A 61-year-old man with a history of hypertension asks what measures he can take from a nonpharmacologic perspective to manage his hypertension. The patient reports that he drinks 1 to 2 beers per day and smokes a half pack of cigarettes per day.
Which of the following lifestyle modifications has been shown to result in the greatest reduction in blood pressure?
Weight loss. The seventh report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends all patients with hypertension (blood pressure of 140/90 mmHg or higher) or prehypertension (blood pressure of 120/80 to 139/ 89 mmHg) execute five lifestyle modifications: Reducing dietary sodium to less than 2.4 g/d; increasing exercise to at least 30 min/d (4 d/wk); limiting alcohol consumption to 2 drinks or less per day for men and 1 drink or less per day for women; following the Dietary Approaches to Stop Hypertension (DASH) diet (high in fruits, vegetables, potassium, calcium, and magnesium; low in fat and salt); and achieving a weight loss goal of 4.5 kg (10 lb) or more. Of these, weight loss has shown to have the highest reduction in systolic blood pressure (reduction from 5 to 20 mmHg) in overweight patients. (A, C, D) These three lifestyle modifications are also recommended and do have a substantial effect on reduction of systolic pressure, just not as much as weight loss does. (E) Smoking cessation should always be encouraged as part of any comprehensive lifestyle modification plan.
A 51-year-old man presents for a routine annual physical examination. The patient only reports constipation, but says it has been present for several years. He has an insignificant past medical history and reports smoking 2 packs of cigarettes per day for the last 15 years. He also drinks 2 to 3 beers per day. Physical examination is within normal limits. A colonoscopy is performed as part of the routine screening measures and demonstrates several diverticular outpouchings in the sigmoid colon. The patient is educated on diverticulosis.
Which of the following is the best recommendation to give to this patient for his newly diagnosed disease?
Increase fiber intake. This patient has asymptomatic diverticulosis. A diverticulum is a pouch (or sac) that protrudes from the colonic wall at a point of weakness. Diverticulosis is often asymptomatic, but can present with constipation, abdominal pain, and painless rectal bleeding. The treatment for asymptomatic diverticulosis is lifestyle modification in the form of increased fiber intake. Fiber allows for the creation of large, bulky stools that increase the width of the colon and minimize the likelihood of diverticular development. (A) Increased iron intake is not part of the treatment of diverticulosis. (C, D) Smoking cessation and decreasing alcohol consumption should always be encouraged as part of any comprehensive lifestyle modification plan, but do not have any proven effect on diverticulosis.
Over the last 10 years, more people in the town of Nankville appear to be suffering from Hodgkin lymphoma than in the town of Gridora.
Which of the following types of studies is best for calculating the difference in incidence between Nankville and Gridora?
Cohort. In this question, we need to find the study that is best for calculating the incidence (the frequency of new cases of a particular disease that arise in a population at risk over a certain time period). One can infer that in order to figure out the incidence, people without the disease need to be followed over a certain time period to determine how many of them develop that disease of interest. The best choice is a cohort study, a prospective observational study. Once residents in Nankville and Gridora have been followed over a certain time period, the incidence of Hodgkin lymphoma can be determined. Furthermore, the comparison of incidences will allow one to calculate the relative risk for developing Hodgkin lymphoma in one town versus the other. (B) Case-control is retrospective and patients with the disease (cases) are compared to patients without the disease (controls). Information is collected about previous exposure to risk factors. Case-control studies allow for calculation of odds ratio, but not incidence. (A) Cross-sectional studies are studies at one point in time, so these studies are ideal for measuring a disease’s prevalence (total number of cases in a population). (D) Clinical trials are used to determine the benefit of an intervention (drug, procedure, etc.) in patients who already have the disease. They do not determine incidence.
A 22-year-old woman presents for a routine annual physical examination. She has no complaints. She smokes 2 packs of cigarettes per day and drinks 2 glasses of wine per day. She is sexually active with one male partner and two female partners. She reports using oral contraceptive pills for birth control and consistent condom use with her male partner. Her family history is significant for breast cancer on her maternal side (aunt) and colon cancer on her paternal side (father died of colon cancer at the age of 52).
What is the recommended screening measure at this patient’s visit?
Chlamydia trachomatis screening. This patient is presenting for a routine physical examination and it must be determined what screening measures are recommended at this time. The U.S. Preventive Services Task Force (USPSTF) in 2007 recommended routine screening for Chlamydia trachomatis infection in all sexually active women who are 24 years and younger, in addition to asymptomatic women of all ages who are at increased risk for sexually transmitted infections (including those with sexually transmitted infections and those with new and/or several sexual partners). (A) Although this patient has a family history of colon cancer, the USPSTF recommends colon cancer screening starting at 50 years of age. However, if there is family history in a first-degree relative, then it should be initiated 10 years before the age of that relative’s diagnosis or 40 years of age, whichever comes first. This patient should have her first colonoscopy at the age of 40 (her father got it at 52 years of age, and 52 minus 10 is 42, so 40 comes before 42). (C) Lipid panel screening is recommended by the USPSTF for men of age 35 and older and women of age 45 and older (those with risk factors can be screened earlier at the age of 20). (D) Mammogram screening per USPSTF recommendations should begin at the age of 50 and older and occur every 2 years (for those with average risk). Of note, recommended immunizations for this patient include the Tdap booster and HPV vaccination (if not already done).
A prospective cohort study was performed to determine the relative risk of radiation exposure on squamous cell carcinoma (SCC) of the skin in elderly Caucasian men. The results showed that radiation exposure increased the risk of cutaneous SCC with a relative risk of 0.76 and p-value of 0.035.
Which of the following is a serious limitation of this study?
External validity. External validity, also known as generalizability, is the applicability of the results of the study to other populations. In other words, it extends the results beyond the cohort being studied. In this study, the external validity is clearly limited (restricted to elderly Caucasian men). (A) Internal validity is the validity of the study within the cohort itself. (C) Reliability is synonymous with reproducibility and precision and is defined as the degree to which repeated measurements under unchanged conditions show the same results. (D) Measurement bias is not the best answer because there is no information in this question related to the how the study was actually designed and conducted.
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