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121 Cards in this Set

  • Front
  • Back
Case Control Study
Observational and RETROspective. Compares a group of people with DISEASE to a group without a disease. Asks the question, "what happened?"

Associated with Odds Ratio
Ex: Patients with COPD had higher odds of a history of smoking than those without COPD.
Cohort Study
Observational and PROspective
Compares a group of people with a given RISK FACTOR to a group of people without risk factor to assess whether the risk factor increases the likelihood of a disease. Asks the question, "what will happen?"

Associated with Relative Risk
Ex: Smokers had a higher risk of developing COPD than did nonsmokers
Cross-Sectional Study
Observational and Acute
Collects data from a group of people to assess frequency of disease(and related risk factors) to a particular point in time. Asks the question, "What is happening?"

Associated with Disease Prevalence. Important to note that you can show risk factors association with disease but DOES NOT establish causality.
Describe a Twin Concordance Study. What does it measure?
Compares the frequency for which monozygotic or dizygotic twins develop a disease. This measures heritability.
Describe an Adoption Study. What does it measure?
Compares siblings raised by biologic vs adoptive parents. Measures heritability and influence of environmental factors.
What do you use clinical trials for? What qualities determine quality of trial?
Study involving humans that compares two or more treatments or of a given treatment to a placebo.

The highest quality study is controlled, randomized and double blinded.
Phase I Clinical Trials
Small number of healthy volunteers. This assesses the safety, toxicity, and pharmacokinetics of the drug.
Phase II Clinical Trials
Small number of patients with disease of interest. Assesses the treatment efficacy, optimal dosing, and adverse side effects.
Phase III Clinical trials
large number of patients randomly assigned either to treatment under investigation or the best available accepted treatment(or if no treatment, placebo).

This compares the new treatment to the current standard of care.
Meta-Analysis
Pools data from several studies to come to an overall conclusion. Achieves greater statistical power and integrates results of similar studies. HIGHEST echelon of clinical evidence.

Cons - May be limited by quality of individual studies or bias in study selection.
Sensitivity
The ability of a test to detect a disease when it is present. Value approaching one is desirable to rule OUT a disease(SNOUT) and indicates a low false negative rate(FN/FN+TP)

Sensitivity = TP/(TP + FN)
Specificity
The ability of a test to indicate non-disease when a disease is not present. Value approaching 1 is desirable for ruling IN a disease(SPIN) and indicates a low false positive rate. Used as a confirmatory test AFTER a positive screening test.

Specificity = TN/(TN+FP)

Example: HIV testing. You screen with ELISA which is very sensitive, high FPR, and low threshold and then after that you confirm with Western Blot which is specific, high FNR and a high threshold.
Positive Predictive Value(PPV)
Probability that a person actually has the disease after being given a positive result.

PPV = TP/(TP+FP)
What can cause confoundingly low PPVs?
If the prevalence of a disease is really low, even tests with high specificity/sensitivity will have low PPVs
Negative Predictive Value(NPV)
Probability that a person is disease free after being given a negative test result.

NPV = TN/(TN+FN)
Point Prevalence
Point Prevalence =
(Total Cases in Population at a given time) / (total population at risk at a given time)
Incidence
(NEW cases in population over a given period of time) / (total population at risk during that time)

Note: REMEMBER when calculating incidence people who currently have the disease are not considered part of the population at risk.
Prevalence
Prevalence ≅ Incidence * disease duration

Obviously,
prevalence > incidence for chronic disease and
prevalence = incidence in acute disease.
Odds Ratio for case controlled studies
The odds of having a disease in an exposed group divided by the odds of having the disease in an unexposed group

This approximates relative risk IF prevalence of disease is not too high.

Odds Ratio = (a/b)/(c/d) = ad/bc
Relative Risk for Cohort Studies
Relative probability of getting a disease in the exposed group compared to the unexposed group.

Relative Risk = Probability of disease in exposed / Probability of disease in unexposed

Relative Risk = a/(a+b) / c/(c+d)
Attributable Risk
The difference in risk between exposed and unexposed groups, or the proportion of disease occurrences that are attributable to the exposure

Attributable Risk = a/(a+b) - c/(c+d)
Absolute Risk Reduction
The reduction in risk associated with a treatment compared to a placebo
Number needed to Treat(NNT)
NNT = 1/Absolute Risk Reduction

The ideal NNT is 1, where everyone improves with treatment and no one improves with control. The higher the NNT, the less effective is the treatment.

This means that if NNT individuals are treated with the experimental treatment, 1 will be cured of the disease that would not have otherwise.
Number needed to Harm(NNH)
NNH = 1/Attributable Risk

This means that if NNH individuals are exposed to the risk factor, 1 will develop the disease that would not have otherwise.
Precision
The consistency and reproducibility of a test(Reliability) as well as the absence of random variation.
Accuracy
The trueness of test measurements.
Systematic Error
Reduces accuracy
Random Error
Reduces precision
Ways to reduce bias...
Blind Studies, Placebo responses, Crossover Studies(each subject acts as own control), and randomization.
Selection bias
non-random assignment to study group.
Recall bias
knowledge of presence of disorder alters recall by subjects.
Sampling bias
subjects are not representative relative to general population; therefore results are not generizable
Late-look bias
information gathered at an inappropriate time.

e.g. using a survey to study a fatal disease(only those subjects still alive will be able to answer survey)
Procedure bias
subjects in different groups are not treated the same.

e.g. more attention is paid to the experimental group, stimulating greater compliance.
Confounding bias
occurs with two closely associated factors; the effect of one factor distorts or confuses the effect of another.
Lead-time bias
early detection confused with increased survival; seen with improved screening.(natural history of disease is not changed, but early detection makes it seem as though survival increased).
Pygmalion Effect
Occurs when a researchers belief in the efficacy of a treatment changes the outcome of that treatment
Hawthorne Effect
Occurs when the group being studied changes its behavior owing to the knowledge of being studied.
Positive Skew
mean > median > mode

Asymmetry with tail on the right.
Negative Skew
mean < median < mode

Asymmetry with tail on the left.
Which statistically significant number is least effected by outliers in the sample?
the mode.
The Null Hypothesis(H0)
There is no statistical difference between the disease and the risk factor. Hypothesis of no difference.
The Alternative Hypothesis(H1)
There is some association between the disease and the risk factor.
Type I Error(α)
Stating that there is an effect or difference when none exists. In other words, to mistakenly accept the alternative hypothesis when the null hypothesis is true.

p = the probability of making a type I error. p is judged against α, a preset level of significance, usually less than 0.05. "False-positive error"

Similar to convicting an innocent man. Related to specificity.
Type II Error(β)
Stating that there is NOT an effect or difference when one exists.(To accept the null hypothesis when the alternative hypothesis is true. In other words, failing to reject the null hypothesis.)
β is the probability of making a Type II error. "False-negative error".

Similar to setting a guilty man free. Related to sensitivity.
Statistical Power(1-β)
Probability of rejecting the null hypothesis when it is in fact false, or the likelihood of finding a difference if one in fact exists. It depends on:
1.) Total number of end points experienced by population
2.) Difference in compliance between treatment groups(differences in the mean values between groups)
3.) Size of expected effect(preset level of significance for p. Raises likelihood of Type I error but reduces likelihood of Type II error)

Notably, if you increase sample size, you increase power. There is power in numbers.

Again, related to sensitivity since it is dependent on β.
Standard Error of the Mean(SEM)
The standard deviation of a sample of means from a given population.

SEM = σ/√n
Confidence Interval
An interval in which you can say contains the true parametric mean with 95% certainty.

CI = mean ± 1.96(SEM)

If the 95% CI for a mean difference between 2 variables includes 0, then there is no significant difference and the null hypothesis cannot be rejected. If the 95% CI for the odds ratio or relative risk includes 1, then the null hypothesis cannot be rejected.
If the CI between 2 groups overlaps, then these groups are not significantly different.
T-Test
T-test checks difference between the means of two groups.

Mr.T is mean
ANOVA
ANOVA checks the difference between the means of 3 or more groups.

ANOVA = Analysis of Variance of 3 or more variables.
χ²(Chi-squared Test)
χ² checks difference between 2 or more percentages or proportions of categorical outcomes.(not mean values).

χ² = compare percentages or proportions.
Correlation Coefficient(r)
value between -1 and 1 representing the degree of linear relationship between two values. The closer to 1, the stronger the relationship.
Coefficient of Determination(r²)
The coefficient of determination represents the percent of the data that is the closest to the line of best fit. For example, if r = 0.922, then r 2 = 0.850, which means that 85% of the total variation in y can be explained by the linear relationship between x and y(as described by the regression equation). The other 15% of the total variation in y remains unexplained.
Disease Prevention
1° - Prevent disease occurrence(Vaccination)

2° - Early detection of disease(Pap smear)

3° - Reduce disability from disease(chemotherapy)

PDR - Prevent, Detect, Reduce Disability
Important Prevention Measures
Diabetes
Drug Use
Alcoholism
Overweight
Homeless, recent immigrant, inmate
High-risk Sexual behavior
Diabetes - Eye, foot exams; urine tests

Drug use - Hepatitis Immunizations; HIV, TB Tests

Alcoholism - Influenza, pneumococcal immunizations; TB Test

Overweight - Blood sugar test for Diabetes

Homeless, Recent immigrant, inmate - TB Test

High-risk Sexual Behavior - HIV, Hepatitis B, Syphilis, Gonorrhea, Chlamydia tests
Reportable Diseases
Reportable in ALL states - AIDS, chickenpox, gonorrhea, hepatitis A and B, measles, mumps, rubella, salmonella, shigella, syphilis, and TB.

Variable reportability - Hep, Hep, Hep, Hooray, the SSSMMART Chick is Gone!

--Hep A
--Hep B
Hep C
HIV
--Salmonella
--Shigella
--Syphilis
--Measles
--Mumps
--AIDS
--Rubella
--Tuberculosis
--Chickenpox
--Gonorrhea
Leading Causes of Death in the US by Age --

Infants
Congenital Anomalies, short gestation/low birth weight, sudden infant death syndrome, maternal complications of pregnancy, respiratory distress syndrome
Leading Causes of Death in the US by Age --

Age 1-14
Injuries, cancer, congenital anomalies, homicide, heart disease
Leading Causes of Death in the US by Age --

Age 15-24
injuries, homicide, suicide, cancer, heart disease
Leading Causes of Death in the US by Age --

Age 25-64
cancer, heart disease, injuries, suicide, stroke
Leading Causes of Death in the US by Age --

Age 65+
heart disease, cancer, stroke, COPD, pneumonia, influenza
Health Care Payment

Medicare vs Medicaid
Insurance for children
Capitation based payment
MedicarE is for Elderly
MedicaiD is for Destitute

Medicare Part A = hospital
Medicare Part B = doctor bills

CHIP = Children's Health Insurance Program.

Capitation basis payment for physicians = fixed payment for period of time, regardless of number of procedures.
Core Ethical Principles -

Autonomy
Obligation to respect patients as individuals and to honor their preferences in medical care.
Core Ethical Principles -

Beneficence
Physicians have special ethical(fiduciary) duty to act in the patient's best interest. May conflict with autonomy. If the patient can make an informed decision, ultimately the patient has the right to decide.
Core Ethical Principles -

Non-maleficence
"Do no harm." However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed(most surgeries)
Core Ethical Principles -

Justice
To treat people fairly.
Informed Consent legally requires...
Legally requires:
1.) Discussion of pertinent information
2.) Patient's agreement to the plan of care
3.) Freedom from coercion

In other words, the patient must understand the risks, benefits, and alternatives, which include no intervention.
Exceptions to Informed Consent
1.) Patient lacks DMC or is legally incompetent

2.) Implied consent in an emergency

3.) Therapeutic Privilege - withholding information when disclosure would severely harm the patient or undermine informed DMC

4.) Waiver - patient waives the right of informed consent.
Consent for minors
Parental consent must be obtained unless minor is emancipated(married, self-supporting, has children or is in military)
Decision-making Capacity -

5 requirements and common problem associated with family.
1.) Patient makes and communicates a choice

2.) Patient is informed

3.) Decision remains stable over time.

4.) Decision is consistent with the patient's values and goals.

5.) Decision is not a result of delusions or hallucinations

The patient's family CANNOT require that a doctor withhold information from a patient.
Oral Advance Directive -

discuss validity
Incapacitated patient's prior oral statement commonly used as a guide. Problems arise from variance in interpretation. If the patient was informed, directive is specific, patient made a choice, and decision was repeated over time, the oral directive is more valid.
Written advance directive -

Living Will
Living Will

describes treatments the patient wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions. Usually, patient directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state.
Written advance directive -

Durable Power of Attorney
Durable Power of Attorney

patient designates a surrogate to make medical decisions in the event that he/she loses DMC. Patient may also specify decisions in clinical situations. Surrogate retains power unless revoked by patient. More flexible than a living will.
Confidentiality
Confidentiality respects patient privacy and autonomy. Disclosing information to family and friends should be guided by what the patient would want. The patient may waive the right to confidentiality(e.g. insurance companies)
Exceptions to Confidentiality -

List 4 common exceptions and 5 common examples
1.) Potential harm to others is serious
2.) Likelihood of harm to self is great
3.) No alternative means exist to warn or to protect those at risk
4.) Physician can take steps to prevent harm

Examples include:
-- Infectious diseases: Physicians may have a duty to warn public officials and identifiable people at risk.
-- The Tarasoff decision: law requiring physicians to inform and protect potential victim from harm; may involve breach of confidentiality.
-- Child and/or elder abuse
-- Impaired automobile drivers
-- Suicidal/homicidal patients: physicians may hold patients involuntarily for a period of time.
Malpractice -

Legal Parameters
Most common factor leading to litigation
Burden of proof
Civil Suit under negligence requires:
1.) Physician had a duty to the patient(Duty)
2.) Physician breached that duty(Dereliction)
3.) Patient suffers harm(Damage)
4.) The breach of duty is what caused the harm(Direct)

The most common factor leading to litigation is poor communication between physician and patient.

The 4 D's - Duty, Dereliction, Damage, Direct.

Unlike a criminal suit, in which the burden of proof is "beyond a reasonable doubt," the burden of proof in a malpractice suit is "more likely than not".
Good Samaritan Law
Relieves healthcare workers, as well as laypersons in some instances, from liability in certain emergency situations with the objective of encouraging health care workers to offer assistance without expectation of compensation.
Ethical Situations -

Patient is non-compliant
Work to improve the physician-patient relationship
Ethical Situations -

Patient has difficulty taking medications
Provide written instructions; attempt to simplify treatment regimens.
Ethical Situations -

Family member asks for information about patient's prognosis
Avoid discussing issues with relatives without the permission of the patient.
Ethical Situations -

A 17-year old girl is pregnant and requests an abortion

When is parental consent required? What is parental consent NOT required for?
Many states require parental notification or consent for minors for an abortion.

Parental consent is NOT required for emergency situations, treatment of STDs, medical care during pregnancy, and management of drug addiction.
Ethical Situations -

A terminally ill patient requests physician assistance in ending his life
In the overwhelming majority of states, refuse involvement in any form of physician assisted suicide. Physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient's life.
Ethical Situations -

Patient states that he/she finds you attractive
Ask direct, closed-ended questions and use a chaperone if necessary. Romantic relationships with patients are NEVER appropriate(excluding the smoking hot women). Never say, "there can be no relationship while you are a patient" because that implies that a relationship may be possible if the individual is no longer a patient.
Ethical Situations -

Patient refuses a necessary procedure or desires an unnecessary one
Attempt to understand why the patient wants/does not want the procedure. Address the underlying concerns. Avoid performing unnecessary procedures.
Ethical Situations -

Patient is angry about the amount of time spent in the waiting room
Apologize to the patient for any inconvenience. STAY AWAY from efforts to explain the delay.(Unless it is to say "Sorry, I was banging one of the really hot patients" in which case he/she will forgive you)
Ethical Situations -

Patient is upset with the way he/she was treated by another doctor
Suggest that the patient speak directly to that physician regarding his/her concerns. If the problem is with a member of the office staff, tell the patient you will speak to that individual.(but not really because your a wimp and avoid confrontation)
Ethical Situations -

A child wishes to know more about his illness
Ask what the parents have told the child about the illness. Parents of a child determine what information can be relayed about the illness.
Ethical Situations -

Patient continues to smoke, believing that cigarettes are good for him.
Ask how the patient feels about his/her smoking. Offer advice on cessation if the patient seems willing to make an effort to quit.
Ethical Situations -

Minor under 18 requests condoms
Physicians can provide counsel and contraceptives to minors without a parent's knowledge or consent.
Ethical Situations -

A drug company offers a "referral fee" for every patient a physician enrolls in a study.
Eligible patients who may benefit from the study may be enrolled, but it is never acceptable for a physician to receive compensation from a drug company.
APGAR score

definition?
evaluated at?
Low Birth Weight -

Definition?
Associated with?
Caused by?
Complications?
Defined as <2500 grams. Associated with higher incidence of physical and emotional problems. Caused by prematurity or intrauterine growth retardation. Complications include infections, Respiratory Distress Syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and persistance fetal circulation.
Early Developmental Milestones -
Birth - 3 months
Motor Milestone - Rooting reflex

Cognitive/Social Milestone - Orients to voice
Early Developmental Milestones -

3 months
Motor Milestone - Moro reflex disappears

Cognitive/Social Milestone - Social Smile
Early Developmental Milestones -

7 - 9 months
Motor Milestone - Sits alone, crawls

Cognitive/Social Milestone - Stranger anxiety
Early Developmental Milestones -

15 months
Motor Milestone - Walks, Babinski reflex disappears

Cognitive/Social Milestone - Few words, separation anxiety
Early Developmental Milestones -

12 - 24 months
Motor Milestone - Climbs stairs; Stacks 3 blocks at 1 year, 6 blocks at 2 years(number of blocks stacked = age in years x 3)

Cognitive/Social Milestone - Object permanence; 200 words and 2-word sentences at age 2
Early Developmental Milestones -

24 - 36 months
Motor Milestone - Eh. Meh.

Cognitive/Social Milestone - Core gender identity, parallel play
Early Developmental Milestones -

30-36 months
Motor Milestone - Stacks 9 blocks

Cognitive/Social Milestone - Toilet Training("pee at age 3")
Early Developmental Milestones -

3 years
Motor Milestone - Rides tricycle(rides 3-cycle at age 3); copies line or circle drawing

Cognitive/Social Milestone - 900 words and complete sentences
Early Developmental Milestones -

4 years
Motor Milestone - Simple drawings(stick figure), hops on 1 foot

Cognitive/Social Milestone - Cooperative play, imaginary friends, grooms self, brushes teeth, buttons and zips
Piagets stages of cognitive development -

Sensorimotor Stage
Occurs between birth to age 2 -

egocentric exploration of the world with the 5 senses. Novel use of objects to obtain a goal(like using a stick to reach something or constructing a complex maze of traps to catch a rat). Understanding of object permanence is achieved.
Piagets stages of cognitive development -

Preoperational Stage
Ages 2 to 7 -

Acquisition of motor skills. Magical thinking predominates with no "logical" thinking.
Piagets stages of cognitive development -

Concrete Operational Stage
Ages 7 to 12 -

Start of logical thinking, but confined to concrete concepts. No longer egocentric.
Piagets stages of cognitive development -

Formal Operational Stage
Ages 12 and on -

Development of abstract reasoning.
Tanner Stages of Sexual Development
1.) Childhood

2.) Pubic hair appears(adrenarche); breasts enlarge

3.) Pubic hair darkens and becomes curly; penis size/length increase

4.) Penis width increases, dark scrotal skin, development of glans, raised areolae

5.) Adult; Areolae are no longer raised
Changes in the elderly -

Sexually
Physiologically
Common medical conditions
Common misconceptions
1.) Sexual changes - Men have slower erection/ejaculation with a longer refractory period while Women have vaginal shortening, thinning and dryness.

2.) Sleep patterns - decreased REM, slow-wave sleep, increased latency and awakenings.

3.) Common medical conditions are arthritis, HTN, heart disease, osteoporosis

4.) decreased incidence of psychiatric disorders

5.) increased suicide rate(males 65-74 years of age have the highest suicide rate in the US)

6.) decreased vision, hearing, immune response, and bladder control.

7.) decreased renal, pulmonary and GI function

8.) decreased muscle mass, increased fat

NOTABLY sexual interest does NOT decrease and intelligence does NOT decrease.
Grief

Normal vs pathological
Normal bereavement characterized by shock, denial, guilt and somatic symptoms, typically lasts 6 months to a year. May experience illusions.

Pathologic grief includes extensively intense or prolonged grief or grief that is delayed, inhibited or denied. May experience depressive symptoms, delusions and hallucinations.
Kubler-Ross Stages of Grief
Denial, Anger, Bargaining, Grieving(depression), Acceptance.

Stages do not necessarily occur in this order and more than one stage can occur simultaneously.

Death Arrives Bringing Grave Adjustments
Physiologic Effects of Stress
Stress induces production of free fatty acids, 17-OH corticosteroids(immunosuppression), lipids, cholesterol, catecholamines; affects water absorption, muscular tonicity, gastrocolic reflex and mucosal circulation
Sexual Dysfunction Differential Diagnosis
Differential Diagnosis includes:

1.) Drugs(antihypertensives, neuroleptics, SSRIs, ethanol)

2.) Diseases(depression, diabetes)

3.) Psychological(performance anxiety)
Body Mass Index(BMI)

Definition
Classifications of Obesity
BMI is a measure of weight adjusted for height.

BMI = weight in kg/(height in meters)²

<18.5 underweight
18.5 - 24.9 normal
25.0 - 29.9 overweight\
>30.0 obese
>40.0 morbidly obese
Sleep Stages -

Awake
Awake(eyes open),alert, active mental concentration
EEG Waveform - Beta(highest frequency, lowest amplitude)

Awake(eyes closed)
EEG Waveform - Alpha
Sleep Stages -

Stage 1
(5%) light sleep

EEG waveform - Theta
Sleep Stages -

Stage 2
(45%) Deeper sleep; bruxism

EEG waveform - sleep spindles and K complexes
Sleep Stages -

Stage 3-4
(25%) Deepest, non-REM sleep; sleepwalking, night terrors, bedwetting(slow-wave sleep0

EEG waveform - Delta(lowest frequency, highest amplitude)
Sleep Stages -

REM
(25%) Dreaming, loss of motor tone, possibly a memory processing function, erections, increased brain O2 use.

EEG waveform - Beta

At night, BATS Drink Blood
Key Points to remember about sleep
1.) Serotonergic predominance of raphe nucleus key to initiating sleep.

2.) NE reduces REM sleep

3.) Extraocular movements during REM due to activity of PPRF(paramedian pontine reticular formation/conjugate gaze center)

4.) REM sleep having the same EEG pattern as while awake and alert has spawned the terms "paradoxical sleep" and "desynchronized sleep"

5.) Benzodiazepines shorten stage 4 sleep; thus useful for night terrors and sleepwalking

6.) Imipramine is used to treat enuresis because it decreases stage 4 sleep.
REM Sleep
increase and variable pulse, REM, increase and variable blood pressure, penile/clitoral tumescence. Occurs every 90 minutes; duration increases through the night. ACh is the principal neurotransmitter involved in REM sleep. REM sleep decreases with age.

REM sleep is like sex: increase pulse, penile/clitoral tumescence, decrease with age
Narcolepsy
Disordered regulation of sleep/wake cycles. May include hypnagogic(just before sleep) or hypnopompic(just before awakening) hallucinations. The patients nocturnal and narcoleptic sleep episodes start off with REM sleep. Cataplexy(loss of all muscle tone following a strong emotional stimulus) in some patients. Strong genetic component. Treat with stimulants(amphetamines and modafinil)
Circadian Rhythm
Driven by suprachiasmatic nucleus(SCN) of hypothalamus; controls ACTH, prolactin, melatonin, nocturnal NE release, SCN --> NE release --> pineal gland --> melatonin. SCN is regulated by environment (i.e. light).