24th Annual ACPM Board Review Course: Answer Key
Biostatistics
1.1) A
1.2) D
1.3) C
1.4) B
2) C
3) C
4) D
5) B
6) C
7) D
8) C
9) D
10) A
11) D
12.1) A
12.2) D
13.1) D
13.2) B
14) D
15) A
16) B
17.1) C
17.2) C
17.3) C
17.4) A
17.5) A
18) A
19) D
20.1) D
20.2) B
21.1) D
21.2) B
21.3) A
22.1) H
22.2) G
22.3) F
22.4) E
22.5) D
22.6) C
22.7) I
22.8) B
22.9) A
Epidemiology
1. e
2. T F T F
3. F T F T
4. b
5. e
6. a
7. T T T T
8. c
9. d
10. T T T F
11. T T T F
12. T T T T
13. T F T F
14. T F T F
15. T T T T
16. F T F T
17. T T T T
18. T F T F
19. T T T F
20. F T F T
21. b
22. e
23. F T F T
24. a
25. F T F T
26. T T T T
27. c
28. a
29. b
30. d
31. e
32. b
33. T T T T
The Maintenance of Certification Part IV: Expert Panel
1. C
2. A
3. C
Clinical Preventive Medicine
1. B. Properly designed and conducted randomized controlled trials are considered to have the most scientific validity when evaluating the effectiveness of various preventive efforts. Other study designs can provide insight into screening effectiveness but are more likely to be biased or confounded by external factors to the preventive service being considered.
2. E. The USPSTF recommends initiating screening for cervical cancer with a pap smear at the age of 21 years or 3 years after the onset of sexual activity. For women who have had at least 3 normal pap smears and who are in monogamous relationships it is acceptable to screen every 3 years rather than annually. For women over the age of 65 years or who have had a hysterectomy for benign disease the screening risks outweigh benefits and screening can be discontinued. There is insufficient evidence to recommend HPV testing as a primary screening test for cervical cancer for average risk women. HPV testing can be used to further assess a finding of atypical squamous cells of undetermined significance (ASCUS).
3. B. The USPSTF recommends a mammogram for breast cancer screening in average risk women starting at 50 years of age. The USPSTF acknowledges that screening between 40 and 49 years may be appropriate for some women but that this is an individual decision between patients and their doctors based on the patient’s risk factors and values. The USPSTF recommends screening every 2 years as screening every two years captures between 70% and 99% of the breast cancers that screening annually would detect. Neither MRI nor self breast examination are endorsed by the USPSTF as primary screening tests for breast cancer. A potential harm caused by mammograms is their high false positive rate. There is a 23% false positive rate over 10 years and a 10% biopsy rate. The false positive rate increases to 49% for women who have had 10 mammograms. In other countries, the false positive rate is much lower than in the U.S.
4. B. The 2005 Dietary Guidelines for Americans made different exercise recommendations based on an individual’s exercise goals. Americans should exercise for at least 30 minutes most days of the week to prevent chronic diseases, 30 to 60 minutes to maintain a healthy weight, and 60 to 90 minutes to sustain weight loss. Dietary recommendations include limiting fat (<30% of daily calories from fat and <10% from saturated fat), limiting alcohol (≤2 drinks per day for men and ≤1 drink per day for women), limiting sugar, and limiting salt intake.
5. D. This patient has no cardiovascular risk factors as defined by the NCEP and accordingly his goal LDL cholesterol is less than 160. NCEP cardiovascular risk factors include cigarette smoking, hypertension (a sustained blood pressure >140/90), an HDL cholesterol less than 40, being a man over 45 or a woman over 55 years of age, or having a family history of premature heart disease (a first degree male relative with onset younger than 55 years and a first-degree female relative with onset younger than 65 years). While prehypertension (blood pressure 121-139/81-89) and a family history of heart disease, but not premature, are factors that increase a patient’s risk, they are not part of the NCEP risk stratification.
6. B. While all of the medications listed can be considered first line antihypertensive medications, JNC VII specifically states that “thiazide diuretics should be used for most patients.” For some patient scenarios, alternative first line antihypertensives might be considered ideal. For example, beta blockers are indicated for the first year after a patient has had a myocardial infarction and ACE inhibitors are indicated for patients with congestive heart failure, diabetes, or renal disease.
7. A, B, C, and D. The U.S. Preventive Services Task Force addresses four primary domains of clinical preventive services – behavioral risk factor counseling, chemoprophylaxis, screening tests, and immunizations. The U.S. Preventive Services Task Force defers to other organizations for guidelines about chronic disease management and tertiary prevention.
8. A, D, and E. Recommendations on hormone replacement therapy (HRT) have undergone significant changes since the results of the Women’s Health Initiative. Currently, the only indication for HRT is symptomatic treatment of menopausal symptoms. HRT is not routinely indicated for the prevention of chronic diseases. While the Women’s Health Initiative demonstrated a decrease in osteoporotic fractures and a decrease in the incidence of colorectal cancer, the overall risks outweigh the benefits. Risks included increased breast cancer mortality, increased incidence of myocardial infarction, increased blood clots, and increased Alzheimer’s type dementia.
9. A, C, and E. Currently endorsed methods to screen for colorectal cancer include annual FOBT, flexible sigmoidoscopy every 5 years, annual FOBT plus flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. While there is emerging evidence that may support stool DNA testing and virtual colonoscopy neither test have been recommended as a means of screening by the U.S. Preventive Services Task Force. However, the U.S. Multisociety recently included virtual colonoscopy and stool DNA testing as potential screening options – representing a divergence in CRC screening recommendations.
10. D. The criteria for assessing the effectiveness of screening tests stipulated that a test had to detect the target condition and that early detection of this condition resulted in an improved outcome compared to treatment of symptomatic disease. Treatments must not only be effective, but be effective for treating asymptomatice disease.
11. A, B, C, and D. Because many preventive interventions are risk-factor specific, all of these histories should be obtained in order to determine what screening tests, counseling interventions and immunizations are appropriate for each patient.
12. A, B, C, and D. All of these conditions benefit from regular physical activity. Other disorders that may benefit from regular physical activity include obesity, certain cancers, and mental health.
13. B. Visual screening to detect ambylopia or its risk factors in children age 3 to 5 can lead to treatments that result in improved visual outcomes. Visual screening for children <3 years of age is on uncertain benefit. Likewise, the evidence is insufficient as to whether screening older adults improves functional outcomes. Visual acuity testing does not accurately identify age-related macular degeneration or cataracts. While visual acuity testing is effective for detecting refractive errors, which improves visual acuity, there is inadequate evidence that this leads to improved functional outcomes.
14. A, B, C, D, and E. All of the examples are potential problems that can occur in studies evaluating cancer screening. Lead-time bias refers to the apparent prolongation in survival among screen detected cancers that occurs because screening moves time of diagnosis back in time, and thus increases survival after diagnosis, even in the absence of any true effect on time of death. Length bias occurs when periodic screening preferentially picks up slow-growing cancers with a longer asymptomatic period, whereas more aggressive cancers are more likely to present with symptoms before they can be identified by screening. Selection bias may occur if persons receiving screening differ from persons who are not screened in other important ways that affect survival (e.g. higher income, better medical care, better underlying health, etc.). Overdiagnosis of cancer is similar to lead-time bias in that screening may identify some cases that appear to be cancer on pathological specimens but that would spontaneously regress or never progress to symptoms. Finally, if screen-detected cases tend to be more recent than the cases diagnosed clinically, improved survival may be due to better treatments rather than a benefit of early detection.
15. D and E. Neither routine ultrasound nor electronic fetal monitoring have been proven to improve important perinatal outcomes in average-risk women. Similarly, although insulin treatment of women with gestational diabetes (GDM) can reduce the risk of macrosomia, the effect of screening on important clinical outcomes (e.g. cesarean section rates, neonatal morbidity or mortality) is uncertain. Due to questions about the balance of risks and benefits of routine screening in low-risk women (e.g. younger, non-obese women), neither the USPSTF, the American Academy of Family Physicians, nor the American College of Obstetrics and Gynecology advocate universal screening for GDM. Folate supplementation given early in pregnancy as part of a multivitamin/multimineral supplement has been shown to reduce the risk of neural tube defects. Prospective trials have demonstrated an increase in birth weight and a decrease in intrauterine growth retardation after smoking cessation counseling of pregnant women; and pregnant women are more likely to be successful with smoking cessation.
16. C. In low-risk women with a history of repeated, normal Pap smear results, annual screening offers little advantage over screening every 3 years. The U.S. Preventive Services Task Force recommends mammography every 2 years. While it would be acceptable to screen women annually who are at higher risk or who more concerned about breast cancer, it should not routinely be offered to all women annually. Screening for colorectal cancer is recommended for men and women beginning at age 50 with either annual fecal occult blood tests or periodic sigmoidoscopy (every 5 years) or colonoscopy every 10 years. While lung cancer is the most common cause of death from cancer for men and women, screening with chest x-ray has not been demonstrated to decrease mortality or improve outcomes. Routine bone densitometry is not recommended, especially in low risk women, until 65 years of age.
17. B and E. Screening for Chlamydia is recommended because infection is generally common in sexually active teens regardless of socioeconomic status. Chlamydia infection is associated with risk of pelvic inflammatory disease and infertility in women. All adolescents and young adults should be asked about sexual history and offered appropriate counseling about effective contraception and measures to reduce STD risk. Clinical breast exam, cholesterol screening for a 18 year old woman, and urinalysis are not of proven benefit in the absence of specific clinical indications.
18. D and E. Screening tests that have been demonstrated to reduce cardiovascular mortality include measurement of blood pressure and lipids. However, there is only evidence to support measuring lipids for at risk women older than 20, at risk men 20-35, and all men older than 35 years. Routine screening for average risk women over the age of 45 is no longer endorsed by the USPSTF. Healthy diet, regular aerobic exercise, and not smoking are also associated with reducing cardiovascular mortality. Clinicians can play an important role in helping patients to quit smoking. While c-reactive protein and coronary artery calcium scores have data to suggest that they are independent risk factors for heart disease there is little current evidence to suggest that this information alters patient outcomes, although these are areas of active research.
19. B, C and D. Prostate cancer is the second leading cancer killer of men in America. Screening increases the likelihood of detecting early stage cancers. Cancers confined to the prostate tend to respond well to treatment, while cancers that extend beyond the capsule of the prostate are less responsive to therapy. What is not known is whether detecting early stage prostate cancer through screening helps to extend men’s life. Screening may merely detect prostate cancers which would not progress to impact men in their natural lifespan. Because mortality from prostate cancer in men with lower grade prostate cancer is not increased for 8 to 15 years, a reasonable treatment option is watchful waiting. However, less than 10% of American men with prostate cancer elect this treatment option. In other countries, 80% to 90% of men with low grade prostate cancers opt for watchful waiting rather than surgery or radiation.
20. A, B, C, D, and E. First-line pharmacotherapy includes nicotine replacement, buproprion, and varenicline. Second-line pharmacotherapy includes clonidine and nortriptyline.. First-line therapy is more effective than second-line therapy, but second-line therapy is more efficacious than no therapy. Telephone counseling can be used alone or in conjunction with pharmacotherapy. Clinician advise to quit is commonly cited by patients as a reason they quit. Even brief advise is effective, but counseling intensity is directly proportional to its effect.