If
you've used a skin-lightening cream and are worried about the effect it has had, see a GP.
"Medically approved preparations prescribed by a GP or a dermatologist are not dangerous, within reason," says Rihal. A
cream that you buy over the counter is not necessarily medically approved and could permanently damage your skin.

The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal

Many women of childbearing age from sub-Saharan Africa use topical skin lighteners, some of which
present a risk of toxic systemic effects. The goals of this study were to evaluate, in this environment,
the frequency of this practice during pregnancy, as well as eventual consequences on pregnancy. Ninety
nine women from 6 to 9 months pregnant were randomly selected among those attending a standard
maternal centre in Dakar for a prenatal visit. Investigations consisted of questions about the use of
skin lighteners, a standard clinical examination, follow-up until delivery and a morning blood sample for
plasma cortisol levels. Sixty-eight of the 99 selected women used skin lighteners during their current
pregnancy, the main active ingredients being hydroquinone and highly potent steroids (used by 64 and
28 women, respectively). No difference in the main outcomes of pregnancy were found between skin-
lightener users and the others; however, women using highly potent steroids, when compared with
those who did not, had a statistically significant lower plasma cortisol level and a smaller placenta,
and presented a higher rate of low-birth-weight infants. Skin lightening is a common practice during
pregnancy in Dakar, and the use of steroids may result in consequences in the mother and her child.
Tanning: Biological and Health Effects

Tanning is the skin’s response to ultraviolet (UV) radiation , a type of light exposure . As skin cells
are exposed to UV radiation , they produce a brown pigment (melanin ) to protect themselves from
further UV exposure . This results in a darkening of the skin (tanning ), which is the body’s natural
defense mechanism and attempt to prevent further damage from UV radiation. Sunlight and artificial
tanning methods, such as tanning booths or salons, are sources of UV exposure. Sufficient amounts
of UV exposure are known to cause adverse health effects in humans and are a public health concern.
Tanning and burning play a role in health effects , including skin cancer . UV radiation damage to
DNA in skin cells can result in mutations that promote or cause cancer, and recurring UV exposures
may result in aging (wrinkles, loss of elasticity, and sun spots). Other short-term effects on skin are
sunburns, fragility, and scarring. Cataracts are a known health effect from UV radiation exposure and
eye protection is essential when tanning.

Banned Sunbeds

Unsupervised sunbeds have “no redeeming features", says Wales’ chief medical officer Dr Tony Jewell
spoke as the facilities are being banned in Wales: laws to clamp down on sunbed use are extended From
Monday, businesses with unstaffed coin-operated sunbeds could be fined £5,000

Welsh cancer charity Tenovus said the ban was important as skin cancer is the most common cancer in 15 to
24-year-olds in the UK, and south Wales has one of the highest incidences in the country.

'Skin cancer incidence is very strongly linked to over-exposure to ultra-violet radiation through sunbeds,
levels of which can be six times stronger than the Australian midday sun," said Tenovus head of research Dr
Ian Lewis.

"Wales alone has 500 cases of malignant melanoma a year, the most dangerous and potentially fatal form of
skin cancer, resulting in nearly 100 deaths annually.

“The rise in incidence of this type of skin cancer is truly alarming; between 1996 and 2006. Wales saw the
rate of malignant melanoma in men and women double.”
 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.

Skin-Lightning Creams: Questions

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 Studies about the effects of steroids on pregnancy?

2 Sun exposure and cancer?

3 What to do if you are concerned that you have a problem?

4 Comparison between hydroquinone and steroids?

5 Malignant melanoma in Wales?

6 Effects of radiation on the eyes?

7 Dermatologists stating the dangers of skin creams?

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 should be done when encountering a problem with a skin-lightning cream?

9 How many people die in Wales each year as a result of malignant melanoma?

10 What are the short term effects of radiation on the skin?

 11 What is the cause of tanning of human skin?

12 What is the effect of steroids on the placenta?

13 Who has done the survey about the opinions of dermatologists on the matter?

14 How was the incidence rate of malignant melanoma in Wales in 1996 in comparison to

2006?

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. Some sorts of skin lighteners may have ....................systemic effects.

16. Steroids can be useful in treating some skin conditions such as ................. and ........................

17. Over exposure to ..................... through sunbeds increases the risk of developing skin cancer.

18. Mutation to the .................... through UV radiation can cause cancer.

19. The use of high dose steroids can cause a lot of problems if its use is .......................

20 ............................................infants may be a consequence of using steroids.

END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED
 Part B
In this part of the test, there are six short extracts relating to the work of
health professionals. For questions, 1-6, choose the answer (A, B or C)
which you think fits best according to the text.

1. The guidelines establish that:

A- The student should always be under supervision when performing a
procedure.
B- How dangerous the procedure is, determines the appropriate supervision
that is required.
C- A student should be under supervision by a fellow when performing a
phlebotomy for the first time.

The first time any procedure is performed on a patient, the student should be
adequately and appropriately supervised. What constitutes adequate and
appropriate supervision depends on the level of risk of the procedure. For
example, phlebotomy or IV placement could be supervised by an intern or a
nurse, but central line or arterial line placement should be supervised by a
fellow or highly experienced resident. In all cases, the supervisor should have a
level of expertise with the procedure that allows him or her to perform it
comfortably and independently.

2. According to the extract:

A- The patient's agent is the one who performs the procedure.
B- Patient's consultations should be with a medical practitioner.
C- A patient advisor is not a registered health practitioner.

The patient’s first consultation should be with the medical practitioner who will
perform the procedure or another registered health practitioner who works
with the medical practitioner who will perform the procedure. It is not
appropriate for the first consultation to be with someone who is not a
registered health practitioner – for example, a patient advisor or an agent.
3. The medical policy states that Ambulatory monitors could:
A- Only be used to monitor asymptomatic patients with the risk of arrhythmia
B- Be used to monitor the effect of therapy.
C- Not be covered to avoid heat.

"When not Covered" section revised to state: "Other uses of ambulatory

event monitors, including outpatient cardiac telemetry and mobile
applications, are considered investigational, including but not limited
to monitoring asymptomatic patients with risk factors for
arrhythmia , monitoring effectiveness of antiarrhythmic therapy and
detection of myocardial ischemia by detecting ST segment changes ."
Policy guidelines and references updated. Policy noticed 6/8/18 for
effective date 8/10/18. Medical Director review.

4. According to the extract:

A- Cimzia may be given to treat active rheumatoid arthritis.
B- Cimzia may be given to treat Crohn's.
C- Cimzia may be given instead of conventional therapy.

Cimzia (certolizumab pegol ) for subcutaneous injection may be

considered medically necessary for adult patients to reduce signs and
symptoms of Crohn's disease and to maintain clinical response in adults
with moderately to severely active disease who have had inadequate
response to conventional therapy ; for treatment of adults with
moderately to severely active rheumatoid arthritis , active psoriatic
arthritis or active ankylosing spondylitis.
5. According to the extract:
A- WHO Patient Safety develops recommendation to insure patient's safety.
B- Gathers experts from all-over the globe.
C- Hand hygiene is the primary measure to reduce the risk of infectious
diseases.

Hand hygiene is a primary measure to reduce infections , including CLABSIs . A

core part of WHO Patient Safety work is related to Global Patient Safety
Challenges . These challenges are international campaigns that bring together
expertise and evidence on important aspects of patient safety.
Recommendations are developed to ensure the safety of patients receiving
care globally . WHO Patient Safety works to make these recommendations
widely available and provides tools to implement the recommendations in a
variety of health care settings worldwide.

6. The contents of the INS published guidelines include:

A- The choice of the type of the device.

B- The choice of the site of insertion.
C- A framework for doctors in order to guide clinical practice.

The INS publication Infusion Nursing Standards of Practice provides a

framework that guides clinical practice. The standards are used to define and
develop organizational infusion-based policies and procedures for all practice
settings. The comprehensive contents include standards of nursing practice
and patient care practices, vascular access device selection and placement, use
of access devices, site care and maintenance, and infusion-related
complications.
 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.

Text1: Understanding OCD

Obsessive -Compulsive Disorder (OCD ) is a surprisingly common psychological

problem . Only 25 years ago, it was believed to be a relatively rare condition . In part,
owing to newer and more effective treatments for it, OCD is now known to affect
many millions of people at any given time. If left untreated, in most cases, OCD can
straight jacket a person 's life with immobilizing anxiety . What's worse, many people
with OCD will develop depression that not only intensifies suffering , but often
complicates and lengthens treatment . Nevertheless , as debilitating as it can be, when
treated with skillfully done , cognitive -behavior therapy (CBT ) that emphasizes a
crucial method called exposure and response or ritual prevention (ERP ), OCD 's
anxiety and depression producing grip can be significantly loosened.

In general terms , the main features of OCD are intrusive , horrific , and relentless
irrational thoughts or images (obsessions ) that drive tremendous anxiety and
specific , usually excessive , repetitive , or unrelated behaviors (compulsions ) that
are performed in an effort to neutralize or reduce the anxious thoughts , feelings
and sensations.

In essence , when someone has OCD his or her brain's danger detection region is
hypersensitive and dramatically overreacts to certain triggers thus launching a
massive, often panic level, anxiety attack (i.e., an exaggerated or inappropriate fight
or flight reaction). At the same time, the brain region that usually indicates safety is
very sluggish , and slow to signal the "all's clear ." Hence , the OCD sufferer will
experience needless or greatly exaggerated surges of intense anxiety related to
terrifying , irrational thoughts that drive him/her to engage in rituals in an effort to
drive down anxiety and restore feelings and sensations of safety . In other words ,
since the person's "automatic " safety signaler is very slow to relieve anxiety, he or
she will try to do it "manually " with a ritual. In the long run, however , rituals don't
work consistently to reduce anxiety due to a process called "negative reinforcement
" that, ironically , further energize the brain's anxiety triggers and makes its safety
signaler even weaker and slower.

Neuroimaging studies using PET scans have identified several hypermetabolic, brain
structures that are almost always associated with OCD . Specifically , a neural
pathway referred to as the supraorbital-cingulate-thalamic circuit - the SOCT circuit -
appears overactive in brain scans of people with OCD . Interestingly , when OCD
sufferers were randomly given either an SSRI or underwent intensive CBT for OCD
with exposure and ritual prevention , those who improved significantly had follow up
PET scans that showed much less activity in their SOCT circuit. Thus, regardless of
whether or not the person got better through CBT or took medication, both therapies
produced essentially the same result on brain activity.
As it was with our remote ancestors , our recognition of danger and safety involves at
least three psychological dimensions - namely , cognitive appraisal (thoughts and
images about the situation), emotional activation (feelings of danger and/or safety),
and sensory stimulation (viscerally sensing the danger or the safety ). Usually ,
people are good at discriminating between the psychological experience of danger
and safety. That is, we typically experience congruence among these psychological
zones . Therefore , when we perceive safety , we have no significant anxious or
intrusive thoughts , dreadful emotions , or anxious sensations . Our minds , moods ,
and sensations are all in alignment and reflect a deep feeling of safety and security
in the situation . And when we perceive actual danger , we usually have worries
about the situation, fearful feelings, and a lot of nervous system arousal that results
in various physical sensations of anxiety, such as muscle tension, clenching gut, dry
mouth, racing heart, rapid breathing, shaking, sweating, etc.

People suffering with OCD try to achieve a specific, physical sensation of safety and
have great difficulty grasping factual safety. For example , a person who feels dirty or
contaminated might wash extensively , far beyond the point of actual cleanliness .
Thus, someone with [this specific type of] OCD will wash (and wash, and wash) until
he/she senses and feels clean even if takes a long, long time to achieve the desired
sensation. In most cases, especially when the illness is first developing, the person
will eventually feel clean enough (i.e., safe from germs , disease , toxins , etc.) at
which time the ritual stops. Unfortunately, as mentioned above, this only strengthens
anxiety and other OCD symptoms because of a process called negative
reinforcement.