Internal Medicine Questions 2

1. Internal Medicine Questions 2

2. Colorectal Cancer: Trends in Screening Prevalence, Incidence, and Mortality • Screening continues to rise while new CRC cases and deaths continue to fall. • The latest data on colorectal cancer (CRC) screening prevalence, incidence, and mortality in the U.S. population are now available. To evaluate trends over time, researchers compiled data from the Behavioral Risk Factor Surveillance System (BRFSS; a telephone-based health survey in the U.S.) and state-specific incidence and mortality data. • BRFSS survey data were utilized to estimate the prevalence of CRC screening. In 2010, 236,186 individuals aged 50 to 75 responded to the BRFSS survey. Every 2 years since 2002, respondents aged 50 have been asked whether they have ever used a fecal occult blood test (FOBT) kit or have ever received a screening endoscopy, and, if so, how long ago. Self-reported use of FOBT within 1 year or endoscopy within 10 years was considered current receipt of CRC screening. Incidence and mortality data in the U.S. were respectively obtained from cancer registries and death certificates. • The prevalence of CRC screening overall increased from 52.3% in 2002 to 65.4% in 2010, and FOBT use declined from 21.1% to 11.8%. From 2003 to 2007, CRC incidence and mortality declined by 13% and 12%, respectively — representing 66,000 fewer new CRC cases and 32,000 fewer CRC deaths than expected during that period compared with 2002. CRC incidence decreased in 35 states, and mortality decreased in 49 states and the District of Columbia. The biggest reductions in incidence and mortality typically occurred in states with the highest screening rates. • Comment: These findings add to recent encouraging evidence regarding colorectal cancer incidence (JW Gastroenterol Jan 15 2010). The authors recommend development of individual state-based programs to enhance screening service delivery systems and further increase adherence.

3. PPIs Are the Most Effective Drugs to Reduce Risk for Upper GI Bleeding • Proton-pump inhibitors bested histamine-2–receptor antagonists and nitrates in patients taking gastrotoxic drugs and in the general population. • Multiple studies have demonstrated the ability of proton-pump inhibitors (PPIs) to reduce the risk for upper gastrointestinal bleeding (UGIB) in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or clopidogrel. To determine if this effect is also seen in general practice, investigators conducted a nested, case-control study involving 2049 patients with UGIB and 20,000 age- and sex-matched controls who were identified in The Health Improvement Network UK primary care database between 2000 and 2007. Records were reviewed to determine the use of drugs that increase the risk for UGIB as well as the use of acid-reduction therapy with PPIs, histamine-2–receptor antagonists (H2RAs), or nitrates. • Current PPI use for >1 month versus nonuse was associated with a reduction in UGIB in the general population (relative risk, 0.80; 95% confidence interval, 0.68–0.94) and in patients taking low-dose aspirin, clopidogrel, both aspirin and clopidogrel, warfarin, and NSAIDs (RR, 0.58; 95% CI, 0.42–0.79). No significant effect was seen in patients taking cyclooxygenase-2 inhibitors or steroids. The impact of H2RAs on the incidence of UGIB was smaller than that of PPIs and was significant only for patients taking NSAIDs. Nitrate use had no effect on the risk for UGIB in the general population or in gastrotoxic drug users. • Comment: This study adds 2 years of follow-up to a prior report that used the same database. The effectiveness of PPI therapy to reduce risk for UGIB in patients taking gastrotoxic drugs confirms results from prior randomized trials. That PPI use reduces the risk for UGIB in the general population suggests that some confounding risk factors for bleeding that are affected by PPI therapy remain unidentified in the current analysis. One of these might be Helicobacter pylori infection, which was not consistently reported. The relatively limited reduction in UGIB with H2RA use is also consistent with other randomized trials, showing that these drugs are not as effective in preventing UGIB. The broad confidence intervals seen in the study suggest that it might have been underpowered to identify a small, but significant effect of H2RAs on bleeding risk. Nonetheless, PPIs seem to be the most effective drugs to prevent UGIB in patients at risk.

4. Helicobacter pylori Therapy in Latin America: Triple-Drug Regimen Still Best • Standard 14-day triple-drug therapy — despite its suboptimal eradication rate — was more effective than shorter-duration concomitant or sequential four-drug regimens. • Helicobacter pylori eradication rates with standard triple therapy are decreasing in Europe and Asia because of antibiotic resistance. Little research has been done to determine the optimal therapeutic regimen in Latin America, where H. pyloriinfection is endemic and antibiotic resistance patterns might be different. Now, investigators have conducted an open trial at seven sites in Latin America to compare the effectiveness of three treatments. • Potentially eligible adults were recruited from the general population; H. pylori infection was confirmed using a urea breath test. A total of 1463 participants were randomized to receive one of three therapy regimens using generic drugs: • Standard (14 days of triple therapy with lansoprazole, amoxicillin, and clarithromycin) • Concomitant (5 days of lansoprazole, amoxicillin, clarithromycin, and metronidazole) • Sequential (5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and metronidazole) • Assessment with a second urea breath test 6 to 8 weeks after randomization showed that the standard-therapy group had the highest eradication rate (82.2%), followed by the sequential- and concomitant-therapy groups (76.5% and 73.6%, respectively). These results did not vary significantly by study site, sex, age, or presence of chronic dyspeptic symptoms. The authors concluded that standard 14-day triple therapy is currently the preferred empirical treatment for H. pylori infection in Latin America. • Comment: This study was undertaken with the aim of possible population-based H. pylori eradication to decrease the incidence of gastric cancer in the region. The authors hypothesized that concomitant or sequential therapy would be at least as effective as standard therapy and would provide a less -expensive alternative. However, the alternative approaches proved inferior to standard therapy, perhaps because antibiotic exposure and resistance are less common in Latin America than in previous study sites. It is important to note that even the standard therapy had a poor eradication rate (82.2%). Further study is needed to evaluate the feasibility and advisability of empirical population-based H. pylori eradication efforts. The study does not assess the frequency of recrudescence and reinfection. Authors and an editorialist note the lack of definitive evidence that mass treatment would reduce incidence of gastric cancer. The editorialist also cautions about potential consequences of population-wide treatment, including adverse drug reactions and antibiotic resistance of H. pylori and other bacteria.

5. Sunscreen Is Expensive • Sun-protective clothing and bulk buying can help reduce the cost. • Skin cancer incidence is rising in the Western world. Ultraviolet (UV) radiation is a known carcinogen and sun-protection strategies, including sunscreen use, have long been advocated. However, many individuals fail to use sunscreen adequately. Sunscreen cost may contribute to poor compliance. • Investigators performed a cost analysis study of sunscreen needs in two scenarios: a family of four on a 1-week beach vacation (4 hours/day in the sun, females in bikinis, males in swim trunks, reapplying sunscreen twice for adults and 3 times for children, no other sun-protective measures taken), and a transplant patient using sunscreen year round. • The researchers evaluated costs of 607 sunscreens from 17 Internet drugstores in seven countries (Europe and North America). Median sunscreen price was US$1.70 per 10 g. Assuming that standard sunscreen application recommendations (2 mg/cm2) were followed, the median cost to the family varied from $178.20 per week (if children were 2-year-olds) to $238.40 per week (if children were 10-year-olds). The cost decreased by 33% if the family wore UV-protective T-shirts and by 41% if large-volume bottles were used (price per gram was less for larger bottles) — both strategies combined produced a 58% decrease in cost. The median cost to the transplant patient varied from $245.30 to $292.30 per year. • The authors conclude that the cost of sunscreen for a weeklong vacation seems acceptable if sun-protective clothing is worn and larger-bottle sunscreens are purchased. Conversely, for sun-sensitive individuals requiring year-round protection, the annual cost is relatively high, and patients may require financial assistance to be compliant. • Comment: Sun-protection behaviors are complex, but there is no doubt — sunscreen is expensive. Buying in bulk and wearing sun-protective clothing greatly decreases sunscreen cost. A sun-protective shirt also offers better protection than sunscreen alone during water sports — very few individuals will interrupt their activity every 1 to 2 hours to reapply sunscreen. In addition, sun-protective shirts and hats can last more than one summer, making them money savers in the long run.

6. Cranberries vs. TMP-SMX to Prevent Urinary Tract Infections • Trimethoprim-sulfamethoxazole was better, at the expense of greater antibiotic resistance. • Premenopausal women who experience recurrent urinary tract infections (UTIs) are sometimes prescribed low-dose antibiotic prophylaxis. Growing concern about antibiotic resistance, coupled with many patients' desire for nonpharmacologic remedies, has led to renewed interest in cranberry consumption for UTI prophylaxis. The presumed mechanism is prevention of bacterial adhesion to uroepithelial cells by proanthocyanidins, a constituent of cranberries. • In a double-blind study, Dutch investigators randomized 221 women (median age, 35) who reported having a median of 6 to 7 UTIs in the previous year to receive either cranberry extract (500 mg twice daily) or trimethoprim-sulfamethoxazole (TMP-SMX; 480 mg nightly). During 12 months of treatment, cranberry-extract recipients had a mean of 4 symptomatic UTIs compared with a mean of 1.8 in the TMP-SMX group — a significant difference; the median time to first recurrence was 4 months in the cranberry group and 8 months in the antibiotic group. Adverse events did not differ between groups, but the dropout rate was about 50% in both. • Comment: Whereas cranberry extract recipients had fewer UTIs than they did in the preceding year, TMP-SMX was more effective. However, antibiotic resistance to TMP-SMX developed in >85% ofEscherichia coli strains in women taking the antibiotic, compared with <30% in those taking cranberry extract. Unfortunately, cranberry juice was no better than placebo for preventing UTIs in a recent study (JW Gen Med Jan 20 2011); whether cranberry or one of its constituents ultimately will prove to be clinically useful remains unclear.

7. Regular Updates of Family History Can Change Cancer Screening Recommendations • Updates are recommended every 5 to 10 years. • Family history of cancer can influence screening recommendations, particularly for colorectal, breast, and prostate cancers. Little is known about the value of regular updates of family history. Researchers used a U.S. population-based registry of people with personal or family histories of cancer to assess changes in family cancer history retroactively (from birth to study enrollment in about 12,000 people) and prospectively (from enrollment for a median of 8 years in a subset of about 2000 people). • Clinically relevant family history that would influence screening recommendations increased with age for all three evaluated cancers. For example, as patients aged from 30 to 50, 5% had clinically significant changes in family histories of colorectal cancer, and 4% had changes for breast cancer. Roughly 2 to 4 per 100 women would have clinically significant changes in family histories in each age decade (20–29, 30–39, and 40–49), based on both retrospective and prospective assessments. • Comment: The full study provides additional helpful information, but the main point is that clinically significant changes in a patient's family history of cancer occur with sufficient frequency that clinicians should update family history on a regular basis — the authors recommend every 5 to 10 years — particularly between the ages of 30 and 50. Once elevated risk has been identified, the challenge then is to overcome the many barriers to appropriate screening.

8. Physical Activity and Cognitive Health, Revisited • Rx: 30 minutes of brisk walking daily to maintain cognition despite vascular risk factors • Cerebrovascular disease risk factors are known to be associated with cognitive decline. Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. To assess the effect of physical activity on cognition in the setting of cerebrovascular disease, researchers conducted a retrospective subgroup analysis of more than 2800 female health professionals (age 65) with at least three vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. The cognitive evaluation was conducted via telephone; 81% of the respondents completed at least three assessments at 2-year intervals. All instruments were previously validated. • Women in the two highest quintiles of physical activity level — equivalent to brisk walking 30 minutes daily — had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the two highest quintiles of physical activity were cognitively 5 to 7 years "younger" than those in the lowest quintile. A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit. • Comment: This analysis adds to a growing body of literature emphasizing the role of physical exercise throughout the life span as an important modifiable risk factor in maintaining cognitive health, even in the context of cerebrovascular risk factors. Although the self-report of physical activity is a potential confounder in this study, another study published in the same journal issue used an objective measure of energy expenditure and showed similar results in a mixed-sex cohort (Arch Intern Med 2011; 171:1251). On the basis of the accumulating evidence correlating physical exercise with cognitive health, a prescription for a daily walk should quite literally be "just what the doctor ordered."

9. ABCD2 Score Might Be Poor Predictor of Stroke Risk • Sensitivity of the score was poor in a cohort of emergency department TIA patients with a 1.8% incidence of stroke at 7 days. • The ABCD2 score (Age, Blood pressure [BP], Clinical features,Duration of symptoms, and Diabetes) was developed to predict which patients with transient ischemic attack (TIA) might be at high risk for stroke, but it has not been prospectively validated in a large study. In this prospective, multicenter Canadian study, researchers assessed the accuracy of the ABCD2 score in 2056 patients (mean age, 68) with emergency department diagnoses of TIA or minor stroke. • Physicians completed ABCD2 data forms and calculated the score for each patient. (The score assigns 1 point each for age 60, BP 140/90 mm Hg, impaired speech without weakness, duration of symptoms 10–59 minutes, and diabetes and assigns 2 points each for unilateral weakness and duration of symptoms 60 minutes.) • The overall incidence of stroke at 7 days was 1.8%. An ABCD2 score >5 had a sensitivity of 32% and a specificity of 87% for predicting stroke at 7 days. At the American Heart Association recommended score cutoff of >2, sensitivity increased to 95% but specificity dropped to 13%. • Comment: In this study, no ABCD2 score cutoff reliably predicted TIA patients at risk for stroke. A cutoff of >5 missed too many at-risk patients. Use of a lower cutoff improved sensitivity, but the reduced specificity would lead to testing many patients who are not at risk. In this population with a 1.8% overall incidence of stroke at 7 days, the ABCD2 score was not an accurate screening tool.

10. When LP Is Not Necessary to Detect Subarachnoid Bleed • CT performed within 6 hours of symptom onset in neurologically intact patients had 100% negative predictive value in this prospective multicenter study. • Standard teaching is that lumbar puncture (LP) is essential in patients with suspected subarachnoid hemorrhage (SAH) despite normal head computed tomography (CT) scans. Researchers prospectively enrolled 3132 consecutive neurologically intact patients older than 15 who underwent head CT with third-generation multislice scanners to evaluate nontraumatic acute headache or headache with syncope at 11 tertiary emergency departments in Canada from 2000 to 2009. LP was performed at the discretion of the treating physician. Experienced radiologists who were blinded to the study interpreted all CT scans. SAH was defined by subarachnoid blood on CT, aneurysm on cerebral angiography, or xanthochromia in cerebrospinal fluid. • Mean headache peak pain severity was 8.7 on a 0–10 scale. LP was performed in 49% of patients after negative CT scans. Overall, 240 patients (7.7%) were diagnosed with SAH. The sensitivity of head CT for SAH was 92.9%, and the negative predictive value (NPV) was 99.4%. Emergency physicians identified all but three cases of SAH; all three patients were scanned >6 hours after headache onset. Among 953 patients who were scanned within 6 hours of symptom onset, head CT had 100% sensitivity and 100% NPV. Follow-up at 1 and 6 months did not identify any cases of missed SAH. • Comment: Because subarachnoid blood diffuses and hemolyzes within hours, CT might not be able to distinguish cerebrospinal fluid from blood as time passes. Patients with histories that raise concern for SAH should be prioritized to undergo CT within 6 hours of symptom onset. If CT is performed with a modern scanner and is interpreted as negative for SAH by an experienced radiologist, LP is unnecessary, unless it is being performed to detect other causes of headache.

11. Safety of Attention-Deficit/Hyperactivity Disorder Medications in Children and Adolescents • The absolute risk for cardiovascular events in stimulant users was low and did not differ significantly from risk in nonusers. • The American Heart Association recommendation to obtain electrocardiograms in children and adolescents taking stimulants for attention-deficit/hyperactivity disorder (ADHD) raised concerns about the safety of these drugs (JW Pediatr Adolesc Med Apr 30 2008). In an industry-supported study, investigators analyzed data from two U.S. administrative databases (1999–2006) to compare rates of severe cardiovascular events (sudden death or ventricular arrhythmia, stroke, or myocardial infarction) among 241,417 children aged 3 to 17 years who received a first prescription for amphetamine, atomoxetine, or methylphenidate and 945,668 nonusers (matched for data source, sex, state, and age). Median follow-up was 135 days of active use for users and 609 days for nonusers. • Rates of validated sudden death or ventricular arrhythmia and of all-cause mortality did not differ significantly between users and nonusers of stimulants (hazard ratios, 1.60 [95% confidence interval, 0.19–13.60] and 0.76 [95% CI, 0.52–1.12], respectively). In both users and nonusers, review and validation of cardiovascular events from medical records was possible for only half the children (155 records). • Comment: These data suggest that ADHD medications do not confer increased risk for severe cardiovascular events. Although review and validation of medical records was possible for only half the children with cardiovascular events, the medical record retrieval rate was similar in users and nonusers.

12. Stable Patients with Pulmonary Embolism Can Be Treated as Outpatients • In a randomized trial of outpatient versus inpatient care, outcomes did not differ between groups. • Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers performed an open-label, randomized, noninferiority study to compare outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4% (based on the PE Severity Index; see table). Patients were excluded if they had oxygen saturation <90% on room air, systolic blood pressure <100 mm Hg, chest pain requiring opioids, active bleeding, or were at high risk for hemorrhage (recent stroke or gastrointestinal bleeding or platelet count >75,000/mm3). All patients initially received subcutaneous enoxaparin (1 mg/kg twice daily) followed by anticoagulation with vitamin K antagonists for at least 90 days. • Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient in each group died, neither from PE. Recurrent venous thromboembolism occurred in only one patient (outpatient group). Major bleeding occurred within 90 days in three outpatients (intramuscular hematoma on day 3 and day 13 and menometrorrhagia on day 50) and no inpatients. At 14 days, more than 90% of patients in both groups were satisfied or very satisfied with treatment. • Comment: These data suggest that stable low-risk patients with PE can be safely and effectively treated as outpatients with low-molecular-weight heparin. The results might not be applicable to older patients than those in this study or to patients with cancer.

14. Guidelines for Delirium Prevention in At-Risk Adults • U.K. national guidelines provide 13 specific recommendations for a multidisciplinary intervention. • Delirium, a common and costly problem among hospitalized elders, has been associated with longer hospital stays, greater relative likelihood of being discharged to a nursing home, and risk for subsequent dementia and death. Now, the U.K.'s National Institute for Health and Clinical Excellence (NICE) has published guidelines on the prevention of delirium in both surgically and medically managed hospitalized adults; members of the guideline development group provided a summary report. • The guidelines are based on a systematic review that ultimately identified eight studies of multicomponent interventions to prevent delirium, although only two studies were of moderate or high quality. The guidelines contain 13 recommendations for interventions that could be tailored to individual patients at high risk for delirium, defined as those older than 65 and those with cognitive impairment, severe illness, or hip fracture. • The recommendations emphasize a multidisciplinary, team–oriented approach that addresses cognitive impairment, dehydration, hypoxia, infection, immobility, pain, poor nutrition, medication overuse, vision and hearing impairment, and sleep deprivation. The authors conclude that this approach could reduce delirium incidence by one third. Results of a cost-effectiveness analysis suggest that the approach would save £8180 per surgically treated patient and £2200 per medically treated patient. • Comment: The NICE clinical guidelines highlight relatively simple, holistic, patient-centered interventions that have been shown to prevent delirium in at-risk hospitalized adults, albeit only in two relatively small, single-center studies of moderate to high quality. At the same time, the guidelines highlight the paucity of data on delirium prevention, despite the prevalence, adverse medical consequences, and economic impact of the condition. A large, multicenter clinical trial is clearly needed to confirm the effectiveness of the recommended interventions; however, because they pose little risk for harm and are likely to be cost-effective, it makes sense for hospitals to explore how to implement them. The NICE guidelines potentially set the standard of care for delirium prevention; at the least, they represent a roadmap for future multicenter studies. Regardless, they are a major step forward.

15. Triglycerides and Cardiovascular Disease: The Experts Speak • Experts redefine an optimal triglyceride level and stress that lifestyle changes are required to reach it. • While debate continues about whether hypertriglyceridemia independently predicts coronary artery disease, mean triglyceride levels in the U.S. are rising, along with rates of obesity and diabetes. In a new scientific statement, the American Heart Association (AHA) outlines the scope of the problem and offers treatment recommendations. Triglyceride levels directly influence high- and low-density lipoprotein metabolism, and hypertriglyceridemia can be mediated genetically or acquired (e.g., in patients with hypothyroidism, diabetes, or renal disease). • The authors propose a "practical algorithm" for initial screening with nonfasting triglyceride measurement. If levels are <200 mg/dL (corresponding to <150 mg/dL on a fasting sample), they suggest that patients continue with healthy diet and activity levels. At levels 200 mg/dL, fasting lipoprotein measurement is advised, and suggested targets are provided for weight loss and intake of dietary carbohydrates, sugars, and fats. Increased physical activity and intake of -3 fatty acids also are advocated for their profound effects on elevated triglyceride levels. At the highest triglyceride levels or in symptomatic patients, pharmacologic therapy can be useful (e.g., to lower risk for pancreatitis in patients with triglycerides >500 mg/dL). At all triglyceride levels, the AHA recommends avoiding consumption of trans fats, which raise triglyceride levels and atherogenic lipid particles. Finally, the guidelines set <100 mg/dL as an optimal triglyceride level. • This statement summarizes what we know about triglycerides and their relation to disease and provides a framework for treating the many patients with suboptimal triglyceride levels (see JW Cardiol Jul 13 2011 for additional commentary from Harlan Krumholz). Patients should be advised that lifestyle changes in diet, weight loss, and exercise are basic to treating most cases of hypertriglyceridemia, although tightening the definition of an optimal triglyceride level could inadvertently invite additional prescribing. • — Kirsten E. Fleischmann, MD, MPH • AN ADDITIONAL PERSPECTIVE FROM the Journal Watch general medicine EDITOR-in-chief: • In this AHA-sponsored statement, the authors acknowledge that the evidence for triglycerides as an independent predictor of cardiovascular events (i.e., after adjustment for other lipid fractions) remains controversial. They also acknowledge the lack of convincing clinical-trial evidence to support triglyceride-lowering drug therapies, independent of LDL-cholesterol–lowering or statin therapy; indeed, no benefit was seen in the recent AIM-HIGH study. Hence, this statement is somewhat self-contradictory: If drugs are not indicated (except to lower risk for pancreatitis when triglycerides are extremely elevated), and if lifestyle modifications that happen to lower triglycerides are worthwhile regardless of triglyceride levels, why should we closely monitor triglyceride levels? I am unaware of evidence that patients who track their triglyceride levels are more motivated to exercise, lose weight, and eat a heart-healthy diet than are patients who receive similar counseling without following triglycerides. A move to more-intense focus on triglyceride levels, and to a more stringent definition of "optimal" triglycerides, thus seems unnecessary and misguided.

16. All the following are examples of normal cognitive changes that occur with aging, except: A) Delayed recall B) Disorientation C) Difficulty finding words or names D) Slowed information processing

17. Answer • B) Disorientation

18. Which of the following is the most likely diagnosis in a patient with mild cognitive impairment affecting memory only? A) Depression B) Vascular dementia C) Frontal temporal dementia D) Lewy body dementia

19. Answer •  A) Depression

20. Unsafe driving increases when personality is characterized as: A) Forgetful B) Introverted C) Aggressive D) Anxious

21. Answer •  C) Aggressive

22. Which of the following is(are) associated with increased risk for unsafe driving? A) Clinical rating score ≥0.5 B) Marginal or unsafe driving rating given by caregiver C) History of serious traffic issues D) All the above

23. Answer • D) All the above

24. Falls occurring in women are less likely to cause _______ and twice as likely to cause _______ as those in men. A) Death; fractures B) Fractures; death

25. Answer • A) Death; fractures

26. Which of the following statements about risk of developing breast cancer is incorrect? A) Breast cancer represents 26% of all cancers (excluding skin cancer) in women B) 40% of woman with breast cancer have a family history of the disease C) Breast-feeding for >1 yr is recommended for risk reduction D) Early child-bearing is associated with reduced risk

27. Answer •  B) 40% of woman with breast cancer have a family history of the disease

28. Studies on the effects of vitamin E supplementation showed an increase in which of the following conditions? A) Uterine and breast cancers B) Colon and breast cancers C) Breast cancer and macular degeneration D) Coronary artery disease and congestive heart failure

29. Answer •  D) Coronary artery disease and congestive heart failure

30. Aspirin has been shown to be highly effective for preventing myocardial infarction in women. A) True B) False

31. Answer •  B) False

32. Bilateral oophorectomy before menopause increases the rate of all the following, except: A) Osteoporosis B) Parkinson disease C) Lung cancer D) Breast cancer

33. Answer •  D) Breast cancer

34. Which of the following has not been shown to be a benefit of drinking one to two glasses of alcoholic beverage each day? A) Reduced risk for cardiovascular disease B) Reduced all-cause mortality C) Reduced risk for breast cancer D) Increased insulin sensitivity

35. Answer • C) Reduced risk for breast cancer

36. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEWhich one of the following includes all 3 facial abnormalities associated with fetal alcohol syndrome?  (check one) A. Low-set ears, large eye openings, large forehead.  B. Small palpebral fissures, smooth philtrum, thin vermilion border.  C. Large palpebral fissures, smooth philtrum, thin vermilion border.  D. Large forehead, flattened cheeks, small eyes.  E. Thin vermilion border, distinct upper lip, esotropia. 

37. Answer •  B. Small palpebral fissures, smooth philtrum, thin vermilion border. 

38. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEWhich one of the following secondary disabilities is experienced by individuals with fetal alcohol syndrome?  (check one) A. Increased incidence of depression.  B. Decreased IQ.  C. Inability to live independently.  D. Increased likelihood to experience trouble with the law.  E. All of the above. 

39. Answer •  E. All of the above. 

40. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEWhich one of the following provides a clue to fetal alcohol effects?  (check one) A. Microcephaly.  B. Growth delays.  C. Cardiac defects.  D. Clinodactyly.  E. All of the above. 

41. Answer •  E. All of the above. 

42. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEWhich one of the following groups is at high risk of fetal alcohol syndrome?   (check one) A. Individuals who flush when they ingest alcohol.  B. Individuals with low socioeconomic status.  C. Individuals with poor nutrition.  D. All of the above.  E. None of the above. 

43. Answer •  D. All of the above. 

44. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEWhich one of the following statements regarding fetal alcohol syndrome (FAS) is true?  (check one) A. The US Preventive Services Task Force recommends screening and behavioral interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.  B. Alcohol use during the second trimester is associated with spontaneous abortion.  C. FAS is associated with radioulnarsynostosis.  D. All of the above.  E. None of the above. 

45. Answer •  D. All of the above. 

46. CLINICAL TOPIC: FETAL ALCOHOL SYNDROMEThere is a standard amount and type of alcohol that is safe for pregnant women to consume.  (check one) A. True  B. False 

47. Answer •  B. False 

48. HYPERTENSION MANAGEMENT IN OLDER PATIENTSHypertension is a major risk factor for which one of the following conditions?  (check one) A. Myocardial infarction.  B. Stroke.  C. Congestive heart failure.  D. Atrial fibrillation.  E. All of the above. 

49. Answer •  E. All of the above.  Book said C online E is correct and I agree. JD

50.  HYPERTENSION MANAGEMENT IN OLDER PATIENTSWhich one of the following statements most accurately describes stovepipe syndrome?  (check one) A. Reduction in renal function.  B. Rapid blood pressure elevation.  C. Rigidity of the blood vessels.  D. All of the above.  E. None of the above.