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157 Cards in this Set
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physician conducted a study where he compared a group of people witha disease to a group without, and looked for prior exposure or risk factor and asked "what happened?"
what is the name of the measurement he would use? |
Odds ratio (OR)
i.e. patients with COPD had a higher odds of a history of smoking than those without COPD case-control study |
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this type of study is usually observational and retrospective
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case-control
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this type of study is usually observational and prospective
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cohort study
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researcher compared a group with a given exposure or risk factor to a group without
- looked to see if exposure ^ the likelihood of disease and asked "what WILL happen?" what is the name of the measurement he would use? |
Relative Risk (RR)
i.e. smokers had a higher risk of developing COPD than did nonsmokers |
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researcher collects data from a group of people to assess frequency of disease (and related risk factors) at a particular point in time and asks "what IS happening?"
what is the name of the measurement he would use? |
Prevalence
- can show risk factor association with a disease, but does not establish causality |
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you want to measure the heritability of a trait
what type of study would you conduct? |
Twin Concordance study
- compares the frequency with which both monozygotic twins or both dizygotic twins develop a disease |
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you want to measure heritability AND the influence of environmental factors
what type of study would you conduct? |
Adoption study
- compares siblings raised by biologica vs. adoptive parents |
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what 3 factors give a clinical trial study the highest quality?
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1. randomized
2. controlled 3. double blind |
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clinical trial
- assessing safety, toxicity, and pharmakinetics on a small number of healthy volunteer patients whats stage? |
Phase I
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clinical trial
- assessing treatment efficacy, optimal dosing, and adverse effects on a small number of patients with disease of interest what stage? |
Phase II
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clinical trial
- comparing the new treatment to the current standard of care - on a large number of patoents randomly assigned either to teh treatment under the test treatment or a placebo stage? |
Phase III
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clinical trial
- detects rare or long-term adverse effects - postmarketing surveillance of patients after approval stage? |
Phase IV
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what is the highest echelon of clinical evidence?
advantage? limitation? |
Meta-analysis
-pools data from several studies to come to an overall conclusion. Advantage - Achieves greater statistial power and integrates results of similar studies. Limited by the quality of individual studies or bias in study selection |
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how do you evaluate a diagnostic test?
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use a 2x2 table comparing test results with the actual presence of disease
TP/FP TN/FN |
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proportion of all people with disease who test positive
AKA the ability of a test to detect a disease when it is present how do you calculate it? |
= TP/(TP+FN)
= 1- false positive rate SNOUT = "SeNsitivity rules OUT" Sensitivity |
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what is a desirable value for sensitivity?
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value approaching 1 is desirable for ruling out disease
- indicates a low false-negative rate sensitivity |
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what diagnostic measure is used in disease with low prevalence?
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sensitivity
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proportion of people without disease who test negative
AKA the ability of a test to indicate non-disease when disease is not present how do you calculate it? |
= TN/(TN+FP)
= 1 - false positive rate SPIN = SPecificity rules IN Specificity |
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what value is desirable for specificity?
when would you use this test? |
value approaching 1 is also desirable for ruling in disease
- indicates a low false-positive rate, low threshold used as a confirmatory test after a positive screening test |
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HIV screening
what test is good to screen with? what test is good to run to confirm this diagnosis? |
Screen - ELISA
(sensitive, high false positive rate, low threshold) Confirm - Western Blot (specific, high false-negative rate, high threshold) |
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probability that a person has the disease if they test positive
how do you calculate? |
= TP/(TP+FP)
Positive Predictive Value (PPV) * If the prevalence of a disease in a population is low, even tests with high specificity or high sensitivity will have low PPVs |
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probability that a person testing negative is actually disease free
how do you calculate this? |
= TN/(FN+TN)
Negative predictive Value (NPV) |
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how do you calculate point prevalence?
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point prevalence = total cases in population at a given time/total population at a given time
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how do you calculate incidence?
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new cases in population over a given time period/total population at risk during that time period
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relationship b/w prevalence and incidence?
for chronic diseases? for acute diseases? |
prevalence = incidence x duration
chronic diseases(i.e. diabetes) - prevalence > incidence acute diseases (i.e. common cold) - prevalence = incidence |
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what groups are excluded when calculating incidence?
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1. people currently with the disease
2. those previously positive for it |
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odds of having disease in exposed group divided by odds of having disease in unexposed group
formula for calculating? |
odds ratio = (a/b)/(c/d) = ad/bc
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relative probability of getting a disease in the exposed group compared to the unexposed group
formula? |
Relative risk = a/(a+b)/c(c+d)
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the difference in risk between exposed and unexposed groups, or the proportion
OR the proportion of disease occurences that are attributable to the exposure (e.g. smoking causes one-third of cases of pneumonia) name? name of its reciprocal? |
Attributable risk
Number needed to harm |
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the reduction in risk associated with a treatment as compared to a placebo
name? name of its reciprocal? |
Absolute risk reduction
Number needed to treat |
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the consistency and reproducibility of a test (reliability)
OR the absence of random variation in a test reduced by what type of error? |
precision
reduced by random error |
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the trueness of test measurements (validity)
reduced by what type of error? |
accuracy
reduced by systematic error |
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nonrandom assignment to study group (e.g. Berkson's bias)
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selection bias
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knowledge of presence of disorder alters recall by subjects
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recall bias
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subjects are not representative relative to general populaton --> results are not generalizable
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sampling bias
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information gathered at an inapproprioate time - e.g. using a survey to study a fatal disease (only those patients still alive will be able to answer survey)
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procedure bias
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occurs with 2 closely associated factors; the effect of 1 factor distorts or confuses the effect of the other
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confounding bias
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early detection confused with ^ survival; seen with improved screening (natural history of disease is not changed, but early detection makes it seem as thought survival increase)
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Lead-time bias
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occurs when a researcher's belief in the efficacy of a treatment changes the outcome of that treatment
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Pygmalion effect
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occurs when the group being studied changes it behavior owing to the knowledge of being studied
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Hawthorne effect
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shape of a Gaussian distribution
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normal - bell shaped
mean = median |
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positive skew
where is most of the graph |
most on the lower end
mean > median > mode - tail on right |
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which metric (mean, median, mode) is least affected by outliers in the sample
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mode
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no association b/w the disease and the risk factor in the population
which hypothesis? what about when there IS a significant different(association) |
H0 - null hypothesis
H1 - alternative hypothesis |
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incorrectly stating that is IS an effect when none exists
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type I error (alpha)
- false positive - convicting an innocent man |
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incorrectly stating that there is NOT an effect when one exists
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type II error (beta)
- false negative - setting a guilty man free |
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probability of correctly rejecting the null hypothesis
formula? what does it depend on? (3) |
Power = 1-B (B= probability of a type II error)
depends on: 1) total number of end points experienced by population 2) difference in compliance b/w treatment groups (differences in the mean values between groups) 3) size of expected effect |
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how do you increase power?
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by increasing sample size
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standard deviation vs. standard error of the mean (SEM)
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1) SEM < standard deviation
2) SEM decreases as n (sample size) increases |
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range of values in which a specified probability of the means of repeated samples would be expected to fall
how to calculate? |
= range from [mean-Z(SEM)] to [mean+Z(SEM)]
confidence interval |
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95% of CI for a mean difference b/w 2 variables includes 0
course of action? what if it includes a 1? |
= no significant difference
H0 is NOT rejected if 95% Cl for odds ratio or relative risk includes a 1, then H0 is not rejected |
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checks the difference b/w the means of 2 groups
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t-test
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checks difference between the means of 3 or more groups
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ANOVA
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checks difference b/w 2 or more percentages or proportions of categorical outcomes (not mean values)
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chi-square
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what will be r value be when there is a strong correlation b/w 2 variables
formula for coefficient of determination? |
r will be close to 1
coefficient of determination = r^2 (value that is usually reported) |
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disease prevention
1) primary? 2) secondary 3) tertiary? |
primary - prevent disease occurence (vaccination)
secondary - early detection (pap smear) tertiary - reduce disability (chemotherapy) |
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which diseases are reportable in all states?
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Hep (A)
Hep (B) Hep (C) Horray (HIV) the S(almonella) S(higella) S(yphillis) M(easles) A(IDS) R(ubella) T(uberculosis) Chick(en pox) is Gone(orrhea) aka: 1) STDs 2) things you get vaccinated for 3) food poisoning |
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leading causes of death in the U.S.
infants |
1) congenital anomalies
2) sudden infant death syndrome 3) respiratory distress syndomr |
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leading causes of death in the U.S.
Age 1-14 |
1) injuries
2) cancer 3) congenital anomalies 4) homicide 5) heart disease |
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leading causes of death in the U.S.
Age 15-24 |
1) injuries
2) homicide 3) suicide |
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leading causes of death in the U.S.
Age 25-64 |
1) cancer
2) heart disease 3) injuries |
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leading causes of death in the U.S.
Age 65+ |
1) heart disease
2) cancer 3) stroke |
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what federal programs came from the Social Security Act and who are they each for?
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MedicarE - Elderly (>65, disabilities, ESRD)
MedicaiD - Destitute (federal+state) |
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parts of Medicare and their function?
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A - inpatient care (hospitals, nursing hospice, home care)
B - outpatient care, doctors services, PT/OT C - combination of A & B D - stand-alone prescription coverage |
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obligation to respect patients as individuals and to honor their preferences in medical care
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Autonomy
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Physicians have a special ethical (fiduciary) duty to act in the patients best interest. May conflict with autonomy. If the patient can make an informed decision, ultimately the patient has the right to decide
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Beneficence
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"Do no harm". However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries)
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Nonmaleficence
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To treat patients fairly
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Justice
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What are the legal requirements for informed consent?
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1. Discussion of pertinent information
2. Patient's agreement to the plan of care 3. Freedom from coercion Patient must understand the risks, benefits, and alternatives, which include no intervention |
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Exceptions to informed consent (4)
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1. patient lacks decision-making capacity or is legally incompetent
2. implied consent in an emergency 3. therapeutic priviledge - withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity 4. Waiver - patient waves the right of informed consent |
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consent for minors
exception? |
any person <18 years of age
- parental consent must be obtained exceptions - minor is emancipated (married, self-supporting, has children, military) |
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minor patient
in which cases is parental consent NOT required (5) |
1) emergency situations
2) contraceptives 3) STD treatment 4) pregnancy care 5) drug addiction |
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What components constitute decision-making capacity
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1) pt makes and communicates a choice
2) pt is informed 3) decision remains stable over time 4) decision is consistent with pt value's and goals 5) decision is not a result of delusions or hallucinations |
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can the pt's family require that a doctor withhold information from a pt?
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NO
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instructions given by a pt in anticipation of the need for a medical decision.
types? |
1) Oral
2) Living will 3) Durable power of attorney |
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How does an oral advance directive work?
what make's one more valid? |
incapacitated pt's prior oral statements commonly used as a guide
- problems arise from variance in interpretation more valid if: 1) if pt was informed 2) directive is specific 3) pt made a choice 4) decision was repeated over time, the oral |
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how does a living will work? (written advance directive)
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describes treatments the pt wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions
- pt usually directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state |
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how does durable power of attorney work?
advantage? |
pt designates a surrogate to make medical decisions in the event that he/she loses decision-making capacity. Pt may also specify decisions in clinical situations.
- surrogate retains power unless revoked by pt - more flexible than a living will |
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respecting pt privacy and autonomy. Disclosing information to family and friends should be guided by what the pt would want
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confidentiality
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exceptions to confidentiality (4)
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1) harm to self
2) harm to others 3) no altenative ways to warn or protect those at risk 4) physicians can take steps to prevent harm |
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exceptions to confidentiality
examples of situations when physicians can take steps to prevent harm |
1) infectious diseases - physicians have duty to warn public officials and identifiable people at risk
2) The Tarasoff decision - law requiring physician to directly inform and protect potential victim from harm, may involve breach of confidentiality 3) child and/or elder abuse 4) impaired automobile devices 5) suicidal/homicidal patients |
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requirements for civil malpractice suit under negligence (4)
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1)Duty - physician had duty to the pt
2) Dereliction - physician breached that duty (Dereliction) 3) Damage - pt suffers harm 4) Direct - breach of duty was what caused the harm |
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what is the most common factor leading to litigation?
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poor communication b/w physician and pt
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how is the burden of proof in a malpractice suit different than a criminal suit?
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criminal suit - "beyond a reasonable doubt"
malpractice suit - "more likely than not" |
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pt is noncompliant
how do you respond? |
- Attempt to identify pt's reason for noncompliance
- determine pt's willingness to change harmful behavior or undergo a necessary procedure - do not attempt to coerce the pt into complying or refer the pt to another physician |
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pt continues to smoke, believing that cigarettes are good for him
how do you respond? |
-ask how the pt feels about his/her smoking
- offer advice on cessation if the pt seems willing to make an effort to quit |
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pt desires an unnecessary procedure
how do you respond? |
- attempt to understand why the pt wants the procedure
- do not refuse to see the pt or refer him/her to another physician - addres the underlying concerns - avoid performing unnecessary procedures |
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pt has difficulty taking medications
how do you respond? |
- provide written instructions
- attempt to simplify treatment regimens |
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family members ask for information about pt's prognosis
how do you respond? |
avoid discussing issues with relatives without the permission of the pt
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a child wishes to know more about his illness
how do you respond? |
- ask what the parents have told the child about the illness
- parents of a child decide what information can be relayed about the illness |
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a 17-year old girl is pregnant and requests an abortion
how do you respond? |
- many states require parental notification or consent for minors for an abortion
- unless she is at medical rism, do NOT advise a pt to have an abortion regardless of her age or the condition of the fetus |
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15-year old girl is pregnant and wants to keep the child. Her parents want you to tell her to give the child up for adoption
how do you respond? |
- The pt retains the right to make decisions regarding her chikd, even if her parents diagree
- provide information to the teenager about the practical issues of caring for a baby - discuss the options, if requested - encourage discussion b/w the teenager and her parents to receive the best decision |
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a terminally ill pt requests physician assistance in ending his life
how do you respond? |
- in majority of states, refuse involvement in any form of physician-assisted suicide
- physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the pt's life |
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pt is suicidal
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- assess the seriousnesso f the threat
- if it is serious, suggest that the pt remain in the hospital voluntarily - pt can be hospitalized involuntarily if they refuse |
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pt states that he finds you attractive
how do you respond? |
ask direct, closed-ended questions and use a chaperone if necessary
- romantic relationshios with pt are NEVER appropriate - never say "There can be no relationship while you are a pt" because it implies that a relationship may be possible if the individual is no longer a pt |
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a middle-aged married woman who had a mastectomy says she feels "ugly" when she undresses
how do you respond? |
find out why the pt feels this way
- do not offer falsely reassuring statements (i.e. "you still look good") |
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pt is angry about the amount of time he spent in the waiting room
how do you respond? |
- acknowledge the pt's anger, but do not take a pt's anger personally
- apologize for any inconvenience - stay away from efforts to explain the delay |
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pt is upset with the way he was treated by another doctor
how do you respond? |
- suggest that the pt speak directly to that physician regarding his concerns
- if the problem is with a member of the office staff, tell the pt you will speak to that individual |
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a drug company offers a "referral fee" for every pt a physician enrolls in a study
how do you respond? |
- eligible pt who may benefit from the study may be enrolled, but it is NEVER acceptable for a physician to receive compensation from a drug company
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function of the Apgar score
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assessing newborn health via a 10-point scale evaluated at 1 minute and 5 minutes
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newborn infant is blue, has 0 pulse, no grimace, limp, and no respiration
Apgar score? |
0 pt each
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newborn infant has pink trunk, <100/min pulse, a grimace, some activity, and irregular respiration
Apgar score |
1 pt each
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newborn infant is all pink, >100/min pulse, grimace+cough, active, regular respiration
Apgar score |
2 pts each
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how is low birth weight defined?
associations? causes? |
<2500 g
- associated with greater incidence of physical and emotional problems - caused by prematurity or intrauterine growth retardation |
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pregnant mother has a premature infant
complications? |
1) infections
2) respiratory distress syndrome 3) necrotizing enterocolitis 4) intraventricular hemorrhage 5) persistent fetal circulation |
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infant
birth-3 mo motor milestone? cognitive/social milestone? |
motor - rooting
social - orients to voice |
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infant 3 mo
motor milestone? cognitive/social milestone? |
motor - holds head up, Moro reflex disappears
social - social smile |
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infant
7-9 mo motor milestone? cognitive/social milestone? |
motor - sits alone, crawls
social - stranger anxiety |
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infant 15 mo
motor milestone? cognitive/social milestone? |
motor - walks, Babinski disappears
social - few words, separation anxiety |
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Toddler
12-24 mo motor milestone? cognitive/social milestone? |
motor - climbs stairs, stacks 3 blocks at 1 year, 6 blocks at 2 years (number of blocks stacked = age in years X3)
social - object permanence; 200 words and 2-word sentences at age 2 |
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Toddler
24-36 mo motor milestone? cognitive/social milestone? |
motor - stacks 6-9 blocks
social - core gender identity, parallel play |
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Preschool
30-36 mo motor milestone? cognitive/social milestone? |
motor - stacks 9 blocks
social - toilet training (pee at age 3) |
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Preschool
3 years motor milestone? cognitive/social milestone? |
motor - rides tricycle (rides 3-cycle at age 3); copies line or circle drawing
social - 900 words and complete sentences |
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Preschool
4 years motor milestone? cognitive/social milestone? |
motor - simple drawings (stick figure), hops on 1 foot
social - cooperative play; imaginary friends; grooms self; brushes teeth; buttons and zips |
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Tanner stages of sexual development? (5)
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1. Childhood
2. Pubic hair appears (adrenarche); breasts enlarge 3. Pubic hair darkens and becomes curly; penis size/length ^ 4. Penis width ^, darker scrotal skin, development of glans, raised areolae 5. Adult; areolae are no longer raised |
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changes in the elderly? (7)
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1. sexual
2. sleep patterns 3. psychiatric disorders (decrease) 4. suicide (increase) 5. vision (decrease) 6.renal, pulmonary, GI function (decrease) 7. muscle, fat (decrease) |
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changes in the elderly
sexual |
men - slower erection/ejaculation, longer refractory period
women - vaginal shortening, thinning, and dryness |
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changes in the elderly
sleep patterns |
REM, slow-wave sleep decreases
latency and awakenings increase |
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changes in the elderly
incidence of psychiatric disorders |
decrease
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changes in the elderly
suicide rates |
increases (males 65-74 have highest rates in US)
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changes in the elderly
vision, hearing, immune response, bladder control |
decrease
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changes in the elderly
renal, pulmonary, GI function |
decrease
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changes in the elderly
muscle mass, fat |
decrease
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changes in the elderly
what is the only thing to really INCREASE in the elderly? |
suicide rate
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bereavement characterized by shock, denial, guilt, and somatic symptoms
- can last up to 2 months - may experience illusions |
normal grief
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intense grief
- lasting >2 months - is delayed, inhibited, or denied - may experience depressive symptoms, delusions, and hallucinations |
Pathologic grief
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Kubler-Ross grief stages
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1. Denial
2. Anger 3. Bargaining 4. Depression 5. Acceptance *stages do NOT necessarily occur in this ORDER, and >1 stage can be present at once` |
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behavior physiology - effects of stress
the production of what compounds is increased by stress? (5) |
production of:
- free fatty acids - 17-OH corticosteroids (immunosuppresion) - lipids - cholesterol - catecholamines |
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behavior physiology - effects of stress
affects which processes? (4) |
1. water absorption
2. muscular tonicity 3. gastrocolic reflex 4. mucosa circulation |
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sexual dysfunction
differential dx? |
1. drugs
2. disease 3. psychological |
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sexual dysfunction
possible drug causes? (4) |
1. anti-HTN
2. neuroleptics 3. SSRIs 4. ethanol |
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sexual dysfunction
possible disease causes? (2) |
1. depression
2. diabetes |
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sexual dysfunction
possible psychological causes? (1) |
performance anxiety
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how do you calculate BMI?
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BMI = (weight in kg)/[height in meteres)^2
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categories for BMI?
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<18.5 = underweight
18.5 - 24.9 = normal 25 - 29.9 = overweight >30.0 = obese >40.0 = morbidly obese |
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percentage of total sleep time in young adults:
light sleep? deeper sleep/bruxism? deepest, non-REM sleep? REM sleep? |
Stage 1: light sleep - 5%
Stage 2: deeper sleep - 45% Stage 3: deepest, non-REM sleep - 25% Stage 4: REM sleep - 25% |
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stages of sleep
eyes open, alert, active mental concentration EEG waveform? |
Beta - highest frequency, lowest amplitude
Awake (eyes open) |
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stages of sleep
Awake (eyes closed) |
Alpha
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stages of sleep
Light sleep wave form? |
Theta
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stages of sleep
deeper sleep, bruxism wave form? (2) |
Sleep spindles and K complexes
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stages of sleep
sleepwalking, night terrors, bedwetting wave forms? |
Delta - lowest frequency, highest amplitude
(slow-wave sleep aka deepest, non-REM sleep) |
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stages of sleep
dreaming, loss of motor tone, memory processing function, erections, ^ O2 use wave form? |
Beta
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what is the key to initiating sleep?
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serotonergic predominance of raphe nucleus
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effect of NE on sleep?
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reduces REM sleep
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what is responsible for extraocular movements during REM sleep?
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the PPRF (paramedian pontine reticular formation/conjugate gaze center)
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what is meant by the terms "paradoxical sleep" and "desynchronized sleep"
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refers to REM sleep having the same EEG waveforms as while awake and alert
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child pt has enuresis?
which drug do you use? mechanism? |
Imipramine
- reduces stage 4 sleep |
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what substances are associated with reduced REM and delta sleep? (3)
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1. alcohol
2. benzodiazepines 3. barbituates |
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child pt has night terrors and sleepwalks
which drug do you prescribe? |
benzodiazepines
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^ variable pulse
^ variable blood pressure penile/clitoral tumescence how often does it occur? what happens to its duration? what is the principle neurotransmitter involved? |
- occurs every 90 minutes
- duration increases over the night - ACh REM is like sex: - penile/clitoral tumescence - decreases with AGE |
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sleep pattern changes in depressed patients (6)
slow-wave sleep? REM latency? REM timing? totaly REM? nighttime awakenings? early-morning awakenings? |
1. slow-wave sleep (↓ )
2. REM latency (↓ ) 3. REM earlier in cycle 4. total REM sleep (^) 5. nighttime awakenings (^) 6. early-morning awakening (^) * important screening question |
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disrordered regulation of sleep-wake cycles
primary characteristic is excessive daytime sleepiness hynagogic? hypnopompic? |
hypnagogic - just before sleep
hypopompic - just before awakening |
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pt with narcolepsy
laughing hard after a joke and collapses suddenly condition? |
Cataplexy - loss of all muscle tone following a strong emotional stimulus
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nocturnal and narcopleptic sleep episodes start off with what type of sleep?
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REM
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naroleptic patient
what drugs do you use to treat him? |
1. stimulants (amphetamines, modafinil)
2. sodium oxybate (GHB) |
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what brain structure drives the circadian rhythm?
mechanism? what regulates this structure? |
driven by suprachiasmatic nucleus (SCN) of hypothalamus
- controls ACTH, prolactin, melatonin, nocturanl NE release SCN --> NE release --> pineal gland --> melatonin SCN regulated by light from the environment |
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periods of terror with screaming in the middle of the night
- most common in children - occurs during which phase? |
slow-wave sleep
Sleep terror disorder - no memory of arousal |
