Final exam Epidemiology, academic year 2018-19 Dpt.

Preventive Medicine and Public Health

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● The exam has 75 questions. You will have 2 HOURS AND 20 MIN for completing it. You will have no
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● Wrong answers will be PENALISED (-0.33 for every wrong answer)
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The following questions refer to the paper you had to read and work on, prior to the exam:

Léo Pomar, Manon Vouga, Véronique Lambert, Céline Pomar, Najeh Hcini, Anne Jolivet, Guillaume
Benoist, et al. Maternal-fetal transmission and adverse perinatal outcomes in pregnant women infected
with Zika virus: prospective cohort study in French Guiana: BMJ 2018;363:k4431

1. In the Abstract, the objectives were: “To estimate the rates of maternal-fetal
transmission of Zika virus, adverse fetal/neonatal outcomes, and subsequent rates of
asymptomatic/symptomatic congenital Zika virus infections up to the first week of life.”
Without reading anything else, you should probably be thinking of measures of:
(1) Association
(2) Absolute frequency
(3) Risks
(4) Speed of occurrence

In the Objective section the authors state the following:

“We conducted a cohort study among pregnant women…Our primary objective was to
estimate the absolute risk of maternal-fetal infection. The secondary objectives were to
estimate the percentage of fetuses/newborns with overt signs of infection or related
complications within the first week of life, by reviewing fetal/neonatal outcomes blinded
to Zika virus status; to estimate the relative risk of adverse perinatal outcomes in infected
fetuses.”

2. What is the main difference between both underlined sentences?

(1) The first one is a measure of association and the second one is a ratio
(2) The first one is purely descriptive and the second one is analytic.
(3) The first one is a crude measure and the second one is an adjusted measure
(4) The first one is a “risk measure” whereas the second on is a “rate” measure

3. According with the Objective section read before, what is the true statement concerning
the study design, that you can infer by reading this paragraph only?
(1) We can’t know, at this point, if it is a prospective or retrospective design
(2) It looks more like a prospective cohort because children are in fact born after the
pregnant woman is identified
(3) It looks more like a retrospective cohort because children are already born in order to
calculate risks and ratios.
(4) It definitely looks like a prospective cohort because they are using risks and ratios and
in other words have to calculate incidences.

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

4. In the Study Population section the authors state the following: “The catchment
population of the CHOG is quite similar of that of all French Guiana, but some
particularities come from the fact that a part of the western population live along the
Maroni river and are more exposed to poverty, difficult living conditions, and subsequent
medical comorbidities (higher rates of pregnancy among adolescents and higher risks of
prematurity, vascular diseases, lead poisoning, and anaemia)”.This probably has to do
with the concept of:
(1) Hawthorne effect
(2) Information bias
(3) Internal validity
(4) External validity

5. In the Methods section the authors state the following: “We collected data on
demographic characteristics, medical parameters, and possible risk factors for congenital
diseases.” Given on of the objectives of the study, the measurement of “risk factors for
congenital diseases” probably has to do with:
(1) Avoiding information bias
(2) Having information about “all” the possible effects of the Zika virus
(3) Adjustment of confounding
(4) External validity

6. In the Methods section the authors state the following: “Gestational age was based on
the crown-rump length (longitud craneo-caudal) on an ultrasound scan performed
between 11 and 13+6 weeks’ gestation.” Suppose this method for measuring gestational
age was inaccurate with respect to the real gestational age. We would probably speak of:
(1) Non differential selection bias
(2) Differential selection bias
(3) Non differential information bias
(4) Differential information bias

7. In the Statistical analysis section the authors state the following: “As the placenta might
be contaminated by maternal blood, we redefined the criteria for a laboratory confirmed
congenital Zika virus infection to exclude placentas and removed them from the analysis.”
The researchers did this because they were worried of the possibility of: ANULADA. ES
PARA CALCULAR LA INCIDENCIA. NO SE REFIERE A EXP Y NO EXP
(1) Non differential selection bias of the outcome
(2) Differential selection bias in exposed
(3) Non differential information bias of the outcome
(4) Differential information bias of the outcome

8. The title of this study is: “Maternal-fetal transmission and adverse perinatal outcomes in
pregnant women infected with Zika virus: prospective cohort study in French Guiana.” In
any case, which of the following statements is correct?
(1) It's a cohort study and the exposed group were the 1690 pregnant women
(2) It's a cohort study and the exposed group were the 490 pregnant and infected women
(3) It's a cohort study and the exposed group were the 305 fetuses of the 300 pregnant
and infected women
(4) In fact, it is not really a cohort study, rather a cross sectional study

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

Please observe this portion of figure 1 from the paper:

9. Which of the following statements is WRONG? ANULADA

(1) It seems like the risk of infection is almost three times higher (215/76=2.83) in the
group of the left side of the figure.
(2) The infection risk is 26%
(3) The risk of symptoms is 1.6 times higher in the infected group (42/27=1.56)
(4) In absolute terms, the number of symptoms are higher in the infected fetuses

10.According to Figure 1, what is the “number necessary to treat” of avoiding a severe

complication?
(1) 16-10=6 (The answer would be “NNT=6”)
(2) 1/0.164=6.09 (The answer would be “NNT=7”)
(3) 0.211/0.0465=4.54 (The answer would be “NNT=5”)
(4) 0.211-0.0465=0.164 (The answer would be “NNT=1”)

11.According to Figure 1, what is the attributable fraction of having a severe complication

when exposed to infection?:
(1) 16-10=6 and then 6/76=0.0789; in other words 7.89%
(2) 1/0.164=6.09; in other words a 509% increase
(3) 0.211/0.0465=4.54 and then 4.54/76=0.0597; in other words 5.97%
(4) 0.211-0.0465=0.164 and then 0.164/0.211=0.7773; in other words 77.7%

Please observe table 1 from the study:

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

12.The main message the authors are trying to convey with this table is that:
(1) Infected and non-infected fetuses are similar with respect to the different variables in
the table.
(2) Women where approximately 3.3 times (40/12=3.33) older in one group
(3) The characteristics of the table do not seem to be confounding the results of the study
(4) One group has had a lot more (111 vs 44) third trimester infection

13.One of the main results of this paper is the incidence of transmission of Zika virus. The
authors affirm in their introduction that incidences vary a lot depending on studies (for
example 40% in Brazil, or 5%-8% in a US Zika pregnancy registry). They report having
found a 26% documented transmission risk. This figure would be correct to the extent the
study was strong mostly in the following characteristics EXCEPT which one?
(1) Sample size
(2) Internal validity
(3) Representativeness
(4) No lost to follow-up

14.The authors say the following in the discussion section: “All fetal/neonatal outcomes
were reviewed independently and blindly for Zika virus status.” The statement they are
making most likely concerns:
(1) Non differential selection bias
(2) Differential selection bias
(3) Non differential information bias
(4) Differential information bias

Please observe table 2:

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

15.The ratio of asymptomatic to non-asymptomatic fetuses when we compare negative

fetuses with positive ones is:
(1) 188/34=5.5
(2) 87/45=1.9
(3) 188/(188+34)=84.7%
(4) We do not have all we need to calculate this ratio

16.The main message the authors are trying to convey with table 2 is that:
(1) Infected and non-infected fetuses are similar with respect to the different
characteristics of the groups compared.
(2) Negative fetuses are 5.5 times (188/34=5.53) more likely to be asymptomatic.
(3) The characteristics of the table do not seem to be confounding the results of the study
(4) Infected fetuses have more outcomes

17.You probably remember table 3 if you have read and worked on the paper. This question
is easy. Table 3 is:
(1) Similar to table 1, in content and information but using more characteristics
(2) Similar to table 2 above, in content and information but using more clinical outcomes
(3) The final logistic regression (multivariable analysis) of the results of the study
(4) The final multivariable binomial Wilson score with confidence intervals using single
proportions and the Pearson exact method to calculate confidence intervals of risk
ratios and medians.

The following sentences come from the Discussion section:

18. “Our results are congruent with another recent study performed in Brazil among 54
pregnant women with RT-PCR confirmed Zika virus infections, in which vertical
transmission was documented in 18/51 (35%) newborns tested, whereas 15 (28%)
newborns had mild/moderate signs.” This sentence has to do with:
(1) External validity
(2) Consistency
(3) Coherence
(4) Selection bias resulting in sub-estimation of effects (26% vs 35% and 28%)

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

19. “The broader number of patients included in our cohort may have enabled the detection
of more uncommon severe anomalies and provided a better estimation of maternal-fetal
transmission.” This sentence has to do with:
(1) Internal validity
(2) Recall bias
(3) Less lost to follow-up
(4) Missing data

20.“This suggests that transient liver damage might be part of a moderate CZS, similarly to
what is known for congenital cytomegalovirus.” This sentence has to do with:
(1) External validity
(2) Consistency
(3) Coherence
(4) Biological gradient

21. “Furthermore, we considered placental and umbilical cord samples in the diagnosis of
congenital Zika virus infection, which may be questionable owing to the risk of maternal
contamination of these samples. Nevertheless, the risk of false positive results due to
maternal contamination seems to be low in this study.” This sentence has to do with:
(1) Discussion of positive evidence in favor of causality
(2) Discussion of negative evidence in favor of causality
(3) Discussion of selection bias
(4) Discussing of the correction of confounding

22. “When we excluded placental samples from our analysis, maternal-fetal transmission
was documented in 18% (52/282) cases, of which 33% (17/52) had severe complications
at birth. Association between a laboratory confirmation of congenital Zika virus infection
and outcomes did not change…” This sentence has to do with:
(1) Discussion of positive evidence in favor of causality
(2) Discussion of negative evidence in favor of causality
(3) Sensitivity analysis
(4) Discussing of the biological plausibility

23.“Some maternal information may have been missed, and invasive testing and complete
genetic analyses were not systematically performed (for evident ethical reasons).
Nevertheless, potential missing information or additional diagnoses not reported would
result in an overestimation of the burden of congenital Zika virus infection observed in
this cohort.” This sentence has to do with:
(1) Discussion of positive evidence in favor of causality
(2) Discussion of negative evidence in favor of causality
(3) Sensitivity analysis
(4) Discussing of the biological plausibility

24.“Selection bias is expected to be limited, as basic maternal characteristics were similar

between patients included in this study and the whole obstetric population delivering at
the CHOG in 2016.” This sentence has to do with:
(1) Internal validity
(2) Information bias
(3) Representativeness
(4) No confounding because groups were similar
--------------------------------------------------

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

Below, you can find excerpts from a paper entitled “Serum antioxidant capacity, biochemical
profile and body composition of breast cancer survivors in a randomized Mediterranean
dietary intervention study” (Eur J Nutr 2018; 57:2133-2145).

25. “Various studies examined the association of BC with serum antioxidants, including
vitamin A (retinol), coenzyme Q10, vitamin E (a-tocopherol) and vitamin C. However they
resulted in conflicting conclusions”. What causality criterion does this statement refer to?
(1) Consistency
(2) Coherence
(3) Experimental evidence
(4) Analogy

26.“Food and nutrients are not consumed alone, and they constitute a complex network of
dietary, biochemical and behavioral factors, which could have antagonistic or synergistic
effect on health outcome”. Which phenomenon/concept is being described here?
(1) Confounding
(2) Interaction
(3) Experimental evidence
(4) Analogy

27. “Various mechanisms have been proposed to explain the beneficial effect of the
Mediterranean diet on breast cancer and cardio metabolic diseases’ risk, including its
richness in fruits and vegetables, significant sources of antioxidants […] and its role in
patients biochemical profile amelioration.” What causality criterion does this statement
refer to?
(1) Consistency
(2) Biological plausibility
(3) Experimental evidence
(4) Strength of association

Below, you will find some excerpts from the paper entitled “Feasibility of structured
endurance training and Mediterranean diet in BRCA1 and BRCA2 mutation carriers – an
interventional randomized controlled multicenter trial (LIBRE-1)” (BMC Cancer 2017;17:752).

28.In the paper, we read: “Women with BRCA germline mutations have considerably
increased lifetime risks for breast (55-60%) and ovarian (16-59%) cancer. However,
current literature implies that the risk of developing cancer in gene carriers may be
influenced through genetic factors (polymorphisms), as well as exogenous factors such as
reproductive factors, lifestyle and physical activity during adolescence.” Regarding breast
cancer as outcome, we could state that BRCA mutations are:
(1) a necessary but not sufficient cause
(2) a sufficient but not necessary cause
(3) both necessary and sufficient for breast cancer development
(4) neither necessary nor sufficient for the development of breast cancer

29.In the paper we read: “Women with BRCA germline mutations have considerably
increased lifetime risks for breast (55-60%) and ovarian (16-59%) cancer. […] The cancer

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

risk is higher, if genotype carriers were obese, physically inactive during their youth, born
after 1940 or had no children”. This statement refers to:
(1) Strength of the association
(2) Confounding by adiposity, physical activity, year of birth and parity
(3) Interaction with adiposity, physical activity, year of birth and parity
(4) Coherence
____________

30.In a case control study of a sensitive topic such as Intimate partner violence (IPV), which
situation would make you worry more?
(1) Cases and controls from different socio economical status
(2) Cases that are prevalent cases of IP
(3) The study of a possible confounder such as the use of the contraceptive pill, because
we would have recall bias in controls when asking what specific pill women took.
(4) Difference of sex between person that collects data and subjects that have suffered
IPV (for example, a man interviewing an abused female or a female interviewing an
abused male).

31. A CDC report (Centers for Disease Control and Prevention) states that 1 in 5 new HIV
diagnoses in the U.S. were among young adults aged 13-24 years. This data corresponds
to a/an:
(1) Proportion
(2) Odds
(3) Incidence
(4) Absolute measure
The following figure from a 2018 UNAIDS report shows the risk of HIV infection in different
groups:

32.Which epidemiological measure is shown in the figure?

(1) Incidence of infection
(2) Relative Risk
(3) Attributable risk
(4) Odds Ratio

33.According to the data in the figure:

(1) It is unclear whether the risk of HIV among the general population is lower than the risk
among the groups shown in the figure because the incidences are not shown.
(2) People who inject drugs have a 22% chance of becoming infected with HIV.
(3) The incidence of HIV infection among female sex workers is 0.13.

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

(4) All groups in the figure have an increased risk of HIV infection of more than 1,000%
compared to the general population.
___________

34.In a review on risk factors for ski injuries we read that 56% of knee sprains in skiers who
wear the equipment in bad shape could be avoided if they wore it in perfect shape. What
epidemiological measure does this figure refer to?
(1) Preventive fraction
(2) Attributable fraction among exposed
(3) Attributable risk among exposed
(4) Population attributable fraction

35.What characteristic is common to cohort studies, case control studies, and experimental
studies?
(1) Price
(2) Can be prospective or retrospective
(3) Usually estimate incidences
(4) They try to simulate the counterfactual model

A clinical trial is designed to find out whether a new lipid lowering drug is more effective
than atorvastatin in reducing the risk of heart attack in patients with elevated LDL-
cholesterol. The study is intended to be double-blind.

36.Who will be included in the study population?

(1) Patients with and without high LDL-cholesterol
(2) Patients with high cholesterol-LDL
(3) Patients with a history of heart attack and high LDL-cholesterol
(4) Patients with elevated LDL-cholesterol who are taking atorvastatin

37.What does it mean that the trial is double-blind?

(1) In neither of the groups do the patients know what medication has been assigned to
them.
(2) Neither patients nor researchers know who is in the control group and who is in the
new drug group.
(3) The analysis and evaluation of the data is done without knowledge of the identity of
the groups.
(4) The researchers and the patients do not know the randomization sequence.

38.What type of analysis would lead to a higher measure of association?

(1) Intention to treat
(2) Protocol
(3) Sequential
(4) Multivariable

39.The researchers find a new drug with a RR for infarction=0.7 (95% CI 0.5-0.9) compared to
atorvastatin. Among the 2000 patients in the control group, 20 people suffered a heart
attack. How many heart attacks could be avoided per 1000 patients treated with the new
drug instead of being treated with atorvastatin?

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

(1) 30
(2) 3
(3) 70
(4) 334
___________

To find out if obesity could lead to hip arthrosis, a sample of 600 people from a health centre
was chosen. Subjects’ height and weight were measured in order to check if they were
obese. Additionally, had x-rays of the hips were performed: 20 out of 100 obese subjects and
50 out of the non-obese subjects had arthrosis.

40.What can you conclude from the data of this study?

(1) That obesity increases the risk of hip arthrosis by 200%.
(2) That obese people have a 2 times higher risk of hip arthrosis compared to non-obese
people.
(3) That there is an association between obesity and hip arthrosis but it cannot be
concluded whether it is statistically significant, due to the design of the study.
(4) It cannot be ruled out that hip arthrosis has led to obesity.

41.What is the main limitation of this study?

(1) Lack of representativeness of the sample
(2) No evidence of a temporal relationship between exposure and outcome
(3) The exposure could not be randomly allocated
(4) Lack of precision of diagnostic equipment, which can lead to information bias
42.In a cohort study about the relationship between alcohol consumption and esophageal
cancer, researchers found a risk difference of 0.02 (95% CI 0.01-0.03). Please, indicate the
correct interpretation:
(1) 2 out of 100 drinkers will have esophageal cancer due to alcohol consumption
(2) 2 out of 100 drinkers will develop esophageal cancer
(3) 2 out of 100 esophageal cancers in drinkers is due to alcohol consumption
(4) 2 out of 100 esophageal cancers are due to alcohol consumption

43.In France and Zimbabwe the incidence of a certain infection is the same. There is no
curative treatment for this infection; the current treatments are very expensive, are more
accessible in developed countries and are intended to chronify the disease. In which of
the countries do you expect to find a higher prevalence?
(1) France
(2) Zimbabwe
(3) The prevalence will be similar in both countries
(4) It is necessary to know how many people there are in each country.

In a study to test the efficacy of the whooping cough (tosferina) vaccine, 1843 newborns
were followed. A total of 1501 children were vaccinated, of whom 164 suffered a whooping
cough episode in the first year of life. Among the unvaccinated, 85 cases were recorded.

44.The vaccine prevents __ of cases of whooping cough:

(1) 44%
(2) 56%
(3) 10,9%
(4) 14%

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

45.For every 100 unvaccinated children, how many cases of whooping cough could be
prevented by vaccination?
(1) 8
(2) 11
(3) 14
(4) 25

46.Taking into account that the study sample is representative of the population, the vaccine
could prevent __ of whooping cough cases in the first year of life in that population.
(1) 19%
(2) 37%
(3) 7,8%
(4) 56%

47.In the city where you work, 90 per cent of newborns are vaccinated against whooping
cough. The preventive population fraction in your city will be:
(1) Higher than the one in the reference study
(2) Equal to the one in the reference study
(3) Lower than the one in the reference study
(4) The % of vaccination will not influence the calculation of the preventive fraction of the
vaccine.

48.What type of study has been conducted to evaluate the effectiveness of the whooping
cough vaccine?
(1) Clinical trial
(2) Prospective Cohort
(3) Retrospective Cohort
(4) Cases control

49.Imagine that you find during data analysis that 15% of the vaccinated children did not
provide any information on whether or not they had had whooping cough. This would
lead to
(1) A selection bias
(2) A non-differential exposure information bias
(3) A differential exposure information bias
(4) Confusion bias

50.What would be the effect of the previous bias on the estimation of vaccine efficacy?
(1) It would be underestimated
(2) It would be overestimated
(3) The bias would not modify it
(4) It would depend on whether those children had actually had whooping cough or not.
_____________

A prospective cohort study included 1534 women at the time of diagnosis of their first
pregnancy. In each of the pregnancy review consultations they were asked about the use of
drugs. At the end of the study it was found that women who had taken benzodiazepines had
a RR=1.8 (95% CI 1.3-2.4) of having a baby with cleft palate (paladar hendido).

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

51.Some women did not report their use of benzodiazepines adequately to their doctor.
What bias may have arisen?
(1) Selection
(2) Differential information
(3) Non-differential information
(4) Missing data

52.Taking this bias into account, can this study conclude that consumption of
benzodiazepines during pregnancy increases the risk of cleft palate?
(1) No, because the exposure is not well recorded.
(2) No, because the bias invalidates the RR estimation.
(3) Yes, even if these data are missing, the sample size is still large enough to adequately
estimate the RR.
(4) Yes, because the RR is underestimated due to the bias (the association will be even
higher than the one found).

A case-control study is conducted to evaluate the association between educational level

(measured as the number of years of education) and the risk of Alzheimer's disease. The
researchers also considered whether having the ApoE-4 genotype could increase the risk of
Alzheimer's disease. The results are shown in the following tables:

People with ApoE-4:

Alzheime No Alzheimer
r
<10 years of education 160 20
>10 years of education 144 36

People without ApoE-4:

Alzheime No Alzheimer
r
<10 years of education 36 144
>10 years of education 20 160

53.Based on these data, please indicate the INCORRECT answer: ANULADA

(1) The ApoE-4 genotype is associated with educational level.
(2) The ApoE-4 genotype increases the risk of Alzheimer's disease in patients with >10
years of education.
(3) The ApoE-4 genotype modifies the effect of education on Alzheimer's disease.
(4) The low level of education increases the risk of Alzheimer's disease by 100%, regardless
of having the ApoE-4 genotype.

In order to know the frequency and distribution of the main risk factors of cardiovascular
disease in Spain, the ENRICA study (Study of Nutrition and Cardiovascular Risk) was
conducted. Using a stratified random sampling, a sample of 11991 people >18 years old was
selected. Information from participants was collected between June 2008 and October 2010
in 3 sequential stages over time:

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

1º. Telephone interview with a structured questionnaire on lifestyles, knowledge and

attitudes about risk factors and cardiovascular events.
2º. First home visit to obtain biological samples (blood and urine).
3º. Second home visit to perform a physical examination (anthropometry and blood
pressure) and obtain a dietary history.

54.What is the design of this study?

(1) Prospective Cohort
(2) Retrospective Cohort
(3) Cross-sectional
(4) Clinical trial

55.What measures will you be able to calculate?

(1) Incidences, RR, ARE and AFE
(2) Prevalences, prevalence ratio
(3) Incidences, OR and RR
(4) Prevalences, incidences, OR and RR

56.The authors reported that the total response rate (including all three phases of data
collection) was 51%. This fact:
(1) It will affect both the internal and external validity of the study.
(2) It will affect the internal validity but not the external validity, because the type of
sampling carried out guarantees the representativeness of the sample.
(3) It implies a selection bias that will underestimate the measures of frequency and
association.
(4) These are non-informative losses and, as there is a large sample size, the results will not
be biased, maintaining the validity of the study.

57.When comparing two populations and in the presence of important differences between
crude rates ratio and adjusted rates ratio by educational level, we can affirm that
probably:
(1) The two populations have the same educational level but a different age distribution.
(2) The counterfactual model complies with both rates
(3) High educational level is protective
(4) There is no homogeneous distribution of educational level among exposure groups.

Schwinkshackl and colleagues published a systematic review and meta-analysis on

adherence to the Mediterranean diet and risk of cancer (Nutrients 2017, 9, 1063). Among
other results, they published this figure:

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

58.What conclusion would you draw about the between-study heterogeneity based on this
figure?
(1) Cohort studies are more heterogeneous than case-control studies because the p value
for cohort studies (p<0.00001) is more significant than for case-control studies
(p=0.002)
(2) Since all the point estimates of the included studies show a risk ratio <1, there is no
heterogeneity
(3) We cannot state anything about the heterogeneity without looking at the funnel plot
(4) The results suggest that there is heterogeneity for the overall sample and the case-
control studies

59.What type of analysis should be conducted given these data for the overall sample?
(1) Fixed-effects method
(2) Random-effects method
(3) Both could be used here but the fixed-effect method would yield narrower confidence
intervals than the random-effects method
(4) We need the value for the Q statistics in order to answer this question
60.What is the purpose of analyzing cohort and case-control studies separately?
(1) Descriptive purposes
(2) Control for confounding by study design
(3) Search for sources of heterogeneity
(4) We would need to read the methods section to answer this question because there is
not enough information in the figure to understand why they did so

61.How should we proceed in a systematic review (with or without meta-analysis)?

(1) The first step is searching for published papers related to the topic we want to address.
(2) Once we identify a study that should be included in our review, we should interpret it
before continuing with our search because we may want to redefine our search based
on these findings.

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

(3) It is recommended to register the search protocol by the time the final paper is
submitted to a journal.
(4) In a meta-analysis the research question should be structured whereas there is no
need for the research question to be structured in a narrative review.

62.What is the causality criterion underlying systematic reviews and meta-analyses?

(1) Coherence
(2) Strength of the association
(3) Consistency
(4) Plausibility

Some researchers have developed a new diagnostic procedure for a disease. They want to
address its validity. Therefore, they select a sample of 200 patients with the disease and 200
participants who do not have the disease. The new procedure failed to detect 20 cases and
missed the result in 10 non-cases. Please, answer the following questions based on this
information.

63.What is the likelihood for the test to detect the disease among sick people?
(1) 80%
(2) 85%
(3) 90%
(4) 95%

64.What is the likelihood for the test to discard the disease among non-cases?
(1) 5%
(2) 85%
(3) 90%
(4) 95%

65.What would you say to a patient with a positive test?

(1) The probability that you have the disease is 95%
(2) You need another test to confirm the disease because the result is probably a false
positive.
(3) You definitely have the disease because this new test is totally reliable (it has a very
high sensitivity).
(4) You need to repeat the test to confirm the results because the sensitivity and the
specificity are not 100%.

Two medical doctors visit 200 patients looking for diagnoses of fibromyalgia. Here you can
find their results:

Doctor 1
Fibromyalgia No fibromyalgia
Doctor 2 Fibromyalgia 70 20
No fibromyalgia 30 80

66.Which epidemiological criteria can be ascertained with these data?

(1) Prevalence of the disease in this sample
(2) Internal validity criteria, i.e., validity of the diagnoses of these two medical doctors
regarding fibromyalgia

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

(3) Strength of association: OR=8.4 (Large OR)

(4) Concordance

67.What is the figure for the expected values in the grey coloured cell?
(1) 35
(2) 40
(3) 45
(4) 55

68.What is the value for the kappa index?

(1) <35%
(2) 35-<45%
(3) 45-<55%
(4) >=55%
___________

69.How does the lead time bias affect the results of a screening program?
(1) It makes the screening program look better than it really is
(2) It makes the screening program look worse than it really is
(3) It does not affect the performance of the screening program
(4) It affects the screening program but the direction of the bias is unpredictable

70.How does the combination of diagnostic tests in series affect the global validity of the
diagnostic procedure?
(1) It increases the global sensitivity of the diagnostic procedure
(2) It increases the global specificity of the diagnostic procedure
(3) The global sensitivity is the same as for the diagnostic test with the highest sensitivity
that is being combined in the set of diagnostic procedures
(4) The global specificity is the same as for the diagnostic test with the lowest specificity
that is being combined in the set of diagnostic procedures

71.Calf circumference (circunferencia del muslo) has been proposed as a screening tool for
malnourishment among elderly since a lower calf circumference may reflect loss of
muscle mass. Some researchers suggest different cut-off points. Increasing the cut-off
point would lead to:
(1) No change in the sensitivity
(2) Lower sensitivity
(3) Higher sensitivity
(4) An increase in the area under the ROC

72.In clinical decision analysis which situation would make you worry more?
(1) A discussion concerning the right decision node to use
(2) Information concerning chance nodes that has ranges of possible correct values
(3) The need of a sensitivity analysis
(4) Discussions concerning what value (utility) to place on an outcome

DEMOGRAPHY QUESTIONS

73.Which of the following figures are suggestive of an expansive population?

¿Cuáles de las siguientes cifras son indicativas de una población en crecimiento?

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Final exam Epidemiology, academic year 2018-19 Dpt. Preventive Medicine and Public Health

(1) Fritz index <60

(2) Sandburg index 1 > Sandburg index 2
(3) Total fertility rate =2
(4) Swaroop and Uemura index=80%

74.Please, select one difference between the census and the municipal roll:
(1) The census is mandatory but the municipal roll is not
(2) The census is individualized but the municipal roll is not
(3) The census is not universal but the municipal roll is universal
(4) The census is a secret statistical document but the municipal roll is an administrative
document with public character

75.When does the time of follow-up end for ascertainment of neonatal deaths?
(1) 7 days after delivery
(2) 28 days after delivery
(3) 42 days after delivery
(4) 1 year after delivery

76.What is the denominator for the general fertility rate (“tasa global de fecundidad
general”)?
(1) All women
(2) Women aged 15 years or older
(3) Women aged 15-49 years
(4) Women who have had at least 1 child

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