NON SCIENCE Flashcards
What is research misconduct?
Falsification, fabrication, and plagiarism in research
What is falsification in research?
Manipulating research materials or changing/omitting data/results such that research is not accurately represented in the research record
What is fabrication in research?
Making up data or results and recording/reporting them
What is plagiarism in research?
Appropriation of another person’s ideas, processes, results, or words w/o appropriate credit
Which federal and institutional offices oversee research misconduct?
Federal - PHS/HHS or OIG
Institutional - office for research integrity
What is the process of investigating misconduct?
Initial assessment –> inquiry committee –> investigation committee –> institutional decision –> federal reporting and oversight review
What is a significant challenge associated with producing data in medical applications for machine learning?
It takes thousands of samples to produce a robust algorithm, which are prone to human subjectivity for images and data on clinical outcomes requires long-term follow up
What are 6 potential advantages of machine learning in diagnostic applications?
1) unbiased way to formulate patterns quicker than humans can
2) reduction in inter-observer variability
3) high reproducibility and standardization
4) improved quantitative measurement and recognition of latent patterns
5) delivering specialized expertise when needed
6) efficiency of analysis
What are 7 disadvantages of machine learning in diagnostic applications?
1) must have adequate, high quality data
2) need well-labeled data
3) labeling data is laborious and subjective
4) large data sets can be heterogenous and have confounding factors
5) machine learning algorithms can be tricked relatively easily
6) bad at extrapolating
7) can reproduce human bias
What are 3 applications of machine learning in pathology?
1) classification of renal allograft biopsies
2) predicting clinical outcomes in patients with diffuse gliomas
3) measuring tumor infiltrating lymphocytes in breast cancer
What are 4 reasons for truth telling?
1) lying undermines social trust
2) loss of trust is bad because trust is essential for doctor-patient relationships
3) a single lie often requires continued deception
4) deception is a slippery slope
What is the relationship between “blame-free medical excuse” in living organ donation and truth-telling
Blame-free medical excuse allows living organ donors to be free from coercion and pressure to donate such that their consent to the procedure is fully informed and voluntary. This requires lying to the patient, in violation of the principle of truth-telling and could lead to more complications and lying down the road, but is generally accepted to protect potential living-donors.
What ethical principles are involved in living organ donation?
Beneficence and non-maleficence (you are harming the donor by performing an unnecessary surgery, but for the good of the donors emotional needs)
What are 4 requirements for informed consent?
Patient must know
1) their diagnosis
2) the recommended treatment
3) alternative treatments/consequences of no treatment
4) risks/benefits/consequences of each option
What four factors are driving national healthcare trends?
- economic forces
- market dynamics
- changing consumers
- policy
What provisions does the ACA provide for value-based care?
It established plans for value-based payment and created the center for medicare and medicaid innovation (CMMI) to test innovative payment models
What is MACRA?
A program that replaced previous methodology for how Medicare increases payments for services year-to-year and includes two tracks for value-based payments
What two tracks did MACRA create for value based care?
Advanced alternative payment models (A-APMs)
Merit-based incentive payment systems (MIPS)
What are the four criteria for MIPS payments?
Quality, cost, improvement activities, promoting interoperability
What is value in healthcare?
A balance that maximizes health outcomes achieved over cost of achieving outcomes
What are episodic payment models?
Payments based on “episodes of care” surrounding a treatment or condition
What are bundled payments?
A payment model where providers receive a set fee fora service that they can split between all providers involved
What are accountable care organizations?
Networks of doctors and hospitals that share responsibility for managing the care of populations
What are “shared savings” programs for ACOs?
Any reductions in cost achieved by an ACO are shared by providers and payers
What are capitated payments for ACOs?
Providers are given a set budget to manage the costs of care of a population
What are similarities and differences between episode-based payment models and population-based payment models?
Similarities: Shifting incentives towards reducing total cost of care and higher quality care
Differences: target populations, scope of services included, “trigger” of payment, duration of time
What is the quadruple aim of value-based care?
1) improved efficiency of care
2) better health outcomes
3) improved clinician experience
4) improved patient experience
What are four ways to increase value for patients?
1) improving outcomes without raising costs
2) maintaining good outcomes while decreasing costs
3) improving outcomes dramatically for a smaller increase in cost
4) improving patient outcomes while decreasing cost
What is healthcare waste?
Anything we do in health care that does not make people healthier
What are 6 major components of healthcare waste?
1) unnecessary services
2) excessive administrative costs
3) inefficient care due to systems errors/coordination failures
4) prices that are extremely high
5) fraud
6) missed prevention opportunities
What are healthcare outcomes?
The results of care on the health of patients, families, and populations
What were the results of the University of Utah Health Care study?
Decreased cost of joint replacement and decreased cost of joint replacement
What is the capability, comfort, calm framework?
Capability - functional outcomes (survival, extent of recovery, ability to perform tasks)
Comfort - reducing physical and emotional pain and suffering
Calm - measures of the amount of time/days lost to treatment, care, payment, and chaos introduced/avoided
What is the international consortium of health outcomes measurement?
International panel of patients and physicians to develop standard patient outcome measurements across the spectrum of patient conditions
What are Patient reported outcomes (PROMS)
An attempt to capture what services provided actually improve a patients sense of well-being, but they are hard to obtain and interpret
What are process measures?
Measures of what is actually done in giving and receiving care. Must have been previously demonstrated to produce a better outcome for it to be valid.
What are structure measures?
Measures of the material, human, and organizational resources available in settings where care is delivered
What are balancing measures?
Measures of efforts to ensure changes do not result in other unintended consequences or effects
What are outcome measures?
Measures of the effects of care on the health status of patients and populations
What is a “cost” in health care?
The dollar amount that it costs to deliver a health care service
What is a “charge” in health care?
The dollar amount a health care provider asks for a service
What is a “price” in health care?
The dollar amount a patient pays out of pocket for a service
What is a “reimbursement” in health care?
The amount a third party payer (insurance) negotiates as payment to the provider for direct and indirect costs
What is capitation in health care?
Payment of a fee to a health care provider providing services to a number of people such that the amount paid is determined by the number of total patients
What is a fee-for-services model of health care?
A payment system where health care services are unbundled and paid for separately
What is time-driven activity based costing?
Requires providers to estimate two parameters at each process step: the cost of each resource and the quantity of time each patient spends with each resource
What are racial disparities?
Differences that adversely affect disadvantaged populations based on one or more health outcomes, usually resulting from the operation of healthcare systems, legal and regulatory climates, and discriminatory biases
What are racial differences?
Clinical, biological, genetic, or epigenetic factors associated with disease risk or outcome not caused by social factors that vary among population groups
Describe how lack of healthcare access contributes to health disparities in CKD?
Lack of health insurance and routine healthcare leads to over 10% of explained disparity and leads to lack of referrals to nephrology evaluations
What are three contributors to health disparities in CKD?
1) healthcare access
2) access to kidney transplant
3) living and working conditions
What is APOL1 and how does it relate to racial differences in CKD?
A gene with genetic variants that provide a survival advantage against African trypanosomiasis that leads to a greater risk of developing CKD. This is an example of racial difference in CKD.
What is a god committee?
A committee that was formed in Seattle to decide which patients would receive a dialysis spot (which were sparse at the time)
What is the leading cause of ESRD?
Hypertension
What is hemodialysis?
Form of dialysis conducted in clinic where blood is passed through a machine and works via counter-current diffusion to clear waste and return clean blood to patient
What is peritoneal dialysis?
A form of dialysis done at home every night while the patient is sleeping. Abdominal peritoneal membrane acts as a filter
What are important dietary restrictions for CKD patients?
Sodium - 1 tsp/day
Potassium - limit bananas, mangoes, orange juice, raisins, potatoes, tomatoes, black beans, etc.
Phosphorous - limit beans, cheese, dairy, milk, fish, grains, nuts, coca cola
Protein - low protein diet
What is the 5 year survival rate for people on dialysis?
40%
How much of the Medicare budget is spent on ESRD?
7%
What are the risk factors for progression of CKD?
Reduced GFR, higher proteinuria, uncontrolled BP, evidence of fibrosis on biopsy
What are causes of hypovolemia from hypotonic fluid loss?
Excess urination, diuresis, kidney dysfunction, diaphoresis
What are symptoms of hypovolemia from hypotonic fluid loss?
Excessive thirst, lightheadedness, fever, sweating, polyuria
What are some causes of hypovolemia from isotonic fluid loss?
Vomiting, diarrhea, hemorrhage (traumatic, GI loss)
What are symptoms of hypovolemia from hypotonic fluid loss?
Vomiting, diarrhea, fatigue, melena, bright red stool
What are some causes of hypovolemia from third space redistribution?
Pancreatitis, crush injuries, bone fractures
What are symptoms of hypervolemia due to heart failure?
Dyspnea on exertion, exercise intolerance, peripheral edema, orthopnea, weight gain
What are symptoms associated with ascites?
Increased abdominal girth, dyspnea, edema, weight gain
What are vital sign findings associated with hypovolemia?
- Hypotension
- Tachycardia
- Orthostatic hypotension and tachycardia
- weight loss
What is the criteria defining orthostatic hypotension?
Fall of SBP by 20 mmHg or DBP by 10 mmHg within 3 mins of standing
What is the criteria defining orthostatic tachycardia?
Increase of pulse by > 30 beats/min following standing
What are physical exam findings associated with hypovolemia?
- dry mucous membranes
- dry axilla
- reduced skin turgor
- poor capillary refill time
- tachypnea
What are vitals sign changes associated with hypervolemia?
Weight gain
What are physical exam findings associated with hypervolemia?
- JVP elevation > 3 cm
- abdominojugular reflux (sustained rise in JVP by 4 cm)
- peripheral edema
- s3 present
- shifting dullness or positive fluid wave
What lab findings are suggestive of hypovolemia?
- elevated BUN/Cr ratio
- elevated urine specific gravity
- reduced Urine Na
- reduced FENa
- increased hemoconcentration
- hypernatremia
What point of care ultrasound findings are suggestive of hypovolemia?
- narrow IVC diameter
- respiration-induced IVC collapse of 100% is suggestive of CVP < 2 cmH2O
What point of care ultrasound findings are suggestive of hypervolemia?
- wide IVC diameter
- lack of respiration-associated IVC collapse is suggestive of CVP > 20 cmH2O
What does rebound tenderness suggest?
Peritonitis
What does involuntary guarding suggest?
Peritonitis
What does percussion tenderness suggest?
Peritonitis
What does shake tenderness suggest?
Peritonitis
What does the shifting dullness test test for?
Ascites
What does the fluid wave test test for?
Ascites
What does the flank dullness test test for?
Ascites
What does a protuberant abdomen suggest?
Ascites
What does murphy’s sign test for?
Cholecystitis
What does the Psoas sign test for?
Appendicitis
What does the obturator sign test for?
Appendicitis
What does costovertebral angle tenderness suggest?
Pyelonephritis
What does it mean for an ultrasound feature to be anechoic?
Without reflection –> appears black and tends to be less dense like water or hydronephrosis
What does it mean for an ultrasound feature to be hyperechoic?
It looks white
What does it mean for ultrasound features to be isoechoic?
Same color/echogenicity relative to another area
What is the color of the right kidney on ultrasound relative to the liver?
Hypoechoic
What does hydronephrosis look like on ultrasound?
Anechoic in collecting structures
What is an echogenic kidney?
A kidney that has increased echogenicity relative to liver
What do kidney stones look like on ultrasound?
They have shadows
What does pyelonephritis look like on ultrasound?
Increased blood flow in areas of infection
What are the benefits of ultrasounds?
No radiation, relatively inexpensive, dynamic, quick assessment of common renal disorders, can detect hydronephrosis, stones, focal pyelonephritis, infarct, etc
What are the pitfalls of using ultrasounds?
Depends on user ability, limited by artifacts and body habitus, requires patient cooperation, findings can be non-specific
What are the indications for renal biopsy?
Hematuria, proteinuria, worsening renal function, does not fit clinical course of disease, surveillance of transplanted kidney
What are some contraindications for renal biopsy?
Uncontrolled HTN, bleeding disorders, active renal or skin infection, atrophic kidneys, horseshoe kidney, solitary kidney, uncooperative patient
Where are renal biopsies taken from?
From the renal cortex to visualize glomeruli
Select the correct statement:
A. High frequency transducer provides deeper tissue penetration with better image resolution compared to a low frequency transducer
B. High frequency transducer provides superficial tissue penetration with better image resolution compared to a low frequency transducer
C. Low frequency transducer provides deeper tissue penetration with better image resolution compared to a high frequency transducer
D. Low frequency transducer provides superficial tissue penetration with better image resolution compared to a high frequency transducer
C. Low frequency transducer provides deeper tissue penetration with better image resolution compared to a high frequency transducer
A structure containing simple fluid would appear
A. Anechoic with posterior acoustic shadowing
B. Hyperechoic with posterior acoustic enhancement
C. Hypoechoic with no relative change in the appearance of structures deep to it
D. Anechoic with posterior acoustic enhancement
E. Hyperechoic with posterior acoustic shadowing
D. Anechoic with posterior acoustic enhancement
A renal stone would generally appear
A. Anechoic with posterior acoustic shadowing
B. Hyperechoic with posterior acoustic enhancement
C. Hypoechoic with no relative change in the appearance of structures deep to it
D. Anechoic with posterior acoustic enhancement
E. Hyperechoic with posterior acoustic shadowing
E. Hyperechoic with posterior acoustic shadowing
Relative to the liver, the kidney should generally appear
A. Anechoic
B. Hypoechoic
C. Hyperechoic
B. Hypoechoic
A renal core biopsy performed as part of the work-up of kidney disease should be obtained from the A. Hilum B. Medulla C. Corticomedullary junction D. Cortex E. Capsule
D. Cortex
Which of the following is NOT considered to increase a patient’s baseline risk of bleeding after renal biopsy according to a study published by Corapi et al.? A. Systolic blood pressure ≥130 mmHg B. Creatinine ≥2 mg/dL C. Hemoglobin concentration <12 g/dL D. Pediatric patient
D. Pediatric patient
Which of the following is TRUE regarding the administration of desmopressin prior to renal biopsies, according to a study published by Manno et al.?
A. There was no difference in the rates of hematomas detected after renal biopsy in the group of patients who received desmopressin compared to placebo
B. Patients who received desmopressin prior to renal biopsy required fewer blood transfusions compared to the patients who received a placebo
C. Patients who received desmopressin had fewer clinically significant bleeding complications compared to patients who received a placebo
D. There was no statistically significant difference in the hemoglobin concentrations of the patients who received desmopressin compared to the patients who received a placebo
D. There was no statistically significant difference in the hemoglobin concentrations of the patients who received desmopressin compared to the patients who received a placebo
“whether or not to give flu shot during hospitalization” is a result of which type of measure?
Process measures
” # of staff needed to deliver flu shots to every hospitalized patient” is a result of which type of measure?
Structure measures
“efforts to discharge by noon, resulting in an increased length of stay because patients were being kept until the next day to be discharged in the morning.” is a result of which type of measure?
Balancing measures
“fewer people receive the influenza vaccine” is the result of what type of measure?
Outcome measures
