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73 Cards in this Set

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Twin concordance study
Compares the frequency with which both monozygotic twins or both dizygotic twins develop a disease. Measures heritability.
Adoption study.
Compares siblings raised by biologic vs adoptive parents. Measures heritability and influence of environmental factors.
Define clinical trial.
Experimental study involving humans. Compres therapeutic benefits of 2 or more treatments, or of treatment and placebo. Highest quality study when randomized controlled, and double blinded.
Describe the study sample and purpose of each phase of clinical trials.
(A) Phase I: Small number of patients, usually healthy; assess safety, toxicity, and pharmacokinetics.
(B) Phase II: Small number of patients with disease of interest; assesses treatment efficacy, optimal dosing, and adverse effects.
(C) Phase III: Large numbers of patients randomly assigned either to treatment under investigation or to the best available treatment (or placebo); compares the new treatment and the current standard of care. More convincing if double blinded.
Meta analysis.
Pools data from several studies to come to an overall conclusions. Achieves greater statistical power and integrates results of similar studies. Highest echelon of clinical evidence. May be limited by quality of individual studies or bias in study selection.
Sensitivity
Proportion of all people with disease who test positive. Value approaching 1 is desirable for ruling out disease and indicates low false negative rate. Used for screening diseases with low prevalence.
Sensitivity=TP/(TP+FN)
Specificity
Proportion of all people without disease who test negative.
Value approaching 1 is desirable for ruling IN disease and indicates a lot false positive rate.
Used as a confirmatory test after a positive screening test.
Specificity=TN/(TN+FP)
Negative predictive value
Proportion of negative test results that are true negative.
Probability that person actually is disease free given a negative test result.
NPV=TN/(FN+TN)
Prevalence
Point prevalence=(total cases in population in given time)/(total population at risk at a given time)
Prevalance is approximately incidence x disease duration.
Prevalence is>incidence for chronic diseases.
Prevalance=incidence or acute disease.
Odds ratio for case control studies
OR=(a/b)/(c/d)=ad/bc
Odds of having a disease in exposed group divided by odds of having disease in unexposed group. Approximates relative risk if prevalence of disease is not too high.
Relative risk (RR) for cohort studies
RR=[a/(a+b)]/[c/(c+d)]
Relative probability of getting a disease in the exposed group compared to the unexposed group.
Calculated as percent with disease in exposed group divided by percent with disease in unexposed group.
Attributable risk
AR=[a/(a+b)]-[c/(c+d)]
The difference in risk between exposed and unexposed groups, or the proportion of disease occurrences that are attributable to the exposure.
Precision
1. The consistency and reproducibility of a test (reliability)
2. The absence of random variation in the test.
Random error reduces precision in a test.
Accuracy
Accuracy is the trueness of test measurements (validity).
Systematic error reduces accuracy in test.
Bias
Occurs when 1 outcome is systematically favored over another. Systematic errors.
Selection bias
Nonrandom 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 generalizable
Late-look bias
Information fathered at an inappropriate time
Procedure bias
Subjects in different gruops are not treated the same-e.g. more attention is paid to treatment group, stimulating greater complicance
Confounding bias
Occurs with 2 closely associated factors; the effect of 1 factor distorts or confuses the effect of the other
Lead time bias
Early detection confused with increased survival.
Hawthorne effect
Occurs when the group being studied changes its behavior to meet the expectations of the researcher.
Ways to reduce bias:
1. blind studies (double blind better)
2. placebo responses
3. crossover studies (each subject acts as own control)
4. randomization
Describe positive skew statistical distribution
Asymmetry with tail on right. Mean>median>mode
Describe negative skew statistical distribution
Asymmetry with tail on left.
Mean<median<mode
Null hypothesis
Hypothesis of no difference
Alternative hypothesis
Hypothesis that there is some difference
Power
(1-beta)
Probability of rejecting 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.
If you increase the sample size you increase the power.
Standard deviation vs standard error
n=sample size
x=standard deviation
SEM=standard error of the mean.
SEM=x/square root of n
SEM<x, and SEM decreases as n increases.
Confidence interval
Range of values in which a specified probability of the means of repeated samples would be expected to fall.
T test
Checks difference b/w means of 2 groups
ANOVA
Checks difference between means of 3+ groups
Chi squared
Checks difference between 2 or more percentages or proportions of categorical outcomes (not mean values)
Correlation coefficient
R is always b/w -1 and 1. The closer the absolute value of r is to 1, the stronger the correlation b/w two variables.
Primary, secondary, and tertiary prevention
Primary-prevent disease occurrence (ex. Vaccination)
Secondary-early detection of disease (screening)
Tertiary-reduce disability from disease
Reportable diseases
Hep Hep Hep Hooray, the SSSMMART Chick is Gone!
HepA
HepB
HepC
HIV
Salmonella
Shigella
Syphilis
Measles
Mumps
AIDS
Rubella
Tuberculosis
Chickenpox
Gonorrhea
Leading causes of death in US by age:
(1)Infants
(2) 1-14
(3) 15-24
(4) 25-64
(5) 65+
(1)Infants: congenital anomalies, SGA/LBW, SIDS, maternal complications of pregnancy, RDS
(2) 1-14: Injuries, cancer, congenital anomalies, homicide, heart disease
(3) 15-24: Injuries, homicide, suicide, cancer, heart disease
(4) 25-64: Cancer, heart disease, injuries, suicide, stroke.
(5) 65+: heart disease, cancer, stroke, COPD, pneumonia, influenza
Exceptions to informed consent
-Patient lacks decision making capacity or is legally incompetent.
-Implied consent in an emergency.
-therapeutic privelage: withholding information when disclosure would severely harm the patient or undermine informed decision making capacity.
-waiver: patient waives right
Two types of written advance directive:
(1) living will-describes treatments the patient wishes to or not to receive if he/she becomes incapacitated.
(2) durable power of attorney-patient designates a surrogate to make medical decisions in the event that he/she loses decision making capacity.
Exceptions to confidentiality:
(1) Potential harm to others is serious.
(2) Liklihood of harm to self is great.
(3) no alternative means exist to warn or protect those at risk.
(3) Physicians can take steps to prevent harm:
Examples:
-Infectious disease
-Tarasoff decision: law requires physician to directly inform and protect potential victim from harm
-Child/elder abuse
-Impaired automobile drivers
-Suicidal/homicidal patients
Requirements for civil suit under negligence (malpractice)
1. physician had duty to patient (duty)
2. physician breached that duty (dereliction)
3. patient suffers harm (Damage)
3. breach of duty was what caused harm (Direct)
Appropriate response:
Patient is noncompliant.
Work to improve the physican-patient relationship.
Appropriate response: Patient has difficulty taking medications.
Provide written instructions; attempt to simplify the regimen.
Appropriate response: family member asks for info about patients prognosis.
Acoid discussing issues w/relatives without permission of the patient.
Appropriate response: a 17 YO girl is pregnant and requests an abortion.
Many states require parental notification or consent for minors wanting an abortion. Parental consent is not required for emergency situations, treatment of STD's medical care during pregnancy, and management of drug addiction.
Appropriate response:
Terminally ill patient requests ending his life.
In the overwhelming majority of states, refuse involvement in any form with physician assisted suicide. Physicans may, however, prescribe medically appropriate analgesics that coincidentally shorten the patients life.
Appropriate response: Patient states that he finds you attractive.
Ask direct, closed ended questions and use a chaperone if necessary. Romantic relationships with patients are never appropriate.
Appropriate response: Patient refuses a necessary procedure or desires an uncessary one.
Attempt to understand why the patient wants/does not want the procedure. Address the underlying concerns. Acoid performing uncessary procedures.
Appropriate response: Patient is angry about the amnt of time he spent in the waiting room.
Apologize to tha ptient for inconvenience. Stay away from exports to explain the delay.
Appropriate response: Patient is upset with the way he 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 his staff, tell the patient you will speak to that individual.
Appropriate response: a child wishes to know more about his illness.
Ask the parents have told the child about his illness. Parents of a child decide what info can be relayed about an illness.
Appropriate response: Patients continue to smoke believing that cigarettes are good for them.
Ask how the patients feel about his/her smoking. Offeradvice on cessation if the patient seems willing to make an effort to quit.
Appropriate response: Minor requests condoms.
Physicans can provide counsel and contracpetive to minors without parents' knowledge or consent.
APGAR scale (description, components, and scoring)
A 10 pt scale evaluated at 1 m and 5 m.
(1) Apperance (0=blue, 1=trunk pink, 2=all pink)
(2) Pulse (0=none, 2=<100/m, 3=>100/m)
(3) Grimace (0=none, 2=grimace, 3=grimace +cough)
(4) Activity (0=limp, 1=some, 2=active)
(5) Respiration (0=none, 1=irregular, 2=regular)
low birth weight
<25000g at birth. Associated with greater incidence of physical/emotional problems. Caused by prematurity or intrauterine growth retardation.
Motor milestones for the following age groups:
(1) Birth-3m
(2) 3m
(3) 4-5m
(4) 7-9m
(5) 12-14m
(6) 15m
(7)18-24m
(8) 24-48m
(9) 24-36m
(10) 30-36m
(11) 3y
(12) 4y
(13) 6-11y
(1) Birth-3m: Rooting reflex
(2) 3m: Holds head up, Moro reflex disappears
(3) 4-5m: Rolls front to back, sits when propped
(4) 7-9m: Sits alone, crawls
(5) 12-14m: Upgoing Babinski disappears
(6) 15m: walks
(7)12-24m: Climbs stairs, stacks 3 blocks
(8) 24-48m: "
(9) 24-36m"
(10) 30-36m: Stacks 9 blocks (number of blocks stacked=age in yrs x 3)
(11) 3y: rides tricycle, copies line or circle
(12) 4y: Simples drawings (stick figure), hopes on 1 foot, copies a cross
(13) 6-11y: Rides bicycle; copies a triangle (age 6)
Cognitive/social milestones for the following age groups:
(1) Birth-3m
(2) 3m
(3) 4-5m
(4) 7-9m
(5) 12-14m
(6) 15m
(7)18-24m
(8) 24-48m
(9) 24-36m
(10) 30-36m
(11) 3y
(12) 4y
(13) 6-11y
(14) 11y (girls)/13y (boys)
(1) Birth-3m: Orients to voice
(2) 3m: social smile
(3) 4-5m: recognizes people
(4) 7-9m: stranger anxiety
(5) 12-14m: n/a
(6) 15m: few words, separation anxiety
(7)12-24m: Object permanence; 200 words and 2 word sentences at 2
(8) 24-48m: parallel play
(9) 24-36m: core gender identity
(10) 30-36m: toilet training
(11) 3y: 900 words and complete sentences.
(12) 4y: cooperative play, imaginary friends, grooms self, brushes teeth, buttons and zips
(13) 6-11y: reads; understands death. Development of conscious (superego), same sex friends, identification w/same sex parent
(14) 11y (girls)/13y (boys): abstract reasoning (formal operations), formation of personality
Tanner Stages of Development
(1) Childhood
(2) Pubic hair begins to develop (adrenarche), increase size of testes, breast tissue elevation
(3) Increased pubic hair, darkens, becomes curly, increased penis size/length
(4) Increase penis width, darker scrotal skin, development of glans, raised areolae
(5) Adult; areolae no longer raised
Changes in elderly
1-sexual
2-sleep
3-common medical conditions
4-psychiatric disorders
5-suicide rate
6-vision, hearing, immune response, bladder control
7-renal, pulmonary, GI fct
8-muscle mass, fat mass
Changes in elderly
1-sexual:
Men=slower erection/ejac, longer refractory period
Women=vaginal shortening, thinning, and dryness
2-sleep: Decr REM, slow wave sleep. Incr latency, awakenings
3-common medical conditions: arthritis, HTN, HD, osteoperosis
4-psychiatric disorders: lower prevalence among healthy elderly than at other life stages (excluding comorbidities)
5-suicide rate (increased-males 65-74 have highest rates in US)
6-vision, hearing, immune response, bladder control (all decreased)
7-renal, pulmonary, GI (all decreased)
8-muscle mass (decr), fat mass (incr)
Kubler Ross grief stages
Denial, anger, bargaining, frieving (depression), acceptance
Do not have to occur in this order and greater than 1 can occur at once.
Physiologic effects of stress
-Induces production of FFA's
-Induced production of 17-OH (immunosuppression)
-Induces production of lipids, cholesterol, and catecholamines
-Affects water absorption
-Affects muscular tonicity
-Affects gastrocolic reflex
-Affects mucosal circulation
Differential diagnosis for sexual dysfct
Drug (antiHTN, neuroleptics, SSRI's, alcohol)
Diseases (depression, diabetes)
Psychological (performance anxiety)
BMI (define and cutoffs)
Measure of weight adjusted for height.
BMI=wt (kg)/ht(cm)2
<18.5 underwt
18.5-24.9 normal
25-29.9 overwt
>30 obese
Describe the different stages of sleep (% of total sleep time, description, and EEG wave form); also include waveforms for being awake
Awake eyes open (beta -highest frequency, lowest amplitude)
Awake eyes closed (alpha)
Stage1 (5%): Light sleep (theta)
Stage 2 (45%): deeper sleep; bruxism (Sleep spindles and K complexes)
Stage 3-4 (25%): Deepest, non REM sleep; sleepwalking, night terrors; bedwetting aka slow wave sleep (delta-lowest frequency, highest amplitude)
REM (25%): Dreams, loss of motor tone, possible memory processing fct, erections, increased brain oxygen use (beta)
How are benzodiazepines useful for sleep aids?
Shorten stage 4 sleep so are useful for night terrors and sleepwalking.
How is imipramine used for sleep aid?
Used to treat enuresis b/c it decreases stage 4 sleep.
What neurotransmitter is necessary to initiate sleep?
Serotonin predominance of raphe nucleus
What neurotransmitter reduces REM sleep?
NE
What neurological structure is responsible for extraocular eye movements during REM?
PPRF
Principle neurotransmitter involved in REM sleep
Ach
Describe narcolepsy
Disordered regulation of sleep-wake cycles. May include hypnagogic (before sleep) or hypnopompic (before awakening). Sleep episodes start with REM cycles. Cataplexy in some patients. Strong genetic component. Treat with stimulants (amphetamines, modafinil)
Describe the neurologic control of 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 (light).