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118 Cards in this Set
- Front
- Back
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case-control study
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compares group of people with a disease to a group without
looks at PRIOR risk factors and exposures observational and retrospective use odd's ratio to measure |
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cohort study
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compares a group with a given exposure or a risk factor to a group without
observational and PROspective see what happens measure with relative risk |
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cross-sectional study
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collects data from group of people to see frequency of disease and related risk factors at ONE POINT IN TIME
what is happening now measures disease prevalence |
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twin concordance study
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comparise frequency with which both monozygotic twins or both dizygotic dtwins develop disease
measures heitability |
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adoption study
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compare siblings raised by biologic vs adopted parents
measure heritablility and influence of environmental factors |
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clinical trial - what is it in general
best conditions? |
EXPERIMENTAL study involving HUMANS
compares 2 or more treatments or treatment and placebo best if: randomized controlled double blinded |
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phase 1 clinical trials
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small number of HEALTHY volunteers
look at: safety toxicity pharmacokinietics |
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phase 2 clinical trials
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small number patients with DISEASE
look at: efficacy optimal dosing adverse effects |
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phase 3 clinical trials
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LARGE number of patients - random assignment to experimental treatment or to best available treatment/placebo
compare new treatment to old or no treatment |
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phase 4 clinical trials
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after approval of drug
surveillance - detects long term adverse effects |
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meta analysis
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pools data from several studies to generate overall conclusion
increased statistical power integrates studies most powerful clinical evidence limited by quality of the individual studies or bias in study selection |
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sensitivity
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SNOUT - SeNsitivity rules OUT
TP/(TP+FN) high sensitivity = low false negative rate good for screen disease with low prevalence |
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specificity
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SPIN - SPecificity rules IN
TN/(TN+FP) high specificity = low false positive rate use as confirmatory test after positive screen |
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why is a western blot given after ELISA for HIV testing?
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ELISA has high sensitivity, low specificity
Western has high specificity, lo sensitvity |
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positive predictive value
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proportion of positive test that are true positive
probability that person has disease given positive test TP/(TP+FP) if prevalence of disease is low, the PPV will be low regardless of high specificity or sensitivity |
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T/F the higher the prevalence of a disease the higher the PPV and the lower the NPV
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True
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negative predictive value
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proportion of net tests that are actually negative for disease
probability that person actually is disease free given a negative test result TN/(TN+FN) |
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prevalence vs incidence
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prevalence is number of cases at a specific point in time
incidence is new cases in a given time period |
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T/F prevalence can be approximated by incidence x disease duration
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true
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T/F prevalence < incidence for chronic disease
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false
prevalence is > incidence for chronic disease |
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T/F prevalence = incidence for acute disease
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true
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T/F people currently with disease or those previously positive for disease are not considered at risk when calculating incidence
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true
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incidence
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new cases in population over a givien time period/total population AT RISK during time period
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how do people leave the population of prevalent cases?
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dying or recovering from illness
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Odd's ratio Equation
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ad/bc
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relative risk equation
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[a/(a+b)]/[c/(c+d)]
probability of getting disease in exposed compared to unexposed |
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attributable risk
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a/(a+b) - c/(c+d)
difference in the risk between exposed and unexposed "smoking causes 1/3 of cases of pneumonia" |
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when does odd's ratio approximate relative risk
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when prevalence is not too high
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absolute risk reduction
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reduction in risk assoicated with treatment compared to placebo
absoluate risk = incidence so if incidence before treatment is 2% and the incidence after treatment is 1.5% then absoluate risk reduction is 2-1.5 = 0.5% risk reduction |
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number needed to treat
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1/absoluate risk reduction
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number needed to harm
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1/attributable risk
number of people needed to be exposed to risk factor for one person to be harmed |
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precision
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consistency and reproducibility of test (reliability)
absence of random variation precision is reduced by random error |
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accuracy
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trueness of test measurement (of what the test is measuring)
accuracy is reduced by systematic error (bias) |
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selection 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 are not representative relative to gen population
results are not generalizable |
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late-look bias
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information gathered at an inappropriate time
studying a fatal disease with a survey (only those living will answer) |
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procedure bias
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subjects in different groups are not treated the same
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confounding bias
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occurs with 2 closely associated factors
1 factor distorts or confuses the effect of other |
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lead-time bias
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early detection confused with increased survival
see with improved screen, the early detection gives false sensation as if survival increased |
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pygmalion effect
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when researcher's belief in efficacy of treatment changes outcome
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hawthrone effect
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occurs when the group being studied changes behavior due to the knowledge of being studied
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ways to reduce bias (4)
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blind studies (double blind better)
placebo responses crossover studies (each subject acts as its own control) randomization |
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positive skew effect on mean,median, mode
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mean > median > mode
tail is on the right |
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negative skew effect on mean, median, mode
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mean < median < mode
tail is on the left |
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null hypothesis
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hypothesis of no difference - no association between disease and risk factor and population
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alternative hypothesis
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hypothesis that there is some difference - there is an association between disease and risk factor
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type 1 error (alpha)
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stating there IS an effect or difference when NONE EXISTS - "false positive error" - like convicting an innocent man
mistakenly accepted the alt hypothesis and rejected the null hypothesis just against alpha with p if p<0.05 then there is less than 5% chance that the data will show something is not there |
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type 2 error (beta)
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stating there is NOT an effect when one DOES EXIST - "false negative error" - setting a guilty man free
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power
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1-beta
ability to detect a difference if there really is one depends on: 1. number of end points experienced by population 2. difference in compliance between treatment groups 3. size of expected effect power in numbers - increase sample size to increase power |
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standard error of mean
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sigma/root(n)
n=sample size sigma = standard dev SEM < sigma SEM decreases as n increases |
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sigma
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standard dev
+/- 1sigma = 68% +/- 2sigma = 95% +/- 3sigma = 99.7% |
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confidence interval
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(mean - Z(SEM), mean + Z(SEM))
Z=1.96 for 95% CI if 95% CI includes 0 for difference between two variables, not significant don't reject null if 95% CI includes 1 for risk factor or odds, not significant and don't reject null if 95% CI for 2 groups overlap, then not significantly different |
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t-test vs ANOVA vs chi-squared
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t-test checks difference of MEANS of 2 groups
ANOVA checks difference of means of 3 or more groups chi-square test - checks differences between 2 or more PERCENTAGES or PROPORTIONS of categorical outcomes |
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corrolation coefficienct (r)
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closer to 1 - the stronger the corrolation
coefficient of determination = r^2 |
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types of prevention
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primary - prevent disease occurance
2ndary - early detection tertiary - reduce disability from disease |
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reportable disease
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Hep, Hep, Hep, Horray the SSSMMART Chick is Gone
HepA HepB HepC HIV Salmonella Shigella Syphilis Measels Mumps AIDS Rubella TB Chickenpox Gonorrhea |
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leading cause of death in the US by age
infants? 1-14? 15-24? 25-64? 65+? |
infants: congenital anomolies, SIDS, RDS
1-14: injuries, cancer, congenital, homocide, heart disease 15-24: injuries, homicide, suicide 25-64: cancer, heart disease, injuries 65+: heart disease, cancer, stroke |
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MedicarE
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all patients > 65
patients < 65 with certain disabilities and ESRD part A - impatient care, skilled nursing, hospice, home health part B - outpatient care, doctors services, PT/OT part C - combo of A+B part D - standalone precription drugs |
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medicaiD
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for destitute, low income
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core ethical principles (4)
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autonomy - patient is an individual and docs must honor their preferences
beneficence - doctor acts in patent best interest, but patient decides as long as he can make the decision nonmaleficence - do no harm, if intervention benefit outweighs risk, patient makes decision justice - treat persons fair |
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informed consent
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requires:
1. discussion of pertinent information 2. patient agreement to plan of care 3. freedom from coercion patient understands risk, benefits, alternatives exceptions: patient can't make decision, emergency is implied consent, if information would be damaging, or waived |
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consent for minors
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a minor is <18
need parental consent unless emancipated (married, self support, children, military) EXCEPT: contraceptives, STD treatment, pregnancy, or drug addiction |
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decision making capacity
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patient makes and communicates a choice
patient is informed decision is stable over time decision is consistent with patient values and goals decision is not a delusion or hallucination |
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advance directives
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given by patient in anticipation of need for medical decision
oral - use as a guide, but variance in interpretation is a problem living will (Written) - describes which treatments patients will or will not receive if patient is incapacitated durable power of attorney - surrogate in event patient loses decision making capacity |
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exceptions to confidentiality
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potential harm to others
likelihood of harm to self no alt means to warn or protect those at risk physician can still take steps to prevent harm - infectious diseases, tarasoff decision, child abuse, impaired auto drivers, suicidal patients |
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tarasoff decision
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physician required to directly inform and protect potential victims from harm - may involve breach of confidentiality
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malpractice
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4Ds - duty, dereliction, damage, direct
requires that: physician must have had duty to patient, he breached that duty, patient was harmed, and the breach of duty was what caused the harm most common due to poor communication between physician and patient |
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if patient is noncompliant
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assess reason fo noncopmliance, determine willingness of patient to change or undergo procedure
DO NOT attempt to coerce or refer to another physician |
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patient smokes and believes its good for him
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ask how patients feels about smoking
offer advice on cessation if patient willing to make effort to quit |
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patients desires unnecessary procedure
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understand why patient wants procedure
avoid unnecessary procedure, address underlying concern DO NOT refuse to see patient or refer patient |
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patient has difficulty taking mediations
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provide written instructions
attempt to simplify treatment registration |
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family members ask for information about prognosis
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avoid discussion with relatives without permission of patient
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child wishes to know more about his illness
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ask parents what they've told child
patients decide what information is given to kid |
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a 17 year old girl is pregnant and requests abortion
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many states require parental notification or consent for minors for abortion
do not advise patient to have abortion unless there is medical risk |
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15 year old girl is preg and wants to keep child but parents want you to tell her to give up child
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patient retains right to make decision regarding child even if parents disaggree
provide info about difficulty of caring for child discuss other options encourage communication between parent and child |
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terminally ill patient requests physician assistence in ending his life
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most states you must refuse involvement in physician assisted suicide
but, physicians can prescribe medically appropriate analgesics that coincidentally shorten the patient's life |
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patient is suicidal
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assess seriousness of threat
if serious, ask that patient remain in hospital. if he refuses, involuntary hospitalize patient |
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patient states that he finds you attractive
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ask, direct, closed-ended questions and use chaparone
romantic relationships with patients are NEVER appropriate (even if not your patient anymore) |
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middle aged married woman who had mastectomy says she feels ugly when she undresses at night
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find out why patient feels this way
DO NOT offer falsely reassuring statements |
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patient is angry about the amount of time spent waiting
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acknowledge patient anger, don't take it personally
apologize for any inconvenience don't try to explain the delay |
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patient is upset with the way she was treated by another doctor
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suggest patient talk to offending doctor
if it was with a office staff, tell patient you will speak to that individual |
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drug company offers "referral fee" for every patient physician enrolls in study
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eligible patients who may benefit may be enrolled, but not acceptable to physician to receive compensation from drug company
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APGAR score
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appearance
pulse grimace activity respiration evaluated at 1 and 5 minutes |
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low birth weight
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< 2500g
higher incidence of physical and emotional problems prematurity or intrautarine growth restruction complications: infection, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, persistent fetal circulation |
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infant dev molestones
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birth - 3mo: rooting reflex, ortients to voice
3: holds headup moro reflex disappears, social smile 7-9mo sits alone, crawls, stranger anxiety 15mo walks, babinski disappears, few words, separation anxiety |
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toddler dev milestones
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12-24mo - clinb stairs, stacks 3 blocks at 1 year, 6 blocks by 2 years, number of blocks stacked = aged in years x 3, object permanence, 200 words and 2 word sentences at age 2
24-36mo: core gender identity, parallel play |
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preschool dev milestones
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30-36mo:stacks 9 blocks, toilet training
3 years: tricycle, copies lines or circles, 900 words and complete sentences 4 years: simple drawings, hops on 1 foot, cooperative play, imaginary friends, grooms self, brush teeth, buttons, zips |
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tanner stages of sexual dev
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1. childhood
2. pubic hair appears (adrenarch, breasts enlarge) 3. pubic hair darkens and curly, increased penis length 4. penis width increases, darker scrotum, dev of glans, raised areolae 5. adult - areolae no longer raised |
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changes in elderly
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sexual changes - men slower erection/ejactulation with longer refractory, female vaginal shortening, thinning, dry
sleep - decreased REM, slow wave sleep and increased latency to sleep and awakenings decreased psych disorders increased suicide rate decreased vision, hearing, immune, bladder control decreased renal, pulm, GI function decreased muslce, increase fat |
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T/F sexual interest decreases in elderly
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FALSE
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T/F intelligence does not decrease in old age
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TRUE
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grief (normal)
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normal berevement chracterized by shock, denial, guilt, somatic symptoms - up to 2 months
may experience illusions |
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grief (pathological)
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excessive grief, prolonged > 2 months or grief that is delayed, inhibited, or denied
depressive symptoms, delusions, hallucination |
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kubler ross grief stages
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denial, anger, bargaining, grieving, acceptance
"death arrives bring grave adjustments" not necessarily in an order and can have more than 1 stage at a time |
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stress effects
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stress induces production of free fatty acids, 17OH corticosteroids -> immunosupression, lipids, cholesterol, catecholamines
affect water absorption, muscular tonicity, gastrocolic reflex, mucosal circulation |
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sexual dysfunction differential
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drugs (antihypertensives, neruoleptics, SSRI, ethanol)
disease (depression, diabetes) psych (performance anxiety) |
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body mass index
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weight in kg/(height in meters)^2
<18.5 underweight 18.5-24.9 normal 25-29.9 overweight >30.0 obese >40 morbidly obese |
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sleep stages % of total sleep time in young adults
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stage 1 - 5%
stage 2 - 45% stage 3-4 - 25% REM - 25% |
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beta waves ECG
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indicate awake (eyes open), alert, active mental
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alpha waves ECG
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awake (eyes closed)
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theta waves ECG
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light sleep
slowed pulse and respiration, decreased BP, episodic body movement |
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sleep spindles/K complexes on ECG
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stage 2 sleep - deeper sleep, bruxism
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delta waves ECG
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stage 3 sleep
high amplitude, low freq deepest sleep non-REM sleep walking, night terrors, bedwetting |
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REM sleep
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see sawtooth beta waves mostly
occurs every 90 minutes with increasing duration through night dreaming, loss of motor tone, erection, increased brain O2 use possible memory processing |
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raphe nucleus
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secretes serotonin
key to initiating sleep |
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T/F NE increased REM sleep
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false - NE decreases REM sleep
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extraocular movements during REM are due to
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activity of PPRF
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treatment for enuresis
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imipramine - decreases stage 4 sleep
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reduced REM sleep - drugs
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alcohol, benzodiazepine, barbs
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treatment for night terrors and sleepwalking
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benzos
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principle neurotransmitter in REM sleep
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ACh
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why is REM sleep like sex
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increased pulse, penile/clitoral tumescence
decreases with age |
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depresssion effect on sleep
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decreased slow wave sleep
decreased REM latency increased REM early increased total REM sleep repeated night wakening early morning wakening |
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narcolepsy
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disordered reg of sleep wake cycle
excessive daytime sleepiness hallucinations before or just after sleep starts with REM sleep cataplexy - loss of all muscle tone follow strong emotional stim |
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treatment for narcolepsy
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treat with stimulants (amphetamines, modafinil) and sodium oxybate
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circadian rhythem
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driven by suprachiasmatic nucleus of hypothalamus - regulated by environment (light) -> NE release -> pineal gland -> melatonin
controls ACTH, prolactin, melatonin, nocturnal NE release |
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sleep terror disorder
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screaming in the middle of night
children mostly occurs with slow wave sleep and no memory of arousal |
