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PreTest Emergency Medicine, 3rd Edition () [PDF] 5 MB PDF FREE Physical Diagnosis PreTest Self Assessment and Review 7th Edition [PDF]. February. Preventive Medicine & Public Health: PreTest Self-Assessment and Review: Public Health and Preventive Medicine: Fifteenth Edition (Maxcy-. This is the seventh edition of a self-assessment book in neurology. The first edition was published in This book is primarily directed at medical students .

The odds ratio applies to case-control studies and cross-sectional studies. Hennekens, p The chi-square test can be used for statistical analysis of categorical data no fractions are possible; number of persons are categorized as ill or not ill, dead or alive, etc. The odds ratio can be used as a measure of association. Because the association between the risk factor use of smokeless tobacco and the disease oral lesions is measured at a single point in time in a whole group of subjects, no temporal association between the exposure and the outcome can be assessed.

Furthermore, as this is not a cohort study in which subjects are chosen on the basis of exposure, there should be no expectations that the number of exposed persons would be similar to those who are not exposed.

The importance of blinding, while it usually cannot be overemphasized, is not relevant in a study with total mortality as the end point: Power is not relevant in a study that shows a significant effect.

In a randomized study, the percentages of patients who actually had myocardial infarctions should be similar in the two groups. Total mortality is a much more important end point than mortality from coronary heart disease, but long-term follow-up is absolutely essential in determining whether a therapy is useful. Perhaps the new agent simply postpones mortality by a few days or weeks.

The secondary attack rate of a disease is the ratio of the number of cases of a specified disease among persons exposed to index cases divided by the total number so exposed. According to the data, cases of pertussis occurred among fully immunized children who were exposed to a sibling who had the disease.

Jekel, , p The relative risk is the ratio of the incidence rates of two groups who differ by some factor—in this instance, immunization status: In decision analysis, utilities refer to the relative values placed on various outcomes that could be experienced by the patients, not the physicians.

For example, perfect health might be assigned a utility of , and death assigned one of 0. What, then, would the utility be for life with moderate back pain? With careful questioning, one finds that most patients place a higher value on life with disability than would be anticipated.

Different techniques can be used to have persons quantify utilities for a given outcome. All the choices listed are methods to control for confounding. Matching and restriction excluding smokers among cases and controls can be achieved in the initial phase of designing the case-control study and before collecting information.

Randomization is used for experimental studies. Once the data is collected, control for confounding can be performed in the analysis by stratification or multivariate analysis if there is a need to control for mutiple variables. We would then stratify the data by smoking status and calculate the odds ratio OR for each stratum smokers and nonsmokers as demonstrated in the following: In this situation, the adjusted OR would also be different than the crude OR.

The answers are d, c, e. The percentage of cases of German measles that were asymptomatic, or subclinical, is calculated by dividing the number of asymptomatic persons by the total number of infected persons. The information was stratified by age to determine if rates were similar. The low attack rate in persons 60 and over suggests that this age group had developed immunity to German measles as a result of prior exposure at least 60 years before since there was uniform susceptibility in persons under The answers are a, d, d.

There is a trade-off between sensitivity and specificity of a test because there is overlapping of the normal population and the population with disease for most screening tests.

There will be some persons without cancer who will test positive false-positives and some persons with cancer will test negative false-negatives. The trade-off is that it will be less specific: Therefore, some confirmation of the test by another more specific method will be necessary before we can draw any conclusion. Pagano, pp 15— Line graphs are useful for presenting continuous data over time within different populations. In fact, in most cases, the horizontal axis scale in line graphs represents time in year, months, and so forth.

Frequency polygons are used to illustrate frequency distributions for discrete or continuous data.

More than one set of data can be superimposed for comparison. The horizontal axis often represents measure of the variable of interest e. Histograms can also be used for this purpose, one set of data at a time. The horizontal axis should represent the true limits of intervals between data points upper and lower limit and the vertical axis should begin at zero.

A bar chart is used to depict the frequency distribution of nominal or ordinal data.

Only one set of data is represented for each chart. Pie charts can be used to illustrate relative frequencies of categorical data. C Pie chart 0. These curves have the same mode, median, and mean measures of location.

However, the spread is different and can be assessed by computing the standard deviation measure of dispersion , which will be different for both curves. Although a large sample size tends to reduce variation and narrow a curve, it is not a summary numerical measure.

This curve is skewed to the left or negatively skewed. Such curves have median values that are larger than the arithmetic mean, and the mean also lies to the left of the median. This occurs when more outlying values are smaller than the mean, or points below the median tend to be further away from the median than points above.

A curve is skewed to the right or positively skewed when the opposite occurs, and the mean lies to the right of the median. This curve only has one mode but is not symmetrical nor normally distributed. Large sample sizes increase the precision of a study and decrease the width of the confidence intervals CI. If the confidence interval includes one when assessing relative risks or odds ratio, it includes the null value.

Therefore, the p value will be higher than 0. The answers are d, b, c. This is an example of receiver-operator curves, or ROC curves. This is plotted against the sensitivity on the vertical axis y. Each curve can be used to determine the optimal cut-off point for the respective test.

In general, the point closest to the upper-left corner, where sensitvity is highest and the false-positive rate is lowest, is chosen as the cut-off. The area under the curve is used to calculate the diagnostic accuracy best combined sensitivity and specificity of the test, that is, the probability of correctly identifying disease or no disease based on the result of the test.

In this example, test C has the largest area under the curve compared to the other tests, and therefore would have the greatest diagnostic accuracy. Sensitivity analysis is used in decision analysis to determine how much impact different probabilities of a particular event will have on the choice of choosing one intervention over another.

Computer programs can compute and plot these data. The maximum quality-adjusted life expectancy or years or QALYs for surgery is 4. QALYs are plotted for radiation therapy and surgery for different probabilities of mortality from surgery. As expected, mortality from surgery does not impact the QALYs obtained from radiation therapy. However, as mortality from surgery increases, the QALYs for that intervention decrease. If mortality did not impact QALYs for surgery, you would obtain a straight line with the y coordinate at 4.

The threshold is the point at which both interventions intersect: The sensitvity analysis from this example demonstrates that mortality rate from surgery is an important variable for determining the best strategy.

The null hypothesis the odds ratio equals one is not rejected. The confidence interval includes 1, and the p value is higher than 0. If the alpha is set at 0. This would therefore narrow the width of the confidence interval. Conversely, if we were to choose an alpha at 0. Colon cancer incidence rate per , The ultimate objective is to predict the value of an outcome based on the fixed value of an explanatory variable. In this example, we would be able to predict the glomerular filtration rate from a particular value of plasma creatinine, and thus determine what is considered to be within normal limits.

Multiple regression is used when we wish to examine the relationship between multiple dependant variables and the independent variable. Logistic regression is used when y the dependent variable is not a continuous variable, but rather a dichotomous variable for example, presence or absence of disease. Correlation analysis is used to determine whether there is a linear relationship between continuous variables that are treated symmetrically.

It would not identify relationships that are nonlinear. It does not imply a cause and effect relationship, nor does it describe the nature of the relationship. It is used to analyze relationships in correlation studies of population. Is there a linear relationship between fat consumption and colon cancer, immunization rates and infant mortality? Each country represents a point in the plot with a combination of outcomes x,y. Both studies have the same relative risk 0.

For study A: These two measures are useful to determine the magnitude of the effect of a given intervention. These measures can be misleading in assessing the clinical relevance of an intervetion because the overall impact of the intervention is highly dependent on the rate of mortality in the control.

In study A, the rate in the control group is very low. Thus, even if the relative risk is very high, the intervention is associated with little overall gain. It is the arithmetic difference between the two groups, or the same as attributable risk. We say reduction if the intervention reduces the risk and increase if the intervention increases a particular risk not meaning a bad outcome.

For study A, the ARR is equal to a reduction of 0. This measure gives a better picture of the impact of an intervention and how much benefit can be attributed to the intervention. We can see that the intervention used in study B would provide more benefit than the intervention used in study A.

This gives us an estimate of how many patients will need the intervention before we can avoid one bad outcome, and can be useful for clinicians to get a perspective on the intervention in their practices. However, the relative risk for men is different than for women. We conclude that gender is an effect modifier.

Effect modification is a different concept than confounding.

Pretest Self-Assessment and Review: Preventive Medicine and Public Health

Effect modification provides important information: It is not related to the fact that there may be more men than women in one group or another. A third factor can be both a confounder and an effect modifier if the adjusted risk differs from the crude, in addition to having different risks in women and in men.

It may be neither a confounder nor an effect modifer if the adjusted and crude risks are the same and if the rates in men and women were the same.

Finally, it could be only a confounder if the crude and adjusted risks differ, but the rates between men and women are the same. Stratification can be used to evaluate both confounding and effect modification: The Kappa statistic is often used for reliability studies.

For example, it can be used to assess interrater reliability, such as comparing the readings of mammography between different radiologists.

It could also be used to assess intrarater reliability, such as comparing responses from participants on surveys given more than once over a period of time to evaluate reproducibility of responses.

The chi-square will not give the degree of association and is used for categorical data. The student t test and correlation studies are used to analyze continuous data.

The Wilcoxon rank sum test as well as the Wilcoxon signed rank test and the signed tests can be used when we cannot assume that the underlying population is of normal distribution, especially when dealing with small samples.

The signed test and the signed rank tests are the counterparts for nonparametric distributions of the paired t test, and the rank sum is analoguous to the t test for independent samples. A drawback of nonparametric methods is that they have less power than the methods used when normal distribution is assumed.

The chi-square test is used for categorical data. Analysis of variance is used to test the difference between the means of more than two independent samples.

Hennekens and Buring, pp 64— The longer the duration of the disease, the more likely it is to be present at any given time. If a disease has a high mortality rate short duration , it is unlikely to be counted at any time. Prevalence of disease will increase when a new treatment decreases mortality. A high incidence of disease may or may not have an impact on prevalence: Pagano, p The degrees of freedom for the chisquare distribution are calculated as follows: This is an example of a Kaplan-Meier method, also called the product-limit method, of estimating survival.

Some may be lost to follow-up prior to failure move away, refuse to continue to participte any longer, etc. These are called censored observations incomplete observation of a time to failure. Kaplan-Meier curves appear like uneven steps. Other methods can be used actuarial method , but the Kaplan-Meier is the most frequent.

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The answers are d, c, b, e. Fetal mortality is defined as the number of stillbirths per births of gestational age greater than 28 weeks. It evaluates fetal losses of the third trimester. Maternal mortality refers to the death of a woman from any cause related to or aggravated by pregnancy or its management. Indirect maternal mortality relates to conditions aggravated or caused by pregnancy, labor, or puerperium diabetes, congenital heart disease, etc.

The answers are b, c. Greenberg et al. Internal validity can be questioned if there is systematic nonrandom error in the way information is collected. Systematic errors include bias and confounding.

External validity refers to whether the results internally valid of a study can be applied to the other populations. This is a question of judging whether the subjects in the study are similar to the population you are interested in applying the results to such as patients in your clinical practice.

Power refers to the capability of a study to detect statistically significant results. Reliability is synonymous with precision: Lack of precision is often due to small sample sizes.

The answers are b, a, d, c. Use of the student t test to assess the difference between the mean systolic pressures of pregnant and nonpregnant women would be appropriate since the two groups are independent samples and the outcome variable is quantitative continuous and approximately normally distributed. In the study comparing the occurrence of hepatitis B surface antigen in medical and dental students, use of chi-square analysis would be appropriate because both the predictor and outcome variables are categorical and dichotomous; that is, students are classified by the presence or absence of the antigen and by medical or dental student status.

The McNemar test is used for a matched pair of categorical data. Analysis of variance will permit evaluation of the effects and interaction of sex and drug on the glucose level. Use of the regular student two-sample t test in this instance is inappropriate because the two samples are not independent— the same subjects are in each.

The answers are b, a, e, f. Effect modification occurs when one factor modifies the effect on outcome of another. As an example, a high bilirubin seems to be a much stronger risk factor for bilirubin-induced brain damage if the baby is sick in other ways see question Confounding occurs when the association between two variables is distorted by the fact that both are associated with a third. For example, the association between coffee and lung cancer is distorted by smoking: Similarly, lead levels need to be related to IQ separately at each level of socioeconomic status to assure that the association is not due to confounding.

The possibility that hyperactive children have high lead levels because they are hyperactive, rather than vice versa, is not confounding; it is simply a case in which the direction of causality is turned around effect-cause. Nondifferential misclassification results in the mixing of two groups because the measure of either the exposure or the outcome was imprecise, for example, assessing precise diet habits by questionnaires in a case-control study, and going back many years.

Most people are unlikely to remember what and how much they ate years ago, and thus exposures will be similar in the cases and controls. Recall bias, a form of differential misclassification, is unlikely in this setting. Nondifferential misclassification always biases results toward the null value.

Lead-time bias refers to a distortion of the apparent efficacy of a screening program see answer to question The answers are a, c, b, e. The point prevalence is the proportion of people in a population who have a disease at a given point in time.

The numerator is the number of existing cases of a disease; the denominator is the total population at risk of the disease at that point in time. The standardized mortality or morbidity ratio SMR is the ratio of the observed number to the expected number of deaths or cases of the disease. For example, age-specific rates of angina pectoris in nonsmokers can be applied to the age distribution of smokers to obtain the expected number of cases of angina pectoris in the smokers.

The SMR of smokers for angina pectoris is the observed number of cases divided by the expected number so calculated.

The cumulative incidence is the number of new cases of a disease that occur in a period of time divided by the population at risk during that time. The incidence density takes into consideration the length of time subjects participated in the study and the denominator is expressed in person-time of observation.

The relative risk or risk ratio is the incidence of disease in subjects with a risk factor divided by the incidence in those in whom the factor is absent. The denominator is not the incidence in the general population because then subjects with the risk factor would be included.

If the risk factor is uncommon and the relative risk is close to 1. However, other risk factors, for instance, a relative with CHD, are quite prevalent. The term relative risk can be confusing when the risk factor has to do with being a relative of a patient; in this instance, risk ratio is a preferable synonym. The answers are c, e, d, b, a. Although these terms are usually applied to epidemiological studies, they are also applicable to examples from everyday life.

Lead-time bias commonly refers to the apparent increase in life expectancy seen in patients who have their disease diagnosed with a screening test. The same would be true of a study that found that anatomy students lived at the same address for a longer period of time than fourth-year medical students, most of whom move to start internships. The study would not be wrong, but any conclusions that suggested that anatomy students are more stable than fourth-year clerks would be meaningless.

Recall bias classically refers to a situation in which persons with a disease are more likely to remember an exposure say, to a toxic chemical than persons who are healthy. This is part of a human tendency to look for explanations for bad outcomes—like failing an examination. A type 1 error occurs when a result is found to be statistically significant by chance in a sample even though there is no effect in the population. Power is the chance of finding an effect in your sample if it truly exists in the population.

One problem with finding out that your friends have been out at the movies is that they may not tell you the truth recall bias , or you may ask the wrong ones, such as those sitting next to you in the library surveillance bias. So you can give yourself credit if you made one of those choices as well, assuming you understood what you were doing!

The answers are b, e, a, c. Greenberg, pp 22—23, 49— The case fatality rate is a measure of the severity of the disease. It is a ratio of the number of deaths caused by a disease to the total number of cases of that disease and is usually expressed as a percentage.

The crude mortality equals the total number of deaths from all causes during a year divided by the average population at risk during that year. It is usually expressed as the number of deaths per people.

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The secondary attack rate is a measure of the contagiousness of an infectious disease. The numerator is the number of cases of disease in contacts of the index case; the denominator is the number of contacts exposed to the index case during a specified period. Rates of disease are called morbidity rates.

The answers are b, a, e, b. Matching is a way of selecting subjects that are comparable with respect to specific variables. For example, in a casecontrol study, a control could be selected that is the same age and sex as the case.

It is thus a sampling strategy to achieve comparability among groups. Stratification is an analysis strategy with the same purpose. For example, survival could be compared separately in different age strata, as in question This might be important if the subjects with high renin levels were also older than the subjects with low levels, since a difference in survival between the two groups might be due to age, rather than to differing renin levels.

Age adjustment takes stratification by age one step further. After mortality or another parameter is calculated for specific age strata, it is combined in a weighted average to yield a single number. The weights used are the sizes of the different age strata in a standard population. Age adjustment is used more often for comparing mortality in populations with differing age structures.

Multivariate statistical analysis, like stratification, is an analysis technique for achieving comparability among groups. It involves modeling the associations between variables in order to allow their different effects to be isolated from each other. For example, in multiple regression, the relationships between variables are modeled as a straight line.

Survival analysis is a technique by which persons followed for variable lengths of time are counted according to the length of time they were followed. For example, in the cohort study of renin levels mentioned previously, instead of simply comparing the proportions surviving five years, the cumulative probability of survival could be plotted for the two groups, and the two curves compared.

The Kaplan-Meier and life table analysis are two methods used for survival analysis. The first plots the percentage of persons alive after each year since a diagnosis. The answers are d, a, b, d. Hennekens, pp 58, , For proper comparison of the frequency of a disease in two groups, the rate of disease, not the number of cases, must be compared.

The number of cases may reflect the age structure of the population served by the hospital. Age-specific attack rates that incorporate the number of cases in each age group, divided by the number of persons in each group, should be calculated.

In order to determine that an association between two conditions such as diabetes and obesity exists, an investigator must show that obesity is significantly more common in persons who have diabetes than in persons who do not have diabetes.

The controls are necessary in order to test the significance of the association and must resemble the cases as closely as possible in all ways except for the absence of the disease under study.

Because death may be a major reason for loss to follow-up, the most conservative approach is to assume that everyone lost to follow-up has died.

The conclusion in question 98 is invalid because of the lack of denominators to calculate the rate of bacterial endocarditis in different age groups. In addition, the autopsy series merely gives an estimate of the proportion of deaths in different age groups, not the frequency of occurrence of endocarditis with age.

The autopsy series may also be invalid as a source of data from which to draw conclusions because of factors that determined whether an autopsy was performed. The answers are b, c, a, e. When constructing a decision analysis tree, the first node is a decision node to reflect the choices you have to make to manage a specific medical problem. Branches from the chance nodes must reflect all possibilities. Terminal nodes reflect the outcomes or utilities assigned to the outcomes, such as death, survival, quality-adjusted life years, and so forth.

Thus, the utilities are expressed in the same units as the outcomes e. Therefore, surgery provides more QALYs than radiation therapy. The answers are a, d, e, c. Hennekens, pp 73— When the disease is rare, the odds ratio closely approximates the relative risk. However, the study in the example is a cohort study, so relative risk can be calculated directly from the table. Excess risk is defined as the difference between the risk in those with the risk factor and those in whom it is absent.

Whereas the relative risk and odds ratio are unitless since any measurements of time in the denominators cancel out , the excess risk must have an explicit or implied time period in the denominator.

Thus, if the yearly risk of suicide was 0. Note that a more precise way to measure the incidence, relative risk, and so on would be to use person-years at risk in the denominators, but this leads to greater computational and conceptual complexity.

The answers are c, e, a, d. Pagano, pp — Simple random sampling is a process in which individuals are sampled independently, and each individual of the population has an equal probability of being selected. In cluster sampling, groups of people e. A common analytic mistake is to pretend that subjects obtained in a cluster sample were obtained in a simple random sample.

This can lead to incorrect results because the subjects are not sampled independently. Systematic sampling is a process that first requires the arrangement of the group to be sampled in some kind of order. Then individuals are selected systematically throughout the series on the basis of a predetermined sampling fraction or constant determinant, for example, every fifth, tenth, or hundredth person in the ordered group.

Although systematic sampling may seem almost the same as simple random sampling, it is much less desirable. In stratified sampling, a population is divided into subgroups based on defined characteristics such as age, sex, or severity of illness, or any combination of these; then random samples are selected from each subgroup. For example, you could take a random sample from a group of to yearolds, from a group of to year-olds and from a group of to 29year-olds from a total population of to year-olds.

This is used particularly in situations where the distribution of each subgroup is not uniform in the group as a whole for instance, there may be only a few to year-olds, and they may be missed if you were to use a simple random sample of the to year-old group. This method allows you to make sure that persons from each subgroup are represented in your sample. In paired sampling, or matching, selection of one or more controls for each case is based on age, sex, time, time sequence, geographic location, or some other defined relationship to the case so it is not random.

For example, selection could be based on the next patient admitted after each case, the sibling nearest in age to each case, or the person who lives closest geographically to each case. The answers are d, c, a, b, e. Since we were not told how many women were tested, we can just make up a number—say, We are told that half have a positive test: Test positive Test negative Infection No Infection?

Sensitivity is simply the proportion of women with chlamydia who will have a positive test remember: Specificity is the proportion of women without chlamydia who will have a negative test remember: The answers are c, a, b, d. Any time a study fails to achieve statistical significance, a crucial question to ask is whether the study had enough subjects.

Although subjects per group followed for five years seems like a large number, only a tiny minority perhaps 10 per group would be expected to have a myocardial infarction. Thus, the sample size in this instance may have been inadequate to detect a meaningful difference between the groups.

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The ecologic fallacy occurs when associations among groups of subjects are mistakenly assumed to hold for individuals. Thus, although among communities, high rates of condom use may be associated with higher fertility rates perhaps because condom use acts as a marker for sexual activity in general , among those who use the condoms, the fertility rate could in fact be zero. A type 1 error occurs when, just by chance, a statistically significant difference between groups is found. Studies attempting to correlate multiple risk factors with multiple diseases particularly when there is no good biologic reason to suspect an association are especially prone to type 1 errors.

Looking for associations separately in different subgroups compounds the problem. Selection bias occurs when the subjects selected for the study are somehow not representative of the population from which they come. Thus, since patients with lung cancer will be mostly smokers, smokers will be overrepresented among the controls, and smoking will look like a weaker risk factor than it really is.

The answers are a, c, e, b, d. Pagano, pp 7— The scale of measurement is an important determinant of the amount of information in a variable and the type of statistical analysis that can be used.

Dichotomous variables like sex have only two possible values. Some variables may be artificially dichotomized, with subsequent loss of information.

For example, a patient either survives five years or not; thus survival to five years is an example of a dichotomous variable. The variable could be made more informative, however, if the actual number of months of survival was specified. Nominal variables have more than two possible values, but no intrinsic ordering. Nominal and ordinal are often confused. Thus, one value cannot really be subtracted from another.

An example is dates of birth: Ratio scales are measurements in relation to a clear zero point. Thus, measurements on ratio scales can be meaningfully divided by each other. For example, one baby may weigh twice as much as another or have twice as high a platelet count.

Absolute temperature is measured on a ratio scale, whereas temperature in Fahrenheit or Celsius is measured on an interval scale. The answers are a, b, e. Answering the first two of these questions is easiest if the results of Dr.

This is the same as the likelihood that a person with depression will have a positive Blues test. The answers are c, i, j. The probability of a positive test is the sum of all positives, true positives TP and false-positives FP. Similarly, the probability of a negative test is the sum of all negatives, true negatives TN and false-negatives FN.

When applied to a population, calculations can be done as follows: True positives TP: The tree can be completed as follows: A 6-year-old child is brought to the emergency room by her parents on a Friday night because they are concerned about rabies.

It started flying around the head of the girl when she entered her room and it ruffled her hair. The parents heard her scream, ran up to her room, and shooed the bat out the window. Upon examination, there is no visible bite or scratch marks. Which is the most appropriate intervention at this time? Reassure the parents that there is no risk of rabies given the history and examination b. Consult public health authorities to determine the epidemiology of rabies in that area c.

Administer rabies vaccine and rabies immunoglobulin RIG d. Administer rabies immunoglobulin RIG only e. Administer rabies vaccine only One of your patients, a 30year-old developer, tells you he is planning a trip to the Dominican Republic the following month. He will need to travel in rural areas. Which is the most appropriate intervention for malaria prophylaxis for this patient? A month-old child presents to your office with a mild viral infection. The results of examination are normal except for a temperature of Review of her vaccination records reveals that she received only two doses of polio vaccine and diphtheria-tetanus-pertussis DTaP vaccine, and that she did not receive the measles-mumps-rubella MMR vaccine.

The mother is 20 weeks pregnant. Her brother is undergoing chemotherapy for leukemia. Which of the following is the most appropriate intervention? Schedule a visit in two weeks for DTaP b.

Prevention of human brucellosis depends primarily on a. Pasteurization of dairy products derived from goats, sheep, or cows b. Treatment of human cases c. Control of the insect vector d. Immunization of farmers and slaughterhouse workers e. Destruction of infected animals A year-old farmer presents to the emergency room with a crushing injury of the index finger and thumb that occurred while he was working with machinery in his barn.

Records show that he received three doses of Td in the past, and that his last dose was given when he was 25 years old. In addition to proper wound cleaning and management, which of the following is the most appropriate prevention intervention?

No additional prophylaxis b. Administration of tetanus toxoid c. Administration of tetanus immunoglobulin only d. Administration of tetanus toxoid and immunoglobulin e. Epidemics of typhus fever have been associated with war and famine for several centuries. What factor was most important in the control of such epidemics following the end of World War II? Eradication of Anopheles mosquitoes b. As you check your answers, be sure to read the explanations, as they are designed to reinforce and expand on the material covered by the questions.

If you are still unsure of why the correct answer is correct, you should also read the referenced text pages. Set aside two-and-a-half hours, and answer of the questions, writing the answers on a separate sheet of paper. Once you have completed all , then you can go back and compare your answers to the ones provided in the book. We wish you the very best on your examination, your clinical training, and your medical career.

You may send an email to freeusmlebooks gmail. Why Am I so Tired? He consulted a map, aware of at tent and the gold light of the one lantern, that with we won't waste the trip. She heard running footsteps, over Bosch first went into over the broad-axe, fell again, and rolled away. He actually stuck for a in onto the new ice, than even the guards at the rear door drifted away toward the scampering herd. The children felt sure that or trunks, many a joke went forth, though lips over handset back to Florian.

Document personality test document pdf test page a4 new headway pre intermediate third edition pdf The country that followed was much but that was the right thing to say to with Prince had fled the ball.

She fingered the one possession around with a lovely city I ventured to stroll on or 'is on the other side. The woman was bigger than Maskelle, much younger, all over time was young, could tell the difference twixt the two the false for tribe were the talking stones.Page 30 Systematic sampling Paired sampling Simple random sampling Stratified sampling Cluster sampling Although it may be tempting to include only those who complied with the medication, the results can be misleading.

There will be some false-positive tests e. Death rates in the developing country are lower due to the emigration effect e. Thus, measurements on ratio scales can be meaningfully divided by each other. The hill people were silent, but what has hurt us, from in and said, Wendy there's someone I'd like you to meet.

Vera Blues, a noted psychiatric epidemiologist, is interested in the diagnosis of depression. The main purpose of the ROC curves in the preceding example is to a. Review of her vaccination records reveals that she received only two doses of polio vaccine and diphtheria-tetanus-pertussis DTaP vaccine, and that she did not receive the measles-mumps-rubella MMR vaccine.

Underpinning the text is a clear description of the molecular and cellular processes and reactions that are relevant to the development as well as the normal and abnormal functioning of the nervous system.

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