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Part A
Folliculitis
TEXT A
Folliculitis is a common skin problem that happens when you get bacteria or a blockage in a tiny pocket in
your skin called a hair follicle. You have hair follicles just about everywhere except your lips, your palms,
and the soles of your feet. Folliculitis can make these hair follicles red and swollen.

You can get this condition anywhere you have hair, but it’s most likely to show up on your neck, thighs,
buttocks, or armpits. You can often treat it yourself, but for more severe cases you may need to see your
doctor.

Different kinds of folliculitis have other names you might have heard, such as:

 Barber’s itch
 Hot tub rash
 Razor bumps
 Shaving rash

TEXT B
Types of Folliculitis

There are two primary types of folliculitis. Superficial folliculitis is when only part of the follicle is
damaged, while deep folliculitis is when the whole follicle is damaged.

The main types of superficial folliculitis are:

Bacterial folliculitis: The most common form, this type causes itchy white bumps filled with pus. You can
get it if you cut yourself and bacteria (usually staphylococcus aureus, also called staph) gets in.

Hot tub folliculitis (pseudomonas folliculitis): You can get this from swimming in a pool or sitting in a hot
tub where pH or chlorine levels aren’t balanced. You’ll see a rash of red, round, itchy bumps a day or so
after being in the water.

Razor bumps (pseudofolliculitis barbae): This type is caused by ingrown hairs linked to shaving or a bikini
wax. You’ll have dark bumps, or keloids, on your face or neck after shaving or in your groin area after a
wax.

Pityrosporum folliculitis: This type happens along with a yeast infection. It causes red, itchy, pus-filled
pimples that show up on your upper body, mostly on your back and chest, but you can also have them on
your neck, shoulders, arms and face.

Types of deep folliculitis include:

Sycosis barbae: This is when the whole follicle gets infected after shaving. It causes large red pus-filled
bumps and can lead to scarring in some cases.
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Gram-negative folliculitis: This type is caused by the use of long-term antibiotics to treat acne. It happens
if the bacteria become resistant to the antibiotics and make the acne worse.

Boils and carbuncles: A boil (a red bump that can be tender or painful) happens when a hair follicle is
seriously infected. A carbuncle is a cluster of several boils.

Eosinophilic folliculitis: People with HIV, late-stage AIDS, or cancer are most likely to experience this
form of folliculitis. Symptoms are intense and recurrent itching and can cause dark patches of skin known as
hyperpigmentation that show up most often on the shoulders, upper arms, neck, and forehead.

TEXT C
Treatments for folliculitis

The treatment for folliculitis varies depending on the type and severity of the condition.

Mild cases often only require home remedies. However, severe or recurrent cases may need medication or
other therapies.

Medication

Various medications are available for folliculitis. They can treat either bacterial or fungal infections,
depending on the condition’s cause. A doctor may also recommend anti-inflammatory drugs.

Light therapy

In severe cases, doctors may recommend light therapy or photodynamic therapy to treat folliculitis. This
type of treatment can help improve symptoms of deep folliculitis.

Lancing

Sometimes a doctor will drain a boil by making a small incision in the lesion to drain the pus. The aim is to
reduce pain and encourage a faster recovery time.

Laser hair removal

Laser therapy may help reduce folliculitis that results from frequent shaving. It destroys the hair follicles,
meaning bacteria, fungi, or viruses can no longer infect them. Several treatments are usually necessary to see
results.

Several home remedies are effective at treating folliculitis and its symptoms. They include:

Warm compresses: Placing a warm compress on the affected area can reduce itching and draw out pus. A
person can make a compress by soaking a cloth in warm water and wringing out the excess.

Over-the-counter products: Several topical creams, gels, and washes are available for folliculitis without a
prescription. These may help reduce general inflammation.

Good hygiene: Gently washing the affected area twice daily with a mild soap will help reduce the infection.
A washcloth is not advisable as it can cause further irritation to the skin.
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Soothing bath: Soaking in a tub of warm water may help reduce the itching and pain associated with
folliculitis.

TEXT D
Associated factors Patient’s number (%)
Acne 25 cases (61)
Dandruff 24 cases (58.8)
Pityriasis versicolor 11 cases (26.8)
Seborrhoeic dermatitis 2 cases (4.9)
Hyperseborrhea 40 cases (97.6)
Sweating (classified level 3 & 4) 7 cases 17.1)
Hair removal 8 cases (19.5)
Daily shaving 1 case (2.4)
Sports 12 cases (9.3)

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.

Folliculitis: 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. Available options for rectifying various folliculitis ___________

2. Laymen’s terms for folliculitis ___________

3. Number of sufferers infected ___________

4. Classifications of folliculitis ___________

5. Non prescribing remedies to reduce inflammation ___________

6. Vulnerable areas where the conditions generally occur ___________

7. An issue associated with the prolonged acne treatment ___________

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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. Which type of therapy is advised for extreme cases of folliculitis?

__________________________
9. How many times should a person clean daily using soap to reduce infection?
__________________________
10. What is the type of folliculitis when only a part of the whole follicle is damaged?
__________________________
11. Which factor had twice the number of cases reported than in sports?
__________________________
12. A type of folliculitis that typically affects the people who have a condition that affects their immune
system is?
__________________________
13. What was the ratio of patients when a case was reported?
_________________________
14. What is a cluster of several boils called?
_________________________

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. The maximum number of cases connected to cause folliculitis was with ______________________.
16. The healthcare professional will drain a ______________________ by making a small incision in
the lesion to drain the pus.
17. _______________________ is caused by ingrown hairs causing keloids, on your face or neck after
shaving or in your groin area after a wax.
18. __________________ destroys the hair follicles, meaning the germs can no longer infect them
reducing the folliculitis due to shaving.
19. A type of folliculitis when only part of the follicle is damaged due to yeast infection is
_______________________ that is more often seen on the back and chest.
20. The organism that cases the most common form of superficial folliculitis is ____________________
which causes itchy white bumps filled with pus.

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 answers (A, B or C) which you think fits best according to the
text.

1. The purpose of the memo regarding the safety update is to.

A inform the doctors to avoid using clozapine medication.

B inform the conditions that can be caused due to clozapine.

C inform the contents emphasized in the warning box.

Clozapine Safety Update

The potentially fatal risk of gastrointestinal hypomotility in patients taking clozapine has been
highlighted with a new boxed warning in the Product Information (PI) for this medicine. Health
professionals should assess for constipation before and during treatment with clozapine, and manage
suspected constipation promptly to prevent severe complications.
The severe gastrointestinal effects of intestinal obstruction, severe constipation and gastrointestinal
hypomotility are among the most serious adverse reactions experienced with clozapine. In post-
marketing experience, severe complications of gastrointestinal hypomotility (such as intestinal
obstruction, faecal impaction, megacolon, paralytic ileus and intestinal ischaemia or infarction) have
resulted in hospitalisation, surgery and death.
The new boxed text and other changes to the PI expand on existing warnings about severe
gastrointestinal adverse reactions associated with clozapine, which are primarily due to its potent
anticholinergic effects.
 2. The guidelines regarding emergency procedure is to suggest.

A the members of the organisation who can do training.

B the things the staff should know and abide by.

C the importance of the Wardens to conduct training annually.

Emergency Procedure
An Emergency Control Organisation (ECO) is made up of staff members from each of the campus
buildings, who are trained to assist in the smooth and safe response in the event of an emergency.
Staff members who perform this role are called Wardens. Wardens are required to undergo emergency
training every year, covering topics such as emergency evacuations, fire extinguisher operation, and
bomb threat procedures. The occupants of the building are responsible for ensuring that all procedures
are followed and practised regularly.
Staff must comply with the directions of wardens during an emergency, or an emergency drill. The staff
should also be well versed with the different codes and their definitions.
Code RED - Fire/ smoke
Code ORANGE - Evacuation
Code BLUE - Medical emergency
Code PURPLE - Bomb threat
Code GREY - Threatening behaviour
Code YELLOW - Internal emergency
Code BROWN- External emergency
Code BLACK - Personal threat
 3. The guidelines inform us that insulin pump therapy.

A should necessarily discontinue the use when in hospital.

B is advisable to all types of diabetes patients.

C are more appropriate to patients during their stay in the hospital.

In-Hospital Management of Insulin Pump Therapy

Insulin pumps have become increasingly prevalent in the management of diabetes in recent years.
Currently, in North America, about 20% to 30% of patients with type 1 diabetes mellitus are pump
users.
Despite their increased use, there is limited published literature outlining the appropriate use of insulin
pumps in the inpatient setting and perioperatively. Patients on insulin pump therapy do not necessarily
need to discontinue this form of therapy while hospitalized and, in fact, most request to remain on the
pump. In many circumstances, insulin pump users are more knowledgeable than their healthcare
providers about diabetes management and should be encouraged to self-manage their diabetes during
their hospitalization.
In a retrospective analysis, Nasser et al found high patient satisfaction and no difference in glycemic
control in patients allowed to remain on insulin pump therapy compared to those switched to alternative
insulin regimens during hospitalization.
In another retrospective study, Cook et al also found no significant difference in mean glucose levels in
patients who remained on insulin pump therapy in hospital compared to those for whom it was
discontinued; however, episodes of severe hyperglycemia and hypoglycemia were significantly less
common among pump users.
 4. The purpose of the extract is to informs us.

A the necessary steps to be taken to prevent any malpractices of information.

B that PROV is the most secure area to store the records of children.

C the records are stored in the form of emails, database and websites.

.
The Royal Children’s Hospital
RCH recognises the ongoing value of records and is committed to the efficient management of
information in line with the standards issued by the Public Records Office of Victoria (PROV).
RCH must collect, use and protect information including but not limited to health and personal
information in accordance with legislation and with procedures RCH has developed to ensure
compliance with its obligations. This policy applies to all aspects of RCH information (regardless of
format) that is created, managed and received during business transactions. This also applies to all
business applications used to create, manage and store records and corporate information including
email, database applications and websites.
RCH is committed to:
1. Meeting all legislative and regulatory requirements
2. Privacy of patient and staff information
3. Ensuring that information is kept in a safe and secure environment
4. Ensuring that information is held in a readable format for the minimum period of time required by
relevant legislation and PROV retention and disposal requirements.
5. Providing appropriate and monitored access to information
6. Ensuring that information collected is accurate, objective and factual
7. Informing patients and their families about their right to access information
8. Informing its staff about the management of information and ensuring staff are aware of their
obligations
 5. The notice is giving information about.

A The misconceptions of some therapists regarding the immunisation.

B The precautionary steps taken to curb the fatalities with preventable diseases.

C The importance of homoeopathic medicine over the traditional vaccines.

Homoeopathic Immunisation
Children are still suffering and dying unnecessarily from the preventable diseases of childhood. Whilst
the incidence of these diseases has declined dramatically since immunisation was introduced, there are
concerns regarding parental apathy in the absence of frequent graphic reminders of these diseases.
There are community misconceptions eg. that catching the “natural” disease is preferable to
vaccination. This is not true. The risk of complications from these diseases far outweighs any risk
associated with vaccination. Some natural therapists (including some well known community identities)
are promoting homoeopathic regimes for immunisation. THERE IS NO SCIENTIFIC EVIDENCE OF
IMMUNITY BEING ESTABLISHED BY HOMOEOPATHIC IMMUNISATION (as confirmed by blood
tests revealing the presence of antibodies). Parents put their children’s health at risk by consulting
untrained homoeopathic practitioners. Australian Natural Therapists Association executive director Mr.
Robert Zindler has advised the Health Department that fully trained natural therapists would not
advocate homoeopathic medicine as a complete alternative to orthodox vaccination.
 6. The guidelines to retail pharmacies inform us that.

A all retail pharmacies cannot operate two programs at the same time.

B they play an important role in dispensing methadone and sterile equipment.

C the highest priority is given to reduce disease transmitted via needle sharing.

Distribution of Needles and Syringes by Retail Pharmacies

Retail pharmacies perform an integral role in the New South Wales methadone program by dispensing
methadone to some individuals in treatment. Retail pharmacies are also an important source of sterile
needles and syringes to active intravenous drug users. The Department is fully supportive of the needle
distribution programme operating through over 350 pharmacies in NSW. The distribution of sterile
injection equipment has the objective of minimising the transmission of Human Immunodeficiency Virus
through needle sharing practices. Some retail pharmacies are involved in both methadone dispensing
and the distribution or sterile needles and syringes and this has given rise to the concern that the two
programs are in conflict and cannot operate well together. NSW has determined that the highest priority
should be given to the objective of limiting the spread of disease transmitted by needle sharing. The
alms or the methadone program includes the reduction of both intravenous drug use and the
transmission of the Human Immunodeficiency Virus and other disease agents. The Department advises
that pharmacists participating in Methadone programs should not be discouraged from supplying sterile
needles and syringes.
 PART C

COPD
Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory condition resulting in gradual
deterioration and worsening of symptoms. Although preventable, once established it cannot be cured, but
effective self-management strategies can lessen the burden of disease and improve quality of life. In 1990,
COPD was the second most common cause of death in terms of age standardised death rate across the world
and in 2019 COPD was the third most common cause of death. From 2007 to 2017, an increase of 15.6% in the
prevalence of COPD was reported, although the age standardised prevalence decreased by 10.1% in men.

COPD is considered a systemic disease and is more common in individuals with a history of tobacco
smoking. A wide range of comorbidities and risk factors are associated with the disease, including genetics,
smoking, infections, malnutrition, ageing, occupational exposures, indoor and outdoor air pollutants, asthma,
and low socioeconomic status. Together, these factors could lead to vascular abnormalities, such as loss of
alveolar capillary endothelial cells, destruction of alveolar cells, and alveolar space enlargement, which are
important contributors in the progression of COPD. Clinical manifestations of COPD, such as dyspnoea, cough,
wheezing, and phlegm, are more severe in the early morning and evening, negatively affecting the patient’s
quality of life. The prognosis of COPD is determined by measuring forced expiratory volume in one second, a
measure of airflow. Moreover, COPD can affect the prognosis of other diseases, such as covid-19, cancer,
mental health conditions, cardiovascular diseases, gastrointestinal disorders, and musculoskeletal disorders.

The burden of COPD reaches its peak in older adults. Physiologically, diminished lung function in advanced
ages, and impaired lung tissue repair and baseline inflammations, could contribute to the increased risk of
death. Moreover, COPD is associated with compromised health status and multiple comorbidities, which
together with the natural comorbidity of old age increases the mortality rate of COPD in elderly people. This
study found that people aged 80-84 years accounted for the highest numbers of deaths related to COPD.
Previous research has reported that the most significant effect of total air pollution, among non-communicable
diseases, is on deaths related to COPD. Furthermore, research has estimated that the highest number of deaths
from total air pollution were seen in those aged 80-84 years. This age pattern is the same as the burden of
COPD, suggesting that older individuals are more vulnerable to the adverse effects of air pollution.

The burdens of COPD are mainly preventable and the disease can be effectively treated, controlling the burden
of COPD requires more attention and a focused effort. Multiple initiatives have been developed to reduce
exposure to these risk factors. WHO endorsed a practical and cost-effective plan for controlling the tobacco
epidemic, MPOWER: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer
help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion,
and sponsorship; and Raise taxes on tobacco. This programme has six measures, focusing mainly on educating
the public about the dangers of tobacco use and banning trade and advertising of tobacco products. The latest
report on the global tobacco epidemic indicates that 75% of countries, comprising a population of 5.3 billion
people, are currently subject to at least one MPOWER measure at the highest level of achievement.
Global tobacco smoking has decreased by 27.5% over the past three decades. Smoking is the most common risk
factor for all chronic respiratory conditions and, apart from being the leading risk factor for COPD, nearly half
of smokers eventually develop the disease. Therefore, preventing exposure to tobacco smoke would be the most
effective long term strategy for reducing the burden of COPD. The US has had success in controlling air
pollution, mainly driven by interventions such as the 1990 Clean Air Act Amendments and the 2002 Nitrogen
Oxides (NOx) State Implementation Plan Call regulation, along with provisions for reducing anthropogenic
emissions from different types of vehicles. Accordingly, the US death burden caused by non-communicable
diseases, particularly COPD, substantially decreased by 54% from 1990 to 2010.

In some low-income regions, such as Oceania, and western, eastern, and central sub-Saharan Africa, household
air pollution from solid fuels was the leading risk factor for COPD, rather than smoking, and this finding was
more evident in women. In agreement with our results, a recent study in 13 low- and middle-income countries
reported that participants with a history of exposure to household air pollution were 41% more likely to develop
COPD, with a stronger association in women. Furthermore, although household air pollution accounted for
13.5% of the prevalence of COPD, smoking explained 12.4% of the prevalence. Research in China showed that
women who did not smoke had a two to three times higher risk of COPD in rural areas, where exposure to solid
fuels was higher, than women in urban areas.

Measures such as the use of alternative clean fuels, improving kitchen ventilation, and providing better stoves
could reduce the risk of COPD and improve the lung dysfunction in patients with the disease. Consequently,
formulating strict health measures towards preventing tobacco smoking and improving air pollution could be
crucial approaches for healthcare policy makers in alleviating the burden of COPD. The new Air Quality
Guidelines issued by WHO on 21 September 2021 recommend lower concentrations for gaseous and particulate
pollutants based on recent evidence of the harmful effects from concentrations below those recommended in
2005. Moreover, in November 2021, the European Environment Agency estimated that 58% (178 000) of
premature deaths could have been avoided in 2019 if the new WHO’s Air Quality Guidelines had been
implemented.

COPD is a major public health problem with extensive healthcare and economic costs. Although the point
prevalence, death, and DALY rates declined during the study period, the corresponding counts are increasing.
With an ageing population, COPD will continue to become an even greater problem in the future. The reported
global, regional, and national burden of COPD, and its risk factors, could help to provide a more accurate
projection of the future disease burden. This knowledge could guide policy makers in planning control
measures and supply services to meet the rising healthcare demands that COPD and its comorbidities will
create.
7. What do we learn about COPD from the first paragraph?

A Mortality due to this condition has deteriorated.

B A preconceived idea prevailed regarding its healing.

C An incurable ailment which can be fatal.

D Occurrence of COPD in men was high.

8. What is said about the indications of COPD in the second para?

A A way to measure the COPD is using airflow.

B Tobacco smoking is the major cause of the condition.

C Extreme during the dawn and dusk.

D Multifactorial conditions cause the disease.

9. What do we learn from the two reports from the 3rd paragraph?

A Further investigation is needed to confirm the cause.

B Indicated that the same agent was responsible for the death.

C Mortality was due to the conditions associated with ageing.

D COPD was more amongst the older population.

10. What do we learn about the most common risk for COPD?

A US have implemented regulations to mitigate the air pollution.

B Marked reduction in COPD rates.
C Smoking rates have deteriorated during the past 30 years.

D Maintaining abstinence is the right approach.

11. What do we learn about the preventive method recommended for controlling tobacco endemic?

A It is a meticulous approach to prevent and cease.

B It requires a systematic and focused approach.

C To get the complete benefit all the steps have to be adhered to.
D It is used in 75 countries under WHO.

12. What is highlighted as the key trigger for COPD in the 6th paragraph?

A Women were more prone to COPD in developing countries.

B Exposure to fumes from the biomass fuels.

C Statistical evidence between the two causative agents.

D More prevalent in people living in affluent areas.

13. In the 7th paragraph, what does the write implies about the guidelines?

A Europe has implemented the guideline.

B WHO has recommended to lower the recommended concentration of the pollutant.

C The recent evidence was not considered by the agency.

D A significant proportion of the people could have reaped the benefit.

14. What does the word this in the final paragraph refers to?

A Projected disease burden.

B Risks of ageing population.
C The amount incurred for COPD patients.
D Control measures of the policy makers.
The optimal use of Colon Capsule Endoscopes
Colon capsule endoscopy (CCE) has been available for nearly two decades but has grappled with being an equal
diagnostic alternative to optical colonoscopy (OC). Due to the COVID-19 pandemic, CCE has gained more
foothold in clinical practice. In this cutting-edge review, we aim to present the existing knowledge on the pros
and cons of CCE and discuss whether the modality is ready for a larger roll-out in clinical settings. CCE is
embedded with a very low risk of severe complications and can be performed in the patient’s home as a pain-
free procedure where the diagnostic accuracy is found to be equal to OC. However, a significant drawback is
low completion rates eliciting a high re-investigation rate. Furthermore, the bowel preparation before CCE is
extensive due to the high demand for clean mucosa. CCE is currently not suitable for large-scale
implementation in clinical practice mainly due to high re-investigation rates. By a better preselection before
CCE and the implantation of artificial intelligence for picture and video analysis, CCE could be the alternative
to OC needed to move away from in-hospital services and relieve long-waiting lists for OC.

Focus on early detection and treatment of colorectal cancer (CRC) has improved symptom awareness and
implementation of population-based CRC screening programmes. Consequently, millions of optical
colonoscopies are performed annually in Europe. OC is a sensitive and accurate diagnostic tool. There are,
however, some concerns. The number needed to scope (NNS) in CRC screening programmes to diagnose one is
increasing. In symptomatic patients referred by their general practitioner, the NNS to diagnose one CRC is even
higher. Moreover, as the current practice is to resect almost every polyp found during an OC, millions of time-
demanding procedures are generated throughout Europe, and resource demands for highly specialised medical
personnel, facilities and equipment are increasing. Even though OC’s complication rate is low, the sheer
number of procedures performed leads to greater than 1000 deaths and greater than 100,000 significant
complications in the EU each year. Furthermore, the rate of minor complications may be underreported. One
investigation reported a 6% sick leave after OC ranging from 1 to 9 days, significantly adding to society’s
costs. Finally, one colonoscopy produces more than 1.5 kg of nonrecyclable plastic and uses high energy and
water levels. Globally, healthcare sectors are responsible for 4.6% of CO2 emissions, whereas endoscopy
activity is a significant contributor.

CCE has been available since 2006. Technical and clinical challenges have prevented CCE’s widespread
adoption and use for years. However, despite improvements in imaging quality, pictures from CCE still fail to
match the picture quality from OC. Consequently, due to lack of evidence, European guidelines recommend
CCE only for a few indications. However, with the pioneering ScotCap programme and, more recently, the
English Camera Capsule Endoscopy programme, there seems to be a change of hearts. More than 10,000 CCEs
have been used in routine clinical practice mainly to exclude colonic neoplasia. CCE’s obvious advantages
(noncontact procedure, favourable safety profile), and the immense pressure generated by the disruption of
colonoscopy services, facilitated a better pitch for CCE during the COVID-19 pandemic. We know patients will
likely prefer CCE, especially if an OC does not follow the CCE test. The advantage of providing the capsule
camera test close to local healthcare centres or even in the patient’s residence is undoubtedly attractive. Data are
accumulating that the sensitivity and quality of CCE can match OC incomplete investigations. The
environmental impact of nonrecyclable colon capsules still needs to be estimated and will of course increase the
overall carbon footprint from the diagnostic pathway when a subsequent OC is warranted.
The CCE procedure is less uncomfortable for patients, causes less anxiety and intimidation and can be regularly
performed on an out-of-hospital basis. Conversely, OC is a test that passed the test of time and continues to
evolve. More than 80% of patients tend to gravitate towards the former when asked to choose between CCE and
OC. This represents only a ‘convenient’ representation of the whole truth. Patients do not tend to favour one or
the other diagnostic test alone; instead, they state their preference based on the assumption that this test will be
the one to give answers and lead to the next step in the management. Therefore, when presented with the
possible consequences of undergoing an inclusive procedure tend to shift towards the test that will give the
answers. In light of this, a recent meta-analysis shows a 50/50 distribution in patient preferences between CCE
and OC diagnostic pathways. Essentially, ‘champions’ for the CCE pathway are those with a complete (and
negative) examination; hence, the patient group does not require a further endoscopic test or other interventional
therapy. However, the ‘losers’ of the CCE diagnostic pathway are those needing two rounds of laxative
preparation, either because the CCE was incomplete or inconclusive or because it showed pathology requiring
more procedures.

Each CCE produces greater than 25,000 images, and reading is time-consuming and costly. Furthermore, CCE
reporting is burdened by remarkable intra- and interobserver variations. Unpublished data from our team show
that although polyp detection has an acceptable interobserver agreement, polyp size reporting and bowel
cleanliness grading carry unacceptable kappa values. Artificial intelligence (AI) algorithms in capsule
endoscopy have shown promising results but developing trustworthy AI is complicated. The results of AI
grading on cleanliness, based on the total number of CCE images of each video, might be quite different from
human assessment and indeed, the ‘truth’; capsule might spend much more time in the caecum than in the
transverse colon. Furthermore, the amount of information on a particular frame on cleanliness depends on the
proximity of the capsule dome to the colon wall. Landmarks such as colonic flexures are used when reporting
the localisation of lesions and segmental bowel cleanliness. Still, as the capsule might pass one flexure several
times, research is needed to investigate the reliability hereof.

CCE will not be a realistic alternative to all colonoscopy procedures. CCE makes sense only in a limited
population where the share of patients avoiding re-investigation after CCE is high. In our minds, CCE should be
offered to patients only with a priory risk of re-investigation of less than 25%. To achieve this, we need efficient
procedures for bowel preparation and transit times and, indeed, carefully selected patient groups. Therefore, the
steps here should be defined as- identify low-risk population cohorts for colorectal neoplasia; identify factors
which favour high completion rates and apply a realistic medicine approach;

National health service (NHS) highlands presented a cost-efficiency analysis on the use of CCE compared with
a colonoscopy-first diagnostic pathway, indicating a 20–30% higher cost with the CCE pathway. The
calculations are very sensitive to the re-investigation rates, which, in both UK pathways, are high. We believe
we can reach an economic break even by reducing the re-investigation rate to approximately 25%. According to
calculations based upon the Danish Care-for-Colon trial, including 6000 FIT-positive screening individuals in a
randomised trial between CCE and colonoscopy, it is indicated that a possible prize reduction in the procedure
of about 20% by adding AI reading to the pathway and reducing manual reading from 60 to 75 minutes to
approximately 10 minutes is achievable. The breakeven will likely be reached within 1–2 years. The economy
will likely further be facilitated as more commercial colon capsule providers enter the market within 2022.
15. What is highlighted as the drawback of CCE.

A Prolonged waiting period for OC.

B Lacks convincing proof in home setup.

C Time consumed in order to get clean mucosa.

D An elevated number who needs to revisit the health center.

16. What does the word ‘foothold’ refer to in the first paragraph?

A Merits and demerits of the endoscopic procedure.

B A position from which further progress can be made in clinical settings.

C A diagnostic alternative for another procedure.

D A method available for 20 years.

17. What does the writer emphasise regarding the industry from the second paragraph?

A The role of being a major contributor to air pollution in undeniable.

B Patients who are referred by the GP are all symptomatic.

C Demand of optic colonoscopy has waned.

D A report found the reason for sick leave which has an effect on economy.

18. According to the writer, the reason for the preference of CCE during the pandemic is due to

A the advancement of new technology into the programme.

B its unavailability in the local healthcare set up.
C the fact that it does not need any physical contact with the person.

D its effect in reducing the carbon emission is lessened.

19. When commenting on the widespread implementation of the CCE in the 4 th, the writer aims to emphasise
that?

A a further study is required to validate them.

B procedure can be done only in the hospital.

C the patient’s preference is pivotal.

D A continuous evolvement occurs in OC.

20. What is highlighted about quality reporting in the fifth paragraph?

A To report the complications size and complications of bowel.

B Further studies are required to authenticate it.

C AI results are more precise than human assessment.

D The need time-lapse in taking pictures.

21. What does the writer emphasize in the 6th para?

A Preselection of patient is mandatory.

B A quarter of patients are only to be considered for the procedure.

C Patients with efficient bowel movement should be selected.

D A high rate is incurred for the completion of the surgery.

22. What is foreseen regarding the cost-effectiveness of CCE from the final para?

A 25% of the cost can be reduced from the re-examination.

B It will still remain as the expensive procedure.
C The entry of more manufacturers can aggravate the burden.
D A positive outcome can be reached from the outcome of the trial.