Epidemiology and Preventative Medicine Flashcards
1.
A 53-year-old woman presents to the clinic for
her yearly physical. She is concerned about
heart disease because her mother recently had
a myocardial infarction at age 74 years and her
father passed away from heart disease at the age
of 63 years. She is a high school teacher who
smokes a half-pack of cigarettes per day. Her
blood pressure during the last two office visits
was 122/69 and 128/73 mm Hg. Her last mea-
sured HDL cholesterol level was 63 mg/dL.
On physical examination she is close to her
ideal body weight, and there are no abnormali-
ties. Which of the following is an appropriate
goal for this patient’s LDL cholesterol level?
(A) 100 mg/dL or less
(B) 130 mg/dL or less
(C) 160 mg/dL or less
(D) 200 mg/dL or less
(E) Direct therapy at raising the HDL cholesterol level, not reducing LDL cholesterol
- The correct answer is C.
According to the
most recent report from the National Choles-
terol Education Program, the goal LDL cho-
lesterol level should take into account the indi-
vidual’s risk factors. This patient’s smoking
history is her only risk factor. In addition, her
relatively high HDL cholesterol level is protec-
tive. Therefore, she should be considered in
the group with a zero to one risk factor, and
her optimal LDL cholesterol level is 160 mg/
dL or less.
2.
Investigators in a multisite trial are attempting
to determine how many patients are needed
before they break the blinding on their study
and analyze their data. They want to ensure
that there are enough patients to detect a dif-
ference between treatment and placebo if one
is actually there. It is a very costly trial, and the
study sponsors do not want to pay for more
work than is needed to prove a difference.
What calculation do the researchers need to
perform to determine how much funding to re-
quest from their sponsoring agency?
(A) Confidence interval
(B) P value
(C) Power
(D) Type I error
(E) Type II error
- The correct answer is C.
Power is the proba-
bility that a study will fi nd a statistically signifi-
cant difference when one is actually there. It
relates directly to the number of subjects. A
power calculation is required in many grant
applications.
3.
A 3-year-old boy is brought to the clinic by his
mother. She is concerned because the patient
has complained of a sore throat over the past 4
days. He is not in day care and has had no
known sick contacts. His 7-year-old sister is
currently healthy. The physician does a throat
swab for a rapid streptococcal test and sends a
second specimen for culture. Why does the
physician perform both tests?
(A) The culture may grow strains of bacteria
which are not detected by the rapid test
(B) The rapid streptococcal test and culture
both have high sensitivity
(C) The rapid streptococcal test and culture
both have high specificity
(D) The rapid streptococcal test has a high sen-
sitivity, while the culture has high specificity
(E) The rapid streptococcal test has a high
specificity, while the culture has high sensitivity
- The correct answer is D.
Screening tests, such
as the rapid streptococcal test, have high sensi-
tivity and low specifi city. If the rapid strepto-
coccal test is positive, this indicates but does
not prove that the patient’s pharyngitis may be
due to group A streptococcal infection. If the
rapid streptococcal test is negative, then no fur-
ther testing is needed, because sensitive tests
effectively rule out disease. The throat culture
is highly specifi c and thus is able to confirm
(rule in) the disease. It may also indicate ex-
actly which organism is involved and narrow
treatment options.
4.
A 34-year-old woman presents to a surgeon to
discuss the possibility of an elective splenec-
tomy. Several weeks ago she was diagnosed
with idiopathic thrombocytopenic purpura. At
that time her platelet count was 24,000/mm³.
Her primary care doctor started her on oral
prednisone, 50 mg/daily. At presentation today
she continues to have lower extremity pete-
chiae along with mucosal bleeding. Her repeat
platelet count is 29,000/mm³. Infection with
which of the following is most likely to result
in postsplenectomy sepsis?
(A) Haemophilus influenzae
(B) Moraxella catarrhalis
(C) Pseudomonas aeruginosa
(D) Staphylococcus aureus
(E) Viridans streptococci
- The correct answer is A.
Asplenic patients are
at an increased risk of developing infections
compared to those patients with functional
spleens. These patients may develop over-
whelming postsplenectomy sepsis in which en-
capsulated organisms (including
Streptococcus pneumoniae, Neisseria meningitidis,
and Haemophilus influenzae) may cause fever,
lethargy, or upper respiratory infection that leads to
coma and death in up to 50% of patients. The
capsule that surrounds these organisms is an
antiphagocytic factor that permits these organ-
isms to survive and cause bacteremia. It is vital
for these patients to receive vaccination against
these encapsulated organisms to prevent the
development of postsplenectomy sepsis.
5.
An investigator wishes to assess whether vacci-
nation increases the incidence of developmen-
tal diseases such as autism. He asks parents of
recently diagnosed cases about their child’s
vaccination history and compares their re-
sponses to those of parents of children who
have not been diagnosed with autism. What is
the most significant type of potential bias present
in this study design?
(A) Confounding bias
(B) Lead-time bias
(C) Length bias
(D) Measurement bias
(E) Recall bias
- The correct answer is E.
Bias is any process
that causes results to systematically differ from
the truth. Recall bias occurs when cases and
controls remember information differently, that
is, when a recent diagnosis may have prompted
them to search their memory for recent events
that they feel may have contributed to the diag-
nosis. A false association may be found because
cases are more likely to remember recent vacci-
nations, not because of any pathological process.
6.
A 65-year-old woman presents with 3 months
of unintentional weight loss, jaundice, and upper
abdominal pain that radiates to her back.
Her gallbladder is palpable on physical exami-
nation, and an ultrasound demonstrates dilated
bile ducts with no visible stones. Which of the
following is a known risk factor for this patient’s
condition?
(A) Chronic gastritis
(B) Diabetes insipidus
(C) Diabetes mellitus
(D) History of cholecystitis
(E) Smoking
- The correct answer is E.
Patients with pancre-
atic cancer can present with weight loss, jaun-
dice, abdominal pain, dark urine, acholic
stools, and pruritus. On physical examination
the gallbladder or other abdominal mass is pal-
pable. Diagnosis is usually made with ultra-
sound with fi ndings of dilated bile ducts or visi-
ble mass, or CT scan which demonstrates the
pancreatic mass. The associated risk factors for
pancreatic cancer include smoking, chronic
pancreatitis, a fi rst-degree relative with pancre-
atic cancer, and high-fat diet.
7.
A 21-year-old woman comes to the clinic for a
health check-up. She has been sexually active
since she was 17 years old and has never seen a
gynecologist before. The physician discusses
the importance of health screening with the
patient and performs a Papanicolaou (or Pap)
smear during the visit. Which of the following
is the most appropriate screening schedule
recommendation?
(A) Pap tests every 3 years beginning approxi-
mately 3 years after first intercourse or at
21 years of age
(B) Yearly Pap test and human papillomavirus
DNA testing beginning approximately 3
years after first intercourse or at 21 years of age
(C) Yearly Pap tests beginning approximately 3
years after first intercourse or at 21 years of age
(D) Yearly Pap tests beginning at menarche
and ending at menopause
(E) Yearly Pap tests once a patient is sexually
active or at 21 years of age
- The correct answer is C.
The American Can-
cer Society and the US Preventive Services
Task Force recommend that cervical cancer
screening take place with yearly Pap tests ap-
proximately 3 years after beginning to have
vaginal intercourse, but no later than age 21
years. Women >30 years old who are at low risk
may then undergo Pap testing every 2–3 years
if they have had at least three normal consecu-
tive Pap tests prior to this time. Women >70
years old with three or more normal consecu-
tive Pap tests and no abnormalities within the
past 10 years may choose to stop having cervi-
cal cancer screening. Furthermore, women
who have had a total hysterectomy may stop
having cervical cancer screening unless they
had their hysterectomy due to cervical carci-
noma or preinvasive changes, or if they had a
hysterectomy without removal of the cervix.
8.
A 78-year-old woman in otherwise good health
schedules a visit with her primary care physi-
cian because she has been experiencing blood
in her stool that she describes as “maroon.”
Her past medical history is signifi cant for psori-
asis and mild degenerative joint disease. In
thinking about the possible causes of her lower
gastrointestinal bleed, which of the following
lists is in order of most common to least common?
(A) Angiodysplasia > cancer/polyp > diverticulosis
(B) Angiodysplasia > diverticulosis > cancer/ polyp
(C) Cancer/polyp > diverticulosis > angiodysplasia
(D) Diverticulosis > angiodysplasia > cancer/ polyp
(E) Diverticulosis > cancer/polyp > angiodysplasia
- The correct answer is E.
Diverticulosis ac-
counts for 42%–55% of lower gastrointestinal
bleeding, followed by cancer/polyps account-
ing for 8%–26%, and bleeding and angiodys-
plasia which accounts for 3%–12%. Other
causes include infl ammatory bowel disease
(2%–8%), anorectal disease (3%–9%), small
bowel disease (3%–5%), infectious colitis (1%–
5%), radiation colitis (1%–5%), and vas culitis
(13%).
9.
A hypothetical study is created to examine the
effect of cigarette smoking on the development
of lung cancer. Patients who smoke at least one
pack per day are matched with an appropriate
group of nonsmokers. Ten years later, informa-
tion on the development of lung cancer is col-
lected, and the following data are observed.
What is the relative risk (risk ratio) of develop-
ing lung cancer for cigarette smokers?
(A) 1 / 20
(B) 19 / 100
(C) 1
(D) 20
(E) 20 / (80 / 99)
- The correct answer is D.
This is an example of
a prospective cohort study. Using the letters
from the table, the relative risk is calculated as
[a / (a + b)] / [c / (c + d)] = 20 (rounded to the
nearest whole number), so smokers have 20
times the risk of nonsmokers of developing
lung cancer.
10.
A study is performed to assess the relationship
of dietary cholesterol and myocardial infarc-
tion. Participants are assigned to either an ex-
perimental group, which eats a low-cholesterol
diet, or a control group, which eats a standard
American diet. Dietary analysis later reveals
that the group assigned a low-cholesterol diet
ended up also consuming less fat than the con-
trol group. In analyzing the relationship be-
tween dietary cholesterol and myocardial in-
farction, the amount of dietary fat consumed
represents what type of study characteristic?
(A) Confounding variable
(B) Enrollment bias
(C) Measurement bias
(D) Recall bias
(E) Self-selection bias
- The correct answer is A.
A confounding vari-
able is a characteristic associated with both the
exposure of interest and the disease or condi-
tion being studied that may have an indepen-
dent effect on the relationship between the ex-
posure and disease of interest. In the study,
dietary cholesterol may infl uence the risk of
myocardial infarction, but dietary fat may also
influence myocardial infarction risk and thus it
is difficult to tell what proportion of decreased
risk is due to which dietary factor.
11.
A 5-year-old boy is brought to his pediatrician
because he has been complaining of fatigue
and headache for several weeks. On examina-
tion he has enlarged lymph nodes and is sent
for a bone marrow biopsy. The biopsy shows
large lymphoblasts with prominent nucleoli
and light blue cytoplasm, and the patient is di-
agnosed with acute lymphoid leukemia. He is
treated with high-dose glucocorticoids, intrave-
nous and intrathecal methotrexate, cyclophos-
phamide, doxorubicin, and vincristine. He
achieves a full remission. Which of the follow-
ing accurately matches the causative drug with
the possible adverse effect that he may experi-
ence now or in the future?
(A) Cyclophosphamide: hearing loss
(B) Glucocorticoids: cataracts
(C) Glucocorticoids: peripheral neuropathy
(D) Methotrexate: cognitive deficit
(E) Methotrexate: pulmonary fibrosis
- The correct answer is B.
Chronic use of high-
dose steroids, as those used to treat acute lym-
phoid leukemia, may result in formation of bi-
lateral cataracts. Patients should be monitored
closely, particularly those that are school-aged,
because they may suffer from visual defects.
12.
A 72-year-old man presents to his primary phy-
sician with complaints of fatigue, weight loss,
dyspnea on exertion, abdominal pain, and dark
blood in the stool. Although the patient had a
negative sigmoidoscopy on routine examina-
tion 6 months ago, colon cancer is strongly sus-
pected. Which is the best diagnostic modality
to use in this patient?
(A) Colonoscopy
(B) CT of the abdomen
(C) Double contrast barium enema
(D) Sigmoidoscopy
(E) Upper gastrointestinal series
- The correct answer is A.
Colonoscopy is the
method of choice in this individual because the
lesion is most likely right sided, as suggested by
a negative sigmoidoscopy 6 months ago. With
colonoscopy, the entire large bowel can be visu-
alized, and it also allows the biopsy of lesions or
removal of polyps found on examination.
13.
A 23-year-old woman presents to her gynecolo-
gist for a refill of her birth control prescription.
She denies recent sexual activity, although she
has been sexually active in the past and is cur-
rently using oral contraceptives to regulate her
menstrual cycle and control acne. Her last Pap
smear was 13 months prior. She says that her
31-year-old sister just went for her annual ex-
amination and was told that she did not need
an annual Pap smear. In which of the follow-
ing populations may an annual Pap smear be
deferred?
(A) HIV-positive women with no documented
history of cervical pathology
(B) Women >30 years old who have had three
consecutive conventional cytology negative Pap smears
(C) Women >60 years old who are positive for
human papillomavirus DNA
(D) Women who have had a hysterectomy and
documented cervical intraepithelial neoplasia II/III
(E) Women with 2 or more negative conven-
tional cytologic studies
- The correct answer is B.
Current recommen-
dations are that a Pap smear be done once ev-
ery 1–3 years based on risk factors and cytology
method. In 2003 the American College of Ob-
stetricians and Gynecologists recommended
that women younger than 30 years be screened
annually, regardless of liquid or conventional
culture method. However, the US Preventative
Services Task Force recommends that women
of any age extend time between screening to
every 2–3 years if they have no risk factors and
have had three or more consecutive negative
cytologic studies by conventional method. Risk
factors include diethylstilbestrol exposure in
utero, prior cervical intraepithelial neoplasia
II/III or abnormal Pap smear, smoking, or im-
munocompromised state. A gonorrhea and
chlamydia screen may be recommended if the
patient is sexually active.
14.
A 53-year-old man presents to his physician’s
office in tears. A close friend of his was recently
diagnosed with lung cancer, so the patient is
concerned because he has smoked a pack of
cigarettes daily for 39 years and his father died
of lung cancer. He recalls that he had a pro-
ductive cough 2 months prior that resolved af-
ter several weeks. He is concerned that he
might have lung cancer or might develop it in
the future. He asks whether there is a test he
can undergo on a regular basis to “catch the
cancer early.” Which of the following is the
most appropriate screening test for this patient?
(A) Annual x-ray of the chest
(B) Biannual low-dose helical CT scan
(C) Biannual sputum cytology
(D) Bronchoscopy
(E) None; advise the patient to quit smoking
and monitor for clinical signs of lung cancer
- The correct answer is E.
Lung cancer is not
hereditary but is based on environmental expo-
sures to radon, asbestos, or cigarette smoke.
There is evidence to suggest that a patient’s risk
of developing lung cancer from tobacco expo-
sure decreases somewhat after the patient quits
smoking, depending on the patient’s smoking
history and medical status. The patient should
be counseled about smoking cessation, and ap-
propriate adjustments to medications should
be made if the patient is started on nicotine
gum or patch. In 2004 the U.S. Preventive Ser-
vices Task Force determined that “the evidence
is insuffi cient to recommend for or against
screening asymptomatic persons for lung can-
cer with either low dose computed tomogra-
phy, plain chest radiographs, sputum cytology,
or a combination of these tests.”
15.
A 34-year-old man was diagnosed with type 2
diabetes mellitus as a child and has been pre-
senting for annual examinations since he was
in his early 20s. Which of the following screen-
ing tests is indicated more than once a year?
(A) Hemoglobin A1c
(B) Lipid profile
(C) Microalbuminuria
(D) Ophthalmologic examination
(E) Podiatry examination
(F) Serum fructosamine
- The correct answer is A.
A hemoglobin A1c
level should be checked every 3 months to as-
sess the average serum glucose levels over that
time period. This is important in adjusting med-
ications and to follow the disease progression.
16.
Laboratory researchers are developing a sali-
vary test for systemic cocaine. The manufac-
turer has requested that their ideal test will
miss very few, if any, people who have used co-
caine recently. Which of the following best de-
scribes what the manufacturer wants in epide-
miologic terms?
(A) Of cocaine users, the probability of testing
positive is very high
(B) Of people with a negative test, the proba-
bility of having used cocaine is very low
(C) Of people with a positive test, the probabil-
ity of having used cocaine is very high
(D) Of those not using cocaine, the probability
of testing negative is very low
- The correct answer is A.
This answer describes
sensitivity. A highly sensitive test will rarely
miss people with the disease, and is thus a good
“rule-out” if negative. It is calculated mathe-
matically by dividing the number of those with
disease (or in this case, condition of interest)
and a positive test by the total number of peo-
ple with disease (or condition).