2 Item: 1 of 6 l lf' Mark <::] t>-

Q. ld : 10092 [ Previous Next

3
4
5
6 A 65-year-old man is scheduled for hip replacement surgery. He is worried about possible complications of
the surgery, particularly the risk of heart attack. A retrospective cohort study identified 98,102 patients who
underwent total knee replacement (TKR) or total hip replacement (THR) surgery and compared their rates of
myocardial infarction (MI) with those of controls matched by age, sex, and geographic region. The following
curves for hazard ratios (HR) were obtained.

::::-
-
::i!
c
0
:;:;
40 e THR
0 TKR
~ 35 --- HRof 1.0
J!!
.!:
iii 30
...
'6
~
0 25
>-
E
...
.E 20
~

IX
-
J:

~
0
15

!.'!!
10
...
"0
Ill
~
J:; 5
...
"0
Q)
Vl
0
:J
'6'
<(
0 8 16 24 32 40 48
Time since surgery in weeks
2 Item: 1 of 6 l lf' Mark <::] t>-
Q. ld : 10092 [ Previous Next
3
4
5
6 iii 30
...
'6
~
0 25
>.
...E
-
.E 20
0:::
:I:
~
15
0
:0:
I!!
10
.,...
"0

til
.c 5
...
"0
Cll
VJ
::s 0
-- -· --------------- .•. ---------- - - -- .
'6"
<(
0 8 16 24 32 40 48

© uwo~d.com Time since surgery in weeks

Based on the study results and assuming statistical significance, w hich of the follow ing provides the best
explanation to the patient?

r A. Although there is no risk of heart attack immediately following surgery, the risk increases after
hospital discharge.
r B. There is an increased risk of heart attack after surgery, w hich is best explained by risk factors and
comorbidities.
r C. There is an increased risk of heart attack right after surgery, but it returns to baseline after 4 w eeks.
r D. There is an increased risk of heart attack up to approximately 8-10 w eeks after the surgery.
r E. There is no substantial proof that the surgery is associated w ith a higher risk of heart attack.
-
1

3
4
5
6
'

Item: 2 of 6
Q. ld: 9991 [
l lf' Mark <::]
Previous
t>-
Next

A research group is studying a new biomarker for prostate cancer screening in a random sample of
asymptomatic men >50 years of age. As the majority of prostate cancers are slow ly progressive, the
investigators are concerned that the benefits of the new screening tool w ill be overestimated due to detection
of a disproportionate number of slow ly progressive, benign cases. The research group is most likely
concerned about the presence of w hich of the follow ing types of bias?

r A. Hawthorne effect
r B . Lead-time bias
r C. Length-time bias
r D. Observer bias
r E. Sampling bias
1

-
2
'

Item: 3 of 6 l lf' Mark <::] t>-

Q. ld: 9987 [ Previous Next

4
5
6 A large study surveyed 24-hour dietary fiber intake in a nationally representative sample of the United States
population. The investigators also collected anthropometric and laboratory data soon after survey
completion. The following results w ere reported for prevalence of obesity, metabolic syndrome, and elevated
inflammatory markers per quintiles of daily dietary fiber intake.

50

P for metabolic syndrome <0.01

40
•••.. .. ... ••
p for inflammation = o.o3 •••• •••••

P for ob:;;;·~·~·~~""··:,::·. A·. ... .~.~·=-~·~·~·~:.~~.:.:.:.;,,....~ ..<~::t:·:·:·:......................_

30
·-. ··- ...
...
20
• • • • Metabolic syndrome
......... Inflammation

10 Obesity

QL-----------~-----------L----------~------------L---------~
Quintile 1 Quintile 2 Quintile 3: Quintile 4: Quintile 5:
0.0-6.8g 6.9-12.8g 12.9-22.8g 22.9-26.1g 26.2-222g

\I)USMLEWorld. LlC Quintiles of dietary fiber intake

W hich of the following is the best interpretation of the study results?

1

-
2
'

Item: 3 of 6 l lf' Mark <::] t>-

Q. ld: 9987 [ Previous Next

4
5 50
6
P for metabolic syndrome <0.01
•••.. ..·-.
40
p for inflammation = o:o3 ...• .....
-----
. ............................. ............~.~ -~ -~ -~ -~ -~ -~~: ..... .
P for obesity = 0.04 -.
............., _ .··-.
...."'-:.::::: ................
...... ...................
30
.. .·- ..~

20
• • • · Metabolic syndrome
_....... Inflammation

10 Obesity

QL-----------~-----------L----------~------------L---------~
Quintile 1 Quintile 2 Quintile 3: Quintile 4: Quintile 5:
0.0-6.8g 6.9-12.8g 12.9-22.8g 22.9-26.1g 26.2-222g

@USMLEWorld, UC Quintiles of dietary fiber inta ke

W hich of the following is the best interpretation of the study results?

r A. Higher dietary fiber intake consistently causes a decrease in inflammatory biomarkers

r B. Higher dietary fiber intake is beneficial in obese patients w ith high inflammatory biomarkers
r C. Lower dietary fiber intake results in obesity and metabolic syndrome
r D. The relative risk of cardiac disease is lower w ith higher dietary fiber intake
r E. There is an association between higher dietary fiber and a lower prevalence of metabolic syndrome
 1
2
'

Item: 4 of 6 l lf' Mark <::] t>-

-
Q. ld : 9986 [ Previous Next
3

5
• 6 A 32-year-old w oman comes to the physician w ith urinary burning and frequency. She has no fever or back
o•
pain. Midstream urine (MSU) cultures grow 1 colony forming units (CFU)/ml of enterococci. A previous
publication studied the accuracy of MSU culture in identifying the causative pathogen in patients w ith
uncomplicated cystitis. W omen ages 18-49 w ith symptoms of cystitis provided MSU specimens for
culture. The investigators also collected urine by means of a urethral catheter for culture, w hich served as the
gold standard for confirming the causative pathogen . The follow ing results relating to enterococcal growth
w ere reported for 404 specimens:
Organism Sensitivity Specificity
Number/Total number (%)
Enterococci (CFU/ml)
~102 4/4 (100) 363/400 (91 )
~1 0
3 4/4 (100) 374/400 (94)
~104 4/4 (100) 393/400 (98)
>105 214 (50) 394/400 (98)

Based on the study results, w hat is the positive predictive value of enterococcal growth of 1OS CFU/ml in the
MSU sample?

r A. 10%
r B. 25%
r c. 33%
r D. 50%
n E. 90%
 1
2
'

Item: 5 of 6 l lf' Mark <::] t>-

Q. ld : 10041 [ Previous Next
3

-
•
4

6 A 45-year-old man is diagnosed w ith dilated nonischemic cardiomyopathy. Late gadolinium enhancement
cardiac magnetic resonance (CMR} imaging show s a left ventricular ejection fraction (LVEF} of 20% and
evidence of extensive midwall m yocardial scarring. A recent study determined prognosis in patients w ith
dilated cardiomyopathy using CMR-derived LVEF and evidence of midwall m yocardial scarring (fibrosis}. Tw o
models w ere assessed: one model w as based on LVEF alone, and the other incorporated the presence or
absence of fibrosis. The follow ing 5-year prediction curves w ere reported:

Dilated cardiomyopathy & mortality

All-cause mortality
70

60
~ - - Fibrosis
.!!I
~ 50 • - • LVEF alone
m
>. • • • • • No fibrosis
~ 40 ... ...
2
.!:! ... ...
¥ 30
0. ... .... .... ... ... ... ...
0~
20 .... .... .... ... ...
.... .... ... ...
............. .......... .......
10
.. .... ._
........ ..........
...... ..-: ... ....... ....-..
Q-L,---------.---------.--------,,--------,---------,
10 20 30 40 50 60
o/o LVEF
1
2
'

Item: 5 of 6 l lf' Mark <::] t>-

Q. ld : 10041 [ Previous Next
3

-
4

6 70

60
Cardiovascular mortality or transplantation

-""
.!!!
:: 50
ro
Q)
>.
''
~ 40 ''
.2l
0 ''
~ 30 ' '
a.
0~
' '
20 ...... ' '
··- ..... ...... ..... ' .... ....,
10 ....... ···•····· ...., ~

....... ........
0~.---------.---------.--------,,--------.---------,
······ . .. . .........
10 20 30 40 50 60
%LVEF
©USMLEWorld, LLC

Based on the study results, what is the approximate predicted 5-year all-cause mortality for this patient?

r A. 10%
r B. 20%
r c. 30%
r D. 40%
r E. 50%
1
2
'

Item: 6 of 6 l lf' Mark <::] t>-

Q. ld: 9979 [ Previous Next
3
4

-
5
Tw o independent research groups are studying the effect of a new anticoagulant on the incidence of
deep-vein thrombosis after hip replacement surgery. The first group designs a 1:1 randomized trial w ith 1000
patients comparing the new drug w ith the standard of care (500 patients in each group). The second group
designs a similar randomized trial but intends to recruit 500 patients (250 patients in each group). Assuming
similar populations for patient recruitment, the small study has a higher chance of w hich of the follow ing?

r A. Early termination
r B. Outcome misclassification
r C. Selection bias
r D. Type I error
r E. Type II error