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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
this type of study is usually observational and retrospective
case-control
this type of study is usually observational and prospective
cohort study
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
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
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
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
what 3 factors give a clinical trial study the highest quality?
1. randomized
2. controlled
3. double blind
clinical trial

- assessing safety, toxicity, and pharmakinetics on a small number of healthy volunteer patients

whats stage?
Phase I
clinical trial

- assessing treatment efficacy, optimal dosing, and adverse effects on a small number of patients with disease of interest

what stage?
Phase II
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
clinical trial
- detects rare or long-term adverse effects
- postmarketing surveillance of patients after approval

stage?
Phase IV
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
how do you evaluate a diagnostic test?
use a 2x2 table comparing test results with the actual presence of disease

TP/FP
TN/FN
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
what is a desirable value for sensitivity?
value approaching 1 is desirable for ruling out disease
- indicates a low false-negative rate

sensitivity
what diagnostic measure is used in disease with low prevalence?
sensitivity
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
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
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)
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
probability that a person testing negative is actually disease free

how do you calculate this?
= TN/(FN+TN)

Negative predictive Value (NPV)
how do you calculate point prevalence?
point prevalence = total cases in population at a given time/total population at a given time
how do you calculate incidence?
new cases in population over a given time period/total population at risk during that time period
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
what groups are excluded when calculating incidence?
1. people currently with the disease
2. those previously positive for it
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
relative probability of getting a disease in the exposed group compared to the unexposed group

formula?
Relative risk = a/(a+b)/c(c+d)
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
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
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
the trueness of test measurements (validity)

reduced by what type of error?
accuracy

reduced by systematic error
nonrandom assignment to study group (e.g. Berkson's bias)
selection bias
knowledge of presence of disorder alters recall by subjects
recall bias
subjects are not representative relative to general populaton --> results are not generalizable
sampling bias
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)
procedure bias
occurs with 2 closely associated factors; the effect of 1 factor distorts or confuses the effect of the other
confounding bias
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)
Lead-time bias
occurs when a researcher's belief in the efficacy of a treatment changes the outcome of that treatment
Pygmalion effect
occurs when the group being studied changes it behavior owing to the knowledge of being studied
Hawthorne effect
shape of a Gaussian distribution
normal - bell shaped
mean = median
positive skew
where is most of the graph
most on the lower end
mean > median > mode
- tail on right
which metric (mean, median, mode) is least affected by outliers in the sample
mode
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
incorrectly stating that is IS an effect when none exists
type I error (alpha)
- false positive
- convicting an innocent man
incorrectly stating that there is NOT an effect when one exists
type II error (beta)
- false negative
- setting a guilty man free
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
how do you increase power?
by increasing sample size
standard deviation vs. standard error of the mean (SEM)
1) SEM < standard deviation
2) SEM decreases as n (sample size) increases
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
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
checks the difference b/w the means of 2 groups
t-test
checks difference between the means of 3 or more groups
ANOVA
checks difference b/w 2 or more percentages or proportions of categorical outcomes (not mean values)
chi-square
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)
disease prevention

1) primary?
2) secondary
3) tertiary?
primary - prevent disease occurence (vaccination)

secondary - early detection (pap smear)

tertiary - reduce disability (chemotherapy)
which diseases are reportable in all states?
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
leading causes of death in the U.S.
infants
1) congenital anomalies
2) sudden infant death syndrome
3) respiratory distress syndomr
leading causes of death in the U.S.

Age 1-14
1) injuries
2) cancer
3) congenital anomalies
4) homicide
5) heart disease
leading causes of death in the U.S.

Age 15-24
1) injuries
2) homicide
3) suicide
leading causes of death in the U.S.

Age 25-64
1) cancer
2) heart disease
3) injuries
leading causes of death in the U.S.

Age 65+
1) heart disease
2) cancer
3) stroke
what federal programs came from the Social Security Act and who are they each for?
MedicarE - Elderly (>65, disabilities, ESRD)

MedicaiD - Destitute (federal+state)
parts of Medicare and their function?
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
obligation to respect patients as individuals and to honor their preferences in medical care
Autonomy
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
Beneficence
"Do no harm". However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries)
Nonmaleficence
To treat patients fairly
Justice
What are the legal requirements for informed consent?
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
Exceptions to informed consent (4)
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
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)
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
What components constitute decision-making capacity
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
can the pt's family require that a doctor withhold information from a pt?
NO
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
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
how does a living will work? (written advance directive)
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
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
respecting pt privacy and autonomy. Disclosing information to family and friends should be guided by what the pt would want
confidentiality
exceptions to confidentiality (4)
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
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
requirements for civil malpractice suit under negligence (4)
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
what is the most common factor leading to litigation?
poor communication b/w physician and pt
how is the burden of proof in a malpractice suit different than a criminal suit?
criminal suit - "beyond a reasonable doubt"

malpractice suit - "more likely than not"
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
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
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
pt has difficulty taking medications

how do you respond?
- provide written instructions
- attempt to simplify treatment regimens
family members ask for information about pt's prognosis

how do you respond?
avoid discussing issues with relatives without the permission of the pt
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
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
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
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
pt is suicidal
- 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
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
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")
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
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
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
function of the Apgar score
assessing newborn health via a 10-point scale evaluated at 1 minute and 5 minutes
newborn infant is blue, has 0 pulse, no grimace, limp, and no respiration

Apgar score?
0 pt each
newborn infant has pink trunk, <100/min pulse, a grimace, some activity, and irregular respiration

Apgar score
1 pt each
newborn infant is all pink, >100/min pulse, grimace+cough, active, regular respiration

Apgar score
2 pts each
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
pregnant mother has a premature infant

complications?
1) infections
2) respiratory distress syndrome
3) necrotizing enterocolitis
4) intraventricular hemorrhage
5) persistent fetal circulation
infant
birth-3 mo

motor milestone?
cognitive/social milestone?
motor - rooting

social - orients to voice
infant 3 mo

motor milestone?
cognitive/social milestone?
motor - holds head up, Moro reflex disappears

social - social smile
infant
7-9 mo

motor milestone?
cognitive/social milestone?
motor - sits alone, crawls

social - stranger anxiety
infant 15 mo

motor milestone?
cognitive/social milestone?
motor - walks, Babinski disappears

social - few words, separation anxiety
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
Toddler
24-36 mo

motor milestone?
cognitive/social milestone?
motor - stacks 6-9 blocks

social - core gender identity, parallel play
Preschool
30-36 mo

motor milestone?
cognitive/social milestone?
motor - stacks 9 blocks

social - toilet training (pee at age 3)
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
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
Tanner stages of sexual development? (5)
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
changes in the elderly? (7)
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)
changes in the elderly

sexual
men - slower erection/ejaculation, longer refractory period

women - vaginal shortening, thinning, and dryness
changes in the elderly

sleep patterns
REM, slow-wave sleep decreases

latency and awakenings increase
changes in the elderly

incidence of psychiatric disorders
decrease
changes in the elderly

suicide rates
increases (males 65-74 have highest rates in US)
changes in the elderly

vision, hearing, immune response, bladder control
decrease
changes in the elderly

renal, pulmonary, GI function
decrease
changes in the elderly

muscle mass, fat
decrease
changes in the elderly


what is the only thing to really INCREASE in the elderly?
suicide rate
bereavement characterized by shock, denial, guilt, and somatic symptoms
- can last up to 2 months
- may experience illusions
normal grief
intense grief
- lasting >2 months
- is delayed, inhibited, or denied
- may experience depressive symptoms, delusions, and hallucinations
Pathologic grief
Kubler-Ross grief stages
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`
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
behavior physiology - effects of stress

affects which processes? (4)
1. water absorption
2. muscular
tonicity
3. gastrocolic reflex
4. mucosa circulation
sexual dysfunction

differential dx?
1. drugs
2. disease
3. psychological
sexual dysfunction

possible drug causes? (4)
1. anti-HTN
2. neuroleptics
3. SSRIs
4. ethanol
sexual dysfunction

possible disease causes? (2)
1. depression
2. diabetes
sexual dysfunction

possible psychological causes? (1)
performance anxiety
how do you calculate BMI?
BMI = (weight in kg)/[height in meteres)^2
categories for BMI?
<18.5 = underweight
18.5 - 24.9 = normal
25 - 29.9 = overweight
>30.0 = obese
>40.0 = morbidly obese
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%
stages of sleep

eyes open, alert, active mental concentration

EEG waveform?
Beta - highest frequency, lowest amplitude

Awake (eyes open)
stages of sleep

Awake (eyes closed)
Alpha
stages of sleep

Light sleep

wave form?
Theta
stages of sleep

deeper sleep, bruxism

wave form? (2)
Sleep spindles and K complexes
stages of sleep

sleepwalking, night terrors, bedwetting

wave forms?
Delta - lowest frequency, highest amplitude

(slow-wave sleep aka deepest, non-REM sleep)
stages of sleep

dreaming, loss of motor tone, memory processing function, erections, ^ O2 use

wave form?
Beta
what is the key to initiating sleep?
serotonergic predominance of raphe nucleus
effect of NE on sleep?
reduces REM sleep
what is responsible for extraocular movements during REM sleep?
the PPRF (paramedian pontine reticular formation/conjugate gaze center)
what is meant by the terms "paradoxical sleep" and "desynchronized sleep"
refers to REM sleep having the same EEG waveforms as while awake and alert
child pt has enuresis?

which drug do you use?
mechanism?
Imipramine
- reduces stage 4 sleep
what substances are associated with reduced REM and delta sleep? (3)
1. alcohol
2. benzodiazepines
3. barbituates
child pt has night terrors and sleepwalks

which drug do you prescribe?
benzodiazepines
^ 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
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
disrordered regulation of sleep-wake cycles

primary characteristic is excessive daytime sleepiness

hynagogic?
hypnopompic?
hypnagogic - just before sleep
hypopompic - just before awakening
pt with narcolepsy

laughing hard after a joke and collapses suddenly



condition?
Cataplexy - loss of all muscle tone following a strong emotional stimulus
nocturnal and narcopleptic sleep episodes start off with what type of sleep?
REM
naroleptic patient

what drugs do you use to treat him?
1. stimulants (amphetamines, modafinil)
2. sodium oxybate (GHB)
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
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