other Flashcards
precision - aka
accuracy - aka
precision = consistency = reproducibility = reliability accuracy = truness = validity
accuracy vs precision according to errors
accuracy –> systemic
precision –> random (explain by chance - unpredicable)
Metanalysis disadvantage
while it pools together the data from many studies, it also pools together the biases and limitations of those individuals studies
case fatality rate
divide number of fetal cases by the the total number of people with this disease
Hawthorne effect
(aka observer effect) is the tendency of study subjects to change their behavior as a result of their awareness that their being studied
how to minimize Hawthorne effect
study subjects can be kept unaware that they are being studied –> this can occasionally pose ethical problems
Health promotion?
according to WHO –> the process of enabling people to increased control over their health + its determinants and thereby improve their health
examples: dietary habits, exercising regularity, no smoking, lossing weight if needed
FALLS UNDER PRIMARY PREVENTION
Detection bias
the risk factor itself may lead to extensive diagnostic investigation and increase the probability that a disease is identified
Sampling bias
non-random sampling selection
Ecological study
like cross sectional but in populations (not in individuals)
t-test types (explain)
- 2 sample T test –> aka Student’s test –> compare means of 2 independed groups
- Paired T test –> depended –> compare 2 means from the same individuals
Fisher’s exact test
like X square test but in smaller sample
less than 10 people in each cell
anova - types (explain)
- 1 way analysis –> 1 variable (weight loos mean in 3 dif groups)
- 2 ways analysis –> 2 variables (eg. weight loss man in 3 dif groups + men vs women
ROC (receiver operating characteristic) def + expl
graphic with sensitiviy at y + 1-specif (FP rate) at x for a diagnostic test
explanation –> the closer the curve to the diagonia, the less discrimination ability of the test. The closer to the y axis, the better discrimination
variables - types and definition
independent –> an experimenter can change it (salt in diet)
depended –> outcomes that reflex to the change (blood pressure)
counfounding bias strategy of reduction
- multiple repeated studies
- crossover studies
- matching
- restriction
- randomization
- standard deviation vs standard error of a mean (SEM)
- how much variability from the mean in a set of values
2. how much variability exits between the sample mean + the true population
case series studies
descriptive study that tracks patients with a known condition (eg. particular exposure, risk factor, disease) to document natural history or response to treatment (qualifying study that cannot quantify statistical significance)
interquartile range
difference between the values corresponding to the 25th and 7th percentile
Standardised mortality ratio
observed number of deaths / expected number of deaths
maternal mortality rate
maternal deaths / live births
cause specific mortality rate
number of deaths from a particular disease / total population
- crude birth rate
2. crude mortality
- number of live birth / total population
2. number of live death / total population
attrition bias?
in prospective studies, if loss to follow-up occurs disproportionately between the exposed + unexposed groups –> attrition bias can result if the lost subjects differ in their risk of developing the outcome compared to the remaining sugjects
(IT IS A FORM OF SELECTION BIAS)
attrition bias does not occur when the losses happen randomly between the exposed + unexposed groups
Community level intervention - example
taxes on cigarretes can be implemented at the community level to improve health on the public
attack ratio
the ratio of number of individuals who become ill divided by the number of individuals who are at risk
(used in outbreak investigations)
Length time bias
phenomenon whereby by screening test preferentially detects less aggressive forms of a disease + therefore increases the apparent survival time
effect modification is present when
the effect of the main exposure on the outcome is modified by the presence of another variable –> NOT A BIAS (confused with confounding)
health risk assessments
questionnaires that use demographic, medical, lifestyle, and family history information to calculate a patient’s “risk age”
attributable risk vs attributable risk percent
- attributable risk = difference in risk between exposed + unexposed
- attributable risk percent = contribution of a given exposure to the incidence = attributable risk / incidence in exposed
- population attributable risk percent: diseased people due to exposure / diseased people = (incidence of disease in population- incidence in nonexposed) / incidence of disease in population
Maternal death is the
death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
Allocation bias
the treatment + control groups are assembled. It may occur if subjects are assigned to the study groups of a clinical trial in a non-random fashion. (eg. in a study compating oral NSAID and intraarticular corticosteroids injections for the treatment of osteoarthritis, obese patients may by preferentially assigned to the corticosteroid groups)
Referral bias?
aka: admission rate bias –> the case + control populations differ due to admission or referral practises. (eg. a study involving cancer risk factors performed at a hospital specializing in cancer research my enroll cases referred from all over the nation. However hospitilized control subjects without cancer may come from only the local area)
intention to treat
the patient’s treatment status at the point of randomization is analyzed –> if a patient in placebo begin taking the medication assigned to the treatment group sometime after study initiation, or if a patient in the treatment group stops taking the prescribed medication, the data from these patines is still analyzed along with their original group –> preserves the benefits of randomization and prevents selective bias
nested case control study
design start with cohort studies in which participants are followed over time, and those participants who develop an outcome of interest become cases for a case-control study
positive and negative likelihood ratios indicate
LR+ = sens / (1 - spec) --> probability of an individual with the condition having a positive test / probability of an individual without the condition having a positive test LR- = (1-sensit) / specif) --> probability of an individual with the condition having a negative test / probability of an individual without the condition having a negative test
children - use of prepositions - age
4
changes in elderly - sleep patern
- decreased REM + slow wave sleep
- increased sleep onset latency
- increased early awaking
Hospice model - everything
- Focus on quality of life, not cure or life prolongation
- Symptom control
- Interdisciplinary team (medical, psycosocial etc)
- Services provided at home, assisted living facility or dedicated facility
- REQUIRES SURVIVAL PROGNOSIS LESS THAN 6 MONTHS
Covered by Medicare PART A
health care expenditures in usa total more than ….% of total economy
14
is usa peple avarege … (number) vistis to physicians per year
5
number of phycisians in USA
950 000
number of hospitals and hospital beds in USA
6000 hospitals
1 mil beds
types of hospitals (and numbers)
all hospitals –> 6000
- community hospitals (5,008)
- federal government hospitals (211)
- nonfederal psychiatric hospitals (444)
- nonfederal long-term care hospitals (117)
community hospitals?
- non government not-for profite
- investor-owned for profit type
- state and local government
federal government hospitals?
veteran’s administration and military hospitals that are federally owned and reserved for those who have served or are serving the military
nonfederal psychiatric hospitals
hospitals for chronically mentally ill patients that usually are owned and operated by state governments
nonfederal long-term care hospitals
hospitals for chronically physically ill patients
Most elderly americans spend the last years of life in ….. (why)
in their own residence
long term care (nursing homes etc) are not covered by medicare –> only 5% go there
Avoidant / restrictive food intake disorder
avoidanc of food intake due to dislike of the sensory experience involved in tasting or eating food and/or the consequences of eating (no disturbance of image)
Behavioural treatment of insomnia - types
- Sleep hygiene: regular sleep schedule, avoid naps, avoid caffeine alcohol, smoking, quite + dark environment, exercise regularly but not before bed
- Stimulus control: use bed only for sleep + sex, leave when you cannot sleep, fixed wake up time (including weekends)
- Relaxation: progressive muscle relaxation, relaxation response
- Sleep restriction, restrict sleep to time patient is actual sleeping, increase time in bed in 15-30 min intervals when sleep efficacy is more than 90%
Tourette vs chronic tic disorder
tourrete –> both motor + vocal tics
chronic tic disorder –> only 1 of motor or vocal
Pica?
compulsive consumption of nonfood and/or non-staple food (common in pregnancy + schoolchildren, esp if loss of weight) (eg. earth/soil rich substance, raw starch, ice)
craving in normal pregnancy
patient desires nutrive food items
Undoing
nullifying an unacceptable or guilt-provoking thought, idea, or feeling by confession or atonement (common in OCD)
premature ejaculation - criteria
ejaculation within 1 minute of penetration, most of the time for least 6 months)
Medical conditions linked to premature ejaculation
prostatitis + thyroid disease
medical conditions that affect nerves of blood flow causes erectile dysfunction
- baby identifies colours - when
2. baby counts to 10 - when
- 4 years
2. 5 years
SSRI - MC side effect
sexual dysfunction (50% of patients –> frequent cause of non-adherence)
Mood stibilizer in bipolar disorder
- Lithium
- Valproate
- Carbamaepine
- Lamotrigine
- quetiapine
resistant schizophrenia - treatment
clozapine
TB patient’s that refuses to treat
you do not have the right to force feed the medications through the nasogastric tube, but you do have the right to remove the patient from his job, and put him in a hospital where he cannot infect other until his sputum is free of acid fast bacili
Diseases that are always reportable
AIDS, syphilis, gonorrhea, TB, childhood disease,
HSV - reportable
no
- MC way to suicide
2. the stronger single risk factor for suicide?
- suicide by firearm
2. history of previous suicide attempts
treating friends and family
ethically problematic + shoul dbe limited to EMERGENCY situations in which NO OTHER physician is available
Protocol of delivering bad news
SPIKES protocol
- Set the stage (private, confortable, introduce, etc)
- Perception (open ended q to assess perception of medical situation)
- Invitation: ask what they would like to know
- Knowledge: warm for bad news, speak simple, check understanding, cognizant of cultural, education, religious)
- Empathy: understanding + support
- Summary + stratefy : summurize + create follow-through plan, including end-of life discussions if applicable
Stages of grief - terminal illness
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
renal insufficiency in a DNR patient
do dialysis –> DNR is only for CRP
Institutional review board (IRB) role
reviews all experimental trials to make sure that the treatment of the subjects is fair and humane - make sure that there is adequate informed consent and that the asked question is a valid question
a father with FAP ask you not inform his ex-wife. they have together 3 children - what are you doing
inform her
a patient tells you that will harm somebody - next step
inform BOTH, the victim + the law
Disagree with other physician
discuss –> if not results –> higher authority
gunshot wounds - report
always –> pursuing a criminal investigation
torture - physician
it is unethical to participate in torture at ANY LEVEL (eg. military)
you may treat injuries by torture once the victims have been removed from an environment where torture may occur. you cannot treat injuries to allow patients to become well enough to withstand more torture
brain death - next step
Although you have the legal right to turn off the ventilator immediately on a person who is brain dead, you should talk to the family first
Malpractice
preventable error in case of the patient resulting in harm (no harm –> no malpractice) (IT IS NOT A MEDICAL ERROR –> IT IS THE RESULT OF MANY ERROR)
sexual relationship between doctor and former patient
- always unacceptable for psychiatrist
- not clear for other physicians
gifts from pharmaceutical industries
never: autonomic presumption that always carry an influence toward a product, service, or prescribing practise. BUT:
MODEST gifts of less than 100 dolars are acceptable only if they are medical of educational in nature (eg. books)
organ donor cards vs family consent
card gives an indication of patient’s wishes, for donation, family consent is still necessary –> family objection can OVERRULE the card
payment for donations
with exception of renewable tissues such as sperm, UNFERTILIZED sperm, and blood, payment for organs is considered ethically unacceptable
(IT IS ACCEPTABLE TO COVER THE COST OF THE DONOR FOR THE DURATION)
obtain for a constant for organ donation
only the organ donor network or uniform network for organ sharing obtain consent for an organ donation
THE MEDICAL TEAM TAKING CARE OF THE PATIENT SHOULD NOT ASK FOR DONATION
donation of sperm and eggs
- there is no legal or ethical contraindication to SELLING sperm and unfertilized eggs
- Fertilized eggs may be donated, not sold
abortion according to gender
it is unethical for a PATIENT to seek n abortion for the purposes of gender selection –> it is ethically unacceptable to determine the gendr of the fetus and then abort the fetus if the sex is unacceptable to the patient
2 methods of defining death are …
- termination of heartbeat
2. brain death
Brain death criteria
loss of brainstem reflexes such as
1. Pupilary light reflex
2. Corneal reflex
3. Oculocephalic (doll’s eyes) reflex
4. Caloric responses to iced water stimulation of the tympanic membrane
5. Absence of spontaneous respiration (observe by remove ventilator)
(EEG OR CEREBRAL BLOOD FLOW STUDY ARE NOT NECESSARY)
abortions in adults according to trimester G
1st trimester: clearly unrestricted
2nd: between woman and her physician
3rd: not available (legally only if her life is at risk, or risk for the fetus)
informed consent for a never-competent person (eg. DOWN)
ask for the consent of the parent or guardian –> if not has –> COURT
(a patient who has never capacity cannot give advance directives etc)
Medical records - patient
cannot take sole possession but has the right to access or copy
(NO one has the right to interfere a patient to get them for any reason)
Pregnant women - decision about the fetus
the woman decide - fetus is not a person until birth
(eg. pregn woman may refuce lifesaving procedures even if the fetus is in danger)
(MOTHER AUTONOMY IS MORE IMPORTANT THAN FETUS OR FATHER)
Telephone consent - valid
yes (try to have also a witness)
Physician burnout
emotional exhaustion, cynicism, depersonalization + decreased sense of personal accomplishment that can result in suboptimal patient care + medical errors
(errors resulting from lack of concern or callousness rather than forgetfulness (fatigue))
risk of wrong site surgery can be reduced by
requiring dual identifiers (usually a nurse + physician) to independently confirm that they have the correct patient, site, + procedure
near miss
medical error recognised before any harm is done to the patine
cane + walkers - risk of falls
although both increase mobility –> there is no evidence that they reduce the risk of falls
- preventable adverse effect
2. non-preventable adverse effect
- injury to a patient due to failure to follow evidence-based best practise guidelines
- complication that cannot be prevented be prevented given the current state of medical knowledge
Structured handoffs
include specified key elements (eg. systematic procedure or sign out, checklists of tasks that need to be completed, a standardised approach to each patient) –> reduce preventable adverse events
sentimal event
unexpected occurrence involving death or serious physical or psychological injury (eg. suicide, death etc) that requires immediate investigation
