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Oct 07, 2015

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Mcem Part a

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1. Causation

(a) A temporal relation between cause and effect may best be demonstrated by a

case-control study.

To prove causation the cause must precede the effect. A cohort study or a RCT is

best to prove this.

(b) To establish causation a cause should be supported by other knowledge.

This is plausibility eg evidence from animal studies or a logical physiological basis

for the cause.

(c) A marginally higher relative risk ratio does not lend strength to a probable

cause.

The strength of an association between a cause and an effect should ideally be

demonstrated by a high relative risk ratio.

(d) Hearing loss and noise is an example of a dose response relationship.

Increased exposure to the possible cause is associated with an increased effect.

This is a dose response relationship.

(e) If causation is to be established reversibility is demonstrated by removing the

possible cause and observing for a reduction of disease risk.

2. In a gaussian distribution:

(a) The mean,median and mode are equal.

In a gaussian distribution the mean,median and mode are equal.

(b) 68% of the observations fall within one standard mean.

In a gaussian distribution 68% of the observations fall within one standard mean.

(c) 99% of the observations fall within 2 standard means.

In a gaussian distribution 95% of the observations fall within 2 standard means.

(d) Has a positively skewed distribution.

A positively skewed distribution is a feature of a distribution which is

asymmetrical.

(e) Has a negatively skewed distribution.

This is a feature of a distribution which is asymmetric.

3. The following are true:

(a) The incidence of community acquired pneumonia is 12 per 1000 adults

The incidence of community acquired pneumonia is 12 per 1000 adults

(b) Streptococcus Pneumoniae is the commonest cause of community acquired

pneumonia and accounts for 50% of cases

Streptococcus Pneumoniae is the commonest cause of community acquired

pneumonia and accounts for 60-75% of cases

(c) Mycoplasma pneumoniae accounts for 5-18% of pneumonia.

Mycoplasma pneumoniae accounts for 5-18% of pneumonia.

(d) Viruses including the influenza virus account for up to 15% of cases of

pneumoniae.

Viruses including the influenza virus account for up to 15% of cases of

pneumoniae.

(e) CSF glucose is increased by bacteria.

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4. Case control studies

(a) Are not suitable for studying rare diseases

(b) It is possible to calculate incidence rates from them

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5. Study Design:

(a) Restriction limits the range of characteristics of patients in the study.

(b) The efficacy of a treatment is the extent to which it produces a beneficial effect

when implemented under the usual clinical conditions.

This definition is of the effectiveness of the drug.

(c) Intention to treat analysis dissociates the effects of treatment from the

suggestive element imposed by the receipt of treatment.

Dissociation of the effects of treatment from the suggestive element imposed by

the receipt of treatment is accomplished by placebo.

(d) Intention to treat analysis does not analyse patients who did not actually

receive treatment.

Intention to treat analysis analyses patients who did not actually receive

treatment and those who did not complete treatment.

(e) Cohort trials are observational.

Cohort trials are observational.

6. Screening Tests. There are four groups. The first group have the disease and

the screening test result is positive for the disease ( a ). The second group do not

have the disease but the screening test is positive ( b ). The third group have the

disease but the screening test is negative ( c ). The fourth group do not have the

disease and the screening test is negative ( d )

(a) In the above, the sensitivity of the test is given by d/b+d

The specificity is given by d/b+d. Specificity is the proportion of true negatives

correctly identified by the test.

(b) In the above the specificity is given by a/a+c.

The sensitivity is given by a/a+c.

(c) The positive predictive value is given by a/a+b.

The positive predictive value is given by a/a+b.

(d) The negative predicitve value is given by d/c+d.

The negative predicitve value is given by d/c+d.

(e) The positive predicitve value depends on the prevalence of the disease and

may vary from population to population.

As does the negative predictive value.

7. Statistics

(a) Type I error is false rejection of the null hypothesis where no true difference

exists.

Backing a loser

(b) Type II error is false acceptance of null nypothesis where a true difference

exists

Missing a winner

(c) Parametric testing is less powerful than non parametric testing.

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deviations. It is more powerful and makes calculation of confidence intervals

easier.

(d) The correlation coefficient measures the degree of association between two

sets of variables and ranges between 0-1.

The correlation coefficient measures the degree of association between two sets

of variables and ranges between -1 and +1. +1: perfect positive association (one

variable increases with the other in a linear fashion) -1: perfect negative

association (one variable decreases with the other in a linear fashion) 0: No

correlation at all.

(e) n-way ANOVA is a types of regression - used to determine the relationship

between categorical variables.

8. Which of the following resuscitation room investigations has a sensitivity of

more than 85%:

(a) CTPA.

CTPA is 83% sensitive and rises to 90% when combined with CT venography.

(b) Erect CXR for pneumoperitoneum(air under diaphragm)

Erect CXR for air under the diaphragm is <80% sensitive.

(c) D-Dimer assay for PE.

D-Dimer assay for PE has a sensitivity of >90%.

(d) Beta-Natriuretic peptide for heart failure.

Beta-Natriuretic peptide for heart failure is about 85% sensitive.

9. In a survey of 100 patients, 30 had ascites of which 25 had alcoholic cirrhosis.

10 other patients who had no ascites did have alcoholic cirrhosis. Which of the

following is correct?

(a) Positive predictive value is 25/(25+5)

(a) Fracture of the ankle or mid-foot occurs in less than 15% of those presenting

with acute traumatic ankle injuries.

The management of ankle sprains is daily routine at emergency departments, and

although most patients undergo radiography, fracture of the ankle or mid-foot

occurs in less than 15%

(b) The mid-foot assessment in the ottawa ankle rules covers the ability to walk

and notes localised tenderness of the cuboid or the base of the fifth metatarsal.

The mid-foot assessment in the ottawa ankle rules covers the ability to walk and

notes localised tenderness of the navicular or the base of the fifth metatarsal.

(c) The ankle assessment in the ottawa ankle rules covers the ability to walk four

steps (immediately after the injury or at the emergency department) and notes

localised tenderness of the posterior edge or tip of either malleolus

The ankle assessment in the ottawa ankle rules covers the ability to walk four

steps (immediately after the injury or at the emergency department) and notes

localised tenderness of the posterior edge or tip of either malleolus

(d) The ottawa ankle rules have a high sensitivity but a low specificity.

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The ottawa ankle rules have a high sensitivity but a low specificity.

(e) Tenderness over the navicular bone is an indication for X Ray according to the

ottawa ankle rules.

Tenderness over the navicular bone is an indication for X Ray according to the

ottawa ankle rules. http://www.bmj.com/cgi/content/full/326/7386/417#F1

11. The following are true:

(a) The positive predictive value is given by the true positives over the true

positives and the false negatives.

The sensitivity is given by the true positives over the true positives and the false

negatives.

(b) The sensitivity is given by the true positives over the true positives and false

positives.

The positive predictive value is given by the true positives over the true positives

and false positives.

(c) The specificity of a test is given by the true negatives over the true negatives

and the false negatives.

The negative predictive value of a test is given by the true negatives over the true

negatives and the false negatives.

(d) The negative predictive value is given by the true negatives over the true

negatives and the false positives.

The specificity is given by the true negatives over the true negatives and the false

positives.

12. A study investigates whether a certain drug A is better alone with the addition

of drug B for ulcerative colitis. After randomizing the patients, a few patients on

both drug A+B drop out due to side effects. How should the data be analysed?

(a) Exclude the patients from statistical analysis

Include these patient outcomes in the drug A+B group. The analysis of patients

dropping out of a study should take into account the adverse effects of a drug (in

this case drug B) causing drop out. Hence even though patients have dropped out,

the 'intention to treat' principle requires the patients to be analysed even if they

did not receive the treatment.

13. Myocardial Infarction

(a) The annual incidence is 50/1000 in the UK

The annual incidence of myocardial infarction is 5/1000 in the UK.

(b) Has a 40% out of hospital mortality rate.

Myocardial Infarction has a 40% out of hospital mortality rate.

(c) Has a 20% in-hospital mortality rate.

Myocardial Infarction has a 20% in-hospital mortality rate.

(d) Has an overall mortality of 27% at 28 days post MI.

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(c) Sensitivity

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(d) Specificity

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(e) Vocational drivers ( HGV etc ) must inform the DVLA of an MI.

Ordinary drivers do not have to inform the DVLA unless a continuing disability

persists.(Vocational drivers are those who drive for a living. HGV=Heavy Good's

Vehicle)

14. The following are true:

(a) Rejecting the null hypothesis when it is true is a type I error.

Rejecting the null hypothesis when it is true is a type I error.

(b) Accepting the null hypothesis when it is false is known as a type II error.

Accepting the null hypothesis when it is false is known as a type II error.

(c) The power of a study is the probability of correctly rejecting the null hypothesis

when it is false.

The power of a study is the probability of correctly rejecting the null hypothesis

when it is false.

(d) Small samples often lead to a type II errors.

Small samples often lead to a type II errors.

15. A blood test for screening heart failure has been introduced. Out of 300

patients, 100 were found to have heart failure with echocardiography. When the

blood test is used, 80 patients were found to have heart failure. 70 of these

patients had heart failure confirmed with echocardiography but 10 did not. Which

of the following are true?

(a) 10/80 is the positive predictive value of the blood test.

70/80 is the positive predictive value of the blood test.

(b) 70/80 is the positive predictive value of the blood test.

70/80 is the positive predictive value of the blood test.

(c) 70/100 is the sensitivity of the blood test.

70/100 is the sensitivity of the blood test.

(d) 80/100 is the specificity of the blood test.

190/200 is the specificity of the blood test.

(e) 70/300 is the positive predictive value of the blood test.

The positive predictive value of the number of true positives (70) out of the

positives (80)detected by blood test. In this case, sensitivity would be the number

of positives detected by the blood test (70) out of the true number of positives

(100).Specificity is 190/200.

16. A new diagnostic blood test for pulmonary embolus has been described. Out of

all patients tested negative, which parameter measures the true numbers of

patient who do not have pulmonary embolus?

(a) Positive predictive value

17. The negative predictive value tells us the proportion of individuals who test

negative who do not have a target condition. The following are True:

(a) As many as 5% of patients with Acute Coronary Syndrome are sent home from

the ED

U Ekelund and J L Forberg New methods for improved evaluation of patients with

suspected acute coronary syndrome in the emergency department Emerg Med J

2007; 24: 811-814. doi:10.1136/emj.2007.048249

(b) In acute coronary syndrome patients with high BNP values indicate an

increased risk of heart failure and death.

In acute coronary syndrome patients with high BNP values indicate an increased

risk of heart failure and death. Emerg Med J 2007; 24: 811-814.

doi:10.1136/emj.2007.048249

(c) CRP is valuable for determining long term prognosis in acute coronary

syndrome.

Emerg Med J 2007; 24: 811-814. doi:10.1136/emj.2007.048249

(d) The sensitivity at presentation for acute myocardial infarction of markers of

myocardial necrosis ( troponin or CkMB ) is below 50%

The sensitivity at presentation for acute myocardial infarction of markers of

myocardial necrosis ( troponin or CkMB ) is below 50% U Ekelund and J L Forberg

New methods for improved evaluation of patients with suspected acute coronary

syndrome in the emergency department Emerg Med J 2007; 24: 811-814.

doi:10.1136/emj.2007.048249

(e) CKMB is useful for the detection of unstable angina.

CKMB is not raised in unstable angina.

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Alcohol Your

Result Result

(a) About 1/3 rd of emergency department attenders have blood alcohol concentrations above the

UK legal driving limit. True

?30-40%. 1 in 5 male admissions to acute medical wards are directly or indirectly due to alcohol.

(b) People with serious drinking problems have a relative risk of dying if 5-6 in comparison to age

and sexed matched members of the general public. False

?People with serious drinking problems have a relative risk of dying if 2-3 in comparison to age

and sexed matched members of the general public.

(c) 1 unit of alcohol contains about 20g of absolute alcohol. False

?1 unit of alcohol contains about 8g of absolute alcohol. 1/2 a pint of beer or a pub measure of

wine is considered a unit of alcohol.

(d) 1 unit of alcohol raises the blood alcohol concentration by about 15-20mg/dL True

?This is the amount that is metabolised in 1 hour.

(e) Blood alcohol levels of over 100mg/dL are associated with respiratory failure, coma and death.

False

?

20-99mg/dL...impaired coordination and euphoria, 100-199mg/dL...ataxia, poor judgement, labile

mood, 200-299mg/dL...marked ataxia and slurred speech;poor judgement, labile mood , nausea

and vomiting, 300-399mg/dL...stage 1 anaesthesia, memory lapse, labile mood,

400mg/dL...Respiratory failure, coma and death

In statistics:

(a) If values are in normal distribution approximately 68% of the values lie within one standard

deviation of the mean. True

?If values are in normal distribution approximately 68% of the values lie within one standard

deviation of the mean.

(b) If values are in normal distribution approximately 95% of the values lie within three standard

deviation of the mean. False

?If values are in normal distribution approximately 95% of the values lie within 1.96 standard

deviation of the mean.

(c) Exactly 95% of the values lie within 1.96 standard deviations of the mean values are in a

normal distribution. True

?Exactly 95% of the values lie within 1.96 standard deviations of the mean values are in a normal

distribution.

(d) The standard error measures how precisely the sample mean approximates the population

mean. True

Standard error = standard deviation / square root of sample size.

(e) The standard error is smaller for larger sample sizes. True

The more observations in the sample the more precisely the sample mean estimates the population

mean- i.e the less the error.

A new test has been designed and tested for the diagnosis of rhabdomyolysis. The sensitivity was

reported as 90%. Which of these statements is true regarding the test?

(a) 90% of the patients with rhabdomyolysis will test positive. True

?

(b) 90% of the patients with rhabdomyolysis will test negative. False

?

(c) 90% of patients in the general population who have the test, will test negative. False

?

(d) 90% of patients in the general population who have the test, will test positive. False

?

(e) 90% of patients who test positive will have a correct diagnosis. False

?

90% of the patients with rhabdomyolysis will test positive. Sensitivity is the probability that a test

will be positive when a patient has the condition. Specificity is the probability that a test will be

negative when a patient does not have the condition.

A group of 100 patients were involved in a study of clubbing and endocarditis. There were 8

patients with SBE and clubbing, 2 patients with SBE without clubbing. 90 patients without SBE

and 5 of these patients had clubbing. Which of the following is true?

(a) Positive predictive value = 8/(8+2) False

?

(b) Negative predictive value = 85/(85+2) True

?

(c) Sensitivity = 8/(8+5) False

?

(d) Sensitivity = 8/(8+85) False

?

(e) Specificity = 85/(85+2) False

?

Negative predictive value = 85/(85+2). This is a good exercise for calculating sensitivity etc. The

total of all patients is 100. PPV = 8/(8+5). NPV = 85/(85+2). Sensitivity = 8/(8+2). Specificity =

85/(85+5).

A new drug for inflammatory bowel disease has been released. The 5 year mortality rate with the

treatment is 50% and without the treatment it is 60%.

(a) The absolute risk reduction is 5%. False

?

(b) The absolute risk reduction is 10%. True

?

(c) The relative risk reduction is approximately 16%. True

?http://www.cmaj.ca/content/vol171/issue4/images/large/35ff1.jpeg

(d) The relative risk reduction is 20%. False

?

(e) The relative risk reduction is 25%. False

?

The relative risk reduction is 10% of 60% ( The 10% absolute difference expressed as a proportion

of the control rate). The absolute risk reduction is 60 - 50% which is 10%.

The following are prognostic indicators according to the Glasgow scoring system for pancreatitis.

(a) Age >55 years True

?Age >55

(b) WCC >11 False

? WCC >15

(c) Fasting Glucose >10 mmol/L True

?Fasting Glucose >10 mmol/L

(d) Urea >10 mmol/L False

?Urea >16 mmol/L

(e) pO2 <10 kPa False

?pO2 <7.9 kPa

Age over 55, WCC >15, Fasting Glucose >10, Urea >16, pO2 <7.9, Ca < 2, Albumin <32, LDH

>600, AST >100 ( all standard units )

Measures of effect:

(a) The odds ratio is approximately equal to the relative risk only when the incidence of disease is

high. False

?The odds ratio is approximately equal to the relative risk only when the incidence of disease is

low.

(b) A Kaplan-Meier analysis is a method to estimate the survival events of a cohort over time,

when some individuals are followed for longer periods than others. True

?A Kaplan-Meier analysis is a method to estimate the survival events of a cohort over time, when

some individuals are followed for longer periods than others.

(c) A Kaplan-Meier analysis is a method to estimate the survival events of a cohort over time,

when some individuals status at the end of follow up are not known. True

?A Kaplan-Meier analysis is a method to estimate the survival events of a cohort over time, when

some individuals status at the end of follow up are not known.

(d) A hazard ratio is used in survival studies and is a measure of relative risk. True

?A hazard ratio is used in survival studies and is a measure of relative risk.

(e) The absolute risk is the rate of occurrence of a disease. True

?The incidence in an exposed population.

The following are true in a cohort study

(a) It is an observational study True

?

(b) It is a retrospective study False

Can be prospective or retrospective

(c) It is good at evaluating rare exposures True

?

(d) Does not involve controls False

(e) Can not establish timing and directionality of events False

?

In cohort studies the sample selection occurs before the nset of the disease and followed over time

to establish who develops the disease and associated factors. Subjects are divided at the outset into

two groups; Those who received exposure and those who didn't.

The power of a test depends on:

(a) The significance level. True

?

(b) The size of the difference you wish to detect. True

?

(c) The sample size. True

?

(d) The confidence interval. False

?The CI is the interval or range about which the 'true' statistic is believed to be within a given

population with a known probability.

(e) The Z score. False

?The Z score examines the comparison between a sample mean and a known population mean by

calculating the ratio of the difference between means to the standard error.

Nice Guidelines: Indications for CT Brain Scan in children ( <16 )

(a) GCS <15 on assessment in the ED for children >1 year False

?GCS <14 on assessment in the ED for children >1 year

(b) GCS <15 on assessment in the ED for children < 1year True

?GCS <15 on assessment in the ED for children < 1year

(c) A tense fontanelle on it's own is not an indication for CT brain scan False

?A tense fontanelle is an indication for a CT brain scan. Suspicion of an open or depressed skull

fracture are also indications for a CT Brain scan.

(d) Postauricular bruising ( Battle's sign ) is an indication for a CT brain as it is indicative of a

base of skull fracture. True

?Postauricular bruising ( Battle's sign ) is an indication for a CT brain as it is indicative of a base

of skull fracture.

(e) Blood in the middle ear space is not an indication for a CT brain in a child. False

?Blood in the middle ear space is an indication for a CT brain in a child as it is indicative of a base

of skull fracture.

http://www.nice.org.uk

NICE Guidelines: CT Brain post head injury

(a) If a patient falls less than 1 metre and loses consciousness but has a GCS of 15/15 on exam

there is no indication for CT Brain. True

?The patient loses consciousness but his/her mechanism of injury is not considered dangerous as

the height is <1 metre.

(b) If a patient is ejected from a vehicle and has amnesia of the events after the injury there is no

indication for CT brain if the GCS is 15/15. False

?If a patient is ejected from a vehicle and has amnesia of the events after the injury there is an

indication for CT brain even if the GCS is 15/15. ( dangerous mechanism of injury and amnesia )

(c) If a patient on warfarin has a history of LOC but a GCS of 15/15 on exam there is an indication

for CT Brain. True

?If a patient on warfarin has a history of LOC but a GCS of 15 on exam there is an indication for

CT Brain.

(d) If a pedestrian is struck by a car and loses consciousness there is an indication for CT Brain

according to the NICE guidelines even if his/her GCS is 15/15 True

?If a pedestrian is struck by a car and loses consciousness there is an indication for CT Brain

according to the NICE guidelines even if his/her GCS is 15/15

(e) If a 70 year old patient has amnesia of events post head injury but a GCS of 15/15 there is an

indication for CT Brain. True

?If a 70 year old patient has amnesia of events post head injury but a GCS of 15/15 there is an

indication for CT Brain. ( As age >65 and amnesia )

http://www.nice.org.uk

The following are true:

(a) The sensitivity of an excercise tolerance test is approximately 0.72 True

?The sensitivity of an excercise tolerance test is approximately 0.72 (Oxford Handbook of Clinical

Medicine: Epidemiology )

(b) The specificity of an excercise stress test is 0.80 True

?The specificity of an excercise stress test is 0.80 (Oxford Handbook of Clinical Medicine:

Epidemiology )

(c) The Number Needed to Treat( NNT ) is given by ( 1/Absolute Risk Reduction ) Multiplied by

100/1 True

?The Number Needed to Treat( NNT ) is given by ( 1/Absolute Risk Reduction ) Multiplied by

100/1

(d) If the risk of dying after an MI is 20% with standard treatment and if this risk is reduced to

15% with a new treatment then the Absolute Risk Reduction is 25% False

?If the risk of dying after an MI is 20% with standard treatment and if this risk is reduced to 15%

with a new treatment then the Absolute Risk Reduction is 5%

(e) If the risk of dying after an MI is 20% with standard treatment and if this risk is reduced to

15% with a new treatment then the Relative Risk Reduction is 5% False

?If the risk of dying after an MI is 20% with standard treatment and if this risk is reduced to 15%

with a new treatment then the Relative Risk Reduction is 25%

SIDS epidemiology

(a) Prenatal and postnatal maternal smoking does not increase the incidence of SIDS. False

?Prenatal and postnatal maternal smoking increase the incidence of SIDS

(b) Sudden infant death syndrome is more likely to occur during the summer months False

?Sudden infant death syndrome is more likely to occur during the winter months

(c) Sudden infant death syndrome is more likely to occur when the infant is awake. False

?Sudden infant death syndrome is more likely to occur when the infant is asleep.

(d) There is a peak at 6 months False

?There are 2 peaks, 1 at 2 months and 1 at 4 months.

(e) Is frequently associated with infection. True

?In up to 50% of otherwise healthy infants there is an associated infection, usually a URTI.

A group of gastroenterologists have performed a randomised controlled trial comparing a new

technique for ERCP as compared to an older currently used technique in the hospital. The

conclusion is that it reduces the risk of bleeding from 10% to 5%. What does the study show

regarding the new ERCP technique?

(a) Failure False

?

(b) Success False

?

(c) Efficacy True

?

(d) Effectiveness False

?

(e) Statistical significance. False

?

Efficacy. This is a study which shows how a procedure does under controlled (laboratory or

hospital) conditions and hence demonstrates efficacy. Effectiveness is measured when the

technique is established and not under trial conditions.

In randomised control trials

(a) The control event rate (CER) is the risk of outcome event in the control group True

?

(b) The experimental event rate (EER) is the risk of outcome event in the experimental group

divided by the control group False

The experimental event rate is the risk of outcome event in the experimental group

(c) Relative risk reduction = (CER- EER)/CER True

?

(d) Absolute risk increase is CER - EER False

Absolute risk REDUCTION is CER - EER Absolute risk INCREASE is EER - CER

(e) Number needed to treat (NNT) is 1/ARR.(One divided by the absolute risk reduction) True

Case-Control studies:

(a) Are suitable for rare diseases. True

?Case-Control studies are suitable for rare diseases.

(b) Generally need a prolonged study time. False

?Short study time and cheap to perform.

(c) Can determine relative risk. False

?Results expressed as odds ratio.

(d) Large number of subjects required. False

?Not necessarily.

(e) Bias may occur in the selection of cases and controls and in ascertaining exposure. True

Statistics:

(a) The variance is a measure of the spread of observations about the mean True

?The variance is a measure of the spread of observations about the mean.

(b) The standard deviation is the square root of the variance. True

The standard deviation is the square root of the variance.

(c) Interquartile ranges are not influenced by extreme observations. True

?Interquartile ranges are not influenced by extreme observations as they are delimited by the 25th

and the 75th percentiles.

(d) In a histogram with equal base lines the height of the block is proportional to frequency. True

?In a histogram with equal base lines the height of the block is proportional to frequency.

(e) In a histogram with non-equal bases the area of each block is proportional to the frequency.

True

?

For the diagnosis of chronic fatigue syndrome or myalgic encephalomyelitis, the patient must have

the following symptoms:

(a) Fatigue for a minimum of one month. False

?Fatigue severe enough to cause a 50% loss of physical or social function for a minimum of 6

months and 4 of 8 other symptoms is required.

(b) Sleep disturbance. True

?Usually hypersomnia and impaired concentration.

(c) Muscle Pain. True

?Or multi joint pains, headaches , post exertional exacerbation of fatigue.

(d) Sore throat. True

?Sore throat and tender lymph nodes may be present.

(e) Depression. False

?A psychiatric disorder such as depression must be excluded before diagnosis can be made.

Indications for a permanent pacemaker

(a) Mobitz type II AV block True

?

(b) Persistent AV block after anterior MI True

?

(c) Symptomatic bradycardia's True

?

(d) Complete AV block True

?Stokes-Adams attacks,asymptomatic,congenital.

(e) Drug resistant tachyarrhythmias True

?

Some say persistent bifasicular block after MI requires a permanent pacemaker but this remains

controversial.

The prevalence rate of a condition:

(a) Must be based on a large population to be valid. False

?A large population is needed for incidence rate , as they tend to be low.

(b) Is an appropriate measure only for relatively stable conditions. True

?Even then a single examination at one point in time tends to underestimate the conditions total

frequency.

(c) Measures the rate of occurrence of new cases. False

?This is the incidence, not the prevalence.

(d) Is the proportion of a defined group having a condition at one point in time. True

?A static measure compared to a kinetic incidence.

(e) Will be high if recovery and death rates for that condition are low. True

?Prevalence= incidence by average duration.

The following are true about confidence intervals:

(a) The intervals are larger with smaller sample size. True

?The intervals are larger with smaller sample size.

(b) They indicate the presence or otherwise of a statistical difference between two groups. False

(c) The standard error of the mean decreases as the number in the sample increases. True

?The standard error of the mean decreases as the number in the sample increases. SEM = SD/

Square root of sample size.

(d) In an odds ratio, if the 95% confidence interval includes unity then no significant difference

may apply. True

?In an odds ratio, if the 95% confidence interval includes unity then no significant difference may

apply.

(e) The intervals give a range of values within which the true value will lie. True

?The intervals give a range of values within which the true value will lie.

Sensitivity and Specificity

(a) The sensitivity of a test is given by the true positives over the sum of the true positives and the

false negatives. True

?The sensitivity of a test is given by the true positives over the sum of the true positives and the

false negatives.

(b) The specificity of a test is the true negatives over the sum of the true negatives and false

positives. True

?The specificity of a test is the true negatives over the sum of the true negatives and false

positives.

(c) The likelihood ratio of a disease given a positive result is the sensitivity/ ( 1 - specificity ) True

?The likelihood ratio of a disease given a positive result is the sensitivity/ ( 1 - specificity )

(d) The likelihood ratio of a disease given a negative result is the specificity/ ( 1 - sensitivity )

False

?The likelihood ratio of a disease given a negative result is the (1 - sensitivity )/specificity

(e) Posterior odds = (prior odds multiplied by the likelihood ratio ) True

?Posterior odds = (prior odds multiplied by the likelihood ratio )

In statistics

(a) A type I error is when a p value is high even though the null hypothesis is false. False

A type II error is when a p value is high even though the null hypothesis is false. I.e p value is not

significant suggesting accepting of null hypothesis even though it's false.

(b) A type II error is when a p value is low leading us to reject then null hypothesis when in fact it

is actually true. False

A type I error is when a p value is low leading us to reject then null hypothesis when in fact it is

actually true.

(c) The p value of 0.049 indicates we should reject the null hypothesis where as a p value of 0.051

would indicate we should accept it. False

In practice there is a grey area between rejecting and accepting the null hypothesis- there is no

fixed cut off point. The p value is simply a probability, as it gets smaller the less likely that the

null hypothesis is true.?There is no sudden change over from accept to reject.

(d) The power of a study is usually expressed as a percentage. True

?

(e) Small sample sizes are more likely to result in type I errors rather than type II errors. False

Small sample sizes are often associated with type II?errors rather than type I. The power of a study

to reject the null hypothesis increases with increasing sample size.

To attribute causation:

(a) The association must be consistent. True

?

(b) There must be biological plausibility. True

?

(c) The strength of the association is not a factor. False

?The size of the relative risk must be significant.

(d) The association does not have to be specific. False

?The degree to which one particular exposure produces one particular response is important in

determining causation.

(e) There must be a temporal relationship of an association. True

?Obviously exposure to factor must precede development of disease.

In statistics the following are true:

(a) If values exist on a normal distribution the standard deviation and the standard error can be

used interchangeably as representing the same measure. False

Standard deviation gives a measure of the spread of the data values. Standard error is a measure of

how precisely the sample mean approximates the population mean.

(b) The p value is a measure of probability. True

?

(c) The p value is a value between 0 and 5. False

(d) The smaller the p value the more likely the null hypothesis is to be true. False

?The smaller the p value the less likely the null hypothesis is to be true.

(e) The power of a study is the probability of correctly accepting the null hypotheis when it is

false. False

?The power of a study is the probability of correctly rejecting the null hypothesis when it is false.

The p value is a probability, it takes values between 0 and 1. Values near to zero suggest the null

hypothesis is unlikely to be true. The smaller the p value the more significant the result. p= 0.05,

the result is significant at 5% (The sample difference has a 1 in 20 change of occuring if the null

hypothesis were true.) The null hypothesis is usually that there is no difference between the groups

under investigation. The power of a study is the probability of correctly rejecting the null

hypothesis when it is false.

A new genetic test for Marfan's syndrome has recently been tested. Which of the following can

correctly test for the number of patients who would be identified by the test?

(a) Positive predictive value. False

?

(b) Negative predictive value. False

?

(c) Variation. False

?

(d) Sensitivity. True

?

(e) Specificity. False

?

Sensitivity. The sensitivity of a test is the proportion of people with the disease who have a

positive test result. The higher the sensitivity, the greater the detection rate.

SIDS epidemiology

(a) SIDS is more likely to occur when the infant is being cared for by a babysitter. True

?

(b) The overall incidence is about 0.8 per 1000 live births True

?

(c) The infant frequently has been premature or small for gestational age True

?

(d) The syndrome is rare in the first month of life True

?

(e) Of the infants who are otherwise healthy, 30 to 50 percent have some acute infection, True

?

Measures of effect:

(a) The absolute risk reduction(ARR) is more clinically relevant than the relative risk reduction

True

?The ARR is more clinically relevant than the RRR because the RRR does not account for the

baseline risk. A large RRR can seem impressive but if an individuals overall risk of contracting a

disease is very small the RRR is not significant.

(b) The relative risk reduction = (1-RR) times 100%. True

?RRR= (1-RR) by 100%

(c) The Number Needed to Treat(NNT)= 1/ARR. True

?The Number Needed to Treat(NNT)= 1/ARR.

(d) It is possible for a treatment of only moderate efficacy to have a small NNT. True

?It is possible for a treatment of only moderate efficacy to have a small NNT because it is based

on the absolute risk difference.

Epidemiological rates:

(a) Prevalence = Incidence by average duration of illness. True

?Prevalence = Incidence by average duration of illness.

(b) The case fatality rate is the number of deaths due to a disease in a specified period of time.

False

?The above is not a rate it is a number. The rate is calculated by multiplying the above by 100 and

dividing by the number of cases of the disease in the same period of time.

(c) Mortality rate is expressed in deaths per one hundred. False

?Mortality rate is expressed as deaths per 1000.

(d) The case fatality rate is normally expressed as deaths per 1000. False

?The case fatality rate is normally expressed as a percentage.

(e) The proportionate mortality rate is used to determine the relative importance of a specific cause

of death in relation to all causes of death in a population. True

?The proportionate mortality rate is used to determine the relative importance of a specific cause

of death in relation to all causes of death in a population.

Methods for controlling selection bias include

(a) Randomisation True

?

(b) Restricted study eligibility of patients True

?

(c) Matching True

?

(d) Comparison of rates within groups of individuals who have the same values for the

confounding variables True

?

(e) Logistical regression True

?Or other adjustments such as multiple linear regression

Stratification is the comparison of rates within groups of individuals who have the same values for

the confounding variables

A sample of 2000 patients has a mean weight of 50 kg and a standard deviation of 5kg. Assuming

normal distribution, which of the following is true?

(a) 95% of the patients have a weight between 45 and 55 kg False

?

(b) 95% of the patients have a weight between 40-60kg True

?

(c) 95% of the patients have a weight between 35-65kg False

?

(d) 68% of the patients have a weight between 35-65kg False

?

(e) 68% of the patients have a weight between 40-60kg False

?

95% of the patients have a weight between 40-60kg. 95% of the population will be within 2

standard deviations of the men, hence, 40-60 kg

Statistics...

(a) The standard deviation is equal to the square root of the variance. True

?The standard deviation gives a measure of the spread of the distribution values. The smaller the

standard deviation( or variance) the more tightly grouped the values.

(b) If values are normally distributed approximately 62% of the values lie within +/- 1 standard

deviation of the mean. False

?If values are normally distributed approximately 68% of the values lie within +/- 1 standard

deviation of the mean.

(c) If values are normally distributed approximately 90% of the values lie within +/- 2 standard

deviation of the mean. False

?If values are normally distributed approximately 95% of the values lie within +/- 2 standard

deviation of the mean.

(d) The standard error of the mean ( SEM ) is a measure of how precisely the sample mean

approximates the population mean. True

?SEM = SD/Square root of the sample size.

(e) The size of the standard error of the mean increases as the sample size increases. False

?The size of the standard error of the mean decreases as the sample size increases.

The frequency of attendance of a 100 medical students at lectures were recorded by an observer

over a 3 month period. The students were then assessed at the end with a multiple choice exam

with a test score marked out of a hundred. Which of these statistical methods is best used to

analyse the effectiveness of frequency of attendance on higher test scores?

(a) Mann-Whitney test False

?

(b) Spearmann correlation True

?

(c) Chi square test False

?

(d) Fisher's exact test False

?

(e) Student's t test False

?

Spearmann correlation. Spearmann's correlation is the best method to determine two variables

which do not follow a normal distribution.

Epidemiology Rates:

(a) The prevalence rate is the number of new cases of disease in a given period divided by the total

population at risk during the same period. False

The incidence rate is the number of new cases of disease in a given period divided by the total

population at risk during the same period.

(b) A change of incidence indicates a change in the balance of aetiological factors. True

A change of incidence indicates a change in the balance of aetiological factors.

(c) The attack rate is the incidence rate calculated in an epidemic population. True

The attack rate is the incidence rate calculated in an epidemic population using a particular

population observed for a limited period of time.

(d) Point prevalence refers to a particular point in time. True

Point prevalence refers to a particular point in time.

(e) Incidence rates are influenced by the duration of the illness. False

Prevalence rates are influenced by the duration of the illness.

The following are true in regard to skewed distributions:

(a) In a left/negative or downward skew the mean value is representative of the bulk of the values.

False

?This is false as in a left/negative or downward skew the mean will be pulled toward the outlying

tail.

(b) In a right/positive or upward skew the mean value is not representative of the bulk of the

values. False

?This is true as in a right/positive or upward skew the mean will be pulled toward the outlying tail.

(c) The median is preferred as a summary of the data in a normal distribution. False

?The median is preferred as a summary of the data in a skewed distribution while the mean is

preferred as a summary of the data in a normal distribution.

(d) The median is preferred as a summary of the data in a skewed distribution. True

?The median is preferred as a summary of the data in a skewed distribution.

(e) If the tail of the distribution data points to the left the skew is a left skew. True

?If the tail of the distribution data points to the left the skew is a left skew.

Which of the following are true regarding standard error of the mean?

(a) It is not affected by standard deviation. False

?

(b) There are no units. False

?

(c) It is not affected by sample size. False

?

(d) It measures the accuracy of the sample mean as an estimate of the true population mean. True

?

(e) It is larger than the standard deviation. False

?

The standard error of the mean (SEM) measures the accuracy of the sample mean as an estimate of

the true population mean. Standard error of the mean is the standard deviation of the sampling

distribution of the mean - which gives an estimate of how close the sample mean is to the true

population mean. The S.E.M. is the standard deviation divided by the square root of the sample

size. It increases with sample size and increases with stand deviation. SEM is always smaller than

the standard deviation.

Drug Development

(a) Phase 1 trials are usually on animals False

?Preclinical trials are on animals. Phase 1 trials are on healthy individuals and/or patients

(b) Phase 2 trials look at drug treatment efficacy True

?Phase 2 trials are in small numbers of patients.

(c) Phase 3 trials include randomized control trials True

?Phase 3 trials include randomized control trials and compare new to standard treatments

(d) The study subjects in phase 4 trials include all patients prescribed the drug True

?Phase 4 trials are to monitor for rare adverse effects and monitor long term safety.

(e) Phase 3 trials are the initial patient trials. False

?Phase 2 trials are usually the initial patient trials.Phase 1 trials are occasionally the initial patient

trials.

The following are correct:

(a) Aspirin must be given to 40 people who are suffering an acute MI to prevent 1 death. True

?Aspirin must be given to 40 people who are suffering an acute MI to prevent 1 death. ( ISIS 1 )

(b) Streptokinase must be given to 40 people who are having an acute MI to prevent 1 death. True

?Streptokinase must be given to 40 people who are having an acute MI to prevent 1 death. ( ISIS 2

)

(c) Ace inhibitors must be given to 6 patients with NYHA class IV heart failure to prevent 1 death

within 1 year. True

?Ace inhibitors must be given to 6 patients with NYHA class IV heart failure to prevent 1 death

within 1 year

(d) The specificity of a test is given by the true positives over the sum of the true positives and

false negatives. False

?The sensitivity of a test is given by the true positives over the sum of the true positives and false

negatives.

(e) The sensitivity of a test is given by the true negatives over the sum of the true negatives and the

false positives False

?The specificity of a test is given by the true negatives over the sum of the true negatives and the

false positives

With regards to sources of error in study design.

(a) Information bias indicates the information is tainted by the subjects own beliefs and values.

True

?

(b) Ascertainment bias occurs when unblinded researchers may alter their approach to certain

subject. False

Ascertainment bias occurs where results are systematically distorted by knowledge of which

intervention each participant is receiving. ?

(c) Objectivity of researchers varies greatly- to the degree that it can introduce bias. True

?

(d) Bias is a random error that distorts the data collected from a clinical trial. False

Bias is not random but systematic.

(e) Bias is completely erradicated in RCT's by double blinding. False

Bias is not totally controlled for ever in any study however RCT'S aim to reduce some of it

through various methods including double blinding.

The following are true in relation to confounding: Y

(a) Confounding is unavoidable. False

?Confounding may be avoided by matching individuals in the groups according to potential

confounders.

(b) Confounding may be avoided by matching individuals in the groups according to potential

confounders. True

?Confounding may be avoided by matching individuals in the groups according to potential

confounders.

(c) A confounding variable is usually the same in both groups being compared. False

?A confounding variable is different in both groups being compared.

(d) A confounding variable does not effect the outcome being studied False

?A confounding variable does affect the outcome being studied and is different between groups

being compared.

(e) Confounding is an infrequent source of statistical error. False

Screening Tests:

(a) Sensitivity is the proportion of true negatives correctly identified by a test. False

?Specificity is the proportion of true negatives correctly identified by a test.

(b) Specificity is the proportion of true positives correctly identified by a test. False

?Sensitivity is the proportion of true positives correctly identified by a test.

(c) Positive predictive value is the proportion of those who test positive who actually have the

disease. True

?Positive predictive value is the proportion of those who test positive who actually have the

disease.

(d) Negative predictive value is the proportion of those who test negative who do not have the

disease. True

?Negative predictive value is the proportion of those who test negative who do not have the

disease.

(e) Positive and negative predictive values are independent of the prevalence of a disease. False

?Positive and negative predictive values depend on the prevalence of the disease and may vary

from population to population.

The following are true:

(a) The positive predictive value is given by the true positives over the true positives and false

positives. True

?The positive predictive value is given by the true positives over the true positives and false

positives.

(b) The sensitivity is given by the true positives over the true positives and the false negatives.

True

?The sensitivity is given by the true positives over the true positives and the false negatives.

(c) The specificity is given by the true negatives over the true negatives and the false positives.

True

?The specificity is given by the true negatives over the true negatives and the false positives.

(d) The negative predictive value of a test is given by the true negatives over the true negatives

and the false negatives. True

?The negative predictive value of a test is given by the true negatives over the true negatives and

the false negatives.

The following are true in regard to standard deviation:

(a) Approximately 50% of the values lie within +/- 1 standard deviation of the mean in normally

distributed values. False

Approximately 68% of the values lie within +/- 1 standard deviation of the mean in normally

distributed values.

(b) Approximately 60% of the values lie within +/- 1 standard deviation of the mean in normally

distributed values. False

Approximately 68% of the values lie within +/- 1 standard deviation of the mean in normally

distributed values.

(c) Approximately 80% of the values lie within +/- 2 standard deviation of the mean in normally

distributed values. False

Approximately 95% of the values lie within +/- 2 standard deviation of the mean in normally

distributed values.

(d) Approximately 90% of the values lie within +/- 2 standard deviation of the mean in normally

distributed values. False

?Approximately 95% of the values lie within +/- 2 standard deviation of the mean in normally

distributed values.

(e) Exactly 95% of the values lie within +/- 1.96 standard deviation of the mean in normally

distributed values

The following are true in regard to the standard error of the mean(SEM):

(a) Is a measure of how precisely the population mean approximates the sample mean. False

It is a measure of how precisely the sample mean approximates the population mean.

(b) The formula requires squaring the sample size,n. ( SEM = SD/n squared ) False

The formula requires calculating the square root of the sample size n. (Standard error of the mean

= SD/Square root of n)

(c) The standard error of the mean is smaller for larger sample sizes. True

?The standard error of the mean is smaller for larger sample sizes.As the sample size n increases

the SEM decreases.

(d) As the sample size,n, increases the SEM increases. False

? As the sample size,n, increases the SEM decreases.

(e) The error of the mean is smaller if there are more observations in the sample. True

?The error of the mean is smaller if there are more observations in the sample.

Cohort Studies

(a) Are suitable for rare diseases False

?Suitable for common diseases.

(b) Have a prolonged study time with increasing drop out potential True

?And are therefore more costly

(c) More selection bias than case control studies occur False

?Less selection bias than case control studies

(d) Relative risk can be determined True

?

(e) Incidence can be determined True

?

The estimate of time from exposure to development of disease can be determined in contrast to

case control studies.

Confidence interval

(a) Provide additional information about the true population value True

?

(b) Measures how accurate the sample mean is as an estimate of the population mean False

?This is a description of the standard error of the mean

(c) The standard practice in academic papers is to use 99% confidence intervals False

?95%

(d) 95% confidence intervals are constructed by adding and subtracting the standard error of the

mean to the mean False

?CI= Mean +/- 1.96(SEM)

(e) Larger samples provide narrower confidence intervals True

The following are true in relation to confidence intervals:

(a) Confidence intervals are constructed using the standard error of the mean. True

?Confidence intervals are constructed using the standard error of the mean. For 95% confidence

intervals the formula is CI= M ? (1.96 * SEM).

(b) With 95% confidence interval there is a 99% chance that the true population mean lies within

the confidence interval. False

?With 95% confidence interval there is a 95% chance that the true population mean lies within the

confidence interval.

(c) The mean +/- 1.96 SEM is the interval for a 95% confidence interval. True

?The mean +/- 1.96 SEM is the interval for a 95% confidence interval. 95%CI= M ? (1.96 *

SEM). The value 1.96 comes from our understanding of the normal curve. The areas between plus

and minus 1.96 standard deviations covers 95% of the cases.

(d) Standard deviation gives a measure of the spread of the data values. True

?Standard deviation gives a measure of the spread of the data values.

(e) The standard error of the mean is a measure of how precisely the sample mean approximates

the true population mean. True

?The standard error of the mean is a measure of how precisely the sample mean approximates the

true population mean.

Drug Development

(a) Preclinical trials are often on animals True

?

(b) Phase 1 trials are usually on large numbers of patients False

?Phase 3 trials are usually on large numbers of patients

(c) Phase 2 trials are on patients True

?Small numbers

(d) Drugs are usually not tested on healthy individuals False

?Usually tested on healthy individuals on phase 1 of clinical trials

(e) Phase 4 trials include post marketing surveillance True

?

Preclinical-Animals or In vitro, Phase 1- Healthy individuals and/or patients, Phase 2- small

number of patients, Phase 3-large number of patients, Phase 4-All patients prescribed the drug

Statistical Significance:

(a) The null hypothesis states that there is no difference in the variable between the 2 groups

studied. True

?The null hypothesis states that there is no difference in the variable between the 2 groups

studied.And that any difference observed is simply the result of random variation.

(b) Statistical significance correlates well with clinical significance. False

?

(c) The smaller the significance value the less likely it is that an observed difference occurred by

chance. True

?The smaller the significance value the less likely it is that an observed difference occurred by

chance.

(d) The significance level is a reflection of the chance of a Type I error. True

?The significance level is a reflection of the chance of a Type I error.

(e) If the significance level is 0.05 there is a 1 in 20 chance of a Type I error. True

?If the significance level is 0.05 there is a 1 in 20 chance of a Type I error.

With regards to a studies ability to prove cause

(a) Cohort studies have moderates ability True

?

(b) Randomised control trials have a strong ability True

?

(c) Case controlled studies have a weak ability False

?

(d) Ecological studies have a weak ability True

?

(e) Cross sectional studies have a moderate ability False

The following are causes of Pancreatitis:

(a) Hypertriglyceridemia True

?Hypertriglyceridemia (When the triglyceride [TG] level exceeds 1000 mg/U, an episode of

pancreatitis is more likely.)

(b) Cardiopulmonary bypass surgery True

?Abdominal or cardiopulmonary bypass surgery, which may insult the gland by ischemia

(c) Trauma to the abdomen or back True

?Trauma to the abdomen or back, resulting in sudden compression of the gland against the spine

posteriorly

(d) Methyldopa True

?

(e) Tetracyclines True

?

http://www.emedicine.com/emerg/topic354.htm

Joint Dislocations

(a) Glenohumeral dislocation is the commonest large joint dislocation. True

?Glenohumeral dislocation is the commonest large joint dislocation.

(b) Patellofemoral dislocation is the second commonest large joint dislocation. True

?Patellofemoral dislocation is the second commonest large joint dislocation.

(c) Elbow dislocations are the third largest large joint dislocation in the body. True

?Elbow dislocations are the third largest large joint dislocation in the body.

(d) The majority of elbow dislocations, like glenohumeral dislocations, are anterior. False

?The majority of elbow dislocations are posterior.

(e) The most common mechanism of injury for an elbow dislocation is fall on an outstretched hand

( FOOSH ) True

?The most common mechanism of injury for an elbow dislocation is fall on an outstretched hand

( FOOSH )

Hypothesis testing:

(a) A Type I error is the probability of detecting a significant difference when the parameters or

treatments are really the same. True

?A Type I error is the probability of detecting a significant difference when the parameters or

treatments are really the same.

(b) A Type II error is the risk of detecting a false positive result. False

?A Type I error is the risk of detecting a false positive result.

(c) A Type II error is the probability of not detecting a significant difference when there really is a

difference. True

?A Type II error is the probability of not detecting a significant difference when there really is a

difference.

(d) One minus the type II error is the Z score of a test. False

?One minus the type II error is the power of a test.Z score is an indicator of heterogeneity. If Z

score is greater than 2.2 then the null hypothesis can be rejected(that is there is heterogeneity

present).

(e) The power of a test depends on the significance level. True

?The power of a test depends on the significance level

Box and whisker plots:

(a) The box represents 50% of the data. True

?In box and whisker plots the box represents 50% of the data.

(b) The box is divided by the mean. False

?The box is divided by the median.

(c) 75% of the values are below the upper quartile. True

?75% of the values are below the upper quartile.

(d) Is used to display quantitative variables which have a normal distribution. False

?Is used to display quantitative variables which have a skewed distribution.

(e) 25% of the values lie below the lower quartile. True

?25% of the values lie below the lower quartile.

The following treatment's or interventions have a Number Needed to Treat ( NNT ) of less than 10

patients.

(a) Percutaneous Coronary Intervention (PCI) coronary angioplasty for an acute myocardial

infarction. False

?The number needed to treat here is 40 patients to prevent one additional bad outcome.

(b) Bolus thrombolytic therapy rather than streptokinase for acute myocardial infarction. False

?The number needed to treat here is 100 patients.

(c) Clopidrogel for acute coronary syndrome. False

?The number needed to treat here is 47 patients ( to prevent one bad outcome )

(d) Therapeutic hypothermia for unconscious ventricular fibrillation survivors. True

?The number needed to treat here is 5 patients ( to prevent one bad outcome ) Nolan J P, Morley P

T, Hoek T L, et al; Advancement Life support Task Force of the International Liaison committee

on Resuscitation. Therapeutic hypothermia after cardiac arrest: an advisory statement by the

advanced life support task force of the international liaison committee on resuscitation.

Resuscitation 2003;57:231?5

(e) Warfarin for atrial fibrillation. False

?

The NNT is the number of patients who need to be treated in order to prevent one additional bad

outcome.NNT = 1/ARR. ARR = |CER - EER|

Myocardial Infarction

(a) The annual incidence is 5/1000 in the UK True

?The annual incidence is 5/1000 in the UK

(b) Has a 60% out of hospital mortality rate. False

?Has a 40% out of hospital mortality rate.

(c) Has a 40% in-hospital mortality rate. False

?Has a 20% in-hospital mortality rate.

(d) Has an overall mortality of 40% at 28 days post MI. False

?Has an overall mortality of 27% at 28 days post MI.

(e) Vocational drivers ( HGV etc ) are not obligated to inform the DVLA of an MI. False

?Vocational drivers ( HGV etc ) must inform the DVLA of an MI.Ordinary drivers do not have to

inform the DVLA unless a continuing disability persists.

Wells Clinical Score for DVT

(a) Any type of cancer scores one point False

?Active cancer with ongoing treatment, or within 6 months or palliation

(b) Recently bedridden for >2 days or major surgery <4 weeks ago scores one point False

?Recently bedridden for >3 days or major surgery <4 weeks ago scores one point

(c) Calf swelling >2 cm compared with the asymptomatic leg scores one point. False

?Calf swelling >3 cm compared with the asymptomatic leg scores 1 point.

(d) Previous DVT documented does not score in wells criteria. False

?Previous DVT documented scores one point in wells criteria.

The following are true with regard to the san francisco syncope rules:

(a) A history of CCF puts a patients who presents with syncope in a high risk group for a serious

outcome. True

?A history of CCF puts a patients who presents with syncope in a high risk group for a serious

outcome.

(b) Haematocrit <40% puts the patient who presents with syncope in a high risk group for a

serious outcome. False

?Haematocrit <30% puts the patient who presents with syncope in a high risk group for a serious

outcome.

(c) Shortness of breath does not put the patient who presents with syncope in a high risk group for

a serious outcome. False

?Shortness of breath puts the patient who presents with syncope in a high risk group for a serious

outcome.

(d) A systolic BP <90mmHg at the time of triage puts the patient who presents with syncope in a

high risk group for a serious outcome. True

?A systolic BP <90mmHg at the time of triage puts the patient who presents with syncope in a

high risk group for a serious outcome.

A systolic BP <90mmHg at the time of triage , shortness of breath , haematocrit <30%, a history

of CCF ,or an abnormal ECG puts the patient who presents with syncope in a high risk group for a

serious outcome.Serious Outcome in this study is defined as "death, myocardial infarction,

arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or

any condition causing a return ED visit and hospitalization for a related event."

http://www.mdcalc.com/sfsyncope

Statistics...

(a) Parametric tests assume the data is normally distributed. True

?An example is the t-test( also called the Student's t-test or the Student's paired t-test. )

(b) Negative values for correlation coefficients indicate that one variable decreases as the other

increases. True

?The correlation coefficient ranges from -1 to 1 and is denoted by r.

(c) A correlation coefficient of 1 ( r=1) indicates that variables are perfectly linearly related. True

?If plotted on a scatterplot the points would form a straight line.

(d) The closer the correlation coefficient is to zero the stronger the association between the 2

variables under scrutiny. False

?The closer the correlation coefficient is to zero the weaker the association between the 2 variables

under scrutiny

(e) The correlation coefficient( of linear correlation) is also called Spearman's rank correlation.

False

?The correlation coefficient( of linear correlation) is also called Pearson's coefficient of linear

correlation.

Medical Formulae:

(a) BMI is calculated by kg/(m)2. True

?BMI is calculated by kg/(m)2.

(b) The anion gap is calculated by (Na + K)-(Cl+HCO3). True

?The anion gap is calculated by (Na + K)-(Cl+HCO3) and the normal range is 8-16mmol/l.

(c) High anion gap is caused by unmeasured cations. False

?High anion gap is caused by unmeasured anions!

(d) Ethylene glycol is also known as methylene blue. False

?Ethylene glycol is also known as anti-freeze.

(e) Anion Gap is raised in uraemic acidosis. True

?Anion Gap is raised in uraemic acidosis and also ketoacidosis, drug ingestion, and lactic acidosis.

In a trial of an antiplatelet therapy in secondary prevention of stroke, the drug was shown to

reduce mortality from stroke, from 8% to 4% over 10 years. What is the number needed to treat to

prevent a death over 10 years?

(a) 4 False

?

(b) 5 False

?

(c) 10 False

?

(d) 25 True

?

(e) 100 False

?

The drug reduced the risk of death post stroke by 4% over 10 years. Therefore if 100 people were

treated we could expect the prevention of 4 deaths. Therefore the number needed to treat would be

25 to prevent 1 death.

UTI:

(a) At all ages occur more frequently in females. False

?UTI's are more common in male neonates than in female neonates.

(b) The incidence of infection in post-menopausal women increases with age. True

?The incidence of infection in post-menopausal women increases with age.

(c) The prevalence of asymptomatic bacteriuria among elderly women in nursing homes can be up

to 40 percent. True

?The prevalence of bacteriuria among elderly women in nursing homes can be up to 40 percent.

(d) The incidence of UTI's in males remains stable throughout life. False

?The incidence of UTI's in men increases as men get older.

(e) Increased intercourse frequency in the past month is a risk factor for a UTI in females. True

?Increased intercourse frequency in the past month is a risk factor for a UTI in females.

Patients with intermittent claudication...

(a) In 30 percent of cases will die within 5 years. True

?And 50% within 10 years, largely from cardiovascular disease.

(b) Pain is always felt in the calves. False

?May be in the buttocks or thighs.

(c) Will benefit from a statin, irrespective of their cholesterol level. True

?Heart protection study showed this,so if cholesterol >3.5mmol/l, then should be on a statin.

(d) Should be advised to stop walking for 10 to 15 minutes when they get the pain. False

?Encourage to 'walk through the pain', so if stop , start walking again once pain relieved.

(e) In most cases will require angioplasty or surgery. False

?Only those with major impairment of quality of life despite appropriate medical management,

would need to be considered for invasive treatments.

Haemoptysis

(a) Tuberculosis is the most common cause. False

?The most common causes are neoplastic ( 25% ), and non-tubercular infectious ( 25% )

(b) 20% of cases are due to cardiovascular causes. False

?Cardiovascular causes account for about 3% of overall cases. Most of these are due to CCF.

(c) A cause is almost always found. False

?25% of cases are of undetermined origin.

(d) 90% of haemoptysis cases occur in males. False

?60% of haemoptysis cases occur in males.

(e) Smoking is not a risk factor. False

?Smoking is a risk factor for haemoptysis, along with age and male sex.

In statistics

(a) Sensitivity is the proportion of true positives correctly identified by the test. True

?

(b) Specificity is the proportion of those who test positive that actually have the disease. False

The positive predictive value is the proportion of those who test positive that actually have the

disease. Specificity is the proportion of true negatives correctly identified by the test.

(c) The likelihood ratio is the proportion of those who test negative who do not have the disease.

False

The negative predictive value is the proportion of those who test negative who do not have the

disease.

(d) The predictive values depend on the prevalence of the disease and may vary from population to

population. True

The predictive values depend on the prevalence of the disease and may vary from population to

population.

(e) The likelihood ratio (LR+) for a positive test result is the sensitivity divided by 1 minus the

specificity. True

The likelihood ratio (LR+) for a positive test result is the sensitivity divided by 1 minus the

specificity.The liklihood ratio (LR-) for a negative test result is 1- sensitivity divided by

specificity.

The following are true:

(a) Serum ALT is usually raised with liver injury True

?Injury 2007; 38: 1069-74

(b) One of the effects of calcium channel blocker overdose is hypoglycaemia False

?One of the effects of calcium channel blocker overdose is hyperglycaemia, caused by the

blockade of pancreatic calcium channels and increased insulin resistance

(c) Glucose levels correlate with severity of calcium channel blockade. True

Jonathan Wyatt and Nick Jenkins ,Sophia, Emerg Med J 2007; 24: 868

(d) Fracture of the posterior process of the talus is often diagnosed as ankle sprain. True

?Fracture of the posterior process of the talus is often diagnosed as ankle sprain. R Ahmad and S

M Y Ahmed Fracture of the posterior process of the talus: an unusual injury Emerg Med J 2007;

24: 867. doi:10.1136/emj.2006.045609

(e) Fracture of the posterior process of the talus is most likely caused by forceful planter flexion of

the ankle with compression of the posterior process between the posterior malleolus and the

calcaneus. True

?Fracture of the posterior process of the talus is most likely caused by forceful planter flexion of

the ankle with compression of the posterior process between the posterior malleolus and the

calcaneus.

Alcohol dependence:

(a) Sons of alcohol-dependent people who are adopted by other families are ten times more likely

to develop drinking problems than are the adopted sons of non-alcohol misusers. False

?They are 4 times more likely to develop alcohol problems.

(b) If a boy grows up in a home where the mother abuses alcohol he is more likely to develop

alcohol misuse than a boy who grows up in a home where the father misuses alcohol. True

?1 in 3 Vs 1 in 4( 1 in 4 for boys who grow up in homes with fathers misusing alcohol)

(c) Psychiatric illness is a common cause of addictive drinking. False

?Psychiatric illness is an uncommon cause of addictive drinking but a treatable one. Patients who

are depressed or anxious are at risk.

(d) The prevalence of alcohol dependence and problems correlates with the general level ( per

capita consumption) of alcohol use in society. True

?The prevalence of alcohol dependence and problems correlates with the general level ( per capita

consumption) of alcohol use in society.

(e) Patients with phobias are at increased risk of alcohol dependence. True

?Also those with depression and anxiety states.

The Null Hypotheses and p values:

(a) The null hypothesis states that there is no difference between the two sample variables. True

?The null hypothesis states that there is no difference between the two sample variables.

(b) The p value is the probability of observing a difference of a given magnitude if the null

hypothesis is true. True

?The p value is the probability of observing a difference of a given magnitude if the null

hypothesis is true.

(c) Values close to zero suggest the null hypotheses is true. False

? Values close to zero suggest the null hypotheses is false.

(d) The term statistical significance and clinical significance are interchangeable. False

?Statistical significance does not equal clinical significance. There might be a stastically improved

outcome with one treatment over another but other factors such as cost or side effect profile might

negate this stastical significance and make the difference not clinically significant.

(e) If p = 0.05, the result is significant at 5%. True

?If p = 0.05, the result is significant at 5%.

Which of the following resuscitation room investigations has a sensitivity of more than 85%

(a) CTPA False

?83% sensitive rising to 90% when combined with CT venography

(b) Erect CXR for pneumoperitoneum(air under diaphragm) False

?<80%

(c) D-Dimer assay for PE True

?>90%

(d) Beta-Natriuretic peptide for heart failure True

?About 85% sensitive

In statistics

(a) Parametric tests usually assume the data are normally distributed True

Examples include the t-test and Pearsons coefficient of linear correlation.

(b) Non parametric tests include Wilcoxon True

?

(c) Non parametric tests include Sign True

?

(d) Non parametric tests include Chi-squared True

?

(e) Chi squared test is used to compare proportions or percentages between groups True

?

Non parametric tests are usually based on rank and include Wilcoxon, Sign, Mann-Whitney U,

Kendall's S, Spearman's rank correlation and Chi-squared.

Intravenous and Nebulised Magnesium Sulphate for Acute Asthma

(a) Magnesium's pharmacological action is based upon it's ability to inhibit the release of sodium

from vesicles in the sarcoplasmic reticulum. False

?Magnesium's pharmacological action is based upon it's ability to inhibit the release of calcium

from vesicles in the sarcoplasmic reticulum, resulting in smooth muscle relaxation.

(b) A single dose of intravenous magnesium sulphate should be considered in adults with acute

severe asthma that has not responded to inhaled bronchodilator therapy. True

?A single dose of intravenous magnesium sulphate should be considered in adults with acute

severe asthma that has not responded to inhaled bronchodilator therapy. ( BTS 2007 )

(c) Intravenous Magnesium sulphate is not effective in children. False

?Mg Sulphate may reduce hospital admissions by 30% in children. S Mohammed and S Goodacre

Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and metaanalysis Emerg Med J 2007; 24: 823-830. doi:10.1136/emj.2007.052050

(d) IV Mg Sulphate does not improve respiratory function in children False

?IV Mg Sulphate does significantly improves respiratory function in children. Intravenous and

nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis Emerg Med

J 2007; 24: 823-830. doi:10.1136/emj.2007.052050

(e) Nebulised Mg Sulphate is more effective than IV Mg Sulphate in children. False

?IV Mg Sulphate is more effective than nebulised Mg Sulphate in children. Intravenous and

nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis Emerg Med

J 2007; 24: 823-830. doi:10.1136/emj.2007.052050

NICE Guidelines: The following are considered dangerous mechanisms of injury when assessing

for the requirement for cervical spine films

(a) Fall of 2 metre's True

?1 metre or 5 steps

(b) Diving True

?Axial load to head.

(c) Rollover motor vehicle accident True

?Or a high speed motor vehicle accident

(d) Bicycle collision True

?

(e) Ejection from a motor vehicle True

?Or a high speed motor vehicle accident, or a rollover.

The following are examples of non-parametric tests:

(a) Spearman's Rank Correlation True

?Spearman's rank correlation is a non-parametric test.

(b) Student's t-test False

?Student's t-test is a parametric test.

(c) Pearson's coefficient of linear correlation. False

?Pearson's coefficient of linear correlation is a parametric test.

(d) Mann-Whitney U test True

?

Parametric tests are tests where the population is assumed to fit the normal

distribution.Nonparametric methods are often referred to as distribution free methods as they do

not rely on assumptions that the data are drawn from a given probability distribution.

Rapid Tranquillisation in the Emergency Department:Haloperidol Injection

(a) The time to a maximum plasma concentration in 5-10 minutes False

?The time to a maximum plasma concentration in 15-60 minutes www.nice.org.uk

(b) The approximate plasma half life is 2-4 hours False

?The approximate plasma half life is 10-36 hours . www.nice.org.uk

(c) Is not indicated for hypomania False

?Mania and hypomania are indications for haloperidol injection.

(d) Is indicated for paranoid psychoses True

?

(e) Is indicated for hyperactivity in the mentally retarded. True

?

SIDS epidemiology

(a) Overall incidence is roughly 0.8-1/1000 live births True

?

(b) There is a peak at 2 months and at 4 months True

?

(c) After 1 month a child has a better anaerobic capacity to survive. False

?SIDS is rare in the first month of life because the neonate has a better anaerobic capacity for

survival.

(d) Infection is rarely associated with SIDS False

?In healthy infants up to 50% who die from SIDS have an infection.

(e) Prenatal and postnatal maternal smoking increase the incidence of SIDS True

?

The following are true

(a) Hip fracture incidence doubles for each decade after 50. True

?

(b) Hip fracture incidence is 5 times higher in women than in men. False

?Hip fracture incidence is 3 to 4 times higher in women than in men.

(c) Overall mortality for intertrochanteric hip fractures is 10 to 30%. True

?

(d) Native valve endocarditis represents 59 to 70% of IE. True

?

(e) Prosthetic valve IE represents 14 to 30% of IE. True

?

Native valve endocarditis represents 59 to 70% of IE.Prosthetic valve IE represents 14 to 30% of

IE.IVDU associated IE 11-30%.

In statistics the following are true:

(a) The mode is the middle value when values are ranked. False

The median is the middle value when values are ranked.

(b) The median is the arithmetic average. False

The median is the middle value when values are ranked. The mean is the arithmetic average.

(c) The gaussian distributaion is the normal distribution. True

?

(d) The normal distribution is symmetric and bell-shaped. True

The normal distribution is sometimes called the gaussian distribuation which is symmetric and bell

shaped.

(e) The larger the standard deviation the more tightly grouped the values. False

The standard deviation gives a measure of the spread of the values- the smaller it is the more

closely grouped the values.

The mode is the most frequently occurring observation.

Coronary artery stenosis and cholesterol levels in patients levels are found to correlate with a

coefficient of 0.70. Which is the best deduction from this?

(a) A scattergram of coronary artery stenosis against cholesterol would have a negative gradient

False

?

(b) A scattergram of coronary artery stenosis against cholesterol would have a positive gradient

True

?

(c) Coronary artery stenosis and cholesterol levels are not correlated False

?

(d) Correlation value r is -0.70 False

?

(e) Correlation value r is 1 False

?

A scattergram of coronary artery stenosis against cholesterol would have a positive gradient. The

scatter plot would give a positive gradient if correlation coefficient r (in this case 0.7) is positive

and likewise if negative.

NICE Guidelines: CT Brain post head injury

(a) If a patient on warfarin has a history of LOC but a GCS of 15/15 on exam there is no indication

for CT Brain False

?If a patient on warfarin has a history of LOC but a GCS of 15 on exam there is an indication for

CT Brain. ( coagulopathy + LOC )

(b) If a 70 year old patient has amnesia of events post head injury but a GCS of 15/15 there is no

indication for CT Brain. False

?If a 70 year old patient has amnesia of events post head injury but a GCS of 15/15 there is an

indication for CT Brain. ( As age >65 and amnesia )

(c) If a pedestrian is struck by a car and loses consciousness there is no indication for CT Brain if

his/her GCS is 15/15 . False

?If a pedestrian is struck by a car and loses consciousness there is an indication for CT Brain

according to the NICE guidelines even if his/her GCS is 15/15.(dangerous mechanism of injury +

LOC )

(d) If a patient is ejected from a vehicle and has amnesia of the events after the injury there is an

indication for CT brain even if the GCS is 15/15. True

?If a patient is ejected from a vehicle and has amnesia of the events after the injury there is an

indication for CT brain even if the GCS is 15/15. ( Dangerous mechanism of injury and Amnesia)

(e) If a patient falls more than 1 metre and loses consciousness but has a GCS of 15/15 on exam

there is no indication for CT Brain. False

?Dangerous mechanism of injury and loss of consciousness.

Statistics...

(a) The power of a study is the probability of correctly rejecting the null hypothesis when it is

false. True

?Power is usually expressed as a percentage.

(b) Rejecting the null hypothesis when it is true is a type I error. True

?Rejecting the null hypothesis when it is true is a type I error.

(c) Smaller differences between groups can be detected with a greater power. True

?Smaller differences between groups can be detected with a greater power.

(d) Small samples often lead to type II errors. True

?As there is not sufficient power to detect differences of clinical importance.

(e) As the p value gets smaller the more likely it is that the null hypothesis is true. False

?As the p value gets smaller the less likely it is that the null hypothesis is true.

NICE Guidelines:In the following circumstances it is safe to assess the ROM of the the neck.

(a) The patient presents with delayed neck pain following an injury. True

?If the patient presents with delayed neck pain following an injury it is safe to assess the ROM of

the the neck.

(b) If the patient was involved in a simple rear-end motor vehicle collision. True

?If the patient was involved in a simple rear-end motor vehicle collision it is safe to assess the

ROM of the the neck.

(c) If the patient is sitting comfortable in the emergency department. True

?If the patient is sitting comfortable in the emergency department it is safe to assess the ROM of

the the neck.

(d) If the patient has ambulatory since the accident and there is no midline cervical spine

tenderness. True

?If the patient has ambulatory since the accident it is safe to assess the ROM of the the neck.

(e) A fall of over 2 stairs is considered to be a dangerous mechanism of injury. False

?A fall of over 5 stairs or over 1 metre is considered to be a dangerous mechanism of injury.

http://www.nice.org.uk/

The following are true regarding study design:

(a) Meta-analysis results are usually expressed as odds ratio or relative risk. True

?Meta-analysis results are usually expressed as odds ratio or relative risk.

(b) The relative risk measures the strength of association between a factor and outcome. True

?The relative risk measures the strength of association between a factor and outcome.

(c) If the relative risk is <1 the risk in exposed individuals is less than the risk in the non exposed

individuals. True

?If the relative risk is <1 the risk in exposed individuals is less than the risk in the non exposed

individuals.

(d) The attributable risk is calculated by subtracting the incidence rate in the non-exposed from the

incidence rate in the exposed. True

?The attributable risk is calculated by subtracting the incidence rate in the non-exposed from the

incidence rate in the exposed.

(e) The population attributable risk is the prevalence of the risk factor divided by the attributable

risk. False

? The population attributable risk is the attributable risk multiplied by the prevalence of the risk

factor.

A group of middle aged subjects are recruited to a study which measures cholesterol. The normal

distribution is assumed. The mean cholesterol was 5.0mmol/l. The standard deviation is 0.3

mmol/l. Which of these statements is correct?

(a) 68% of subjects have a cholesterol between 4.85 to 5.15. False

?

(b) 68% of subjects have a cholesterol between 4.4 to 5.6. False

?

(c) 95% of subjects have a cholesterol between 4.4 to 5.6. True

?

(d) 95% of subjects have a cholesterol between 4.85 to 5.15. False

?

(e) 99% of subjects have a cholesterol between 4.3 to 5.6. False

?

95% of subjects have a cholesterol between 4.4 to 5.6. Assuming normal distribution - 99% of

subjects are within 3 standard deviations of the mean, 95% of patients within 2 standard

deviations, 68% within 1 standard deviation. In this question, 99% of subjects should have a

cholesterol within 4.1 and 5.9, 95% between 4.4 and 5.6, 68% of subjects between 4.7 and 5.3.

Observational Studies...

(a) Include cross-sectional, case control, ecological and cohort studies. True

?Cross-sectional studies may also be called prevalence studies, case-control studies may also be

caused case-reference studies, cohort studies may also be called follow-up studies.

(b) Case control studies are suitable for diseases with a long latency period. True

?And case control studies are also suitable for rare diseases.

(c) Case control studies are suitable for the study of rare exposures. False

?Case control studies are unsuitable for the study of rare exposures,they cannot establish the

sequence of events, the selection of an appropriate control group may be difficult and they rely on

record and recall.

(d) Case Control studies can establish the sequence of events. False

?Case control studies are unsuitable for the study of rare exposures,they cannot establish the

sequence of events, the selection of an appropriate control group may be difficult and they rely on

record and recall.

(e) Case control studies establish the relative risk of cases vs controls. False

?Case control studies establish the odds ratio of cases vs controls. Cohort studies establish relative

risk.

Symptoms and Signs that should raise suspicions of elder abuse include Your

Result Result

(a) Dementia False

(b) Untreated injuries in various stages of healing True

(c) Inadequate clothing. True

(d) Sudden changes to will True

(e) Unexplained fear. True

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