, SECTION I q
General Considerations in Clinical Medicine q q q q
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qqqq QUESTIONS
DIRECTIONS: Choose the one best response to each question.
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I-1. All of the following statements regarding practice guidelines set forth by governing agencies and professional
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qorganizations are true EXCEPT: q q q
A. Clinical practice guidelines protect caregivers against inappropriate charges of malpractice, yetdo not
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provide protection for patients from receiving substandard care.
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B. Practice guidelines have largely reached a stage of nuance allowing them to address every uniqueillness and
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patient presented to the modern physician.
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C. Practice guidelines provide a legal constraint to physicians, and deviation from guideline-basedcare
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invariably leaves physicians vulnerable to legal action.
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D. Where different organizations disagree regarding practice guidelines, a third-party agency has been
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appointed to mitigate these disagreements such that now all major organizations’ guidelines are consistent.
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E. All of the above statements are not true.
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I-2. Regarding molecular medicine, which of the following statements represents an INACCURATE example of the
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qlisted area of study:
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A. Exposomics: An endocrinologist studies sunlight exposure and population risk of hip fracture.
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B. Metabolomics: A biochemist studies the rate of flux through the creatine kinase pathway during the cardiac
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cycle.
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C. Metagenomics: A biologist studies the genomic alterations in molds commonly found in humandwellings.
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D. Microbiomics: A microbiologist studies the genomic variation in thermophiles, bacteria that cansurvive
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extreme heat near deep ocean vents.
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E. Proteomics: A cardiologist studies desmosomal proteins and their posttranslational modifications in
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studying arrhythmogenic right ventricular dysplasia.
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I-3. Which of the following is the best definition of evidence-based medicine?
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A. A summary of existing data from existing clinical trials with a critical methodologic review andstatistical
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analysis of summative data
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B. A type of research that compares the results of one approach to treating disease with anotherapproach to
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treating the same disease
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C. Clinical decision-making support tools developed by professional organizations that includeexpert opinions
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and data from clinical trials
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D. Clinical decision making supported by data, preferably randomized controlled clinical trials
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E. One physician’s clinical experience in caring for multiple patients with a specific disorder over many years
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I-4. Which of the following is the standard measure for determining the impact of a health condition on a
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qpopulation?
A. Disability-adjusted life-years q
B. Infant mortality q
C. Life expectancy
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D. Standardized mortality ratio q q
E. Years of life lost q q q
,I-5. Which of the following statements regarding disease patterns worldwide is true?
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A. Childhood undernutrition is the leading risk factor for global disease burden.
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B. In a 2006 publication, the World Health Organization (WHO) estimated that 10% of the totalglobal burden
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qof disease was due to modifiable environmental risk factors.
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C. In 2010, ischemic heart disease was the leading cause of death among adults.
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D. In the last two decades, mortality attributed to communicable diseases, maternal and perinatalconditions,
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qand nutritional deficiencies has remained fairly stable, with the majority (76%) of mortality from these
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qcauses occurring in sub-Saharan Africa and southern Asia.
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E. While poverty status has been shown to be linked to health status on the individual level, thesame
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qrelationship does not hold true when studying the link between national health indicators and gross
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qdomestic product per capita among nations. q q q q q
I-6. You are appointed to a governmental healthcare advisory subcommittee concerned with addressing problems
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q facing the global health community. Your task is to draw general conclusions from the global fight against
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q tuberculosis (TB) and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) that
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q may be applied in combatting other diseases, including noncommunicable diseases. Which of the following
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q conclusions is reasonable when considering HIV/AIDS and TB as chronic diseases?
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A. Barriers to adequate healthcare and patient adherence imposed by extreme poverty must beconcomitantly
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addressed to adequately treat and prevent chronic disease in developing nations.
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B. Charging small fees for health services (e.g., AIDS prevention and care) supplies the patient witha sense of
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the treatment’s value and increases compliance and overall public health.
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C. Despite adequate available tools to practice their trade locally in developing nations, manyphysicians and
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nurses emigrate to developed nations to practice their respective trades, a phenomenon called “brain
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drain.”
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D. In developed nations where physicians are abundant, community health worker supervision ofthe care of
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chronically ill patients is not effective.
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E. In the case of chronic infectious diseases, switching from one drug to another through aprolonged course of
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treatment provides the highest cure rate by obviating the infectious agent’s ability to develop resistance to
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any single drug.
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I-7. Mrs. Jones, a 22-year-old African American woman, presents to Dr. Smith, an internal medicine specialist, with
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q a facial rash. Mrs. Jones states that the rash began after spending a day at the beach with her family. She also
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q notes that her metacarpophalangeal and proximal interphalangeal joints have been painful and swollen for the
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q preceding 2 weeks. On examination, the joints are swollen and tender. Laboratory analysis discloses reduced
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q creatinine clearance, proteinuria, and hemolytic anemia. Antinuclear antibodies (a test with a high negative
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q predictive value for systemic lupus erythematosus) are detected at significant titer, and ultimately, the
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q diagnosis of systemic lupus erythematosus is made.
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Two weeks later, Mrs. Johnson, a 24-year-old African American woman, presents with a facial rash and elbow
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q pain to Dr. Smith. After a cursory interview and brief physical exam, Dr. Smith sends blood work only testing for
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q antinuclear antibodies. When the test returns negative (no antibodies detected), Dr. Smith presumes this to be
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q a false-negative result and starts Mrs. Johnson on hydroxychloroquine and prednisone for treatment of
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q systemic lupus erythematosus. Which heuristic(s) did Dr. Smith likely employ in diagnosing Mrs. Johnson with
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q systemic lupus erythematosus? q q
A. Availability heuristic q
B. Anchoring heuristic q
C. Bayes’ rule q
D. Confirmation bias q
E. A and B q q
I-8. You have invented a blood test, which you name “veritangin,” to determine if patients are having a myocardial
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q infarction. You devise an experiment to determine the performance of your veritangin assay by testing it versus
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q the troponin assay, the currently accepted gold standard for determining myocardial infarction, in 100 random
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q emergency department patients with chest pain. You choose a veritangin result >1 ng/dL as positive for
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q myocardial infarction. Your results are listed in the table below.
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, Which of the following statements regarding the characteristics of the veritangin assay in this trial is true?
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A. The posttest probability of the veritangin test does not depend on the population studied.
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B. The sensitivity of the veritangin assay depends on the population studied and the diseaseprevalence in that
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population.
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C. The sensitivity of the veritangin assay will decrease by 50% if you reduce the threshold for apositive result
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to >0.5 ng/dL.
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D. The sensitivity of the veritangin test cannot be calculated based on the above data.
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E. The specificity of the veritangin assay is 0.93 (70/75).
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I-9. You are designing a clinical trial to test the use of a novel anticoagulant, clotbegone, in the treatment of deep
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q vein thrombosis. Which of the following statements regarding the design of the trial is true?
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A. An optimal study design would assign many patients to clotbegone and compare their outcomesto the
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outcomes of prior (historical) patients not taking clotbegone. This would allow faster trial completion.
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B. If the trial returns a positive result (clotbegone is superior to placebo), that means that anypatient with a
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clot would benefit from clotbegone therapy.
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C. Observing the outcomes of patients already taking clotbegone versus patients who are not ispreferable to
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assigning patients to clotbegone or placebo in a blinded fashion. The observational strategy is more “real
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world,” applicable to the general population, and free of bias.
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D. Population selection for the trial enrollment is not important as long as careful attention torandomization
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and blinding is observed.
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E. The advantage of performing a randomized clinical trial of clotbegone over a prospectiveobservational
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study of clotbegone is the avoidance of treatment selection bias.
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I-10. A receiver operating characteristic (ROC) curve is constructed for a new test developed to diagnose disease X.
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qAll of the following statements regarding the ROC curve are true EXCEPT:
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A. One criticism of the ROC curve is that it is developed for testing only one test or clinicalparameter with
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exclusion of other potentially relevant data.
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B. ROC curve allows the selection of a threshold value for a test that yields the best sensitivity withthe fewest
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false-positive tests.
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C. The axes of the ROC curve are sensitivity versus 1 – specificity.
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D. The ideal ROC curve will have a value of 0.5.
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E. The value of the ROC curve is calculated as the area under the curve generated from the true-positive rate
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versus the false-positive rate.
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I-11. When considering a potential screening test, what end points should be considered to assess the potential
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qgain from a proposed intervention?
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A. Absolute and relative impact of screening on the disease outcome
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B. Cost per life-year saved q q q
C. Increase in the average life expectancy for the entire population
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D. Number of subjects screened to alter the outcome in one individual
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E. All of the aboveq q q
I-12. You are appointed to an advisory committee in the WHO tasked with making recommendations regarding
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qbreast cancer screening and prevention. In regard to screening and preventing breast cancer in women, which
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qof the following potential recommendations from your committee would be valid?
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