Unit 4 Practice Questions

Epidemiology 6000

A case-control study of 1700 participants looked at the association between Tamoxifen

and uterine cancer. The study included 689 cases. There were 139 cases and 58 controls
taking Tamoxifen. Fill in the 2x2 table below.

Uterine Cancer
Tamoxife Yes No
n
Yes 139 58
No 550 953

1a. Calculate the odds ratio of the above study.

(139 * 953)
OR = = 4.15
(58 * 550)

1b. Interpret the measure of association.

The odds ratio is greater than 1.0, therefore Tamoxifen is a risk factor for uterine
cancer. People that use Tamoxifen have a 4.15 times greater risk of developing
uterine cancer compared to people who do not take Tamoxifen.

2. The Nurse’s Health Study followed more than 120,000 women for several decades.
During the follow-up period 1500 women developed melanoma. Researchers sent
questionnaires to the 1500 cases and a control group made up of 3000 other study
participants, to collect additional information about exposures possibly associated with
melanoma. What type of study design is this?

a. Case-cohort
b. Case-crossover
c. Nested case-control
d. Retrospective cohort

3. Which of the following is characteristic of a case-crossover study?

a. Each person serves as their own control.

b. Controls are a random sample selected at the beginning of a cohort study.
c. The study is conducted within a cohort study
d. Both a and c

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 4. Calculate the odds ratio for the following matched pairs case-control study.
200 pairs where the case is exposed and the control is not.
50 pairs where the control is exposed and the case is not.
130 pairs where cases and controls are exposed.
85 pairs where cases and controls are unexposed.

Controls
Cases Exposed Unexposed
Exposed 130 200
Unexposed 50 85

OR = b/c = 200/50 = 4

5. Which of the following are disadvantages of the case-control study design?

(check all that apply)
 Cannot calculate relative risk directly
Cannot determine the odds ratio
 Cannot determine prevalence
Expensive to conduct
 Generally not good for studying rare exposures
Not good for studying rare disease
Relatively long time required to complete study
 Relies on recall or existing records
 Selection of controls may be difficult
Usually requires a relatively large number of subjects

6. Name the bias that may arise from the situations described below:
 A case is more motivated to participate than a control, and thus more likely to report
past exposures accurately Recall Bias
 An interviewer learns to distinguish cases from controls, and subsequently differs
slightly between them in how she asks her questions. Observer Bias (also called
interviewer bias)

7. In a sentence or two, describe why sampling incident cases is better than sampling
prevalent cases for a case-control study. Sampling incident cases is better because
with prevalent cases there is the possibility of including long-lived cases that are
not representative of all cases of the disease. (e.g. they may have a milder, less
lethal form of disease, or there may be some personal characteristic that allows
them to live particularly long with the disease)

8. Which of the following are undesirable characteristics in a control group:

a. All members lack the disease of interest
b. Control sampling related to exposure status
c. Control would have become a case if they had gotten the disease
d. Controls and cases are from the same source population
e. Hospital-type controls have a disease related to study exposure

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 9. The following is a classic 2x2 table:

Case Control
Exposed a b
Unexposed c d

a. What does a/b signify? (Hint: it’s an odds of…) a/b is the odds of
being a case among the exposed.
b. What does c/d signify? c/d is the odds of being a case among the
unexposed.
c. What is the formula, using this table, for calculating an odds ratio?
The formula for calculating the OR is (a/b) / (c/d) or,
mathematically the same, ad/bc.
d. Based on this table, and the formula from c, what would an odds ratio
of 0.8 mean? 1.0? 3.2? An OR of 0.8 indicates that exposure is
negatively associated with disease (is a protective factor). 1.0
means that exposure is not related to disease. An OR of 3.2 would
indicate that exposure is positively associated with disease.

10. An investigator conducts a study to determine whether there is an association

between caffeine intake and Parkinson’s disease. He assembles 230 incident
cases of PD and samples 455 controls from the general population. After
interviewing all subjects, he finds that 64 of the cases had high daily intake of
caffeine (exposed) prior to diagnosis and 277 of the controls had low daily
intake of caffeine (unexposed) prior to the date of the matched case’s
diagnosis.
a. Assemble the 2x2 table for this study using the information given.
Case Control
Exposed 64 178
Unexposed 166 277
230 455
b. Calculate the odds of being a case among the exposed
a/b = 64/178 = 0.360 (or about 1 in 3, 1/3 or 1:2)

c. Calculate the odds ratio for disease given exposure to high daily intake
of caffeine (versus low daily intake of caffeine).
OR= ad/bc = 17728/29548 = 0.60
Note: For the visually oriented, it may help to remember the OR
as a “cross-product” calculation, because you’re multiplying the in
an “X” across the standard 2x2 table.

d. What does the odds ratio indicate?

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 The OR of 0.60 indicates that high caffeine intake is negatively
associated with Parkinson’s disease. You could say it is a
protective factor.

11. A study was conducted to examine risk factors for spontaneous pneumothorax
(collapsed lung), including use of car air fresheners. 430 emergency room
cases were identified from Florida hospitals in 2005, and 1204 controls were
sampled from the patients admitted to the emergency room for broken bones
or lacerations. It was found that 110 of the cases and 214 of the controls used
a car air freshener regularly. The remaining cases and controls did not use air
fresheners in their car.
a. Assemble the 2x2 table for this study using the information given.
Case Control
Exposed 110 214
Unexposed 320 990
430 1204
b. Calculate the odds of being a case among the unexposed
c/d = 320/990=0.323 (or about 1 in 3, 1/3, or 1:2)

c. Calculate the odds ratio for disease given exposure to regular car air
freshener use compared to no air freshener use.
OR= ad/bc = 108,900/68,480 = 1.6

d. What does the odds ratio indicate?

The OR of 1.6 indicates that being exposed to regular car air
freshener use is positively associated with spontaneous lung
collapse. Note: this was entirely fictional!

12. A state epidemiologist wanted to investigate stomach cancer and shellfish

consumption. She conducted a study with 125 stomach cancer cases and 125
controls, pair-matched on age and gender. After conducting the study, it was
found that there were 35 pairs in which both cases and controls ate shellfish
more than 3 times per week (exposed), and 15 pairs in which both cases and
controls ate shellfish less than once per month (unexposed). There were 28
pairs where the control ate shellfish more than 3 times per week and the case
rarely at shellfish, and 47 pairs where the case at shellfish more than 3 times
per week and the control at shellfish rarely.

a. Construct the appropriate 2x2 table for this study using the information
given.
Controls
Exposed Unexposed
Cases

Exposed 35 47
Unexposed 28 15

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 b. Calculate the pair-matched odds ratio for stomach cancer from
exposure to eating shellfish regularly compared to eating shellfish
rarely.
The pair matched OR divides case-exposed discordant pairs over
control-exposed discordant pairs:
b/c = 47/28 = 1.7

c. What does this odds ratio indicate?

This pair-matched OR indicates that eating shellfish regularly is
positively associated with having stomach cancer.

13. When is it NOT appropriate to use the odds ratio to approximate the relative
risk?
a. When the controls’ exposure history is representative of all subject
without disease
b. When the case selection is representative of all subjects with
disease (e.g. unbiased incident cases)
c. When the study disease occurs frequently
d. When the study outcome is rare

14. The case-cohort design and the nested case-control design are both designs in
which a case-control study is conducted using the participants in an existing
cohort study. What is the basic difference between them? The basic
difference between the case-cohort and nested case-control is in the
sampling procedure for the controls. In a case-cohort, the controls are a
random sample of all study subjects at baseline. In a nested case-control,
a control is chosen randomly from among the subjects that are still
disease-free at the time each case got the disease (as in a case-cohort, a
control matched to a previous case can later turn out to be a case
himself).

15. A study of gym members was undertaken to see if machine-users were more prone to
injury than free-weight users. Assume for this study that you can only be injured in the
gym once in your lifetime. 1500 gym patrons across the county were polled beginning
January 1, 2003. On June 5, 2003, it was discovered that 75 of those gym patrons
currently had gym-related injuries. After June 5, the remaining injury-free patrons were
enrolled in a cohort study, classified as machine-users (n=1000) and free-weight users
(n=425), and followed for 3 years. 85 machine-users and 15 free-weight users became
injured in the 3 years. All follow-up stopped on exactly June 5, 2006. Assuming
complete ascertainment and no drop-outs:

a. Calculate the point-prevalence of injury on June 5, 2003.

Point prevalence = # of cases on prevalence day / # at risk on prevalence
day
= 75/1500
= 0.05 or 50 per 1000 population on June 5, 2003.

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 b. Calculate the cumulative incidence of injury in the entire sample between
June 5, 2003 and June 5, 2006.
Calculate total at risk at baseline (denominator):
1500 – 75 prevalent cases = 1425 at risk on June 5, 2003
Calculate total incident cases:
85+15 = 100 incident cases
Three-year Cumulative Incidence = 100/1425 = 0.0702 or 70.2 per 1,000.
(don’t forget to state the time frame for a cumulative incidence!)

c. Calculate the incidence of injury among the exposed and unexposed.

Exposed 3-yr incidence (machine-users): 85/1000 = 0.085
Unexposed 3-yr incidence (free-weights): 15/425 = 0.035

d. Calculate the relative risk of injury among machine users compared to free-
weight users.
RR = 0.085/0.035 = 2.4

e. Is this a risk ratio or rate ratio?

This is a risk ratio, because it uses cumulative incidence.

f. Calculate the odds ratio for injury among machine users (yes! You can
calculate an odds ratio for any 2x2, although it’s most common in case-control
and cross-sectional studies – actually required because you can’t calculate
incidence in those studies for a relative risk).

Inj No Inj Total

Exposed 85 915 1000
Unexposed 15 410 425

OR = (85*410) / (915*15) = 2.5

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