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Question 1 of 40
1. Question
A 5-day-old girl is brought to the office by her adoptive parents for her first newborn visit. The girl has been doing well. The parents are concerned about her risk of having hemophilia A. The birth father and his brother (the paternal uncle) have hemophilia A. The birth mother does not, and there is no history of bleeding in her family, including in male relatives. The girl is well-appearing and has no abnormalities on examination. Which of the following is the most appropriate response?
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Question 2 of 40
2. Question
A 30-year-old woman comes to the physician after finding a breast mass on self examination. After the appropriate workup, the physician decides to proceed with fine-needle aspiration (FNA). Cytology of the aspirate comes back negative for malignancy. However, the patient is still concerned about the possibility of breast cancer despite her negative FNA result. Which of the following test parameters would be the most helpful for determining this patient’s residual risk of breast cancer?
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Question 3 of 40
3. Question
A large study examined the role of a new medication X in patients with known atherosclerotic vascular disease. Study subjects were randomized into intervention (medication X) versus placebo groups and followed for a mean of 3.9 years. The following results were reported:
Which of the following is the most accurate statement about the study results?
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Question 4 of 40
4. Question
A 38-year-old primigravid woman comes to the physician’s office at 20 weeks gestation for prenatal counseling. She is concerned about her baby’s risk for Down syndrome and asks about measures to diagnose it early. The physician explains that triple screening may detect up to 60% of cases of chromosomal abnormalities and that amniocentesis may detect approximately 90% of cases. The patient decides not to undergo any testing. When explaining that amniocentesis detected a higher percentage of cases compared to triple screening, the physician was referring to which of the following values?
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Question 5 of 40
5. Question
A study assesses the length of stay in the intensive care unit after common surgical procedures. The following graph is obtained by plotting the number of admissions against length of stay (in days).
Which of the following corresponds to the measures of central tendency on the graph?
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Question 6 of 40
6. Question
A 45-year-old man is diagnosed with dilated nonischemic cardiomyopathy. Late gadolinium enhancement cardiac magnetic resonance (CMR) imaging shows a left ventricular ejection fraction (LVEF) of 20% and evidence of extensive midwall myocardial scarring. A recent study determined prognosis in patients with dilated cardiomyopathy using CMR-derived LVEF and evidence of midwall myocardial scarring (fibrosis). Two models were assessed: one model was based on LVEF alone, and the other incorporated the presence or absence of fibrosis. The following 5-year prediction curves were reported:
Based on the study results, what is the approximate predicted 5-year all-cause mortality for this patient?
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Question 7 of 40
7. Question
The following vignette applies to the next 2 items.
A 28-year-old woman comes to the office due to chronic diarrhea. She also has osteoporosis and anemia. The diagnosis of celiac sprue is considered. An article reviewing the efficacy of 2 new tests available for celiac sprue diagnosis contains the following 2 tables:
Test X and celiac sprue
Test result
Sprue (+)
No disease
Total
Positive
60
60
120
Negative
20
260
280
Total
80
320
400
Test Y and celiac sprue
Test result
Sprue (+)
No disease
Total
Positive
65
50
115
Negative
15
270
285
Total
80
320
400
Item 1 of 2
Based on these data, which of the following statements is most accurate?
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Question 8 of 40
8. Question
Item 2 of 2
After careful analysis of the data from the 2 tables, a decision is made to use these new tests to determine whether the patient has celiac sprue. Which of the following represents the most appropriate testing strategy?
CorrectIncorrect -
Question 9 of 40
9. Question
A cohort of patients with myotonic dystrophy was retrospectively analyzed from 1993 to 2010 to identify incident cases of cancer. The researchers identified 2 cases of thyroid cancer and reported a standardized incidence ratio of 7.4 (P-value = 0.02). This ratio was derived using which of the following formulas?
CorrectIncorrect -
Question 10 of 40
10. Question
The drug advertisement in the exhibit applies to the next 2 items.
A 32-year-old woman comes to the office for follow-up. She had been seen in the emergency department 3 days ago due to an acute asthma exacerbation. The patient says that her current medication is not helping her as before and that her asthma is uncontrolled. Blood pressure is 150/95 mm Hg. BMI is 29.4 kg/m2. Physical examination is unremarkable.
Item 1 of 2
Based on the drug advertisement, which of the following conclusions is most appropriate when considering the care of this patient?
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Question 11 of 40
11. Question
Item 2 of 2
Considering the data in the drug advertisement, how many patients with severe uncontrolled asthma need to be treated with lorumab to cause 1 additional serious adverse event as compared to placebo?
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Question 12 of 40
12. Question
A study was conducted to examine the association between benzodiazepine use and hip fracture in patients age >70. Patients admitted with hip fracture (n = 180) and patients admitted for a different reason (n = 200) to 10 hospitals were included in the analysis. Of patients admitted with hip fracture, 10 had used benzodiazepines in the week before admission. Of patients admitted for a different reason, 7 had used benzodiazepines in the week before admission. Based on the study design, which of the following calculations will provide an estimate of the measure of association between benzodiazepine use and hip fracture in patients age >70?
CorrectIncorrect -
Question 13 of 40
13. Question
A retrospective cohort study examines the long-term risk of ischemic stroke in patients with perioperative atrial fibrillation following cardiac and noncardiac surgery. The following data are reported:
Cumulative rate of stroke 1 year after
hospitalization, % (95% confidence interval)
Type of surgery
Perioperative atrial fibrillation
No perioperative atrial fibrillation
Hazard ratio
(95% confidence interval)
Noncardiac
1.37 (1.22–1.69)
0.32 (0.31–0.41)
1.9 (1.5–2.4)
Cardiac
0.91 (0.88–1.07)
0.82 (0.74–0.86)
1.3 (1.1–1.7)
Which of the following best describes the study results?
CorrectIncorrect -
Question 14 of 40
14. Question
A biomedical research company creates 2 similar real-time, nondestructive cancer diagnostic devices (X and Y) in the form of a pen. The pens are applied to the tissue surface for a few seconds, during which time each pen releases a single water droplet onto the tissue. The water droplet, which picks up small biomolecules from the tissue, is then sucked back into the pen and transferred via tubing to a mass spectrometer. The spectrometer performs a quick molecular analysis and determines whether the tissue is normal (noncancerous) or abnormal (cancerous). The devices allow surgeons to know which tissue to remove and which not to remove. The performance of Devices X and Y was compared using the same samples of tissue. The biomedical research company reported that, compared to Device Y, Device X is better at identifying cancerous tissue as abnormal but worse at identifying noncancerous tissue as normal. Based on this information, which of the following conclusions about the diagnostic devices must be true?
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Question 15 of 40
15. Question
A group of researchers conducted a case-control study to investigate an outbreak of aflatoxin poisoning in a rural area. A total of 40 affected individuals and 100 controls were randomly selected to participate in the study. Every participant was interviewed, and data were collected on potential risk factors. Data showed that 32 affected individuals reported harvesting and storing maize indoors rather than outdoors, compared to 20 controls. Which of the following is closest to the estimated odds ratio of aflatoxin poisoning in individuals who stored maize indoors compared to individuals who stored maize outdoors?
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Question 16 of 40
16. Question
The following vignette applies to the next 2 items
A study is conducted to assess the role of different treatment regimens on cardiovascular outcomes. Two treatment arms are evaluated: high-dose hydrochlorothiazide (100 mg/day) and low-dose hydrochlorothiazide (25 mg/day). After a defined follow-up period, the mean systolic blood pressure (BP) in the high-dose group is 139 mm Hg, with a mean diastolic BP of 88 mm Hg. In the low-dose group, the mean values are 143 mm Hg and 92 mm Hg, respectively. A 2-sample t-test gives p-values of 0.03 for the systolic BP and 0.04 for the diastolic BP differences between the high-dose and low-dose groups. The relative risk of sudden cardiac death in the low-dose as compared to the high-dose group is 0.4 (95% confidence interval 0.25-0.55).
Item 1 of 2
Which of the following is the best statement concerning the results of the study with this patient sample?
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Question 17 of 40
17. Question
Item 2 of 2
Another subset of patients from this sample was given a placebo, and the risk of sudden cardiac death was assessed. When compared to the low-dose hydrochlorothiazide group, the placebo group’s relative risk of sudden cardiac death was very close to 1.0. The mean systolic and diastolic blood pressures in the placebo group were higher when compared to the low-dose hydrochlorothiazide group. Which of the following is the best statement concerning the risk of sudden cardiac death in the overall sample of patients?
CorrectIncorrect -
Question 18 of 40
18. Question
Title: Risk of new-onset diabetes mellitus with intensive-dose versus moderate-dose statin therapy
Hypothesis: Statin therapy has been associated with an increased risk of new-onset diabetes mellitus. Is intensive-dose statin therapy associated with a higher risk of incident diabetes compared to moderate-dose statin therapy?
Methods:
Design: Pooled meta-analysis of 5 randomized controlled trialsPatients: 32752 participants without diabetes at baseline, followed for >1 year
Intervention: Intensive-dose or moderate-dose statin therapy
Outcome measures: New-onset diabetes, major cardiovascular events
Results:
The following data were reported for the intensive as compared to the moderate therapy groups:Incident diabetes
Major cardiovascular events
Intensive statin therapy group
18.9 cases per 1000 patient-years
44.5 events per 1000 patient-years
Moderate statin therapy group
16.9 cases per 1000 patient-years
51.6 events per 1000 patient-years
The differences were statistically significant.
Out of the 32752 participants:
Diabetes: 2749 developed diabetes. There were 149 more cases of incident diabetes among participants receiving intensive statin therapy (1449 out of 16408) than among those receiving moderate statin therapy (1300 out of 16344).
Major cardiovascular events: 6684 experienced major cardiovascular events. There were 416 fewer patients who experienced major cardiovascular events among participants receiving intensive statin therapy (3134 out of 16408) than among those receiving moderate statin therapy (3550 out of 16344).
Structured abstract is based on: JAMA. 2011;305(24):2556-2564.
The abstract shown above applies to the next 2 items.
A 59-year-old man comes to the office for follow-up. He has a history of hypertension for which he takes 2 antihypertensive agents. The patient has no other cardiovascular problems and does not smoke. On examination, his blood pressure is 145/90 mm Hg and BMI is 25.4 kg/m2. The remainder of the examination is unremarkable. Laboratory studies show elevated fasting lipid levels, including LDL cholesterol. His 10-year risk of cardiovascular events is calculated as 10%, and a discussion regarding moderate or intensive statin therapy is initiated. The patient has read that statins may cause diabetes and asks if there is an even more increased risk with intensive compared to moderate statin therapy.
Item 1 of 2
Based on the abstract results with regard to incident diabetes, what is the approximate number needed to harm over 1 year for intensive compared to moderate statin therapy?
CorrectIncorrect -
Question 19 of 40
19. Question
Title: Risk of new-onset diabetes mellitus with intensive-dose versus moderate-dose statin therapy
Hypothesis: Statin therapy has been associated with an increased risk of new-onset diabetes mellitus. Is intensive-dose statin therapy associated with a higher risk of incident diabetes compared to moderate-dose statin therapy?
Methods:
Design: Pooled meta-analysis of 5 randomized controlled trialsPatients: 32752 participants without diabetes at baseline, followed for >1 year
Intervention: Intensive-dose or moderate-dose statin therapy
Outcome measures: New-onset diabetes, major cardiovascular events
Results:
The following data were reported for the intensive as compared to the moderate therapy groups:Incident diabetes
Major cardiovascular events
Intensive statin therapy group
18.9 cases per 1000 patient-years
44.5 events per 1000 patient-years
Moderate statin therapy group
16.9 cases per 1000 patient-years
51.6 events per 1000 patient-years
The differences were statistically significant.
Out of the 32752 participants:
Diabetes: 2749 developed diabetes. There were 149 more cases of incident diabetes among participants receiving intensive statin therapy (1449 out of 16408) than among those receiving moderate statin therapy (1300 out of 16344).
Major cardiovascular events: 6684 experienced major cardiovascular events. There were 416 fewer patients who experienced major cardiovascular events among participants receiving intensive statin therapy (3134 out of 16408) than among those receiving moderate statin therapy (3550 out of 16344).
Structured abstract is based on: JAMA. 2011;305(24):2556-2564.
Item 2 of 2
Based on the abstract, what was the pooled odds ratio of major cardiovascular events among participants on intensive compared to moderate statin therapy?
CorrectIncorrect -
Question 20 of 40
20. Question
Treatments for depression in bipolar disorder (BD) are far less developed than for unipolar major depressive disorder. New experimental approaches have been emerging recently, including use of the dissociative anesthetic ketamine. To study the effectiveness of this new experimental treatment, 2 psychiatrists decide to conduct 2 separate studies to compare treatment outcomes between patients receiving ketamine and patients receiving the standard treatment for BD. Study A, by the first psychiatrist, identifies 25 patients who have been on each of these treatments for BD for at least 6 months. Study B, by the second psychiatrist, randomly assigns 25 patients to each treatment and evaluates treatment outcomes after 6 months. Which of the following best describes each of these 2 studies?
CorrectIncorrect -
Question 21 of 40
21. Question
The proportion of colonoscopies performed by a physician with at least 1 detected adenoma is called the adenoma detection rate. A study examined the association between the adenoma detection rate and the risk of colorectal cancer 6 months to 10 years after colonoscopy. In the graph below, physicians were sorted into quintiles based on their adenoma detection rate, with quintile 1 being the lowest rate of detection and quintile 5 being the highest. There were no significant differences in rates of complications. The hazard ratios (HRs), shown along with their corresponding 95% confidence intervals (CIs), were adjusted for other variables including patient age, sex, comorbidities, and indication for colonoscopy.
Which of the following statements best describes the study results?
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Question 22 of 40
22. Question
The following vignette applies to the next 3 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A researcher wants to conduct a prospective cohort study to determine whether the use of tamoxifen as preventive treatment in premenopausal women at high risk for breast cancer is associated with mild cognitive impairment. The researcher plans to select premenopausal women newly identified to be at high risk for breast cancer who have no cognitive impairment and who recently started tamoxifen treatment.
Item 1 of 3
Based on this information, which of the following should the researcher select for the comparison group?
CorrectIncorrect -
Question 23 of 40
23. Question
Item 2 of 3
The researcher plans to contact potential participants to explain the purpose of the study. All women who choose to participate in the study will be interviewed to collect information on demographics, general health, medical history, and baseline data. Which of the following should the researcher use to minimize the possibility of outcome misclassification in the study?
CorrectIncorrect -
Question 24 of 40
24. Question
Item 3 of 3
The institutional review board approved the researcher’s proposed study. A total of 4,700 participants were enrolled. All participants were assessed for cognitive function at baseline and at 2-year follow-up. The table below shows a summary of preliminary findings.
Tamoxifen use
Yes
No
Mild cognitive impairment at follow-up
Yes (n) 650
58
No (n) 2,600
1,392
A hypothesis test revealed a statistically significant association between tamoxifen treatment and mild cognitive impairment. Which of the following is a correct interpretation of the preliminary findings?
CorrectIncorrect -
Question 25 of 40
25. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
An 84-year-old man comes to the physician with persistent dyspnea despite being treated with optimal medical therapy for congestive heart failure with low left ventricular ejection fraction. A recently published randomized clinical trial compared an angiotensin-neprilysin inhibitor (ANi) to an angiotensin-converting enzyme inhibitor (ACEi) in patients who have heart failure with a reduced ejection fraction. The following results were reported:
Item 1 of 2
Which of the following would be of most concern when switching from an ACEi to an ANi?
CorrectIncorrect -
Question 26 of 40
26. Question
Item 2 of 2
The investigators also reported the following results for patients in the angiotensin-neprilysin inhibitor (ANi) and angiotensin-converting enzyme inhibitor (ACEi) groups:
Which of the following is the best interpretation of these results
CorrectIncorrect -
Question 27 of 40
27. Question
Title
Efficacy and therapy costs associated with different treatments for rheumatoid arthritis (RA) in patients previously treated with methotrexate (Mtx).
Hypothesis
Addition of either subcutaneous (SC) tocilizumab (TCZ) or SC abatacept (ABT) to Mtx may result in better outcomes in patients showing little improvement when treated with Mtx alone.
Methods
Design: Meta-analysis
Study selection: 41 articles reporting on 26 randomized clinical trials
Interventions: The efficacy and therapy cost of Mtx therapy alone compared to those of combination therapy with either SC tocilizumab (TCZSC) in addition to Mtx or SC abatacept (ABTSC) in addition to Mtx
Outcome measures: Therapy efficacy defined as ≥70% improvement based on the American College of Rheumatology Criteria (ACR 70) and the additional yearly cost of treatment per person compared to Mtx
Results
The abstract shown above applies to the next 2 items.
A 46-year-old woman comes to the office due to persistent joint pains. She has a history of rheumatoid arthritis and, for the past 6 months, has been on methotrexate (Mtx) therapy. However, her symptoms have shown little improvement. She has morning stiffness that lasts for >1 hour, and her erythrocyte sedimentation rate is 40 mm/hr. A discussion is initiated regarding modifying her therapy to include either subcutaneous (SC) tocilizumab (TCZSC) or SC abatacept (ABTSC) in addition to Mtx. The patient expressed wanting to attempt the most effective treatment and avoid having to modify her treatment again.
Item 1 of 2
Based on the study results, compared to Mtx therapy alone, what is the approximate number needed to treat over 1 year to prevent 1 additional clinical response of <70% improvement with (ABTSC + Mtx) and (TCZSC + Mtx) ?
CorrectIncorrect -
Question 28 of 40
28. Question
Title
Efficacy and therapy costs associated with different treatments for rheumatoid arthritis (RA) in patients previously treated with methotrexate (Mtx).
Hypothesis
Addition of either subcutaneous (SC) tocilizumab (TCZ) or SC abatacept (ABT) to Mtx may result in better outcomes in patients showing little improvement when treated with Mtx alone.
Methods
Design: Meta-analysis
Study selection: 41 articles reporting on 26 randomized clinical trials
Interventions: The efficacy and therapy cost of Mtx therapy alone compared to those of combination therapy with either SC tocilizumab (TCZSC) in addition to Mtx or SC abatacept (ABTSC) in addition to Mtx
Outcome measures: Therapy efficacy defined as ≥70% improvement based on the American College of Rheumatology Criteria (ACR 70) and the additional yearly cost of treatment per person compared to Mtx
Results
Item 2 of 2
The mean cost of treatment per number needed to treat (NNT), obtained by multiplying the yearly individual cost by the NNT, is considered an indicator of the clinical benefits and costs linked to the use of the therapies. Based on the results of the meta-analysis, which of the following best describes the clinical benefits and costs of rheumatoid arthritis therapies per NNT in patients previously treated with Mtx?
CorrectIncorrect -
Question 29 of 40
29. Question
Title
Physical activity (PA) and disease severity and prognosis in patients with chronic obstructive pulmonary disease (COPD)
Hypothesis
High-level PA is associated with health-related quality of life, depression, and exercise capacity in elderly patients diagnosed with COPD.
Methods
Design: Secondary analysis of data from a cross-sectional study.
Participants: 160 patients age ≥65 with COPD of varying severity.
Assessment: Medical charts, questionnaires, surveys, and disease-specific instruments and scales.
Outcome measures: PA levels (low [<30 min/day] vs high [≥60 min/day]); 6-min walk distance (6MWD), where test results <250 m indicate decreased exercise capacity; anxiety and depression symptomatology (Hospital Anxiety and Depression Scale [HADS], where scores ≥8 indicate probable presence of a mood disorder); dyspnea (modified Medical Research Council [MMRC] scale, where scores ≥2 indicate more severe symptoms); and physical functioning (36-item short-form health survey [SF-36], ranging from 0 indicating worst health to 100 indicating best health).
Results
The following data using odds ratios from unadjusted and adjusted (multiple regression) analyses were reported:
Factors associated with high-level physical activity
Factor
Univariate (unadjusted) analysis OR* (95% CI)
Multiple regression analysis OR*† (95% CI)
6MWD (<250 m)
0.22 (0.07, 0.68)
0.48 (0.11, 1.20)
HADS-Anxiety ≥8
0.38 (0.13, 1.05)
0.50 (0.12, 1.02)
HADS-Depression ≥8
0.42 (0.21, 0.83)
0.48 (0.24, 0.98)
MMRC scale (≥2)
0.29 (0.13, 0.67)
0.39 (0.17, 0.93)
SF-36 physical functioning
1.04 (1.01, 1.06)
1.01 (0.96, 1.10)
6MWD = 6-min walk distance; CI = confidence interval; HADS = Hospital Anxiety and Depression Scale; MMRC = modified Medical Research Council; OR = odds ratio; SF-36 = Medical Outcomes Short Form-36.
*OR of high-level (ie, ≥60 min/day) compared to low-level (ie, <30 min/day) physical activity.
†Adjusted by age, sex, and other potential confounders.
The abstract applies to the next 2 items.
A 71-year-old man comes to the office due to slowly progressive shortness of breath for the past year. He enjoys working in his garden, but shortness of breath has forced him to reduce the time he spends there. The patient also has a mild morning cough productive of whitish sputum. He estimates that his physical activity level is <30 min/day. The patient has a history of hypertension. He is a retired middle-school teacher, and smoked 2 packs of cigarettes daily for 20 years before quitting 15 years ago. Blood pressure is 127/85 mm Hg, pulse is 78/min, respirations are 14/min, and pulse oximetry is 93% on room air. BMI is 24 kg/m2. Occasional end-expiratory wheezes are present on lung examination, and the heart examination demonstrates a regular rate and rhythm. Chest x-ray shows hyperinflation, and pulmonary function test results are consistent with an obstructive defect.
Item 1 of 2
The patient states that he is willing to increase his physical activity level to ≥60 min/day. Based on the results of the study and compared to a physical activity level of <30 min/day, a physical activity level of ≥60 min/day in this group of patients is associated with which of the following?
CorrectIncorrect -
Question 30 of 40
30. Question
Title
Physical activity (PA) and disease severity and prognosis in patients with chronic obstructive pulmonary disease (COPD)
Hypothesis
High-level PA is associated with health-related quality of life, depression, and exercise capacity in elderly patients diagnosed with COPD.
Methods
Design: Secondary analysis of data from a cross-sectional study.
Participants: 160 patients age ≥65 with COPD of varying severity.
Assessment: Medical charts, questionnaires, surveys, and disease-specific instruments and scales.
Outcome measures: PA levels (low [<30 min/day] vs high [≥60 min/day]); 6-min walk distance (6MWD), where test results <250 m indicate decreased exercise capacity; anxiety and depression symptomatology (Hospital Anxiety and Depression Scale [HADS], where scores ≥8 indicate probable presence of a mood disorder); dyspnea (modified Medical Research Council [MMRC] scale, where scores ≥2 indicate more severe symptoms); and physical functioning (36-item short-form health survey [SF-36], ranging from 0 indicating worst health to 100 indicating best health).
Results
The following data using odds ratios from unadjusted and adjusted (multiple regression) analyses were reported:
Factors associated with high-level physical activity
Factor
Univariate (unadjusted) analysis OR* (95% CI)
Multiple regression analysis OR*† (95% CI)
6MWD (<250 m)
0.22 (0.07, 0.68)
0.48 (0.11, 1.20)
HADS-Anxiety ≥8
0.38 (0.13, 1.05)
0.50 (0.12, 1.02)
HADS-Depression ≥8
0.42 (0.21, 0.83)
0.48 (0.24, 0.98)
MMRC scale (≥2)
0.29 (0.13, 0.67)
0.39 (0.17, 0.93)
SF-36 physical functioning
1.04 (1.01, 1.06)
1.01 (0.96, 1.10)
6MWD = 6-min walk distance; CI = confidence interval; HADS = Hospital Anxiety and Depression Scale; MMRC = modified Medical Research Council; OR = odds ratio; SF-36 = Medical Outcomes Short Form-36.
*OR of high-level (ie, ≥60 min/day) compared to low-level (ie, <30 min/day) physical activity.
†Adjusted by age, sex, and other potential confounders.
Item 2 of 2
Suppose that only 115 of the 160 (71.9%) patients in the study completed all the surveys and questionnaires. Which of the following best explains a potential bias introduced by the nonresponse?
CorrectIncorrect -
Question 31 of 40
31. Question
A large-scale clinical trial was conducted to assess the effect of a multivitamin supplement on the risk of future cardiovascular events. Study outcomes included cardiovascular mortality, nonfatal myocardial infarction, and coronary revascularization procedures. According to the study results, the overall relative risk of a cardiovascular event occurring in the placebo group compared to the treatment group was 1.5 (p = .30). However, when data accrued only during the fifth year of follow-up were examined, the relative risk of a cardiovascular event occurring in the placebo group compared to the treatment group was 2.05 (p = .01). Survival curves for the 2 groups are shown below:
Which of the following best explains the study results?
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Question 32 of 40
32. Question
A systematic review examines the effect of drug X, a commonly used medication, on all-cause mortality in patients with a chronic pulmonary problem. A systematic search identified 12 retrospective cohort studies. The pooled odds ratio of mortality with drug X use was 0.72 (95% confidence interval: 0.61-0.79). The authors also reported the following funnel plot of the 12 studies, centered around the log of the pooled odds ratio:
The graphical findings suggest the presence of which of the following?
CorrectIncorrect -
Question 33 of 40
33. Question
The drug ad applies to the next 3 items
The following advertisement is focused on LDL particle number (LDL-P) testing, a novel new screening method used for assessing LDL.
A 54-year-old man comes to the physician for a routine health examination. He has no complaints and feels well. He has a history of hypertension and his current medications include aspirin, hydrochlorothiazide, and lisinopril. The patient has smoked 1 pack of cigarettes a day for the past 35 years but denies alcohol or illicit drug use. He exercises twice a week and eats a low-fat diet. His father died of a myocardial infarction at age 52. His vital signs are within normal limits. Physical examination shows a BMI of 26 kg/m2 but is otherwise unremarkable. The patient is concerned about having a heart attack because of his family history. The physician considers obtaining the patient’s LDL-P levels.
Item 1 of 3
Based on the advertisement, 95% of patients will most likely have LDL-P levels that lie between which of the following limits?
CorrectIncorrect -
Question 34 of 40
34. Question
The following advertisement is focused on LDL particle number (LDL-P) testing, a novel new screening method used for assessing LDL.
Item 2 of 3
Based on the study shown in the advertisement, initial levels of LDL-C and LDL-P were obtained in 5584 individuals and the cumulative incidence of cardiovascular events was tracked. Which of the following choices best identifies the study design used in the advertisement?
CorrectIncorrect -
Question 35 of 40
35. Question
The following advertisement is focused on LDL particle number (LDL-P) testing, a novel new screening method used for assessing LDL.
Item 3 of 3
The patient’s fasting serum lipid profile and LDL-P levels are as follows:
Total cholesterol
220 mg/dL
High-density lipoprotein
50 mg/dL
Low-density lipoprotein
140 mg/dL
Triglycerides
150 mg/dL
LDL-P
610 nmol/L
Given these results combined with the patient’s risk factors for cardiovascular disease, the physician discusses lifestyle modifications with the patient and decides to start him on a statin. The treatment of his lipids for the prevention of myocardial infarction is an example of which of the following?
CorrectIncorrect -
Question 36 of 40
36. Question
Women with inflammatory bowel disease (IBD) appear to be at greater risk for human papillomavirus (HPV) infection and HPV-related malignancies compared to healthy counterparts. A new study evaluated knowledge about HPV infection among women with IBD. Potential participants were identified from among patients seeking care at local clinics, and all women age ≥15 with an established diagnosis of IBD from 2009 to 2010 were invited to participate in the study. A questionnaire was used to collect information on demographics, lifestyle, sexual behavior, and HPV-related knowledge; simultaneously, the association between HPV-related knowledge and the other factors was analyzed. Which of the following best describes the study design?
CorrectIncorrect -
Question 37 of 40
37. Question
A study of patients with metastatic renal cell carcinoma (RCC) compared the effectiveness of standard chemotherapy to a novel tyrosine kinase inhibitor (TKI) with activity against vascular endothelial growth factor in progression-free survival (primary end point) as first-line treatment. Tumor response was significant in both groups at final follow-up (p < 0.05). Preliminary analysis reveals the following Kaplan-Meier survival curve for overall survival.
Treatment-related adverse events such as diarrhea, nausea, vomiting, hypertension, hand-foot syndrome, asthenia, leukopenia, neutropenia, thrombocytopenia, lymphopenia, and increased lipase and uric acid occurred more frequently in the TKI group than in the standard chemotherapy group (p < 0.05). Based on the findings of this preliminary analysis, which of the following conclusions is justified?
CorrectIncorrect -
Question 38 of 40
38. Question
Objective
To evaluate the efficacy and safety of Drug X, a gonadotropin-releasing hormone receptor antagonist, compared with placebo and Drug Y (the standard of care) in women with dysmenorrhea and endometriosis-associated pain.
Methods
Design: Phase 2, multicenter, randomized, double-blind, placebo-controlled study.
Participants: Adult premenopausal women with dysmenorrhea and endometriosis-associated pelvic pain.
Interventions: 12-week treatment with Drug X 10 mg, 25 mg, or 40 mg once daily by mouth; or placebo once daily by mouth; or Drug Y 3.75 mg as a monthly subcutaneous injection.
Outcome measures: Primary: mean change from baseline in visual analog scale (VAS) score for pelvic pain (from 0 mm for absence of pain to 100 mm for unbearable pain) during 28 days before the end of treatment. Secondary: mean VAS scores for pelvic pain throughout the treatment period.
Results
The mean changes (95% confidence interval [CI]) in mean VAS score for pelvic pain during the 28 days before the end of the treatment period were the following:
VAS score for pelvic pain
Mean change* (95%CI)
Difference** in
mean change (95%CI)p-value
Placebo (n = 97) −3.8 (−5.9 to −1.6)
–
–
Drug X 10 mg (n = 103) −6.2 (−8.0 to −4.4)
−2.9 (−5.3 to −0.5)
< 0.05
Drug X 25 mg (n = 100) −10.2 (−11.9 to −8.5)
−6.5 (−8.8 to −4.2)
< 0.001
Drug X 40 mg (n = 103) −10.4 (−12.6 to −8.3)
−6.8 (−9.2 to −4.4)
< 0.001
Drug Y (n = 80) −10.6 (−12.9 to −8.3)
–
–
*Mean change = mean VAS score at 28 days before the end of treatment (in mm) minus mean VAS score at baseline (in mm). **Difference = Drug X vs placebo.
CI = confidence interval; VAS = visual analog scale.
The mean changes in mean VAS scores for pelvic pain in the Drug X 25-mg and 40-mg groups were comparable to those in the Drug Y group (p > 0.05). The mean VAS scores for pelvic pain in the Drug X groups started to decrease within the first month of treatment and continued to decrease until the end of the study.
Adverse events with Drug X were hot flush, metrorrhagia, menorrhagia, and irregular menstruation, which were also observed with Drug Y. Compared to Drug Y, the frequency of adverse events was similar in the Drug X 25-mg group but significantly higher in the Drug X 40-mg group.
Conclusion
Oral administration of Drug X alleviated endometriosis-associated pain and was generally well tolerated.
A 32-year-old woman comes to the office for a follow-up appointment. The patient has endometriosis that was diagnosed 6 months ago. She is currently receiving monthly injections of Drug Y to treat her dysmenorrhea and severe endometriosis-associated pelvic pain. Treatment with Drug Y has been effective; however, the patient wants to try an alternate noninjectable medication.
The abstract shown above applies to the next 2 items.
Item 1 of 2
The patient is a candidate for Drug X. Based on the study results, which dose of Drug X is most likely to produce efficacy and safety/adverse event profiles comparable to Drug Y?
CorrectIncorrect -
Question 39 of 40
39. Question
Objective
To evaluate the efficacy and safety of Drug X, a gonadotropin-releasing hormone receptor antagonist, compared with placebo and Drug Y (the standard of care) in women with dysmenorrhea and endometriosis-associated pain.
Methods
Design: Phase 2, multicenter, randomized, double-blind, placebo-controlled study.
Participants: Adult premenopausal women with dysmenorrhea and endometriosis-associated pelvic pain.
Interventions: 12-week treatment with Drug X 10 mg, 25 mg, or 40 mg once daily by mouth; or placebo once daily by mouth; or Drug Y 3.75 mg as a monthly subcutaneous injection.
Outcome measures: Primary: mean change from baseline in visual analog scale (VAS) score for pelvic pain (from 0 mm for absence of pain to 100 mm for unbearable pain) during 28 days before the end of treatment. Secondary: mean VAS scores for pelvic pain throughout the treatment period.
Results
The mean changes (95% confidence interval [CI]) in mean VAS score for pelvic pain during the 28 days before the end of the treatment period were the following:
VAS score for pelvic pain
Mean change* (95%CI)
Difference** in
mean change (95%CI)p-value
Placebo (n = 97) −3.8 (−5.9 to −1.6)
–
–
Drug X 10 mg (n = 103) −6.2 (−8.0 to −4.4)
−2.9 (−5.3 to −0.5)
< 0.05
Drug X 25 mg (n = 100) −10.2 (−11.9 to −8.5)
−6.5 (−8.8 to −4.2)
< 0.001
Drug X 40 mg (n = 103) −10.4 (−12.6 to −8.3)
−6.8 (−9.2 to −4.4)
< 0.001
Drug Y (n = 80) −10.6 (−12.9 to −8.3)
–
–
*Mean change = mean VAS score at 28 days before the end of treatment (in mm) minus mean VAS score at baseline (in mm). **Difference = Drug X vs placebo.
CI = confidence interval; VAS = visual analog scale.
The mean changes in mean VAS scores for pelvic pain in the Drug X 25-mg and 40-mg groups were comparable to those in the Drug Y group (p > 0.05). The mean VAS scores for pelvic pain in the Drug X groups started to decrease within the first month of treatment and continued to decrease until the end of the study.
Adverse events with Drug X were hot flush, metrorrhagia, menorrhagia, and irregular menstruation, which were also observed with Drug Y. Compared to Drug Y, the frequency of adverse events was similar in the Drug X 25-mg group but significantly higher in the Drug X 40-mg group.
Conclusion
Oral administration of Drug X alleviated endometriosis-associated pain and was generally well tolerated.
Item 2 of 2
Which of the following is the strongest additional support for causality between treatment with Drug X and reduction in endometriosis-associated pelvic pain in this randomized, double-blind, placebo-controlled study?
CorrectIncorrect -
Question 40 of 40
40. Question
A group of cardiologists hypothesized that a new ACE inhibitor improves outcomes among patients with left ventricular dysfunction whether they have heart failure or not. The cardiologists assessed the role of the new ACE inhibitor in patients who were at high risk for cardiovascular events but who did not have left ventricular dysfunction or heart failure. A total of 8,560 high-risk patients (age ≥55) with evidence of vascular disease or diabetes plus one other cardiovascular risk factor but with no known history of heart failure were randomly assigned at a ratio of 1:1 to receive the new ACE inhibitor or placebo for a mean of 5 years. The primary outcome was death from cardiovascular causes. A total of 261 patients assigned to receive the new ACE inhibitor (6.1%) died from cardiovascular causes, compared to 346 patients assigned to receive placebo (8.1% percent) (relative risk = 0.75; p < 0.05). Which of the following conclusions can be drawn from these results?
CorrectIncorrect