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Item: 1 of 24 ljl f> Mark <::J t::>

Q. ld: 7943 [ Previous Next

The drug ad in the exhibit button applies to the next 2 items

6
The drug advertisement suggests the addition of extended-release niacin to low -dose simvastatin for the
7
treatment of high-risk patients w ith type 2 hyperlipidemia or mixed dyslipidemia .
8
9 Item 1 of 2
10
11 A 56-year-old man w ith exertional chest pain comes to the physician because his exercise stress
12 echocardiogram show ed evidence of mild ischemia in the posterior w all. He w as recently diagnosed w ith type
13 2 diabetes mellitus and hypertension. He is a current smoker but is w illing to quit. His father died of a heart
14 attack at age 51. Physical examination is unremarkable.
15
16 Laboratory results are as follow s:
17 Creatinine 1.1 mgldL
18 High-density lipoprotein 41 mgldL
19 Low -density lipoprotein 122 mgldL
12ol Triglycerides 220 mg/dL
. L?.J HemoglobinA10 7.6%
22
23
Based on the information in the drug advertisement, w hich of the follow ing changes in HDL and LDL
24
cholesterol w ould be expected if this patient w as started on combined Zettiga and simvastatin compared to
simvastatin alone?
LDL cholesterol HDL cholesterol

View Drug Ad

r Decrease Increase
A.

r Decrease No significant change


B.

r No significant change Increase


C.
Item: 1 of 24 ljl f> Mark <::J t::>
Q. ld: 7943 [ Previous Next
I rl~ U IUY i:::I U V~Ill~~riU:~rll ~u yy ~~l~ Ult::' i:::IUUIUU rl U l ~Xl~ri U ~U-I~I~i:::l~t::' IIIC::IC.UilU I U W -U U ~~ :SUIIVi:::I:Sli:::llUII U I Ult::'
treatment of high-risk patients w ith type 2 hyperlipidemia or mixed dyslipidemia .
6
Item 1 of 2
7
8 A 56-year-old man w ith exertional chest pain comes to the physician because his exercise stress
9 echocardiogram show ed evidence of mild ischemia in the posterior w all. He w as recently diagnosed w ith type
10
2 diabetes mellitus and hypertension. He is a current smoker but is w illing to quit. His father died of a heart
11
attack at age 51. Physical examination is unremarkable.
12
13 Laboratory results are as follow s:
14
Creatinine 1.1 mg/dL
15
High-density lipoprotein 41 mg/dL
16
Low -density lipoprotein 122 mg/dL
17
Triglycerides 220 mg/dL
18
HemoglobinA10 7.6%
19
12ol
. L?.J Based on the information in the drug advertisement, w hich of the follow ing changes in HDL and LDL
cholesterol w ould be expected if this patient w as started on combined Zettiga and simvastatin compared to
22
23 simvastatin alone?
24 LDL cholesterol HDL cholesterol

View Drug Ad

r Decrease Increase
A.

r Decrease No significant change


B.

r No significant change Increase


C.

r No significant change No significant change


D.
.
.
.
.
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11
12
13
14
Z e t t i g a
niacin extended-release tablets
15
16
17
18

22 Add Zettiga to simvastatin for improved HDL-C


23
24 Efficacy of Zettiga 1200 mg/simvastatin 20 mg at week 36 (n = 206)
LIPID2 study design: 36 week multicenter, randomized, double-blinded,
controlled study comparing the safety and efficacy of Zettiga
1200 mg/simvastatin 20 mg to low-dose simvastatin in patients with type 2
hyperlipidemia or mixed dyslipidemia.
0
Primary endpoint was o/o change in non -HDL-( .

Efficacy of simvastatin 20 mg (n = 202): HDL-C, 9%; non-HDL-C, -6%; LDL-C,


-8%; TG, -16%; Apo B, -5% (baseline values displayed in chart).

30
0

0
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7
8
9
; .
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FitWidth
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Efficacy of simvastatin 20 mg (n = 202): HDL-C, 9%; non-HDL-C, -6%; LDL-C,


10
11 -8%; TG, -16%; Apo B, -5% (basel ine values displayed in chart).
12
13
14
15 30
16 HDL-C
17
QJ 20
18 c:
Qj

2l"' 10
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22
23
24
-0
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QJ
Cl
c: 41 mg/dl 162 mg/dl 121 mg/dl 214 mg/dl 105 mg/d l
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30 TG

a Results significant vs simvastatin 20mg, p < 0.05.


ll Median value reported forTG.
.
.
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10

Z e t t i g a
11
12
13
14
15
niacin extended-release tablets
16
17
18

22
23
24
Prescribe Zettiga when diet & exercise alone are inadequate
Zettiga in combination with simvastatin or lovastatin is indicated for the
treatment of primary hyperlipidemia and mixed dyslipidemia when
monotherapy with simvastatin, lovastatin, or niacin is inadequate.
Limitations of use: There is no established benefit of Zettiga in combination
with simvastatin or lovastatin on cardiovascular morbidity and mortality
over that demonstrated by simvastatin, lovastatin, or niacin alone.

Important safety information


~
GJ~
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' ~
6
7 10(
8
9
10
11
over that demonstrated by simvastatin, lovastatin, or niacin alone.
12
13
14
15
Important safety information
16
17
Zettiga is contraindicated in patients with active liver disease, persistent
18 hepatic transaminase elevations, and active peptic ulcer disease or arterial
bleeding.
22
Substitution of sustained-release niacin for equivalent doses of immediate-
23 release niacin has resulted in severe hepatic toxicity.
24
Zettiga is associated with myopathy, rhabdomyolysis, and elevations in liver
enzymes and serum uric acid levels.
Zettiga should be used with caution in patients who consume large
quantities of alcohol.

Please see full prescribing information for additional


safety information and common adverse reactions.
Item: 2 of 24 ljl f> Mark <::J t::>
Q. ld: 7944 [ Previous Next

6 Item 2 of 2
7
8 According to the drug advertisement, the investigators reported the median value and the median percentage
9 change from baseline for triglyceride levels in the study patients. W hich of the follow ing best explains the
10 reason for reporting median values as opposed to mean values?
11
12 View Drug Ad
13
14
15 r A. High number of missing values
16
r B. Narrow range of values
17
18 r C. Skew ed distribution
19
r D. Small sample size
12ol
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.
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.
.
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FitWidth
_n_
~~
~
GJ~
i\LJ
' ~ 10(

10
11
12
13
14
Z e t t i g a
niacin extended-release tablets
15
16
17
18

22 Add Zettiga to simvastatin for improved HDL-C


23
24 Efficacy of Zettiga 1200 mg/simvastatin 20 mg at week 36 (n = 206)
LIPID2 study design: 36 week multicenter, randomized, double-blinded,
controlled study comparing the safety and efficacy of Zettiga
1200 mg/simvastatin 20 mg to low-dose simvastatin in patients with type 2
hyperlipidemia or mixed dyslipidemia.
0
Primary endpoint was o/o change in non -HDL-( .

Efficacy of simvastatin 20 mg (n = 202): HDL-C, 9%; non-HDL-C, -6%; LDL-C,


-8%; TG, -16%; Apo B, -5% (baseline values displayed in chart).

30
0

0
6
7
8
9
; .
~~
Page 1 of 2
C IOI
1~1
FitWidth
_n_
~~

Efficacy of simvastatin 20 mg (n = 202): HDL-C, 9%; non-HDL-C, -6%; LDL-C,


10
11 -8%; TG, -16%; Apo B, -5% (basel ine values displayed in chart).
12
13
14
15 30
16 HDL-C
17
QJ 20
18 c:
Qj

2l"' 10
E
22
23
24
-0
~

QJ
Cl
c: 41 mg/dl 162 mg/dl 121 mg/dl 214 mg/dl 105 mg/d l
"'
.r.
u
1------
....c:
QJ
u
~ -I 0
QJ
a.
c:
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20

30 TG

a Results significant vs simvastatin 20mg, p < 0.05.


ll Median value reported forTG.
.
.
.
.
6
7
8
9
; .
~~
Page 2 of 2
OlD
1~1
FitWidth
_n_
~~
~
GJ~
i\LJ
' ~ 10(

10
11
12
13
14
Z e t t i g a
niacin extended-release tablets
15
16
17
18

22
23
24 Prescribe Zettiga when diet & exercise alone are inadequate
Zettiga in combination with simvastatin or lovastatin is indicated for the
treatment of primary hyperlipidemia and mixed dyslipidemia when
monotherapy with simvastatin, lovastatin, or niacin is inadequate.
Limitations of use: There is no established benefit of Zettiga in combination
with simvastatin or lovastatin on cardiovascular morbidity and mortality
over that demonstrated by simvastatin, lovastatin, or niacin alone.

Important safety information


~
GJ~
i\LJ
' ~
6
7 10(
8
9
10
11
over that demonstrated by simvastatin, lovastatin, or niacin alone.
12
13
14
15
Important safety information
16
17
Zettiga is contraindicated in patients with active liver disease, persistent
18 hepatic transaminase elevations, and active peptic ulcer disease or arterial
bleeding.
22
Substitution of sustained-release niacin for equivalent doses of immediate-
23 release niacin has resulted in severe hepatic toxicity.
24
Zettiga is associated with myopathy, rhabdomyolysis, and elevations in liver
enzymes and serum uric acid levels.
Zettiga should be used with caution in patients who consume large
quantities of alcohol.

Please see full prescribing information for additional


safety information and common adverse reactions.
Item: 3 of 24 ljl f> Mark <::J t::>
Q. ld: 5273 [ Previous Next

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6 The following vignette applies to the next 2 items
7
8 A 28-year-old Caucasian female comes to your office complaining of chronic diarrhea . She also has
9 osteoporosis and anemia . You suspect celiac sprue, and w ant to test her for the disease. During a searchfor
10 the new est existing literature on the Internet, you find an article w hich review s the efficacy of two new tests
11 that are available for celiac sprue diagnosis. In the article, you find the follow ing table:
12
13
Table 1: Test X and celiac sprue.
14 Test result Sprue (+) No disease Total
15 Positive 60 60 120
16 Negative 20 260 280
17 Total 80 320 400
18
19 Table 2: Test Y and celiac sprue.
12ol Test result Sprue (+) No disease Total
. L?.J Positive 65 50 11 5
22 Negative 15 270 285
23 Total 80 320 400
24
Item 1 of 2

After comparing the two tables you, can conclude that:

r A. Test Y is more sensitive but less specific than test X for the diagnosis of celiac sprue
r B. Test X is more sensitive and specific for the diagnosis of celiac sprue
r C. Test Y is more specific but less sensitive than test X for the diagnosis of celiac sprue
r D. Test X is less sensitive than test Y for the diagnosis of celiac sprue, but equally specific
r E. Test Y is more specific and sensitive for the diagnosis of celiac sprue
1
2 Item: 4 of 24 ljl f> Mark <::J t::>
Q. ld: 5274 [ Previous Next

5
6 Item 2 of 2
7
8 After carefully analyzing the data from the two aforementioned tables, you decide to use these new tests to
9 determine if your patient has celiac sprue. W hich of the follow ing w ill be your testing strategy?
10
11
12
r A. To order first test X, and if it is positive, to confirm w ith test Y
13 r B. To order first test Y, and if it is positive, to confirm w ith test X
14
r C. To order only test Y
15
16 r D. To order only test X
17 E. To order both tests at the same time
18
19
12ol
. L?.J r
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23
24
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2 Item: 5 of 24 ljl f> Mark <::J t::>
Q. ld: 5130 [ Previous Next

6 A 30-year-old w oman comes to the physician after finding a breast mass on self examination . After the
7 appropriate w orkup, the physician decides to proceed w ith fine-needle aspiration (FNA). Cytology of the
8 aspirate comes back negative for malignancy. How ever, the patient is still concerned about the possibility of
9 breast cancer despite her negative FNA result. W hich of the follow ing test parameters w ould be the most
10 helpful for determining this patient's residual risk of breast cancer?
11
12
13
r A. Negative predictive value
14 r B. Positive predictive value
15
16
r C. Sensitivity
17 r D. Specificity
18
19
r E. Validity
12ol
. L?.J
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2 Item: 6 of 24 ljl f> Mark <::J t::>
Q. ld: 9945 [ Previous Next

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9
5

10
A study examines the association between benzodiazepine use and hip fracture in elderly patients > 70 years
of age. A total of 180 patients admitted to 20 hospitals w ith hip fracture w ere included in the analysis; 10
patients used benzodiazepines in the w eek before admission. For comparison, the investigators selected 200
patients w ho w ere admitted for a different reason; 7 of them used benzodiazepines in the w eek before
admission. W hich of the follow ing is the best measure of association to be reported for this study?
11
12
13
r A. ( 10 1 180) I (7 I 200)
14 r B. (10 193) I (7' 170)
15
16
r C. (10 1 170) - (7 1 193)
17 r D. ( 10 200) I (7' 180)
18
19
r E. ( 1o+ 7) I ( 180 + 200)
12ol
. L?.J
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2 Item: 7 of 24 ljl f> Mark <::J t::>
Q. ld: 9910 [ Previous Next

- 6

8
9
10
11
A systematic review examines the effect of drug X, a commonly used medication, on all-cause mortality in
patients w ith a chronic pulmonary problem . A systematic search identified 12 retrospective cohort studies.
The pooled relative risk of mortality w ith drug X use w as 0.72 (95% confidence interval : 0.61-0.79). The
authors also reported the follow ing funnel plot of the 12 studies:

12 Funnel plot
13
14 0
15
16
17
18 0.1
19
12ol
. L?.J
22
..g 0.2
23
24 ..
Cll
'C
Ill
'C
c:
~ 0.3
(/)

0.4

-0.5 -0.3 -0.1 0 0.1 0.3 0.5


IE)USMLEWorld, LLC Log(odds ratio)

The graphical findings suggest the presence of w hich of the follow ing?
1
2 Item: 7 of 24 ljl f> Mark <::J t::>
Q. ld: 9910 [ Previous Next
autnors also reponea me rouow 1ng runnel plot or me 1 L stumes:

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8
9
10
11
0
Funnel plot

12
13 0.1
14
15
16 ....
17 e.... 0.2
Cll
18 "0
19
....
Ill

[J
2
"0

-c:
Ill
( /)
0.3
22
23
24
0.4

-0.5 -0.3 -0.1 0 0.1 0.3 0.5


IE)USMLEWorld, UC Log(odds ratio)

The graphical findings suggest the presence of w hich of the follow ing?

r A. Lead-time bias
r B. Placebo effect
r C. Publication bias
r D. Sm all samples in drug X treatment arms
1
2 Item: 8 of 24 ljl f> Mark <::J t::>
Q. ld: 9953 [ Previous Next

6 A cohort of patients w ith m yotonic dystrophy w as retrospectively analyzed from 1993 to 2010 to identify

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7

10
11
12
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 w as derived using w hich of the follow ing formulas?

r A. Expected number of cases divided by the population at risk


r B. Observed incidence of cancer minus expected incidence of cancer
13
14 r C. Observed number of cases divided by expected number of cases
15
16
r D. Observed number of cases divided by population at risk
17 r E. Observed number of cases plus projected number of cases
18
19
12ol
. L?.J
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24
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2 Item: 9 of 24 ljl f> Mark <::J t::>
Q. ld: 9928 [ Previous Next

6 A non-inferiority study is conducted to assess a new anti-Xa inhibitor (drug A) in patients w ith atrial fibrillation.
7 W arfarin is chosen as comparator. Study results are show n on the image below .

- 8

10
11
12
13
Non-inferiority

Hemorrhagic stroke
margin~
14
15
Myocardial infarction
16
17
18 All-cause mortality
19
12ol
. L?.J
22
;1--J Ischemic stroke

23
24

- - - - Favors warfarin - - - - 0 Favors drug A - - -
@USMLEWorld, UC

W hich of the follow ing best describes the effect of drug A in preventing m yocardial infarction?

r A. Drug A is inferior to w arfarin in preventing m yocardial infarction


r B. Drug A is non-inferior and not superior to w arfarin in preventing m yocardial infarction
r C. Drug A is non-inferior and superior to w arfarin in preventing m yocardial infarction
r D. Non-inferiority in preventing m yocardial infarction is not show n for drug A
1
2 Item: 10 of 24 ljl f> Mark <::J t::>
Q, ld: 9954 [ Previous Next

A study examined the role of a humanized monoclonal antibody (mAb) that binds soluble forms of amyloid in
6 treating Alzheimer disease. Patients w ere randomly assigned to a mAb injection or placebo group for 14
7 months. The outcomes included changes in cognitive performance assessed by different scores at w eek 72
8 compared to baseline. Higher scores indicate worse impairment. The following numbers w ere reported for

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11
12
13
14
patients w ith mild and moderate Alzheimer disease.

Cognitive performance scores in patients with mild to moderate Alzheimer disease

Variable Mild Alzheimer disease Moderate Alzheimer disease Q statistic


15 test for
Mean change Mean Mean change heterogeneity
16 from baseline to from baseline to Mean
weel< 72 difference P valuef week 72 difference
17 (95% CI) (95% Cl) P valuef Pvaluef
18 Placebo mAb Placebo mAb
19
Soore 1 5.2 3.7 -1.5 (-2.~.8) 0.19 11.1 10.3 -0.8(-2.8-1 .4) 0.45 0.67
12ol
. L?.J Soore2 6.2 4.6 -1.6 (-3.6-1.2) 0.42 13.5 11.6 -1.9 (-3.4- 1.1 ) 0.37 0.86
22
Soore3 2.7 2.1 -0.6 (-0.7-{).3) 0.18 3.6 2.9 -0.7 (-0.~.2) 0.49 0.94
23
24 Cl = confidence interval; mAb = monoclonal antibody
In the placebo group, 351 patients had mild Alzheimer disease and 198 had moderate Alzheimer disease; in the mAb group,
329 patients had mild Alzheimer disease and 193 had moderate Alzheimer disease. lntention-t<Hreat analysis.
+The P value resuns from the oompalison between the mAb group and the placebo group.
+The P value resuns from the oompalison between patients 1Mth mild and moderate AlZheimer disease.

W hich of the following is the most accurate interpretation of these study results?

r A. mAb therapy effectively slowed the process of mild and moderate Alzheimer disease
r B. mAb therapy w as more effective in patients w ith mild Alzheimer disease
r C. mAb therapy w as more effective in patients w ith moderate Alzheimer disease
r D. Patients w ith mild Alzheimer disease had a sharper decline in all cognitive performance scores
r E. There w as no differential response to mAb therapy depending on Alzheimer disease severity
1
2 Item: 11 of 24 ljl f> Mark <::J t::>
Q, ld: 9948 [ Previous Next

6 A retrospective cohort study examines the long-term risk of ischemic stroke in patients w ith perioperative atrial
7 fibrillation follow ing cardiac and noncardiac surgery. The follow ing data is reported:
8
9 Cumulative rate of stroke 1 year after

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12
13
14
15
Type of
surgery
hospitalization, % (95% confidence interval)

Perioperative atrial
fibrillation
No perioperative atrial
fibrillation
Hazard ratio
(95%
confidence
interval)
16 Noncardiac 1.37 (1.22-1.69) 0.32 (0.31 -0.41 ) 1.9 (1.5-2.4)
17 I
18 Cardiac 0.91 (0.80-1.17) 0.82 (0.74-0.93) 1.3 (1.1-1.7)
I
19
12ol W hich of the follow ing best describes the study results?
. L?.J
22
23 r A. Cardiac surgery carries a low er risk of atrial fibrillation than noncardiac surgery
24 r B. Patients w ith perioperative atrial fibrillation follow ing cardiac surgery should not receive
anticoagulation
r C. Perioperative atrial fibrillation increases the risk of stroke w ith either type of surgery
r D. Perioperative atrial fibrillation is not predictive of stroke in patients undergoing cardiac surgery
r E. The risk of stroke after noncardiac surgery is higher compared to that of cardiac surgery
1
2 Item: 12of24 ljl f> Mark <::J t::>
Q, ld: 5469 [ Previous Next

6 A 42-year-old Caucasian w oman comes to the office for a routine follow -up. She w as diagnosed w ith multiple
7 sclerosis three months ago, and has had no relapses ever since. She refused to take medications before, but
8 she is now w illing to do so. She has no other medical problems. She does not use drugs, alcohol or
9 tobacco. Examination show s no abnormalities. There is a new treatment A available that is apparently highly
10 effective in preventing multiple sclerosis relapses. A randomized trial show s that the incidence of relapses

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13
14
15
16
w as 20% after 6 months of treatment. Patients managed w ith placebo had an incidence of 25% during the
same time period. Considering this information, how many patients w ill need to be treated in order to prevent
one relapse during the first six months of therapy?

r A. Four patients
17 r B. Eight patients
18
19
r C. Tw enty patients
12ol r D. Ten patients
. L?.J r E. Five patients
22
23
24
1
2 Item: 13of24 ljl f> Mark <::J t::>
Q, ld: 9937 [ Previous Next

6 Researchers are evaluating a diagnostic test for Legione//a infection that relies on detection of bacterial
7 antigens in the serum . The test is compared to bacterial cultures, w hich are the gold standard for diagnosis.
8 Among 100 patients w ith culture-positive infection, the antigen test w as positive in 90 patients. Among 100
9 patients w ith negative cultures, the test w as positive in 30 patients. W hat is the positive predictive value of the
10 new serum antigen test?
11

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14
15
16
17
r A. 30%
r B. 70%
r c. 75%
r D. 88%
18
19
r E. 90%
12ol
. L?.J
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23
24
1
2 Item: 14of24 ljl f> Mark <::J t::>
Q, ld: 9957 [ Previous Next

6 A study evaluated the accuracy of using midstream urine (MSU) culture to identify the causative pathogen in
7 patients w ith uncomplicated cystitis. W omen ages 18-49 w ith symptoms of cystitis provided MSU
8 specimens for culture. The investigators also collected urine by means of a urethral catheter for culture,
9 w hich served as the gold standard for confirming the causative pathogen . Bacterial growth w as determined in
10 colony forming units per ml. Correlation coefficients (I) w ere calculated for several organisms by comparing
11 the logarithm of bacterial growth in urethral catheter specimens to that of bacterial growth in MSU specimens:
12

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15
16
17
18
Enterococci
Pathogen

Escherichia coli

Klebsiella pneumoniae
Correlation coefficient (I)

0.927

0.341

0.983
I
I
I
I
19
Group B streptococci 0.510
12ol I
. L?.J Other gram-negative rods 0.810
I
22
23 Staphylococcus saprophyticus 0.999
I
24
W hich of the follow ing organisms identified by MSU has the low est positive predictive value in revealing the
causative pathogen for cystitis?

r A. Enterococci
r B. Escherichia coli
r C. Group B streptococci
r D. Klebsiella pneumoniae
r E. Staphylococcus saprophyticus
1
2 Item: 15of24 ljl f> Mark <::J t::>
Q, ld: 9909 [ Previous Next

6 A large randomized double-blinded study compares a new inhalational steroid agent to fluticasone in patients
7 w ith moderate i)ersistent asthma The follow ing results are highlighted in the study
8
9
New inhalational
Fluticasone P-value
10 steroid agent
11
Mean number of rescue
12 22 .6 24.1 0.04
doses of albuterol per month
13

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16
17
18
19
The investigators conclude that the study drug is more effective in this patient population. W hich of the
follow ing is the major limitation of this conclusion?

r A. Clinical significance
r B. Lack of pow er
12ol
. L?.J r C. Lead-time bias
22
r D. Surrogate endpoint
23
24 r E. Type 1 error
1
2 Item: 16of24 ljl f> Mark <::J t::>
Q, ld: 9936 [ Previous Next

The proportion of colonoscopies performed by a physician w ith at least 1 detected adenoma is called the
adenoma detection rate. A study examined the association between the adenoma detection rate and the risk
6
of colorectal cancer 6 m onths to 10 years after colonoscopy. In the graph below , physicians w ere sorted into
7
quintiles based on their adenoma detection rate, w ith quintile 1 being the low est rate of detection and quintile 5
8
being the highest.
9
10
11
Risk of developing colorectal cancer
12
13 1.5
14

--

15

17
18
1.2

19
12ol
. L?.J
-
.2
....
tO

'E 0.9
22 tO
N
23 tO
~
24

--
'0
G)

~
'0
0 .6

<
0.3
-

0.0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
HR=1.00 HR=0.93 HR=0.85 HR=0.70 HR=0.52
(reference) (95% Cl, 0.751.16) (95% Cl, 0.66-1 .1) (95% Cl, 0.52.0.9) (95% Cl, 0.32.0.69)
Cases of
colorectal 183 145 137 166 75
cancer
1
2 Item: 16of24 ljl f> Mark <::J t::>
Q, ld: 9936 [ Previous Next

1.2
6
7
8
9
10
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tO
11 N
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12 ~

13
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~
0.6

--

15

17
18
19
'0
<
0.3

12ol
. L?.J
22 0.0
23
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
24
HR=1.00 HR=0.93 HR=0.85 HR=0.70 HR=0.52
(reference) (95% Cl, 0.751.16) (95% Cl, 0.66-1 .1) (95% Cl, 0.52.0.9) (95% Cl, 0.32.0.69)
Cases of
colorectal 183 145 137 166 75
cancer
@USMLEWorld, UC

W hich of the follow ing statements best describes the study results?

r A. Adenoma detection rate is a useful quality measure of a physician's colonoscopy performance


r B. Adenoma detection rate is not associated w ith the incidence of colorectal cancer
r C. Patients w ith no adenomas can be safely follow ed for 10 years w ithout repeat colonoscopy
r D. Physicians in quintile 3 prevent significantly m ore colorectal cancers than those in quintile 1
r E. The risk of colorectal cancer appears to increase w ith higher adenoma burden
1
2 Item: 17 of 24 ljl f> Mark <::J t::>
Q, ld: 9951 [ Previous Next

A study examines the relationship between urine sodium excretion and systolic blood pressure in a large
cohort of patients from several countries. The follow ing results are reported for change in systolic blood
6 ~Jressure for every_ 1:9 increase in urine sodium excretion
7
Change in systolic blood pressure
8
in mm Hg for every 1-g increase in P-value for
9 N
urine sodium excretion interaction
10
(95% confidence interval)
11
12 Total 98,029 2.01 (2.00-2.31)
13
14 Sodium excretion <0.001
15

-
<3 g/day 11 >132 0.68 (-0.32- 1.92)
16
3-5 g/day 44,143 1.80 (1.19- 2.09)
18
19 >5 g/day 42,754 2.71 (2.37- 2.81)
12ol Hypertensive state <0.001
. L?.J
22 No hypertension 55,271 1.38 (1.24- 1.41)
23
24 Hypertension 42,758 2.37 (2.31- 2.71)

Age <0.001
<45 years 30,910 2.01 (1.91 - 2.21 )
45-55 years 32,217 2.48 (2.26-2.71)
>55 years 34,902 3.01 (2.80-3.23)

W hich of the follow ing best describes the study results?

r A. High sodium excretion causes susceptibility to hypertension


r B. In non-hypertensive individuals, there is no association between systolic blood pressure and
increase in sodium excretion
r C. The slope of association is steeper for patients w ith hypertension than those w ithout hypertension
r n v ,.., ll'"l rt Q.r" inrl iH irl . 1-:IIC' ( ':j rt Q. <'II,::;\ -:l r"Q. 1"'1"'1 1'\r"Q. C'l IC' r ontihlo t " tho offort n f C'nrli. 11"'1"'1 n n hlnnrl r"\r"Q.C'C'I lr"Q.
1
2 Item: 17 of 24 ljl f> Mark <::J t::>
Q, ld: 9951 [ Previous Next
~ressure tor every_ 1:9 1ncrease 1n unne sod1um excretion
Change in systolic blood pressure
6 in mm Hg for every 1-g increase in P-value for
7 N
urine sodium excretion interaction
8 (95% confidence interval)
9
10 Total 98,029 2.01 (2.00-2.31)
11
12
Sodium excretion <0.001
13 <3 g/day 11 >132 0.68 (-0.32- 1.92)
14
15 3-5 g/day 44,143 1.80 (1.19- 2.09)

16

18
19
12ol
. L?.J
Hypertensive state
>5 g/day 42,754

No hypertension 55,271
2.71 (2.37- 2.81)

1.38 (1.24- 1.41)


<0.001

Hypertension 42,758 2.37 (2.31- 2.71)


22
23 Age <0.001
24
<45 years 30,91 0 2.01 (1.91 - 2.21 )

45-55 years 32,21 7 2.48 (2.26-2.71)

>55 years 34,902 3.01 (2.80-3.23)

W hich of the follow ing best describes the study results?

r A. High sodium excretion causes susceptibility to hypertension


r B. In non-hypertensive individuals, there is no association between systolic blood pressure and
increase in sodium excretion
r C. The slope of association is steeper for patients w ith hypertension than those w ithout hypertension
r D. Younger individuals (age <45) are more susceptible to the effect of sodium on blood pressure
r E. Younger individuals (age <45) have higher sodium excretion
1
2 Item: 18of24 ljl f> Mark <::J t::>
Q, ld: 9933 [ Previous Next

6 Investigators w ant to explore a possible association between the use of nonsteroidal antiinflammatory drugs
7 (NSAIDs) and the development of Crohn disease. They plan to administer a standardized questionnaire on
8 NSAID use over the past year to patients w ith new ly diagnosed Crohn disease and to age- and sex-matched
9 healthy volunteers. The study design is most concerning for w hich of the follow ing?
10
11
12 r A. Lack of external validity
13
r B. Lack of statistical pow er
14
15 r C. Length time bias
16

- 17
r D. Misclassification of exposure
r E. Misclassification of outcome
19
12ol
. L?.J
22
23
24
1
2 Item: 19of24 ljl f> Mark <::J t::>
Q, ld: 9952 [ Previous Next

A randomized study assigned patients w ith sickle cell anemia and silent stroke to either m onthly transfusion
therapy (transfusion group of 11 0 patients) or usual care (observation group of 105 patients). An excerpt of
6 the study results is i)rovided below
7
8 Incidence rate ratio
Adverse event N
Total adverse
(95% confidence
P-
9 events value
10 interval)
11
Acute chest syndrome 0.14 (0.05-0.31) <0.001
12
13 Observation group 105 43
14
15 Transfusion group 11 0 7
16
Avascular hip necrosis
17 0.27 (0.04- 0.81) 0.03
(symptomatic)
18

tr
Observation group 105 7

Transfusion group 11 0 2
22
Headache 0.69 (0.32- 1.21 ) 0.51
23
24 Observation group 105 89

Transfusion group 11 0 79

Iron overload (ferritin > 1500 ng/ml) 16.41 (6.21 - 849.21 ) <0.001

Observation group 35 38

Transfusion group 91 1370

Vasoocclusive crisis 0.42 (0.18- 0.79) 0.004

Observation group 105 301

Transfusion group 11 0 143

W hich of the follow ing adverse event estimates is m ost subject to selection bias?
1
2 Item: 19of24 ljl f> Mark <::J t::>
Q, ld: 9952 [ Previous Next
I I

Acute chest syndrome 0.14 (0.05-0.31) <0.001


I
6
Observation group 105 43
7 I
8 Transfusion group 11 0 7
9 I
10 Avascular hip necrosis
0.27 (0.04- 0.81) 0.03
11 (symptomatic)
12
Observation group 105 7
13 I
14 Transfusion group 11 0 2
15 I
16 Headache 0.69 (0.32- 1.21 ) 0.51
I
17
Observation group 105 89
18 I

tr
22
23
Transfusion group 11 0

Iron overload (ferritin > 1500 ng/ml)

Observation group 35
79

38
16.41 (6.21 - 849.21 ) <0.001
I
I
I
24 Transfusion group 91 1370
I
Vasoocclusive crisis 0.42 (0.18- 0.79) 0.004
I
Observation group 105 301
I
Transfusion group 11 0 143

W hich of the follow ing adverse event estimates is most subject to selection bias?

r A. Acute chest syndrome


r B. Avascular hip necrosis
r C. Headache
r D. Iron overload
r E. Vasoocclusive pain
1
2 Item: 20 of 24 ljl f> Mark <::J t::>
Q, ld: 9946 [ Previous Next

The follow ing vignette applies to the next 2 items. The items in the set must be answered in sequential
6 order. Once you click Proceed to Next Item, you w ill not be able to add or change an answer.
7
8 Item 1 of 2
9
10 An 84-year-old man comes to the physician w ith persistent dyspnea despite being treated w ith optimal
11 medical therapy for congestive heart failure w ith low left ventricular ejection fraction. A recently published
12 randomized clinical trial compared an angiotensin-neprilysin inhibitor (ANi) to an angiotensin-converting
13 enzyme inhibitor (ACEi) in patients w ho have heart failure w ith a reduced ejection fraction. The follow ing
14 results w ere reported:
15
16 ANi ACEi
P-value
17 =
(N 5012) =
(N 5130)
18
n (%)
19 I

~
> 1 hospitalization for congestive heart
failure exacerbation w ithin 90 days of 626 (12.5) 826 (16.1) 0.002
22 trial initiation
23
24 Symptomatic hypotension (systolic
205 (4.1) 67 (1.3) <0.001
blood pressure <90 mm Hg)

Elevated creatinine (>2.5 mg/dl) 145 (2.9) 210 (4.1) 0.006


I
Elevated serum potassium (>5.5
842 (16.8) 882 (17.2) 0.21
mmoi/L)

Cough 506 (10.1) 703 (13.7) <0.001

W hich of the follow ing w ould be of most concern w hen sw itching from an ACEi to an ANi?

r A. Dangerous hyperkalemia
r B. Increased hospitalizations for heart failure
r C. Uncomfortable cough
r D. Unsafe drop in blood pressure
1
2 Item: 20 of 24 ljl f> Mark <::J t::>
Q, ld: 9946 [ Previous Next
. - -- --.-.-- - -- - - - -- . - -- ... - --- -- -- -- .. - -- ... -- -.-- -
~ ~ - --

order. Once you click Proceed to Next Item, you w ill not be able to add or change an answer.

6
Item 1 of 2
7
8 An 84-year-old man comes to the physician w ith persistent dyspnea despite being treated w ith optimal
9 medical therapy for congestive heart failure w ith low left ventricular ejection fraction. A recently published
10 randomized clinical trial compared an angiotensin-neprilysin inhibitor (ANi) to an angiotensin-converting
11 enzyme inhibitor (ACEi) in patients w ho have heart failure w ith a reduced ejection fraction. The follow ing
12 results w ere reported:
13
14 ANi ACEi
P-value
15 =
(N 5012) =
(N 5130)
16
n (%)
17 I
18 >1 hospitalization for congestive heart
19 failure exacerbation w ithin 90 days of 626 (12.5) 826 (16.1) 0.002

~
22
trial initiation

Symptomatic hypotension (systolic


205 (4.1) 67 (1.3) <0.001
23 blood pressure <90 mm Hg)
24
Elevated creatinine (>2 .5 m g/dl) 145 (2.9) 210 (4.1) 0.006
I
Elevated serum potassium (>5.5
842 (16.8) 882 (17.2) 0.21
mmoi/L)

Cough 506 (10.1) 703 (13.7) <0.001

W hich of the follow ing w ould be of m ost concern w hen sw itching from an ACEi to an ANi?

r A. Dangerous hyperkalemia
r B. Increased hospitalizations for heart failure
r C. Uncomfortable cough
r D. Unsafe drop in blood pressure
r E. W orsening renal function
1
2 Item: 21 of 24 ljl f> Mark <::J t::>
Q, ld: 9947 [ Previous Next

6 Item 2 of 2
7
8 The investigators also reported the follow ing results for patients in the angiotensin-neprilysin inhibitor (ANi) and
9 angiotensin-converting enzyme inhibitor (ACEi) groups:
10
11 ANi ACEi
P-value
12 =
(N 5012) =
(N 5130)
13
n (%)
14 I
15 Angioedema
16
I
17 No treatment needed or only
11 (0.2) 5 (0.1) 0.21
18 antihistamines used
19
Catecholamines/glucocorticoids used

~
5 (0.1) 4 (0.1) 0.64
but no hospitalization

22 Hospitalization but no airway


3 (0.1) 2 (<0.1) 0.31
23 compromise
24
Airway compromise 0 0 -

W hich of the follow ing is the best interpretation of these results

r A. The interpretation of the results is confounded by the placebo effect


r B. The study results reassure that there is no danger of drug-induced angioedema w ith the new drug
due to the absence of airway compromise
r C. There is a higher number of angioedema events w ith the new drug, w arranting a larger
randomized clinical trial to investigate safety
r D. There is a higher number of angioedema events w ith the new drug, w arranting postmarketing
surveillance if the drug is approved
r E. There is a small but statistically significant increase in the rate of angioedema w ith the new drug
1
2 Item: 22 of 24 ljl f> Mark <::J t::>
Q, ld: 9934 [ Previous Next

6 An epidemiologic study is conducted to evaluate the long-term complications of coronary stent placement.
7 10,000 patients w ho underwent emergency or elective percutaneous coronary intervention at tertiary care
8 centers around the nation w ere randomly selected and monitored for the development of adverse events.
9 According to the study results, 2% of patients w ho received bare metal stents developed stent thrombosis
10 w ithin a year. 40% of the patients w ho developed stent thrombosis died as a result. The risk of death in a
11 patient w ho develops stent thrombosis is best described by w hich of the follow ing epidemiologic parameters?
12
13
14 r A. Attack rate
15 r B. Case fatality rate
16
17 r C. Median survival time
18 r D. Mortality rate
19
r E. Standardized mortality ratio

~ 23
24
1
2 Item: 23 of 24 ljl f> Mark <::J t::>
Q, ld: 9902 [ Previous Next

6 A large longitudinal study examined the association between obesity (defined as body mass index ~30 kglm 2)
7 and risk of ischemic stroke in a cohort of patients. After assessing participant baseline characteristics,
8 researchers follow ed 2,300 patients for a mean of 2.7 years and determined the incidence of major
9 cardiovascular events The follow ing results w ere rei)orted
10
Risk of stroke among obese versus non-obese Relative risk (95% confidence interval)
11
In all cohort patients 2.4 (1.8-2.6)
12
13
In cohort patients w ith diabetes mellitus 1.1 (0.8-1.6)
14 In cohort i)atients w ithout diabetes mellitus 1.0 (0.7-1.5)
15
16 W hich of the follow ing is the best interpretation of the findings of this study?
17
18 r A. Obesity increases the risk of stroke only in patients w ith diabetes
19
r B. Obesity independently increases the risk of stroke in the study population
~ f20l
-~ r C. Obesity is confounding the association between stroke and diabetes

-
22

24
r D. The association between stroke and obesity is confounded by diabetes
r E. The same relative rate of stroke is seen in obese and non-obese patients
1
2 Item: 24 of 24 ljl f> Mark <::J t::>
Q, ld: 6154 [ Previous Next

INext I
6 A clinical trial w as conducted to compare the effects of ACE inhibitors and diuretics in elderly patients w ith
7 hypertension. The investigators believed that ACE inhibitors provide som e additional survival benefits over
8 diuretics use in elderly subjects because of their neurohumoral effects. The study lasted five years and the
9 investigators !)resented the follow ing results after the comi)letion of the study
10
11
ACE inhibitor Diuretic
Hazards ratio (95%
12 Rate per Rate per
Events Events Confidence Interval)
13
1000 1000
14
15 All-cause m ortality 190 15.5 210 17 0.90 (0.80 - 1.01)
16
I
17 Any non-fatal
57 4.8 82 6.7 0.68 (0.45 - 0.96)
18 cardiovascular event
19 Heart failure 69 5.6 78 6.4 0.85 (0.62 - 1.1 8)
~ f20l I
~ According to the information given, w hich of the follow ing is the best interpretation of the study results?
22

--
23
r
r
r
A. ACE inhibitors have no overall advantage over diuretics
B. ACE inhibitors are associated w ith higher risk of heart failure
C. ACE inhibitors may protect from som e cardiovascular events
r D. ACE inhibitors decrease the risk of m ortality
r E. ACE inhibitors should be used w ith caution in elderly patients

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