1)

A study concludes that the relative risk of developing laryngeal cancer in

smokers compared to non-smokers is 15. The incidence of laryngeal cancer in
the non-smoker group is 0.05. What is the attributable risk?
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A.

0.25

B.

0.40

C.

0.50

D.

0.60

E.

0.70

F.

0.75
0.80

G.

Explanation Hide Explanation

Choice (E) is the correct answer. Relative risk is defined as the ratio of the incidence of disease
in the exposed group compared to the incidence of disease in the unexposed group. The
incidence of laryngeal cancer in the unexposed group (non-smokers) is 0.05 or 5%. The relative
risk is 15. 15 x 5 is equal to 75% or 0.75, which equals the incidence of disease in the exposed
group. The attributable risk is defined as the difference between the incidence of disease in the
exposed group and the incidence of disease in the unexposed group. In other words, 0.75 - 0.05,
which equals 0.70 or 70%. In other words, 70% of laryngeal cancer cases can be attributed to
smoking.

2)

Fasting blood glucose levels are used in screening for diabetes. A fasting
blood glucose level that is greater than or equal to 126 mg/dL is considered
diagnostic for diabetes. Suppose the cutoff level for diagnosing diabetes is
lowered to 110 mg/dL. What effect will this have on the sensitivity and
specificity of the fasting blood glucose screening test in diagnosing diabetes?
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A.

Increased sensitivity; Increased specificity

B.

Increased sensitivity; Decreased specificity

C.

Decreased sensitivity; Decreased specificity

73

asdf

D.

Decreased sensitivity; Increased specificity

Explanation Hide Explanation

Choice (B) is the correct answer. Sensitivity is defined as TP / (TP + FN). Specificity is
defined as TN / (TN + FP). As you lower the cutoff value for a screening test, the number of
false positives increases. In this example, if the fasting blood glucose cutoff level is lowered to
110 mg/dL, more patients will be diagnosed with diabetes who do not actually have the disease.
The number of false negatives decreases since most patients with diabetes would have a positive
screening test with a lowered cutoff value. The net result of lowering the cutoff value is an
increase in sensitivity and a decrease in specificity of the screening test.

3)

A 56-year-old male is concerned that he may have contracted hepatitis C and

would like to have himself tested. A screening test for hepatitic C has a
sensitivity of 95% and a specificity of 90%. What is the likelihood ratio of a
positive test result?
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705

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A.

0.55

asdf

B.

0.1

C.

D.

9.0

E.

9.5
12

F.

Explanation Hide Explanation

Choice (E) is the correct answer. The likelihood ratio of a positive test result is defined as
(sensitivity) / (1 - specificity) and tells us the odds of someone with the disease having a positive
test compared to somebody without the disease having a positive test. In this case, the screening
test has a 95% sensitivity and a 90% specificity. The likelihood ratio of a positive test result is
therefore equal to (0.95) / ( 1 - 0.9) which equals 9.5. A likelihood ratio greater 1 indicates an
increased probability of having the condition with a positive test.

4)

A recent study shows that a Papanicolaou (PAP) smear is 75% sensitive and
93% specific in diagnosing high-grade, precancerous cervical lesions. What
is the false negative rate of the PAP smear in detecting high-grade cervical
lesions?
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A.

7%

B.

18%

C.

25%

D.

32%

E.

45%

F.

75%
93%

G.

Explanation Hide Explanation

Choice (C) is the correct answer. The false negative rate is defined as (1 - sensitivity).
Sensitivity can be thought of as the true positive rate: in other words, the number of individuals
with a disease who test positive. In this example, the sensitivity of the PAP smear in diagnosing
high-grade cervical lesions is 75%. This means that if we take 100 patients who have high-grade
cervical lesions, 75 lesions will be detected with the PAP smear. (1 - sensitivity) is known as the
false negative rate, in this case 25%. The other choices are incorrect.

5)

Diseases often lie on a spectrum, and this fact can present a challenge when
developing a screening test for a particular disease. The graph below
represents a population with a frequency of Disease X represented by the red
line and the frequency of normal individuals represented by the blue line.
Point A on the X-axis represents the cutoff point for a screening test for
disease X. Individuals at or to the right of point A are considered to have a
positive screening test. Suppose the screening test cutoff point is moved to
point B. What effect will this have on the sensitivity and specificity of the
screening test?

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77

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NO

A.

Increased sensitivity; Increased specificity

B.

Increased sensitivity; Decreased specificity

C.

Decreased sensitivity; Increased specificity

Decreased sensitivity; Decreased specificity

D.

Explanation Hide Explanation

Choice (C) is the correct answer. If the screening test cutoff value is moved to point B, this will
result in a smaller number of false positives but at the expense of a larger number of false
negatives. Increasing the number of false negatives results in decreased sensitivity, and a
decreased number of false positives will result in increased specificity. The other choices are
incorrect.

6)

The table shown below represents the results of a case-control study. Which
of the following best defines the odds ratio in a case control study?

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A.

(b x c) / (a x d)

B.

[a / c] / [b / d]

C.

[a / b] / [c / d]

D.

[a / (a + b)] / [c / c + d]
a / (a + c)

E.

Explanation Hide Explanation

Choice (B) is the correct answer. In case-control studies, study subjects are selected based on
the presence (cases) or absence of disease (controls). Investigators then look retrospectively to
see if the two groups were exposed to a certain risk factor or exposure. In case-control studies,
relative risk cannot be used to quantify risk, since the incidence of the disease is unknown.
Disease incidence is unknown because subjects are selected based on whether or not they have
the disease. Instead, the odds ratio must be used in case-control studies to quantify risk. In case
control studies, the odds ratio is defined as the ratio of the odds that cases were exposed
compared to the odds that controls were exposed. The odds that cases were exposed is a / c. The
odds that controls were exposed is b / d. The odds ratio is therefore equal to [a / c] / [b / d], which
can be reduced to (a x d) / (b x c). Now, this is the confusing part: [a / b] / [c /d] (Choice C) can
also be reduced to (a x d) / (b x c). Choice (C) actually represents the odds ratio calculated from
a cohort study. Suppose the two by two table above were the results of a cohort study, where
cases and controls are replaced with disease development and absence of disease, repectively. In
cohort studies, study participants are selected on the presence or absence of the exposure or risk
factor, NOT the presence or absence of disease. The odds ratio in a cohort study is calculated as
the ratio of the odds of disease development in exposed individuals compared to the odds of
disease development in unexposed persons. The odds of disease development in exposed
individuals is mathematically defined as a /b, and the odds of disease development in unexposed

individuals is c / d. The odds ratio in a cohort study is therefore defined as [a / b] / [c / d], which
can also be reduced to (a x b) / (b x d).

7)

A new chemotherapy drug is found to prolong survival in breast cancer

patients. The new drug will have which of the following effects on breast
cancer epidemiology?
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A.

Increased mortality

B.

Decreased specificity

C.

Increased sensitivity

D.

Decreased disease incidence

Increased disease prevalence

E.

Explanation Hide Explanation

Choice (E) is the correct answer Since the new chemotherapy drug results in increased breast
cancer survival, there will be more patients with breast cancer at any given time. The result will
be an increase in disease prevalence. Prevalence is defined as the total number of cases of a
particular disease in a specified population at a particular time point. Incidence, on the other
hand, is defined as the number of new cases of a particular disease per unit time in a specified
population. The other choices are incorrect.
8)

A study is designed to evaluate whether or not infants in day care develop

lower respiratory tract infections more frequently than infants who do not
attend day care. 500 infants less than 1-year-old who attend day care are
selected to participate in the study. 500 infants less than 1-year-old who do
not attend day care are selected as matched controls. The infants are followed
for 1 year and the rate of lower respiratory tract infections is determined
between the two groups. Infants who attend day care are found to develop
lower respiratory tract infections 1.8 times more frequently than the matched
controls. What type of study is this?
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A.

Double-blinded placebo controlled study

718

asdf

B.

Case-control study

C.

Cohort study

D.

Cross sectional study

Case study

E.

Explanation Hide Explanation

Choice (C) is the correct answer. A cohort study involves selecting patients based on the
presence or absence of a risk factor or exposure. In this case, the risk factor is day care. The two
groups are followed through time, and the incidence of disease, in this case lower respiratory
infection, is determined in the two groups. The groups are then compared to see if there is an
association between the risk factor and the development of disease. Double-blinded placebo
controlled studies (Choice A) are the best studies for studying drugs. For example, say drug X is
a new drug for depression. One group with depression would get the actual drug X to treat
depression, and a second matched group with depression would get a placebo pill. Neither the
study subjects nor the investigators know who is receiving drug X or placebo. At the end of the
study period, the improvement in depression in the group who received drug X is compared to
the improvement in depression in the placebo group. In case-control studies (Choice C), study
subjects are selected based on the presence (cases) or absence of disease (controls). Investigators
then look retrospectively to see if the two groups were exposed to a certain risk factor. In casecontrol studies, relative risk cannot be used to quantify risk, since the incidence of the disease is
unknown. Disease incidence is unknown, because subjects are selected based on whether or not
they have the disease. The odds ratio must be used instead. A cross-sectional study (Choice D),
also known as a prevalence study, takes a snapshot of a population at any given time and assesses
both disease prevalence and exposure simultaneously. A case study (Choice E) is an analysis of a
single event or case. Case studies are non-comparative studies and are often used for generating
hypotheses rather than testing hypotheses.

9)

An epidemiologist is evaluating data on a screening test for HIV. A useful

screening test would have a negative likelihood ratio closest to which of the
following?
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706

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A.

B.

C.

D.

5
100

E.

asdf

Explanation Hide Explanation

Choice (A) is the correct answer. The negative likelihood ratio is defined as the ratio of the
false negative rate to the true negative rate. The false negative rate equals (1 - sensitivity), and
the true negative rate is equal to specificity. The negative likelihood ratio can therefore be
calculated using the formula (1 - sensitivity) / specificity. The negative likelihood ratio represents
the odds ratio of infected individuals with negative screening tests (false negatives) to uninfected
individuals with a negative screening test (true negatives). A good screening test has a negative
likelihood ratio close to zero.

10)

A screening test for disease X has a sensitivity of 90% and a specificity of

80%. Disease X has a prevalence of 4% in the population. Suppose the
disease prevalence increases to 6%. What effect will an increase in disease
prevalence have on the screening test for disease X?
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720

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NO

A.

Increased sensitivity

B.

Decreased specificity

C.

Decreased positive predictive value

D.

Increased positive likelihood ratio

Decreased negative predictive value

E.

Explanation Hide Explanation

Choice (E) is the correct answer. Sensitivity, specificity, and likelihood ratios are independent
of disease prevalence. Predictive values, however, do change with disease prevalence. As disease
prevalence increases, the positive predictive value of a screening test increases. Positive
predictive value can best be summarized as, "Of those who test positive, those who have the
disease." In other words, the positive predictive value is equal to (true positives) / (true positives
+ false positives). Negative predictive value, on the other hand, decreases as disease prevalence
increases. Negative predictive value can best be described as, "Of those who test negative, those
who do not have the disease." Mathematically, the negative predictive value is defined as (true
negatives) / (true negatives + false negatives). The other choices are incorrect.

11)

A 62-year-old woman presents to the emergency room with the sudden onset

of weakness on the right side of her body. Physical exam is significant for a
dense right hemiplegia. At CT angiogram of the cerebral vascular shows a
large clot in the left middle cerebral artery. Thrombolytic therapy is promptly
initiated. Suppose that thrombolytic therapy increases the risk of intracranial
hemorrhage from 0.2% to 1%. How many patients would have to be treated
with thrombolytics before causing an intracranial hemorrhage?
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NO

A.

50

B.

75

C.

100

D.

125

E.

150

F.

175
200

G.

Explanation Hide Explanation

Choice (D) is the correct answer. The number need to harm (NNH) is calculated by taking the
reciprocal of the absolute risk increase. In this case, thrombolytic therapy raises the risk of an
intracranial hemorrhage from 0.2% to 1%. The absolute risk increase is therefore 1 - 0.2 = 0.8%.
There is a 0.8% absolute risk increase in intracranial hemorrhage with the use of thrombolytics.
To calculate the number needed to harm, take the reciprocal of 0.8%, which equals 1 / 0.008 =
125. What this means is that 125 patients must be treated with thrombolytics before causing 1
intracranial hemorrhage. The other choices are incorrect.

12)

A group of 10,000 cigarette smokers are followed prospectively for 20 years.

Of the 10,000 smokers, 2,000 develop lung cancer. A matched control group
of 10,000 non-smokers is also followed prospectively during the same time
period. 200 non-smokers in the control group develop lung cancer within the
20 year period. What is the relative risk of developing lung cancer if you
smoke?
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702

NO

A.

0.1

B.

0.2

asdf

C.

0.6

D.

E.

F.

10
15

G.

Explanation Hide Explanation

Choice (F) is the correct answer. Relative risk is defined as the ratio of exposed individuals
who develop the condition divided by unexposed individuals who develop the condition. In this
example, cigarette smoking is the exposure, and lung cancer is the condition. The risk of
developing lung cancer in the exposed group is 2000 / 10,000 which equals 0.20 or 20 percent.
The risk of developing lung cancer in the unexposed group is 200 / 10000 which equals 0.02 or 2
percent. 20% / 2% = 10. The relative risk is equal to 10. This means that smokers have a 10-fold
increased risk of developing lung cancer compared to non-smokers. A 2 x 2 table is shown
below:

13)

A group of researchers is testing a new diagnostic test for HIV. 100 patients
with known HIV infection underwent testing with the new diagnostic test. Of
the 100 HIV-infected patients, 95 had a positive test, while 5 had a negative
test. A second group of 100 known HIV negative patients also underwent
testing with the new diagnostic test. Of the 100 HIV negative patients, 92 had
a negative test, while 8 had a positive test. What is the likelihood ratio of a
negative test?

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A.

95 / (95 + 5)

B.

92 / (92 + 8)

C.

[5 / (5 + 95)] / [92 / (92 + 8)]

D.

[95 / (95 + 5)] / [8 / (8 + 92)]

E.

92 / (92 + 5)
95 / (95 + 8)

F.

Explanation Hide Explanation

Choice (C) is the correct answer. The likelihood ratio of a negative test is equal to the false
negative rate divided by the true negative rate. The false negative rate is equal to (1 - sensitivity),
and the true negative rate is the same as the specificity. The likelihood ratio of a negative test can
therefore be calculated if the sensitivity and specificity are known using the following equation:
Negative likelihood ratio = (1 - sensitivity) / (specificity). The likelihood ratio of a negative test
can be interpreted as the ratio of infected individuals with a negative test (false negative rate)
compared to uninfected individuals with a negative test (true negative rate or specificity). A
useful screening test will have a negative likelihood ratio close to zero, which is good for ruling
out disease. (Choice A) represents the sensitivity. Screening tests with high sensitivities are
useful for ruling out disease. (Choice B) represents specificity. Confirmatory tests have a high
specificity and are useful for ruling in disease. (Choice D) is the likelihood ratio of a positive test
and is defined as the true positive rate divided by the false positive rate. In other words, the
positive likelihood ratio = sensitivity / (1 - specificity). The positive likelihood ratio tells us the
odds of an individual with the condition having a positive test compared to uninfected
individuals having a positive test. (Choice E) represents the negative predictive value. (Choice F)
represents the positive predictive value. Both positive predictive value and negative predictive
value change with disease prevalence. Sensitivity and specificity do not change with disease
prevalence.

14)A medical student is studying the likelihood ratios of a particular

screening test. Which of the following would be characteristic of the
likelihood ratio of a positive test (LR+) in a useful screening test?
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A.

A useful screening test would have an LR+ with a large positive value

B.

A useful screening test would have an LR+ equal to one.

C.

A useful screening test would have an LR+ equal to zero.

D.

A useful screening test would have an LR+ with a large negative value

Explanation Hide Explanation

Choice (A) is the correct answer. The likelihood ratio of a positive test result (LR+) is defined
as (sensitivity) / (1 - specificity) and tells us the odds of someone with the disease having a
positive test compared to someone without the disease having a positive test. In other words, the
LR+ is the true positive rate divided by the false positive rate. Useful screening tests have a
large, positive LR+.

15)

An African community with a population of 10,000 people has a 5%

prevalence of HIV. A screening test for HIV has a 98% sensitivity and 95%
specificity. If the prevalence of HIV doubles in the community, how will the
sensitivity and positive predicted value (PPV) of the screening test be
affected?
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NO

A.

Increased sensitivity; Increased PPV

B.

Increased sensitivity, Decreased PPV

C.

Increased sensitivity; No change in PPV

D.

Decreased sensitivity; Increased PPV

E.

Decreased sensitivity; Decreased PPV

F.

No change in sensitivity; Increased PPV

No change in sensitivity; Decreased PPV

G.

Explanation Hide Explanation

Choice (F) is the correct answer. The sensitivity and specificity of a screening test do not
change with changes in disease prevalence. Positive predictive value is proportional to disease
prevalence: as prevalence increases so does the positive predictive value. As prevalence
decreases, positive predictive value decreases. Negative predictive value, on the other hand, is
inversely proportional to disease prevalence: as disease prevalence increases, negative predictive
value decreases. As disease prevalence decreases, negative predictive value increases.

16)

A group of researchers has designed a study to determine whether or not

pesticide use among farmers is associated with an increased risk of cancer.
100 farmers with known pesticide exposure are followed for 10 years. 100
organic farmers with no pesticide exposure are followed for ten years. At the
end of 10 years, it is determined that 12 of the farmers with pesticide
exposure developed cancer compared to 4 of the organic farmers with no
pesticide exposure. What type of study is this?
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NO

A.

Case-Control study

B.

Cohort study

C.

Cross-sectional study
Case Study

D.

Explanation Hide Explanation

Choice (B) is the correct answer. In a cohort study, two groups are selected based on exposure.
In this example, one group has been exposed to pesticides and the other has not. The two groups
are followed over time and the incidence of disease, in this case cancer, is determined. A casecontrol study (Choice A) involves starting with two groups, one with the disease of interest
(cases) and a second group of controls. Exposure is then determined among the two groups to
determine if there is a relationship between exposure and disease development. A cross-sectional
study (Choice C), also known as a prevalence study, takes a snapshot of a population at any
given time and assesses both disease prevalence and exposure simultaneously. A case study
(Choice D) is an analysis of a single event or case. Case studies are non-comparative studies and
are often used for generating hypotheses rather than testing hypotheses.

17)

In a case-control study, 100 women with known metastatic breast cancer and
100 matched controls without breast cancer are polled and asked if they were
ever exposed to estrogen. In the breast cancer group, 55 women stated that
they had been exposed to estrogen, while 45 women had not. In the control
group, 50 women stated that they had been exposed to estrogen, while the
other 50 women had not. What is the relative risk of developing breast cancer
if exposed to estrogen?
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NO

A.

(55 / 105) / (45 / 95)

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704

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B.

(55 x 50) / (45 x 50)

C.

55 / (55 + 45)

D.

50 / (50 + 50)
Cannot be calculated

E.

Explanation Hide Explanation

Choice (E) is the correct answer. In case-control studies, the population is selected based on
whether or not individuals have the condition. In this case, 100 women were selected with
metastatic breast cancer (cases) along with 100 matched controls without breast cancer
(controls). Case-control studies then look retrospectively to see if the population was exposed to
a certain risk factor, in this case estrogen. Case-control studies try to find an association between
exposure and the development of disease. Since case-control studies start with cases (those with
the condition) and controls (matched controls without the condition), information about disease
prevalence is unknown. As a result, relative risk cannot be used as a calculation in case-control
studies. Instead, the odds ratio is used to calculate the ratio of the odds that cases were exposed
to the odds that controls were exposed. (Choice B) is the calculation for the odds ratio. The other
choices are incorrect.

18)

In a group of 100 patients with known occupational asbestos exposure, 9

developed malignant mesothelioma. In a matched control group of 100
patients without asbestos exposure, 1 patient developed malignant
mesothelioma. What is the attributable risk of asbestos exposure?
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NO

A.

1%

B.

2%

C.

3%

D.

5%

E.

8%

F.

9%
10%

G.

Explanation Hide Explanation

Choice (E) is the correct answer. Attributable risk is defined as the incidence of disease in the
exposed group (9 / 100) minus the incidence of disease in the unexposed group (1 / 100). This

results in an attributable risk of 8 / 100 or 8%. What this means is that 8% of cases of malignant
mesothelioma are due to asbestos exposure. The other choices are incorrect.

19)

Investigators are developing a new diagnostic test for HIV. 50 patients with
known HIV are tested with the new test. 50 known HIV negative patients are
also tested as controls. The test results are shown in the diagram below. What
is the positive predictive value of the test?

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NO

A.

47 / 50

B.

49 / 50

C.

49 / 52

D.

47 / 48

E.

3 / 50
1 / 50

F.

Explanation Hide Explanation

Choice (D) is the correct answer. Positive predictive value can best be summarized as, "Of
those who test positive, those who have the disease." In this case, a total of 48 patients tested
positive for HIV (47 + 1). Of those, 47 are true positives, so the positive predictive value is
47/48. The other choices refer to the following: 47/50 (Choice A) describes the test sensitivity. 49
/ 50 (Choice B) is the test specificity. 49 / 52 (Choice C) is the negative predictive value. 3 / 50
(Choice E) is the false negative rate. 1 / 50 (Choice F) is the false positive rate.

20)

A patient is considered diabetic if a fasting blood glucose level is greater than

or equal to 126 mg/dl. Suppose the cutoff value for diagnosing diabetes is

increased to 136 mg/dl. What effect will this have on the fasting blood
glucose screening test?
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NO

A.

Increased sensitivity

B.

Decreased specificity

C.

Increased negative predictive value (NPV)

D.

Increased positive predictive value (PPV)

Increased incidence of diabetes

E.

Explanation Hide Explanation

Choice (D) is the correct answer. Increasing the cutoff value of the fasting blood glucose
screening test for diabetes results in an increase in positive predictive value, a decrease in
negative predictive value, a decrease in sensitivity, and an increase in specificity. Shifting the
cutoff to 136 mg/dl from 126 mg/dl results in an increase in the number of false negatives. An
increase in false negatives results in decreased test sensitivity and a decreased negative
predictive value. In addition, as the screening test cutoff value is raised, the number of false
positives decreases, resulting in an increase in specificity and positive predictive value. The other
choices are incorrect.

21)

A new screening test is being developed for disease X. The graph below
represents the screening test results for a particular population. The blue line
represents individuals without disease X, while the red line represents
individuals affected with disease X. The screening test results lie on a
continuum. Points A, B, C, D, E, and F represent different cutoff points for
the screening test. Points lying to the right of the cutoff indicate a positive
screening test for disease X. Points to the left of the cutoff indicate a negative
screening test for disease X. Which cutoff point would result in the screening
test having a 100% sensitivity?

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707

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NO

A.

Point A

B.

Point B

C.

Point C

D.

Point D

E.

Point E
Point F

F.

Explanation Hide Explanation

Choice (A) is the correct answer. Sensitivity is defined as (true positives) / (true positives +
false negatives). As the sensitivity of a screening test increases, the number of false negatives
decreases. In addition, sensitivity is inversely related to specificity. In other words, as sensitivity
increases, specificity decreases. In the graph shown, as the screening test cutoff point is shifted to
the left, the number of false negatives decreases. At point A, there is a 100% sensitivity, because
there are no false negatives. The specificity decreases as the cutoff point is shifted to the left,
because the number of false positives increases. The other choices are incorrect.

22)

1000 adults are selected randomly to participate in an intelligence test. The

test is scored between 1 and 200 with a mean score of 100 and a standard
deviation of 15. The scores of the 1000 adults has a normal, Gaussian
distribution. How many of the adults scored between 100 and 115 on the
intelligence test?
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722

NO

A.

220

asdf

B.

340

C.

400

D.

500
680

E.

Explanation Hide Explanation

Choice (B) is the correct answer. Normal Gaussian distribution occurs as a bell-shaped curve
with the mean in the middle of the curve. 68% of the population lies within 1 standard deviation
above and below the mean. This means that 34% of the population lies within 1 standard
deviation above the mean, and 34% of the population lies 1 standard deviation below the mean.
The question is asking how many adults scored within 1 standard deviation above the mean. 34%
of 1000 is 340 adults. The other choices are incorrect.

23)

A screening test for disease X has a sensitivity of 96%, a specificity of 98%, a

positive predictive value of 70%, and a negative predictive value of 82%.
What is the false positive rate of the screening test?
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703

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NO

A.

2%

B.

4%

C.

6%

D.

8%

E.

12%
30%

F.

Explanation Hide Explanation

Choice (A) is the correct answer. The false positive rate is equal to (1 - specificity) which
equals 2% in this example. Specificity is also known as the true negative rate and can be
described as the number of individuals without the condition who test negative for the condition.
Individuals without the condition who have a positive screening test are known as false positives.
A screening test with a high specificity has a low false positive rate. In this example, the
specificity is 98%, so the false positive rate is (1 - 0.98) = 0.02 or 2 %. The false positive rate is
therefore 2%. The other choices are incorrect.

24)

A group of researchers is developing a rapid screening test for hepatitis C. A

useful screening test would have which of the following characteristics?
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NO

A.

High positive predictive value

B.

Low negative predictive value

C.

Low positive likelihood ratio (LR+)

D.

High sensitivity
Low specificity

E.

Explanation Hide Explanation

Choice (D) is the correct answer. Sensitivity is defined as (true positives) / (true positives +
false negatives). A useful screening test has a high sensitivity with a low false negative rate. A
screening test with a high sensitivity is useful in ruling out disease. Confirmatory tests with a
high specificity are useful for ruling in disease. The other choices are incorrect.

25)

A drug company publishes an original study stating that Drug X does not
cause birth defects in pregnant women. Later, it is discovered that Drug X
does actually cause birth defects. The original study most likely contained
which type of error?
7175

710

25

asdf

710

asdf

NO

A.

Type I error

B.

Type II error

C.

(1 beta) error

D.

Delta error
Kappa error

E.

Explanation Hide Explanation

Choice (B) is the correct answer. Type II or beta error results from failure to reject the null
hypothesis when the null hypothesis is actually false. In other words, the null hypothesis is
accepted for reality when indeed the null hypothesis is incorrect. The null hypothesis is the
hypothesis that states there is no association between a risk factor and a particular disease or

condition. In the drug company study, the null hypothesis states that there is no association
between Drug X and birth defects in pregnant women. The alternative hypothesis states that there
is an association between Drug X and birth defects. As stated above, type II error involves the
failure to reject the null hypothesis when the null hypothesis is false. Failure to reject is the same
as accepting: the null hypothesis is accepted although it is false. In other words, the hypothesis
that Drug A does not cause birth defects is accepted even though in reality Drug A does cause
birth defects. Type I error (Choice A) is known as alpha error and results from rejecting the null
hypothesis when it is actually true. Rejecting the null hypothesis is same as accepting the
alternative hypothesis. Concluding that Drug X is not safe when it really is would be considered
type I error. (1 - beta) (Choice C) is known as power. Delta error (Choice D) and kappa error
(Choice E) are distractors.

The prevalence of HIV in an African community is 25%. The pretest odds of

having HIV in this community is equal to which of the following?
7175

717

26

asdf

717

asdf

NO

A.

1:2

B.

1:3

C.

1:4

D.

1:5
1:6

E.

Explanation Hide Explanation

Choice (B) is the correct answer. The prevalence is equal to the pretest probability and must be
converted to odds to determine the pretest odds. Probabilities are converted to odds using the
formula odds = (probability) / ( 1 - probability). In this case, the pretest odds = (0.25) / (1 - 0.25)
= 0.33 = 1:3. The pretest odds can be multiplied by the positive likelihood ratio (LR+) of a
particular diagnostic test to determine the post-test odds. The LR+ is derived from the sensitivity
and specificity of the diagnostic test and equals the following: LR+ = (sensitivity) / (1 specificity). The other choices are incorrect.

27)In a study of 10,000 adult males in the United States over 65 years of age,
the average total cholesterol was found to be 210 mg/dl with a standard
deviation of 10. What is the standard error?
7175

724

27

asdf

724

NO

A.

0.01

asdf

B.

0.1

C.

D.

E.

10
100

F.

Explanation Hide Explanation

Choice (B) is the correct answer. Standard error, also known as the standard error of means
(SEM) is defined as the standard deviation of the sampling distribution and is calculated by
dividing the standard deviation by the square root of the sample size. In this example, the
standard deviation is 10, and the sample population is 10,000. 10 divided by the square root of
10,000 equals 0.1. The standard error is equal to 0.1. Increasing the sample size decreases the
standard error. The other choices are incorrect.

28)A laboratory technician is testing a new piece of equipment that calculates

a patient's hemoglobin from a drop of blood. 5 drops of blood are submitted
by a patient, and the machine returns hemoglobin values of 9.6 g/dl, 9.6 g/dl,
9.7 g/dl, 9.8 g/dl, and 9.8 g/dl. The patients actual hemoglobin concentration
is determined to be 13.0 g/dl by the gold standard test. The new piece of
equipment can be described as which of the following?
7175

709

28

asdf

709

asdf

NO

A.

Accurate and precise

B.

Accurate but not precise

C.

Precise but not accurate

Neither accurate nor precise

D.

Explanation Hide Explanation

Choice (C) is the correct answer. Precision can best be described as reproducibility, while
accuracy is a measure of closeness to the actual result. In this case, all 5 hemoglobin values are
clustered on or around 9.6 g/dl, indicating a reproducible or precise result. The actual
hemoglobin value is 13.0 g/dl, which is significantly different from 9.6 g/dl. This indicates that
the piece of equipment is not accurate in determining hemoglobin concentration. Therefore, the
new piece of laboratory equipment can best be described as precise but not accurate. The other
choices are incorrect.

29)

Medication X is being studied for its efficacy in reducing fractures in elderly

women. A double-blinded placebo controlled study is conducted over 12
months. 100 women aged 67 are allocated to the treatment group and are
given medication X over the 12 month time period. 100 women aged 67 are
allocated to the control group and receive placebo for 12 months. Over the 12
months, 5 fractures were found in the treatment group compared to 15
fractures in the control group. What number of 67-year-old women would
need to be treated with medication X to prevent 1 fracture over 12 months?
7175

75

29

asdf

75

asdf

NO

A.

B.

C.

10

D.

50
60

E.

Explanation Hide Explanation

Choice (C) is the correct answer. Number needed to treat is defined as the reciprocal of the
absolute risk reduction. Absolute risk reduction is defined as the difference in the rate of an event
in the control group minus the rate of an event in the treatment group. In this example, the
treatment group is the group receiving medication X, and the control group is the group receiving
placebo. The event being measured is the number of fractures over a 12 month period. The rate
of fractures in the treatment group is 5/100, and the rate of fractures in the control group is
15/100. So, (15/100) - (5/100) = 10/100 or 10%. The reciprocal of 10% is 1/0.1 = 10, which is
the number needed to treat. In other words, 10 women aged 67 would have to be treated with
medication X over 12 months to prevent 1 fracture. These types of problems are best approached
with the use of a two x two table, which is shown:

30)

A statistician is reviewing a double-blinded placebo control study for type I

error. Which of the following statements best describes type I error?
7175

711

30

asdf

711

asdf

NO

A.

Failure to reject the null hypothesis when it is false

B.

Rejecting the null hypothesis when it is true

C.

Accepting the alternative hypothesis when it is true.

D.

Accepting the null hypothesis when it is true

Rejecting the null hypothesis unconditionally

E.

Explanation Hide Explanation

Choice (B) is the correct answer. Type I error is known as alpha error and results from rejecting
the null hypothesis when it is actually true. Rejecting the null hypothesis is same as accepting the
alternative hypothesis. The dia

gram below illustrates the concept of error: