BOARD

REVIEW : EBM & PREVENTION

Q & A: Harrisons I-1
A physician is deciding whether to use a new test
to screen for Disease X. The prevalence is 5%.
SensiGvity 85% Specicity 75%. In a populaGon
of 1000, how many with X will be missed in
screening?
A 50
B 42
C 8
D 4
E 10

Sensi;vity
The percentage of persons with the disease of interest
who have positive test results
= True-post/(True-post + False-neg) x 100 (HUH??)
= True positives/All pts w disease (OK!!!)
Tests that are very sensitive are clinically useful to rule out a
diseasebecause if you had it, you would be positive
IDEPENDENT of the prevalence of disease

Specicity
The percentage of persons without the disease who
have negative test results
= True-neg/(True-neg + False-post)
= True-neg/All patients with disease
The more specific the more likely persons without the disease
of interest will be excluded.
Both sensitivity and specifity are independent of prevalence

Q & A: Harrisons I-1

A physician is deciding whether to use a new test to screen for
Disease X. The prevalence is 5%. SensiGvity 85% Specicity 75%.
In a populaGon of 1000, how many with X will be missed in
screening?
A 50
B 42
C 8
D 4
E 10
The answer is C. 8
Prevalent cases 50
True posiGves=Prev Cases*Sens= 50*.85= 42.5
False negaGves=Prev Cases-TP=7.5

Q&A
What is this quesGon asking?
How many people w disease have negaGve test?
What is the expected number of false negaGves?
%FN=(1-sensitvity) or #FN= Prevalent cases-TP cases

Prevalence = number of people with disease

Prevalence = 5% * 1000 = 50

Sensi;vity= 85% with disease will be True PosiGves

Sens= .85*50 = 42.5 True PosiGves
FN = 50-42.5= 7.5 FN

Q & D
PREVALENCE: Prob (+ disease)
SENSITIVITY: Prob (True Posi;ve) given
disease
SPECIFICITY: Prob (True NegaGve) given no
disease
PPV: Prob (+disease) given posiGve test
NPV: Prob (-disease) given negaGve test

2x2 Table

Q&A Harrisons I-2

How many paGents were told erroneously
that they have disease based on this test?
A.713
B.505
C.237
D.42
E.8

ANSWER
What is the question asking?
How many without disease have a positive test?
How many false positives are expected?
Total without disease TN cases= # False positives
Prevalence = number of people with disease
People w/o disease = 1000-(5% * 1000) = 950

Specificity= 75%of people without disease will be TN

cases
Spec(TN) cases= .75*950 = 712.5 TN cases
FPcases = 950-712.5= 237 FP cases

The answer is C. 237

Q&A: Harrisons I-3

Drug X is investigated in a meta-analysis for its
effect on mortality after a myocardial
infarction. It is found that mortality drops
from 10 to 2% when administered. What is the
ARR?
A. 2%
B. 8%
C. 20%
D. 80%

Q&A: Harrisons I-4

How many patients will have to be treated with
drug X to prevent one death?
A. 2
B. 8
C. 12.5
D. 50
E. 93
The answer is C. 12.5
The NNT is equal to the inverse of the ARR
1/ARR= 1/8% = 12.5

ANSWER
ANSWER IS B 8%
ARR = Difference between risk in Exposed
(Exposed Event Rate) vs risk in Control
(Control Even Rate)
ARR= CER-EER
10%-2%=8%
The RELATIVE RISK REDUCTION=ARR/
CER= 8%/10%=80%

Q&A: Harrisons I-6

Which of the following regarding CAD in women
is true?
A. Death rates for CAD for men and women have
been increasing over the last 30 years.
B. The most common iniGal symptom of heart
disease in women is angina.
C. Women with AMI are more likely than men to
present with VTach.
D. Women in all age groups have lower mortality
from MI than males do.

ANSWER
The answer is B.
Mortality from CAD has been increasing among
women for the last 30 years and among men it
has been decreasing.
According to Framingham study angina is the
most common presentaGon of coronary heart
disease in women.
Females w MI are more likely than males to
present w cardiogenic shock and males are more
likely to present w Vtach

Study Types
Case report/Case series: a description of single or
multiple anecdotal presentation and management of
diseases
Case-control: typically identify patients with an outcome
and then make retrospective survey of exposures. Matches
cases with disease to controls without disease and check
for exposures.
Cohort study: prospective study that follows groups (the
cohorts) divided by exposure to measure risk of
development of outcome over time
Systematic review: a literature assessment that
identifies a question, eliminates/includes sources, appraises
results and synthesizes/describes conclusions.

Q&A: MKSAP14 FIM-7

19 yo F w RLQ abd apin and fever. Abd tender to palpaGon
w/o rebound/guarding. Pelvic exam normal. From
experience the probability of acute appendiciGs is 50%. A
posiGve abdominal CT has a likelihood raGo of 13.3 for the
diagnosis of acute appendiciGs. If the CT scan is posi;ve
for appendici;s what is the approximate increase in
probability that the pa;ent has appendici;s?
A. 5%
B. 15%
C. 30%
D. 45%
E. 60%

Q&A: MKSAP14 FIM-4

23 yo woman evaluated for migraine occurring ves Gmes
per month wants to restart prophylacGc medicaGon
regimen. The pt has already responded poorly to Betablockers and amitriptyline in the past. She wonders
whether gabapenGn will help.
Which of the following sources is most likely to provide
reliable informa;on for answering this pa;ents ques;on?
A. Randomized controlled trial
B. Case report
C. Case controlled studies
D. SystemaGc reviews
E. Drug informaGon inserts

ANSWER
The answer is D: systemaGc review
SystemaGc reviews and meta-analyses are provided summaries of
voluminous informaGon from mulGple publicaGons of original
research. They can show where a body of literature has both
consistencies and controversies and be generalized more reliably
across popula;ons.
Single RCTs rarely provide deniGve answers to broad clinical
quesGons due to the diculty in generalizing to a single paGent and
the probability of dierences being due to chance alone (type I
error).
Case reports are clinical observaGons that should never be used to
draw clinical conclusions.
Case controlled studies are not randomized and prone to bias and
typically describe the associaGon between and exposure and an
event.

LIKELIHOOD RATIOS

LR: considers both the sensitivity and specificity

combined into a single measure of diagnostic
effectiveness
+LR= sensitivity/(1-spec)
Proportion of pts with disease that test positive versus
the prop of pts w/o disease who test positive
The greater the magnitude of a LR, the more useful the
test is for increasing the probability for confirming a
target disease.
Positive LR of 2, 5, and 10 increase the probability of
disease by 15%, 30% and 45% respectively
The answer is D: 45%

MKSAP14 FIM13
55 yo w cough and malaise that occurs mulGple Gmes
per year. He has 40 pack-year history. On exam he is
afebrile HR, RR, BP wnl. Cardiopulmonary exam is
normal, chest clear w/o consolidaGon/wheeze and
heart regular. Which of the following is the most
appropriate ini;al smoking cessa;on management
step during this visit?
A. Recommend nicoGne gum
B. Provide a clear, personalized message to the paGent
C. Refer the paGent to behavioral modicaGon
D. Prescribe bupropion

MKSAP GIM6
25 yo woman evaluated during for rouGne exam,
nonsmoker, social alcohol drinker, denies illicit drug
history. She has had 3 sexual partners and is in a
serious monogamous relaGonship. She has no history
of STIs and takes OCP for pregnancy prevenGon. She
has a scheduled Pap smear. Which of the following is
most appropriate for this pa;ent?
A. Encourage sunscreen use
B. Prescribe mulGvitamin with folic acid
C. Screen for Chlamydia
D. Measure fasGng plasma glucose

MKSAP 14 GM37
45 yo AAM is evaluated for concerns about prostate
cancer. A close friend was recently diagnosed w
extensive disease and has a poor prognosis. The
paGent asks if he should have a screening test for the
disease. He has once per night nocturia and no
hesitancy, freq, or dribbling. Which is the most
appropriate plan of ac;on?
A. PSA measurement
B. PSA and DRE
C. Transrectal US
D. Random biopsies
E. Shared Decision making

ANSWER
The answer is B. Provide a clear, personalized
message to the paGent
Although buproprion, nicoGne replacement, and
behavioral therapy are appropriate adjunct
intervenGons, however, using these without
adequately assessing the paGents readiness for
behavioral change is premature.
Brief intervenGons for as few as 1-3 min have
been shown to result in an increased number of
paGents who quit and abstain from cigarene
smoking.

ANSWER
The answer is C: Screen for Chlamydia
CDC recommends annual screening for sexually acGve
women aged 25 and younger at increased risk for infecGon
New or mulGple sexual partners
History or current symptoms of STI
History of unprotected intercourse

Age <25 is strongest predictor in men and women

Benet of counseling to paGents w high sun exposure is
unknown
A mulGvitamin w folic acid is recommended for pregnant
women to prevent neural tube defects but is not necessary
in this paGent she is not pregnant and on OCPs.
FPG is not recommended for rouGne screening without
risk factors for DM.

ANSWER
The answer is E: Shared Decision Making
discussion risk and benets.
USPSTF recommends shared decision making
on the potenGal risk and benets of screening
for prostate cancer.
The PPV for PSA is 30%. Of the men with
posiGve test, only a third actually have
prostate cancer.

MKSAP 63

ANSWER

22 yo nursing school grad is evaluated for preemployment. She has hx of SLE and no recollecGon of
having chickenpox and her varicella Gter is negaGve.
Which is the most appropriate recommenda;on?
A. No vaccinaGon
B. Single vaccinaGon (shortened series), clear for work
C. Single vaccinaGon, delay work 4 weeks
D. Two-dose vaccinaGon series over 6 weeks, clear for
work
E. Two dose vaccinaGon series over 6 weeks, delay
work for 4 weeks.

The answer is E: Two dose vaccinaGon series

over 6 weeks, delay work for 4 weeks.
Due to her age and occupaGon she is at high risk
for VZV infecGon an should be immunized w the
usual two doses. The vaccine is recommended
for all adults with no evidence of immunity.
The live vaccine can cause shedding in the 4
weeks following injecGon so she should avoid
paGents who might be sick from exposure to her.
A single dose is not advised for anyone

MKSAP14 HO-70
30 yo woman G3P2 evaluated for rouGne exam, two years
had bilat tubal ligaGon. Took OCPs for 5 years between
births. Healthy and w/o complaints. FH sig for maternal
cousin diagnosed w OvarianCa at age 48. No other FH Brst
or Ovrn Ca. Exam normal. Has friend of Askenazi Jewish
descent w strong FH. Pt wants to know what she can do to
reduce her own risk Brst/Ovrn Ca. Which of the following
would be most appropriate?
A. RouGne Ca screening
B. ProphylacGc bilat ooporectomy
C. CA-125 measurement
D. Restart OCPs
E. RouGne daily vitamins

ANSWER
The answer is A: rouGne screening.
Pt not a high risk for cancer so only age and
gender appropriate screening are indicated.
Pts friend most likely harbors BRCA1 gene
women with this abnormality are encouraged
to use shared decision-making to consider
prophylacGc oophorectomy,
chemoprophylaxis or rouGne CA-125
screening.

MKSAP HO-84

Answer

59 yo woman is evaluated during a rouGne exam. Her

family history includes a sister who was recently diagnosed
with advanced stage-ovarian cancer. The remainder of her
medical and family history is noncontributory. Physical
exam normal. Pt is concerned about her risk for developing
ovarian cancer and ask what rouGne screening methods
will decrease her risk. Which of the following is the most
appropriate recommenda;on for ovarian cancer
screening in this pa;ent?
A. No Screening test
B. Serum CA-125
C. Transvaginal US
D. Doppler ovarian exam

The correct answer is A.

No screening tool has been shown to decrease
ovarian cancer mortality in general or in at risk
risk populaGons.
No clinical review organizaGons recommend
rouGne ovarian ca screening.
PredicGve models developed show the
available screening tools would have at most a
small benet.