Tamiflu and ADHD

OET:

Reading Part B – Tamiflu and ADHD

Reading Sub-test B Time allowed : 45 minutes There are two reading passages in this test. After each passage you will find 10 questions or unfinished statements about the passage, each with four suggested answers or ways of finishing. You must choose the one which you think fits best, i.e., the best answer. For each question, 1-20, indicate on your answer sheet the letter A, B, C or D against the number of the question. Answer all questions. Marks will not be deducted for incorrect answers. You must complete your answer sheet within the 45 minutes allowed for this sub-test.

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Reading Part B – Tamiflu and ADHD Test 1

Title: Does Tamiflu really work? Paragraph 1 The British Medical Journal (BMJ) was dominated in 2009 by a cluster of articles on oseltamivir (Tamiflu) Between them the articles conclude that the evidence that oseltamivir reduces complications in otherwise healthy people with pandemic influenza is now uncertain and that we need a radical change in the rules on access to trial data. Paragraph 2 The use of meta-analysis is governed by the Cochrane review protocol. Cochrane Reviews investigate the effects of interventions for prevention, treatment and rehabilitation in a healthcare setting. They are designed to facilitate the choices that doctors, patients, policy makers and others face in health care. Most Cochrane Reviews are based on randomized controlled trials, but other types of evidence may also be taken into account, if appropriate. Paragraph 3 If the data collected in a review are of sufficient quality and similar enough, they are summarised statistically in a meta-analysis, which generally provides a better overall estimate of a clinical effect than the results from individual studies. Reviews aim to be relatively easy to understand for non-experts (although a certain amount of technical detail is always necessary). To achieve this, Cochrane Review Groups like to work with "consumers", for example patients, who also contribute by pointing out issues that are important for people receiving certain interventions. Additionally, the Cochrane Library contains glossaries to explain technical terms Paragraph 4 Briefly, in updating their Cochrane review, published in late 2009. Tom Jefferson and colleagues failed to verify claims, based on an analysis of 10 drug company trials, that oseltamivir reduced the risk of complications in healthy adults with influenza. These claims have formed a key part of decisions to stockpile the drug and make it widely available. Paragraph 5 Only after questions were put by the BMJ and Channel 4 News has the manufacturer Roche committed to making "full study reports" available on a password protected site. Some questions remain about who did what in the Roche trials, how patients were recruited, and why some neuropsychiatric adverse events were not reported. A response from Roche was published in the BMJ letters pages and their full point by point response is published online.

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Reading Part B – Tamiflu and ADHD

Paragraph 6 Should the BMJ be publishing the Cochrane review given that a more complete analysis of the evidence may be possible in the next few months? Yes, because Cochrane reviews are by their nature interim rather than definitive. They exist in the present tense, always to be superseded by the next update. They are based on the best information available to the reviewers at the time they complete their review. The Cochrane reviewers have told the BMJ that they will update their review to incorporate eight unpublished Roche trials when they are provided with individual patient data. Paragraph 7 Where does this leave oseltamivir, on which governments around the world have spent billions of pounds? The papers in last years journal relate only to its use in healthy adults with influenza. But they say nothing about its use in patients judged to be at high risk of complications— pregnant women, children under 5, and those with underlying medical conditions; and uncertainty over its role in reducing complications in healthy adults still leaves it as a useful drug for reducing the duration of symptoms. However, as Peter Doshi points out on this outcome it has yet to be compared in head to head trials with non-steroidal inflammatory drugs or paracetamol. And given the drug’s known side effects, the risk-benefit profile shifts considerably if we are talking only in terms of symptom relief. Paragraph 8 We don’t know yet whether this episode will turn out to be a decisive battle or merely a skirmish in the fight for greater transparency in drug evaluation. But it is a legitimate scientific concern that data used to support important health policy strategies are held only by a commercial organisation and have not been subject to full external scrutiny and review. It can’t be right that the public should have to rely on detective work by academics and journalists to patch together the evidence for such a widely prescribed drug. Individual patient data from all trials of drugs should be readily available for scientific scrutiny.

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Reading Part B – Tamiflu and ADHD Questions: Tamiflu

1 A cluster of articles on oseltamivir in the British Medical Journal conclude ...... A B C D

complication are reduced in healthy people by oseltamivir the efficacy of Tamiflu in now in doubt complications from pandemic influenza are currently uncertain a series of articles supporting Tamiflu

2 Cochrane Reviews are designed to ...... A B C D

set randomized controlled trials to specific vaues compile literature meta-analysis peer review articles influence doctors choice of prescription

3 According to the article, which one of the following statements about Tamiflu is FALSE? A B C D

The use of randomized controls is suspect The efficacy of Tamiflu is certain Oseltamivir induces complications in healthy people Cochrane reviews are useful when examining the efficacy of Tamiflu

4 According to the article, Cochrane Review Groups …... A B C D

like to work for "consumers". are being overhauled. use language suitable for expert to expert communication. evaluate a clinical effect better than individual studies.

5 Which would make the best heading for paragraph 4? A B C D

Analysis of 10 drug company trials The stockpiling of Oseltamivir Risk of complications in healthy adults Tamiflu claims fail verification

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Reading Part B – Tamiflu and ADHD

6 According to the article, which one of the following statements about Roche is TRUE? A B C D

Full study reports were made freely available on the internet Patients were recruited through a double blind trial The identities and roles of researcher in the Roche trials are not fully accounted for Not all neuropsychiatric adverse events were reported

7 Cochrane reviews should ………….. A B C D

use a more complete analysis not be published until final data is available be considered interim rather than definitive advice be superseded by a more reliable method of reporting results

8 Which would make the best heading for paragraph 7? A B C D

Risk-benefit profile of Tamiflu Studies limited to healthy adults High risk of complications Oseltamivir only for high risk patients

9 Which one of the following is given as THE LEAST CERTAIN application of oseltamivir? A B C D

All of the below Healthy adults with influenza Patients judged to be at high risk of complications In terms of symptom relief

10 From the article, it can be inferred that …... A B C D

Ressearch on Tamiflu needs to be re-evaluated and more transparent There is no need to stockpile Tamiflu The studies by Roche may have been falsified The effectiveness of Tamiflu in healthy adults is validated

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Reading Part B – Tamiflu and ADHD TEST 2 Title: Is ADHD a valid diagnosis in adults?

Paragraph 1 Attention deficit hyperactivity disorder (ADHD) is well established in childhood, with 3.6% of children in the United Kingdom being affected. Most regions have child and adolescent mental health or paediatric services for ADHD. Follow-up studies of children with ADHD find that 15% still have the full diagnosis at 25 years, and a further 50% are in partial remission, with some symptoms associated with clinical and psychosocial impairments persisting. Paragraph 2 ADHD is a clinical syndrome defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, by high levels of hyperactive, impulsive, and inattentive behaviours in early childhood that persist over time, pervade across situations, and lead to notable impairments. ADHD is thought to result from complex interactions between genetic and environmental factors. Paragraph 3 Proof of validity. Using the Washington University diagnostic criteria, the National Institute for Health and Clinical Excellence (NICE) reviewed the validity of the system used to diagnose ADHD in children and adults. Paragraph 4 Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are found to cluster together in both clinical and population samples. Studies in such samples also separate ADHD symptoms from conduct problems and neurodevelopmental traits. Twin studies show a distinct pattern of genetic and environmental influences on ADHD compared with conduct problems, and overlapping genetic influences between ADHD and neurodevelopmental disorders such as autism and specific reading difficulties. Disorders that commonly, but not invariably, occur in adults with ADHD include antisocial personality, substance misuse, and depression. Paragraph 5 Symptoms of ADHD are continuously distributed throughout the population. As with anxiety and depression, most people have symptoms of ADHD at some time. The disorder is diagnosed by the severity and persistence of symptoms, which are associated with high levels of impairment and risk for developing co-occurring disorders. ADHD should not be diagnosed to justify the use of stimulant drugs to enhance performance in the absence of a wider range of impairments indicating a mental health disorder.

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Reading Part B – Tamiflu and ADHD

Paragraph 6 ADHD symptoms have been tracked from childhood through adolescence into adult life. They are relatively stable over time with a variable outcome in which around two thirds show persistence of symptoms associated with impairments. Current evidence defines the syndrome as being associated with academic difficulties, impaired family relationships, social difficulties, and conduct problems. Cross sectional and longitudinal follow-up studies of adults with ADHD have reported increased rates of antisocial behaviour, drug misuse, mood and anxiety disorders, unemployment, poor work performance, lower educational performance, traffic violations, crashes, and criminal convictions. Paragraph 7 Several genetic, environmental, and neurobiological variables distinguish ADHD from non-ADHD cases at group level, but are not sufficiently sensitive or specific to diagnose the syndrome. A family history of ADHD is the strongest predictor—parents of children with ADHD and offspring of adults with ADHD are at higher risk for the disorder. Heritability is around 76%, and genetic associations have been identified. Consistently reported associations include structural and functional brain changes, and environmental factors (such as maternal stress during pregnancy and severe early deprivation). Paragraph 8 The effects of stimulants and atomoxetine on ADHD symptoms in adults are similar to those seen in children. Improvements in ADHD symptoms and measures of global function are greater in most studies than are reported in drug trials of depression. The longest controlled trial of stimulants in adults showed improvements in these response measures over six months. Stimulants may enhance cognitive ability in some people who do not have ADHD, although we are not aware of any placebo controlled trials of the effects of stimulants on work or study related performance in healthy populations. This should not, however, detract from their specific use to reduce symptoms and associated impairments in adults with ADHD. Paragraph 9 Psychological treatments in the form of psychoeducation, cognitive behavioural therapy, supportive coaching, or help with organising daily activities are thought to be effective. Further research is needed because the evidence base is not strong enough to recommend the routine use of these treatments in clinical practice. Paragraph 10 Conclusions. ADHD is an established childhood syndrome that often (in around 65% of cases) persists into adult life. NICE guidelines are a milestone in the development of effective clinical services for adults with ADHD. Recognition of ADHD in primary care and referral to secondary or tertiary care specialists will reduce the psychiatric and psychosocial morbidity associated with ADHD in adults.

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Reading Part B – Tamiflu and ADHD Questions: ADHD

11

The article reports what proportion of diagnosed children present with ADHD in adulthood? A B C D

Half 3.6% A quarter 15%

12 According to the article …… A B C D

ADHD is triggered by genetic factors ADHD is the result of environmental factors both A and B. neither A nor B.

13 According to the article symptoms ……… A B C D

vary across clinical and population samples. varies across situational factors. need to pervade across time and situations for a diagnosis to be made. are not reliably identifiable.

14 Which co-occurring disorders does ADHD frequently present with? A B C D

Antisocial personality disorder. Substance misuse. Depression. All of the above.

15 According to the article, which one of the following statements about ADHD is FALSE? A B C D

The use of stimulants is justified in the absence of a wider range of impairments. Symptoms of ADHD are evenly prevalent throughout the population. The criteria for diagnosis measure the severity and persistence of symptoms. High levels of impairment and risk for developing co-occurring disorders are related with ADHD.

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Reading Part B – Tamiflu and ADHD

16 Which heading would best describe paragraph 6? A B C D

Symptoms associated with impairments. ADHD and outcomes in adulthood. Further definition of the syndrome. none of the above

17 The strongest predictor of ADHD is ……….. A B C D

Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Social and academic impairment. Heritability. Family environment.

18 The effectiveness of atomoxetine on ADHD symptoms is …………. A B C D

less than described in drug trials of depression. greater when measured over six months. reduced in adults with ADHD. known to improve measures of global functioning.

19 Which heading would best describe paragraph 9? A B C D

Recommendations. Use of alternative treatments. Programs thought to be effective. Psychological treatments.

20 It can be inferred from the article the author believes, ...... A B C D

ADHD is a non-persistent syndrome. The majority of children with ADHD will go on to display symptoms in adulthood. Psychological treatments should replace drug treatment. There is a need to develop clinical services for adults with ADHD.

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OET:

Reading Part B – Tamiflu and ADHD Answers

Tamiflu

ADHD

1

b

11

d

2

b

12

c

3

b

13

c

4

d

14

d

5

d

15

a

6

a

16

b

7

c

17

c

8

a

18

d

9

d

19

a

10

a

20

d

10