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220 Cards in this Set
- Front
- Back
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Why do we measure comparisons?
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summarize relationships between exposure and disease by comparing at least two measures of disease frequency |
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two main options for comparison (2)
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2. difference between two measures of disease frequency |
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rate/risk ratio (also called relative risk) definition
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comparing disease occurrence among exposed with disease occurrence among comparison group (usually unexposed) in a ratio measure |
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formula for rate/risk ratio (relative risk) |
Rexp/Runexp |
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cumulative incidence formula
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CIexp/CIunexp [a/(a+b)]/[c/(c+d)] |
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incidence rate formula |
IRexp/IRunexp (a/person-time exp)/(c/person-time unexp) |
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what does calculating the rate/risk ratio (relative risk) tell you? |
gives info on the relative effect of the exposure on the disease --> tells us how many times higher/lower the disease risk is among the exposed, compared to the unexposed |
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RR = 1.0 |
no association between exposure and disease |
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RR = 2.0 |
two times the risk of disease in the exposed as compared to the unexposed |
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RR = 1.6
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1.6 times a risk of getting the disease in the exposed compared to the unexposed...or 60% increased risk of disease in the exposed |
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RR = 0.5
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0.5 times or half the risk of disease in the exposed compared to the unexposed |
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what is a difference measure?
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comparing disease occurrence among the exposed with the disease occurrence among the unexposed by subtracting one from the other |
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rate/risk difference formula (attributable risk/rate) |
RD = Rexp - Runexp |
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Confidence interval difference formula |
[a/(a+b)] - [c/(c+d)] |
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Incidence rate difference formula |
(a/persontime of exp) - (c/person-time for unexp) |
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RD = 0 |
no association |
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what does the rate/risk difference (attributable risk) give info on? (3) |
2. gives the excess disease risk in the exposed group compared to unexposed 3. gives the public health impact of an exposure...assuming exposure causes the disease, how much disease would be prevented if the exposure were removed |
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If RR for lung cancer = 14.0 vs. 1.6 for heart disease, AND RD for lung cancer = 130/100,000/yr vs. 256/100,000/yr, how do we interpret the results? (they surveyed those who smoke and don't smoke)
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cigarette smoking is a much stronger risk factor for lung disease than for heart disease BUT the elimination of cigarettes would prevent far more deaths from heart disease than lung disease (# people impacted from heart disease is larger than for lung disease) |
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population risk/rate difference (PRD) definition |
measures excess disease occurrence among the total population that is associated with the exposure.--> Helps evaluate which exposures are most relevant to the health of the population |
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two formulas for PRD
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2. PRD = Rtotal - Runexp --> Rtotal = risk/rate in total population, Runexp = risk/rate among unexposed |
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if PRD = 85/100,000 for hypertension disease (non-fatal heart attack is the diagnosis/effect), interpret the results
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If hypertension were eliminated, 85/100,000 cases of non-fatal heart attacks could be eliminated among the total population studied
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cohort study definition
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study where two or more groups of people are free of disease (differing in their exposure vs. unexposure) and are compared with respect to disease incidence
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In a cohort study, can the researcher allocate exposure?
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no...he must observe the relationship |
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Ranch hand study: exposed group
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air force servicemen who sprayed agent orange in Vietnam war (1960's) |
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rand hand study: unexposed group
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air force servicemen who flew other missions than the agent orange one during Vietnam war (1960's)
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ranch hand study: outcome of interest
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cancer, PTSD, adverse male mediated pregnancy outcomes |
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ranch hand study: hypothesis |
discover if agent orange is not associated with the outcomes under study, then the outcome rates will be the same in both groups |
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randomization of treatments: for a cohort study
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can't randomize in an observational study so we select a comparison group as alike as possible to the exposed group |
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pacebo use to reduce bias: for a cohort study
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can't use placebo in observational study so must make groups as comparable as possible |
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blinding to avoid bias: for a cohort study
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crucial to have follow-up rates and comparable ascertainment of outcomes in the exposed and comparison groups |
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timing of cohort study : retrospective |
both the exposure and disease have occurred at the start of the study |
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timing of cohort study: prospective
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exposure has occurred, disease has not occurred |
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timing of cohort study: ambi-directional |
elements of both the exposure and disease have occurred, but not all of either |
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retrospective traits against prospective?
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cheaper, faster --> efficient with a disease with long latency period --> exposure data may be inadequate |
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prospective traits against retrospective? |
more expensive/time consuming --> not efficient with disease with long latency period --> better exposure and confounder data --> less vulnerable to bias |
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issues with cohort study design (8)
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2. selection of unexposed group 3. the need to assemble special cohorts for rare exposures 4. assembling a general cohort that will facilitate accurate and complete data if disease is common 5. three possible source of comparison groups 6. Multiple sources of exposure info 7. multiple sources of outcome info 8. multiple approaches to follow-up |
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how do you select the exposed group? Give some examples (6)
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1. occupational groups 2. groups undergoing specific medical treatment 3. groups with unusual diet/life style 4. professional groups 5. students/ college alumni 6. geographically defined areas |
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give an example of a special cohort
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rubber workers in Akron, OH --> exposed to benzene industrial solvent --> got cancer |
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give an example of a general cohort
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Framingham Heart studies --. exposure was smoking and family history --> got heart disease, stroke, gout, etc |
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What's the principle in selecting the unexposed group? |
you want unexposed to be as close as possible to the exposed group with respect to all factors except the exposure |
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counterfactual ideal: in selecting the unexposed group
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the ideal comparison group consists of exactly the same individuals in the exposed group had they not been exposed |
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three possible sources of comparison group (3) |
2. comparison cohort: a cohort who is not exposed from another similar population 3. general population data: use pre-existing data from the general pop. as basis for comparison |
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which of the three possible sources of comparison is the best?
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depends on situation |
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Sources for exposure info? (3) |
2. questionnaires, interviews (good but not routinely recorded and have potential for recall bias) 3. direct physical exams, tests, environmental monitoring |
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sources of outcome information (4)
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2. physician, hospital, health plan records 3. questionnaires 4. medical exams |
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why would you use blinding in a cohort study? what would it entail?
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to ensure that there is comparable ascertainment of the outcome in both groups -->the people who are doing the experiment don't know those who are exposed and those who are unexposed |
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what does every cohort study require in order to ascertain the outcome data?
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follow-up
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follow-up definition
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tracing or following all subjects from exposure into the future |
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what are resources utilized to conduct follow-up?
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town lists, phone books, birth/death/marriage records, driver's license lists, hospital records, friends/family, etc |
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what is the weakness of follow-up? |
time consuming |
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what's the problem if one loses a lot of follow-ups? |
the validity of the study becomes doubtful |
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bias in cohort studies (3) |
2. confounding 3. misclassifying |
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loss to follow-up definition
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researcher loses contact with the participant resulting in the loss of data from that person |
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healthy worker effect
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workers represent the exposed group and tend to be healthier than the general population |
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confounding bias |
confounding factor (other factor) is associated with both the exposure and the outcome under study...needs to be controlled for/adjusted for or the data will be skewed |
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misclassification |
-if misclassification of outcome is related to exposure, then it's non-random -if misclassification of outcome is not related to the exposure, then it's non-differential random |
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strengths of cohort study (3) |
2. can evaluate multiple effects of an exposure 3. if prospective, good info on exposures, less vulnerable to bias, and a clear temporal relationship between the exposure and the disease |
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weaknesses of cohort study (3) |
2. if retrospective, poor info on exposures and more vulnerable to bias 3. if prospective, expensive and time consuming, inefficient for diseases with long induction/latency periods |
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"TROHOC" studies
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term originally given to case-control studies because their logic seemed backwards (to a cohort study) and they seemed more prone to bias --> no basis to this assumption |
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case-control study
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method of sampling a population in which cases of the disease are identifies, and a sample of the population that produced the cases --> exposures are determined for individuals in each group |
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when would we want to conduct a case-control study? (5) |
2. when the disease has a long induction/latent period 3. when the disease is rare 4. when little is known about the disease 5. when the underlying problem is dynamic |
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what kind of cases do we use in case-control?
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ALWAYS use incident (new) cases |
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why do we always use "new" cases in case-control?
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2. determinants of survival are excluded 3. reduced confusion between cause and effect of disease |
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what do the cases provide in a case-control?
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the numerator to the rates of disease in exposed and unexposed |
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what do the controls provide in a case-control? |
the denominator |
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case-control studies can be considered a ???? of a cohort study |
more efficient form |
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purpose to the controls in the case-control |
to estimate the exposure distribution in the source population that produced the cases |
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what are sources for finding controls?
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random digit dialing, residence lists, drivers' license records |
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advantage of general population controls |
assurance that they come from the same base population as the cases |
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disadvantage of the general population controls |
time consuming, expensive, hard to contact and get cooperation, may remember the exposures differently than cases |
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recall bias in case-control |
those with a health problem recall the exposure better |
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response bias in case-control
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those who respond are different than those who don't |
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Berksonian bias |
occurs when hospital controls are not from the same source as the cases |
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advantage of hospital controls (4)
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1. same selection factors that led cases to hospital also led the controls to hospital 2. easy to identify and access 3. accuracy of exposure recall compared to those of cases since controls are also sick 4. more willing to participate bc they're bored |
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disadvantage of hospital controls (2)
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2. hospital catchment areas may be different for different diseases |
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what illnesses make good hospital controls?
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this that have no relation to the risk factors under study |
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special controls: who are they and when are they used? |
friends, spouses, siblings, deceased people --> rarely used |
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The "would criterion" |
if a member of a control group actually had the disease would he/she end up as a case in my study? answer should be yes!
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test to analyze a case-control study
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odds ratio |
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odds definition
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the ratio of the probability of an event occurring to that of it not occuring |
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odds ratio formula |
odds of exp being a case/odds of an unexp being a case (a/b)/(c/d) |
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strengths of case-control (2)
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2. can evaluate many risk factors for the same disease |
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weaknesses of case-control (4) |
2. vulnerable to bias because of retrospective nature of the study 3. may have poor information on exposure because retrospective 4. difficult to infer temporal relationship between exposure and disease |
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9 steps to a good epi analysis - see assign 7 and lecture 9 notes (no notecards) |
N/A
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Merriam-Webster's "cause" definition
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something that brings about a result
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Rothman's "cause" definition |
an event, condition, or characteristic that without which, the disease would not have occurred (something that has to be there for the disease to occur) |
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Susser's "cause" definition |
something that makes a difference |
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association is ??? to causation |
not equal |
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5 things to consider when evaluating epi associations (5) |
1. could the association be due to chance? 2. could the association be due to bias? 3. could the association be due to confounding? 4. how representative are the results? 5. does the association represent a cause/effect relationship? |
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characteristics of a cause (3) |
1. temporality: the cause must precede the effect 2. cause can be either host or environmental factors 3. presence of a causative exposure (positive) or lack of a causative exposure (negative) |
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many times causes get confused with what? |
risk factors (ex. location) sometimes it's looked at as a cause when really it's just a risk factor |
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divine retribution |
theory of God's will: you did something wrong and so that's why you're sick...imbalance in body caused by air, water, land, stars, etc |
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miasma |
disease transmitted by miasmas/clouds clinging to earth's surface |
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germ theory of disease and Henle-koch postulated |
microbes must always be found with the disease...single agent --> single disease...one to one relationship between exposure and disease |
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web of causation |
the idea of multiple causes contributing to a chronic disease |
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recent controversies about causation |
causation cannot be established and causal criteria should be abandoned |
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timeline of causation theories (5) |
1. divine retribution 2. miasma 3. germ theory 4. web of causation 5. controversy |
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creator of causal pies |
KJ Rothman |
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causal pies: sufficient cause |
the whole pie: set of conditions without any one of which the disease would not have occurred |
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causal pies: component cause |
one piece of the pie: any one of the set of conditions which are necessary for the completion cause |
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causal pies: necessary cause |
a component cause that is a member of every sufficient cause |
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attributes of the causal pies (4) |
1. completion of sufficient cause means occurrence of disease 2. component causes can act far apart in time 3. a component cause can involve the presence/lack of a causative exposure 4. blocking the action of any component cause prevents the completion of the sufficient cause and therefore prevents the disease |
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Sir AB Hill (1965) causal "guidelines" (9) |
1. strength of the association 2. consistency 3. specificity 4. temporality (cause before effect) 5. biological gradient 6. plausibility 7. coherence 8. experiment 9. analogy |
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what are sir AB Hill's causal guidelines? |
guidelines to help determine if associations are causal |
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should Hill's viewpoints be used as "hard and fast rules" |
no |
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strength of association |
the larger the association, the more likely the exposure is causing the disease --> strong associations are more likely to be causal bc they're less likely to be due entirely to confounding or bias --> weak associations may be causal but it is harder to rule out confounding or bias |
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consistency
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association is observed repeatedly in differing PPT --> replicating the association in different sample (with different studies) gives evidence of causation |
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specificity |
a single exposure should cause a single disease (especially for infectious disease) --> it's presence DOES provide causality , but it's absence does not mean causation |
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temporality |
causal factor must precede the disease in time |
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which one of Hill's guidelines does everyone agree with? |
temporality |
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biological gradient |
a dose-response relationship between exposure and disease --> some exposures have a "threshold" below which there are no adverse outcomes rather than a "dose-response" |
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plausibility/coherence |
it just makes sense: association does not conflict with current knowledge, research, history, and biology |
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experiment |
investigator-initiated intervention can modify the exposure (lessen it) and in turn lessen/remove the disease (good evidence of causation, but most studies are just observational) |
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analogy |
has a similar relationship been observed with another exposure/disease? |
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what is a requirement for causality? |
temporality |
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why do we perform clinical trials? |
document effectiveness/safety of a new "therapy" to obtain FDA approval |
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characteristics of clinical trials? |
focused on individuals, exposure is manipulated, tightly controlled, restricted bc only those that met the study criteria can participate |
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definition of "phases" of clinical trial and how many phases are there? |
stage that occurs in drug development...there's 4 phases |
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clinical means... |
human |
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pre-clinical means... |
animals |
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T/F: pre-clinical studies must occur before clinical |
true |
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phase 1 |
<100 healthy people --> gather data on safety, toxic effects, gross side effects |
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phase 2 |
100-200 sick people --> safety, side effects, proof of concept |
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phase 3 |
3K to 9K sick individuals --> 4 yrs --> safety, effectiveness, side effects, indications of use--> 5 diff doses |
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phase 4 |
marketplace --> safety and effectiveness --> general population with disease and off-label use |
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after drug is in stage 4, the company has to tract what? |
adverse effects and outcomes |
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after drug is out, what happens is one sees it doing a different positive effect |
they go back to phase 3 and do a new study for that new effect |
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strengths to animal studies (4) |
1. few ethical issues 2. low costs 3. fast results 4. gives a "model" |
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weaknesses to animal studies (2) |
1. results may not be applicable to humans 2. dosing amounts are different |
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ethical issues with clinical studies: historically |
informed, voluntary consent must be obtained before study begins |
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ethical issues with clinical studies: control groups |
all controls must be treated with same care and "treatment" as cases...they still get a placebo, it's just not the real drug |
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other considerations with clinical trial: study group |
must be representative of the whole population |
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attrition |
people dropping out of study is a worry, so figure out why they're dropping out...intent-to-treat |
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community trial strengths |
ability to obtain direct, realistic estimates |
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community trial limitations |
less control over study populations/randomization |
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screening tests goal |
recognize a disease before the onset so we can have earlier intervention |
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screening tests strengths (4) |
1. less expensive 2. quicker 3. less effort 4. less risk |
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screening tests limitations (2) |
1. bias 2. reliability/validity of tests |
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screening |
identification of unrecognized disease or defects by the application of tests, exams, other rapidly applied tests --> positive screens are followed by diagnostic tests to confirm actual disease |
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situations for screening tests/programs |
social scientific ethical |
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social |
health problem is important to community --> diagnostic follow-up and intervention is available when required --> favorable cost-benefit ratio --> public acceptance is high |
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scientific |
history of the condition is understood --> prevalence of disease is high |
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ethical |
program can alter the natural history of the condition in a significant proportion to those screened --> suitable, acceptable tests for screening and diagnosis of the condition as well as acceptable, effective prevention methods |
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when should a screen test NOT be performed? |
when there's no treatment available
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characteristics of a good screening test (5) |
1. simple 2. rapid 3. inexpensive 4. safe 5. acceptable |
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evaluation of screening tests (2) |
1. reliability: repeated measurements, consistency 2. validity: content accurate |
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reliability |
precision: the ability of a measuring instrument to give consistent results |
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repeated measurement reliability |
degree of consistency among repeated measurements of the same person on more than one occasion |
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internal consistency reliability |
the degree of agreement or homogeneity within a questionnaire measure of an attitude, personal characteristic, psychologic attribute |
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interjudge reliability |
reliability assessments derived from agreement among trained experts |
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validity |
accuracy: the ability of a measuring instrument to give a true measure |
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relationship between reliability and validity |
it's possible to be highly reliable and not valid --> it's not possible to be valid but not reliable |
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measurement bias |
constant errors that are introduced by a faulty measuring device and tends to reduce the reliability of measurements |
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study screening calculations --> lecture 10b --> assign 8 |
NA |
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study age adjustment calculations --> lecture 11 --> assign 9 |
NA |
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charity reporting act of 1994 |
required for all not-for-profit hospitals --> makes sure that the needs of the community are being met
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definition/purposes/attributes of community based health care (10) |
1. dynamic process - changes based on the needs of the community 2. identify health problems and goals 3. establishes health priorities 4. facilitates collaborative action planning 5. improves community health status, quality of life, reduces overall healthcare costs 6. improve multiple sectors of the community 7. based on quantitative/qualitative population based health status/services data 8. emphasis on community ownership 9. develop community competence in IDing and responding to health problems and goals 10. prioritizes need to strategically plan |
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components of a community health assessment (6) |
1. assemble existing data 2. assess quality of data among the data sets (there may be costs associated with this) 3. collect additional data: objective and subjective 4. identify and prioritize concerns 5. inventory resources 6. compare concerns with resources to ID unmet need and opportunities for collaborative effort (collaborate, don't compete) |
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objective data |
medical records/lab tests |
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subjective data |
surveys/focus groups/key informants (a leader in the community that has a unique knowledge about the community and what you are studying--> they may be helpful in pushing things through and answering Q's) |
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info needed for community based research (7) |
1. good quality data (objective) 2. perceived needs 3. perceived barriers (planning for a data/project analysis mid program and allocating funds/gathering data at the beginning for the analysis) 4. attitudes (are people collaborative or confrontational?) 5. behaviors (are they easy or hard to change?) 6. knowledge 7. support/decision info |
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data concerns in community health based program (4) |
1. cost per effort to obtain 2. quality (reliability/validity?) 3. population based/sampling scheme 4. standard measures |
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direct outcomes of community health assessment (6) |
1. better understand the health status of the community 2. description of health indicators 3. identification of health concerns 4. prioritizing of health concerns - developing a strategic plan 5. matching resources with needs 6. recommendation of appropriate actions - evidence based decision making |
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indirect outcomes of community health assessment (4) |
1. build alliances between/among agencies and facilities 2. foster community involvement 3. learn how to better measure health indicators 4. reputation as a community resource knowledge about community health problems/concerns |
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environmental hazard exposures (6) |
1. chemical agents 2. electromagnetic radiation 3. ionizing radiation 4. heavy metals 5. air pollution 6. temperature increases from global warming |
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health effects attributed to environmental exposures (4) |
1. cancer 2. infertility 3. reproductive/developmental impacts 4. infectious diseases (Malaria) |
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hazardous agents in the workplace (5) |
1. ionizing radiation 2. infectious agents 3. toxic substances 4. drugs 5. carcinogenic agents |
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health effects attributed to hazardous agents in the workplace (5) |
1. health risks for pregnant workers and unborn fetus 2. various lung diseases 3. dermatologic problems 4. bladder cancer among dye workers 5. leukemia among workers exposed to benzene |
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study designs in env. epi and what they do (3) |
1. descriptive - provide info for IDing new problems and hypothesizing new risks 2. etiologic - shows exposure-effect relationships 3. retrospective cohort studies - studies the effects of occupational exposures |
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what does one use to collect exposure data in the work place? |
employment records (personal ID info, demographics, work history, info about potent ion confounders) |
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healthy worker effect in relation to occupational exposure (hint: morbidity and mortality) |
health worker effect may reduce the measure of effect for an exposure that increases morbidity or mortality |
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ecologic study designs do what? |
measure the association between exposure with morbidity/mortality |
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case-control studies (pertaining to ecological studies) |
provide more complete exposure data (against cross sectional) but precise exposure data may be difficult bc of confounding |
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env epi: dose-response curve |
assess the effect of exposure...as dose goes up, effect should go up |
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env epi: threshold |
lowest dos at which a response occurs |
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env epi: latency |
time period between initial exposure and a measurable response |
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env epi: synergism |
combined effect of several exposures is greater than sum of individual effects (2+2=5) |
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chemical agents |
household cleaners, paints, pesticides, auto chemicals |
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what are acute toxicity effects of chemical agents? |
skin irritation |
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what are chronic toxicity effects of chemical agents? |
cancer |
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insecticides |
kills insects |
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herbicides |
kills plants (weeds) |
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rodenticides |
kills rodents |
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four classes of insecticides |
1. organophosphates 2. organocarbamates 3. pyrethroids 4. organochlorides |
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three examples of organochloride insecticides |
1. DDT - toxic to wildlife 2. lindane - head lice treatment 3. chlordane *all very persistent |
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asbestos |
mineral fiber used in building materials associated with lung cancer (used in insulation, ship building materials, construction, cars) |
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three toxic metals |
1. arsenic 2. mercury 3. lead |
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mercury's uses |
used to treat syphilis, agricultural fungicide, and in dental amalgams |
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what effects is mercury responsible for? |
Minamata disease (mid 1950s) in Minamata, Japan --> neurological condition due to contaminated fish consumption |
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lead's uses |
paints, gasoline |
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what effects is lead responsible for? |
central nervous system effects (even at low levels), intelligence/development/behavior effects |
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during what years did children's elevated blood lead levels decline? |
1988-2002 |
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electron/magnetic fields include... |
nonionizing radiation: power lines, microwaves, radios, ovens, stoves, clocks, cell phones |
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LA and swedish studies found an association between proximity to power lines and .... |
cancer risk |
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US and norwegian studies found increased risk for .... among male electrical workers? |
male breast cancer |
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ionizing radiation consists of... |
high energy protons, neutrons, and particles (alpha/beta) --> electromagnetic energy in x-rays/gamma rays |
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ionizing radiation: natural sources |
radon and cosmic rays--> radon is the cause of nearly 20% of U.S. lung cancers |
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ionizing radiation: synthetic sources |
medical x-rays and nuclear generators |
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allergens |
provoke an allergic reaction in those susceptible |
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physical and mechanical energy |
agents associated with accidental injury/ unintentional injuries/ noise, vibration, temperature extremes |
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what is the leading cause of death within the age group 1-44? |
accidental injuries |
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hazard surveillance (in the occupation) |
ID and characterize the known chemical, physical, biologic agents |
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sentinel health event |
case of unnecessary disease, disability, death --> the occurrence of it is a warning signal that the preventative actions and medical care needs improved |
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biologic hazards |
hospital employees, sewage workers, agricultural workers are exposed to biohazards daily |
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mineral and organic dusts |
coal dust (mining and black lung disease) and rubber dust (COPD) |
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vapors |
organic solvents (benzene) can cause cancer and damage organs (especially the liver) --> drunken symptoms |
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exposure in the occupational setting is up to .....times ....than in the ambient environment |
100 times higher |
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psychosocial aspects of occupational health |
work overload (coronary heart disease), job stress, absence, and physical activity |
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a study found an association between work stress and what disease? |
periodontal disease |
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community environmental health hazards (4) |
1. hazardous waste sites 2. air pollution 3. nuclear facilities 4. drinking water |
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notorious waste sites (5) |
1. love canal, NY 2. valley of the drums, KY 3. times beach, MO 4. string fellow acid pits, Ca 5. Casmalia waste disposal facility, Ca |
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what's the biggest concern with hazardous waste sites? |
contaminated water supplies |
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air pollutants (4) |
1. sulfur oxides 2. particulate matter 3. ozone 4. heavy metals |
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studies conducted in.... and....and....show a correlation between increased air pollution and.... |
NYC, St Louis, Tennessee --> increased air pollution and daily mortality |
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environmental tobacco smoke (ETS) --> second-hand smoke causes what? |
reduced lung function --> 3,000 lung cancer deaths annually --> bronchitis, asthma, pneumonia |
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nuclear facilities include |
weapon production, testing sites, and nuclear power plants |
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studies show that living in proximity to nuclear facilities shows results of what? |
cancer |
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drinking water may be what? |
may be contaminated from toxicants leaching into ground water |
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what helps clean drinking water? what does this decrease? |
chlorination --> decreases new cases of GI disease |
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what toxicants are most present in drinking water? |
lead, asbestos |
