Behavioral Science

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Case control study

Back 1

-observational and retrospective
-uses odds ratio
-Compares group of people with disease to a group without

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Cohort study

Back 2

-observational and prospective
-uses relative risk
-compares given risk factor to assess whether the risk factor increases likelihood of disease

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Cross-sectional study

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-observational
-uses disease prevalence
-collects data to assess frequency of disease at particular time
-can show risk factors association but not causality

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Twin-concordance study

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-frequency with which monozygotic or dizygotic twins develop a disease
-measures heretabilty

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Adoption study

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-compares siblings raised by biologic vs adoptive parents
-measures hereitabilty and influence of environmental factors

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Clinical trial phase I

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Study sample-small healthy volunteers
purpose-assesses safety toxicity and pharmacokinetics

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Clinical trial phase II

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Sample-small with disease of interest
purpose-treatment efficacy, dosing, adverse effects

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Clinical trial phase III

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sample-large randomly assigned to treatment or placebo
purpose-compare new treatment to current standard

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meta-analysis

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-pools data from several studies to come to overall conclusion (integrates results)
-limited by quality of individual studies or bias in study selection

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Sensitivity

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-ability to test disease when present
-value close to one is desirable for ruling out disease and indicates low false negative rate
-used for screening disease with low prevalence
=tp/(tp+fn)
=1-fn

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specificity

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-ability to indicate no disease when no disease present
-value close to one rules in disease
-used to confirm after positive screening test
=tn/(tn+fp)
=1-fp

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positive predictive value (ppv)

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- if prevalence of a disease in a population is low even tests with high specificity or high sensitivity will have low positive predictive values
=tp/(tp+fp)

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negative predictive value (npv)

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=tn/(tn+fn)

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point prevalence
incidence

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-total cases at a given time/total at risk at a given time
-new cases in population over given time/total at risk during that time

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odds ratio

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(a/b)/(c/d)

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relative risk

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(a/(a+b))/(c/(c+d))

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attributable risk

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a/(a+b)-c/(c+d)

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absolute risk reduction

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reduction in risk associated with a treatment as compared to a placebo

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number needed to treat

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1/absolute risk reduction

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number needed to harm

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1/attributable risk

Front 21

precision

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-consistency and reproducibility of a test
-absence of random variation of a test
-reduced by random error

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accuracy

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-trueness of test measurements
-reduced by systematic error

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selection bias (berksons bias)

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nonrandom assignment to study group

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recall bias

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knowledge of presence of disorder alters recall by subjects

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sampling bias

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subjects not representative relative to general population

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late-look bias

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information gathered at an inappropriate time

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procedure bias

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subjects in different groups not treated the same

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confounding bias

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occurs with 2 closely associated factors; one factor affects the other

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lead time bias

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early detection confused with increased survival; improved screening

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pygmalion effect(Rosenthal)

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researcher's belief in efficacy of a treatment changes outcome of that treatment

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hawthorne effect

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group gains awareness of being studied and changes behavior

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ways to reduce bias

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-blind studies
-placebo
-crossover studies(each patient is their own control)
-randomization

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positive skew

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mean>median>mode

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negative skew

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mean<median<mode

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normal (gaussian)

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mean=median=mode

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bimodal

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two humps
mode least affected by outliers

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Type I error (alpha)

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-false positive error
-use p

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Type II error (beta)

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-false negative error
-not enough power

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power

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1-B
-total number of end points experienced by pop
-difference in compliance between treatment groups
-size of expected effect

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standard error of measurement (SEM)

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=sigma/sqrt(n)
-68,95,99.7

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confidence interval

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=mean+-Z(SEM)
z=1.96 with p=.05 and 95% CI

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t-test

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difference between means of 2 groups

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ANOVA

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analysis of variance between 3 or more groups

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x2

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difference between 2 or more percentages of categorial outcomes

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correlation coefficient
coeffecient of determination

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between -1 and +1
=r2

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disease prevention

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PDR
prevent
detect
reduce disability

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reportable disease

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Hep ABC HIV samonella shigella syphilis measles mumps AIDS rubella tuberculosis chickenpox gonorrhea

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leading causes of death
(infants)

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congenital anomalies, short gestation, sudden infant death syndrome, materal complications, respiratory distress syndrome

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leading causes of death (1-14)

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injuries, cancer, congenital anomalies, homicide, heart disease

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leading causes of death (15-24)

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injuries, homocide, suicide, cancer, heart disease

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leading causes of death (25-64)

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cancer, heart disease, injuries, suicide, stroke

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leading causes of death (65+)

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heart disease, cancer stroke, COPD, pneumonia, influenza

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autonomy

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honor patients' preferences in medical care

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beneficence

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act in patients' best interest
ultimately patient makes decision

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nonmaleficence

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do no harm
benefits outweigh risks patient can make informed decision

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justice

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treat persons fairly

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informed consent

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-discussion of pertinent information
-patient's agreement to plan of care
-freedom from coercion

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exceptions to informed consent

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-legally incompetent
-implied consent in emergency
-therapeutic privilege
-waiver

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decision-making capacity criteria

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-patient makes and communicates choice
-patient is informed
-decision remains stable
-consistent with values and goals
-not a result of delusions or hallucinations

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oral advance directive

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prior oral statements used as guide
if patient is capable of making decisions then oral directive is used

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written advance directive

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living will
durable power of attorney-surrogate decision maker can be revoked by patient

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exceptions to confidentiality

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-harm to others
-harm to self
-no other way to warn others
-some infections
-tarasoff decision-must inform potential victim
-child/elder abuse
-impaired auto drivers
-suicidal/homocidal patients

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4 d's of malpractice

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duty
dereliction
damage
direct
most commonly poor communication

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apgar

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1 and 5 minutes after birth
appearance, pulse, grimace, activity, respiration
p 61

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low birth weight

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<2500g
complications-infections, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, persistent fetal circulation
caused by prematurity or intrauterine growth retardation

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birth-3 mo

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rooting reflex
orients to voice

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3 mo

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holds head up
moro reflex disappears
social smile

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7-9 mo

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sit alone, crawls
stranger anxiety

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15 mon

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walks babinski disappears
few words separation anxiety

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12-24 monts

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climb stairs, stacks 3 and 6 blocks
object permanence, 200 words 2 word sentences at 2

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24-36 mo

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core gender identity, parallel play

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30-36 mo

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stack 9 blocks
pee at 3

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3 yrs

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rides tricycle; copies line or circle
900 words and complete sentences

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4 yrs

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simple drawings, hops on one foot
cooperative play, imaginary friends, grooms self, brushes teeth, buttons, zips

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sensorimotor

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birth to 2
egocentric exploration with 5 senses
use objects to obtain goal
object permanence obtained

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preoperational stage

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2-7
motor skills
magical thinking predominates no logical thinking

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concrete operational stage

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7-12
start of logical thinking
no longer egocentric

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formal operational stage

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12+
abstract reasoning

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Tanner stages

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1-childhood
2-pubic hair appears, breasts enlarge
3-pubic hair darkens and curls
4-darker scrotal skin development of glans, raised areolae
5-adult; areola no longer raised

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Kubler-Ross grief stages
death arrives bringing grave adjustments

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denail, anger bargaining grieving depression acceptance

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sexual dysfunction
differential diagnosis

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drugs (antihypertensives, neuroleptics, SSRIs, ethanol), diseases (diabetes depression), psychologic (performance anxiety)

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BMI

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weight in kg/height in m sq
<18.5 underweight
18.5-24.9 normal
25-29.9 overweight
>30 obese
>40 morbidly obese

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stress effects

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-produce free fatty acids,17-OH corticosteroids (immunosuppression)
lipids cholesterol catecholamines; water absorption muscular tonicity, gastrocolic reflex, mucosal circulation

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grief

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shock denial guilt somatic symptomsusually 6 mo to a year sometimes illusions
pathologic grief-excessively intense or prolonged, delayed, ihibited or denied, may experience depression, delusions, hallucinations

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narcolepsy

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-disordered regulation of sleep wake cycles
-hypnagogic and hypnopompic hallucinations sometimes
-early REM
-cataplexy with emotional stimulus

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circadian rhythm

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suprachiasmatic nucleus of hypothalamus
SCN-NE realease-pineal gland-melatonin
regulated by light and also controls ACTH, prolactin, melatonin, noctural NE release

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REM sleep
like sex

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-increase pulse clitoral tumescence
-decrease with age
-incerase blood pressure
-duration increases throughout night
-ACh principal neurotransmitter

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Awake eyes open
awake closed

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-Beta (highest frequency and lowest amplitude)
-Alpha

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stage 1 sleep

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5% light sleep Theta

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Stage 2 sleep

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45% deeper sleep
bruxism
sleep spindles and k complexes

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stage 3/4 sleep

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25 % deep sleep
delta-lowest frequency highest amplitude
sleepwalking night terrors bedwetting
treated by benzodiazepines and imipramine

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REM sleep

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beta waves
dreaming, loss of motor tone, memory processing functions, increase brain o2 use, erections