PBL, TBL, HS, LM, MDM, and HQPS Flashcards
five stages of readiness to change
pre-contemplation, contemplation, preparation, action, and maintenance
four of the most useful processves of change
consciousness raising, environmental reevaluation, helping relationships, self-reevaluation
Health Belief Model
the principle that health behavior change is a function of the individual’s perceptions regarding his or her vulnerability to illness and perceived effectiveness of treatment
Self-Determination and Motivational INterviewing
people are motivated to act by very different types of factors, either because thye value a particular activity (internal motivation) or because there is strong external coercion (external motivation)
sequence that all behaviors pass through
control by others, control by self, and automatization
four general principles of MI to explore resolve ambivalence
express empathy, develop discrepancy, support self-efficacy, and roll with resistance
behavioral gap
the importance of change and the distance a patient’s behavior would need to travel in order to reach the desired level
social cognitive theory/ecological models
emphasizes the interactions between the person and his or her environment
behavior is a function of aspects of both the environment and the person, all of which is in constant reciprocal interaction
two central concepts of social learning theory
self-efficacy - patient’s belief to in his or her ability to change or maintain a specific behavior under a variety of circumstances
outcome expectations - the degree to which a patient believes that a given course of action will lead to a particular outcome
theory of planned behavior
the intention to act is guided by three belief considerations - behavioral beliefs, normative beliefs, and control beliefs
behavioral chagne is always immediately preceded by intetnion as well as perceived and actual control
behavioral belief
the patient’s perceived outcomes and attitudes toward engaging in the behavior
normative beliefs
the subjective norms or pressure of others in the family or community regarding the behavioral change
control beliefs
the presence of factors that may facilitate or iumpede performance of the behavior and the perceived power of these factors
cognitive behavioral therapy
focuses on short-term, problem-oriented tratements that address the present and future
primary goal is cognitive change, paying attention to inner thoughts, attitudes, and emotions as well as the events that both trigger and result from our actions
three key traditional cognitive behavior therapy techniques for treating patients with obesity
self-monitoring - recording behavior
stimulus control - avoiding behavior or thoughts that incite a behavior
cognitive restructuring - change internal dialogue and be more aware of distructive or distorted thoughts and beliefs
three content areas of HS
personal health, population health, and global health
five determinants of health
socail environment, individual behavior, biology and genetics, health services, physical environment
HS covers everything except biology and genetics
barriers to accessing health services
lack of availability
high cost
lack of insurance coverage
limited language access
non-communicable diseases
cardiovascular diseases
chronic respiratory disease
diabetes
boesity
cancer
calculation of LDL cholesterol
LDL = Total cholesterol - (HDL + triglycerides/5)
HbA1C
correlates with blood glucose levels, monitors long-term blood glucose levels
blood cholesterol measurements
less than 200 - desirable
200-239 - borderline high
>= 240 - high
LDL choleserol level
less than 100 - optimal
100-129 - near optimal
130-159 - borderline high
160-189 - high
>=190 - very high
triglyceride level
less than 150 - normal
150 - 199 - borderline-high
200-499 - high
>= 500 - very high
glucose levels
51-99 - normal
100-125 - pre-diabetes
>= 126 - diabetes
HbA1c levels
- 0-5.6 - normal
- 7-6.4 - pre-diabetes
>=6.5 - diabetes
What is social medicine?
seeks to understand individual clinical problems in a social context and to improve health at multiple levels:
clinical care
community outreach
research and advocacy
social determinants of health
The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.
public health
Health-activities that society undertakes to ensure the conditions in which people can be healthy. These include organized community efforts to prevent, identify and counter threats to the health of the public.
population health
the physical, mental, and social well-being of defined groups of individuals and the differences or disparities in health between and among population groups
global health
the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide
epidemiology
study of risk factors and causes of health problems
upstream determinants
those that occur at the macro level and include global forces and government policies
midstream determinants
intermediate factors such as health behaviors
downstream determinants
occur at micro level and include one’s genetics
prevalence
proportion of a given disease or condition in a population at a snap shot in time (cross-section)
incidence
number of new diagnoses of a disease or condition that develop over time in a population (rate)
cumulative incidence
accumulated number of events in a population in a fixed time: good for short and consistent follow-up time
25 events out of 108 students with normal baseline BP: 25/108 = 23% phase I CUMULATIVE incidence
incidence rate
number of events per person-years of follow-up time: good for long and variable follow-up time
25 events per (108 students x 20 months of phase I = 2,160 person-months or 180 person-years), which is 14 per 100 person-years incidence RATE
PDSA cycle
PLAN - the change to be tested or implemented
DO - carry out the test or change
STUDY - data before and after the change and relfect on what was learned
ACT - plan the next change cycle or full implementation
Heisenberg Principle
The very act of observing a phenomenon alters that phenomenon in some way
Hawthorne Effect
The tendency of some people to work harder and perform better when they are observed
Individuals may change their behavior due to the attention they are receiving
Developing Goals - SMART
- S Specific: choose one specific behavior modifier per goal to work on
- M Measurable: Can you measure this against a baseline?
- A Attainable or Action Based behavior: Is the goal attainable? Use action words when writing goals such as “I will” or “I do”, rather than “try, should, would, could.”
- R Realistic: Do you have honest and realistic expectations of yourself with your time, body, likes/dislikes?
- T Timely: is the time allotted reasonable and manageable for you right now?
Health Equity
depends vitally on the empowerment of individuals to challenge and change unfair and steeply graded distribution of social resources to which everyone has equal claims and rights
inequity in power interacts across four main dimensions - political, eocnomic, social, and cultural - atogether constituting a continuum along which groups are to a varying degree excluded or included
cultural competence
implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities
cultural knowledge
familiarization with selected cultural characteristics, history, values, belief systems and behaviors of the members of another ethnic group
cultural awareness
developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others
cultural sensitivity
knowing that cultural differences as well as similarities exist, without assigning values, i.e better or worse, right or wrong, to those cultural differences
reccommended daily nutrition intake
less than 2,300mg of salt
10% of calories from saturated fatty acids
less than 300mg of dietary cholesterol
reduce sugar and fat intake
limit refined grains
no more than two drinks per day
food desert
areas that lack access to affordable fruits, vegetables, whole grains, lowfat milk, and other foods that make up the full range of a healthy diet
food security
high food security - no reported indications of food-access problems or limitations
marginal food security - anxiety over food sufficiency or shortage of food in teh house, little or not indication of changes in diets or food intake
food insecurity
low food security - reports of reduced quality, variety, or desirability of diet, little or no indication of reduced food intake
very low food security - reports of multiple indications of disrupted eating patterns and reduced food intake
WIC
women, infants, and children - a federally funded health an dnutrition program for women, infants, and children
SNAP
the Supplemental Nutrition Assistance program - helps low-income people and families buy the food they need for good health
Link
the Illinois Link card is a plastic card that looks and works like a debit card
NSLP
National School Lunch Program - available nationwide for low income children to provide free or reduced cost for lunches depending upon the family income
DRIs
Dietary Reference Intakes - reference values used to plan and evaluate diets for healthy populations with an emphasis on prevention of chronic diseases and promotion of optimal health
social-ecological model of influences on health behavior
SEGUE
Set the stage
Elicit informatin
Give information
Understand patient’s perspective
End the encounter
blood pressure ranges
120-139/80-89 prehypertension
140-159/90-99 Stage I Hypertension
>160/>100 Stage II Hypertension
BMI ranges
18.5-24.9 healthy weight
25-29.9 overweight
30-34.9 class I obesity
35-39.9 class II obesity
>= 40 class III obesity
normal waist circumference
men
women >35 in
OLDCARTS
Onset, Location, Duration, Characteristics/quality, Aggravatin/alleviating factors, Radiation, Treatment, Significance
health literacy
the degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
past medical history
general state of health
childhood diseases
mediucal illnesses
surgeries
gynecological history
psychiatric
hospitalizations
exposes to contageons
immunizations
screetning tests
medications
name, strength, dose, frequency
inhalers, birth control, over-th-counter, home remedies, supplements, herbal medications
allergies
to medications, foods, inhalants, or skin exposures
record the reaction
family history
first-degree and second-degree relatives
relationship, age, illness, death
focus on cancer, anemia, peptic ulcer, tb, diabetes, heart attack, hypertension, thyroid disease, kidney disease, osteoporosis, mental illness, allergies, other
social history
home situation
daily life and activities
support systems
stresses
educational and occupational history
travel history
tobacco
alcohol
drugs
nutrition
physical activity
sexual history
trauma risks
intimate partner violence
review of systems
general, skin, head, ears, nose, mouth and throat, neck, polmonary, CV, gastro, genitourinary, gynecologic, musculoskeletal, neurologic, psychologic
enzymatic defect in Gaucher Disease
aced beta-glucosidase (glucocerebrosidase)
acts to cleave glucosyl group, separating it from a ceramide
symptoms of Gaucher
hepatomegaly and splenomegaly
thrombocytopenia, anemia, leukopenia
bone disease, bone pain (erlenmeyer flask deformity)
treatment of Gaucher Disease
enzyme replacement therapy
Type I Gaucher Disease
autosomal recessive, one of the most common
1 in 40,000-60,000 in general population
1/500 in Ashkenazi Jews
Orphan Drug Act
law passed to promote development of drugs for rare diseases
Fabry Disease
1 in 40,000 to 1 in 60,000 males
X-linked inheritance
defect in gene that encodes for lysosomal enzyme alpha-galactosidase A
unable to break down lipids, especially bglobotraosyl-ceramide (GL-3)
symptoms/pathophysiology of Fabry Disease
end-organ damage from GL-3 accumulation
narrowing of blood vessels
accumulation in nerve cells and other tissues
severe episodes of pain
decreased or absent sweating
corneal opacities (verticillata)
angiokeratomas
kidney failure, heart failure, stroke in adults
sarcoidosis
autoimmunde disease affecting lungs, lymph nodes, joints, kidneys, liver, and heart
prevalence of abou 10-20 per 100,000
difficult to diagnose
six aims for improvement in medicine
safe, timely, effective, efficient, equitable, patient-centered
Levels of System in quality
implicit and explicit measuring
implicit - another professional reviews and makes judgments about the quality of care
explicit - measurement using defined criteria
kapp statistic for binary outcome
0 = amount of agreement expected by chance
1 = perfect agreement
topology of quality measures
structures - measure of a static characteristic such as policy or procedure
processes - measurements of what takes place during the delivery of care such as the tratments prescribed or the procedures done
outcomes - measurements of health status or clinical condition, can include costs or reported outcomes of the consumer
types of outcomes
intermediate, end point, or expenditure
barriers to outcome measures
remotemenss, relative rarity of end points, confounders
adverse event
an injury caused by medical management not the disease process that led to a prolonged hospital stay or disability at discharge
swiss cheese model
A complex system exhibits complex interactions when it has:
Unfamiliar, unplanned, or unexpected sequences which are not visible or not immediately comprehensible
Design features such as branching, feedback loops
Opportunities for failures to jump across subsystem boundaries.
A complex system is tightly coupled when it has:
Time-dependent processes which cannot wait
Rigidly ordered processes
Only one path to a successful outcome
Very little slack (requiring precise quantities of specific resources for successful operation)
human factors and ergonomics paradigm
physical ergonomics - environment, tools, and artifacts
cognitive ergonomics - tasks, people
macro ergonomics - interrelations and organization
affordances
perceived and actual properties that give an idea how the device might be used
mappings
connection between what is intended and the means to accomplish it
conceptual model
mental picture of “how things work”
constraints
physical/cultural limits to “what can be done”
design principles for physical ergonomics
importance - more important items should be more accessible
ferquency - more frequently used items should be mroe accessible
function - group components together according to function
sequence of use - group components in “natural” sequence of use
design constraints for physical ergonomics
clearance - space in and around equipment
reach - frequently used objects should be closer
adjustability - make customization to human variation easy
taxonomy of error
automatic mode - effortless and rapid, attention only when change, parallel processing
problem solving mode - conscious and slow, intense mental activity, requires utilization of stored knowledge
cognitive biases
anchoring, attentional bias, availability heuristic, confirmation bias, frequency illusion, hindsight bias, information bias, irrational escalation
anchoring
the tendency to rely too heavily, or “anchor,” on a past reference or on one trait or piece of information when making decisions
attentional bias
the tendency of emotionally dominant stimuli in one’s environment to preferentially draw and hold attention and to neglect relevant data when making judgments of a correlation or association
availability heuristic
the tendency to overestimate the likelihood of events with greater “availability” in memory, which can be influenced by how recent the memories are, or how unusual or emotionally charged they may be.
confirmation bias
the tendency to search for or interpret information in a way that confirms one’s preconceptions
frequenct illusion
hindsight bias
sometimes called the “I-knew-it-all-along” effect, the tendency to see past events as being predictable[29] at the time those events happened. Colloquially referred to as “Hindsight is 20/20“
information bias
the tendency to seek information even when it cannot affect action
irrational escalation
the phenomenon where people justify increased investment in a decision, based on the cumulative prior investment, despite new evidence suggesting that the decision was probably wrong.
processing of a clinical lab speciman
collect, receive and process, analysis, storage, discard
lab test results are used to aid…
diagnosis of a disease
prognosis or outcome predictions
patient management
brain-to-brain loop
turnaround time (TAT)
the time between the lab receiving a specimen and the time that the result is produced
priority of lab tests
routine - collected whenever convenient and analyzed as a batch or as received
timed - collected at a specific time and analyzed in batch or as recieved, prioritized with/after stat
stat - collected immediately and analyzed/reported without delay
possibilities for error in specimen collection
patient variables
proper technique
tube color
collection volume
temperature/time
possibilities for error in specimen receiving
unlabeled/mislabeled specimen
specimen rejection
delays in receiving
wrong orders received
errors in storage
mint green, dark green, lavender, blue top tubes
contains blood plasma
liquid fraction of whole blood (uncoagulated)
contains clotting factors and fibrinogen
red and gold top tubes
contains blood serum
liquid fraction of coagulated blood
possibilities for error in specimen processing
unlabeled/mislabeled specimen
specimen rejection
delays in processing
errors in processing
errors in storage
possibility for error in specimen analysis
equipment malfunction
poor assay calibration or precision
technologist error
test interferences or other effects on measurement
causes of optical interference
hemolysis, lipemia, and icterus
critical values
those that represent a life-threatening situation and require immediate communication to a medical provider that can provide necessary intervention
possible errors in the post-analytical phase
delayed results
technologist error (manual entry error, verification error, failure to notify clinician of critical value)
red cap
serum, no additives or clot activator
gold cap
serum, additive of clot activator and serum-separator gel
light blue cap
plasma, addition of citrate
purple cap
whole blood or plasma
addition of ETDA
mint green cap
plasma
additive of lithium heparin
dark green cap
whole blood or plasma
additive of sodium heparin
gray cap
plasma
additive of fluoride and/or oxalate
yellow cape
plasma or whole blood
additive of acid/citrate/dextrose
methods of PCR fluorescent detection
SYBR Green, Taqman, Molecular Beacons, Light Cycler
qPCR (target region, resolution, comments)
quantitative PCR, uses fluorsecence to measure the initial concentraiton of the DNA of interest
single targeted region
resolution of a few bases
need prior knowledge of sequence
NASBA
DNA amplification method that does not require heat cycles
signal amplifcation methods
branched DNA
hybrid capture
invader technology
target vs. signal amplification
target amplification methods have the advantage of greater analytical sensitivity (lower limit of detection)
however, target amplification carries a risk of contamination of negative samples with amplified product leading to false positive results
advantages and disadvantages of Array CGH (target region, resolution, comments)
advantage: allows detection of much smaller deletions or duplications
disadvantage: unable to detect translocations and conditions where there are no copy number variants
whole genome, single exon resolution
Multiplex ligation-dependent probe amplification (target region, resolution, comments)
widely used to support sequencing
two probes for every target - contains specific sequence
can do up to 50 probes at a time
few base resolution
need prior knowledge of sequence
FISH (target region, resolution, comments)
few loci targeted
about 200kb resolution
advantage of seeing mechanism
chromosome analysis (target region, resolution, comments)
whole genome targeted, 3-10 Mb resolution, advantage of seeing mechanism
Sanger Sequencing
limitations - cis vs. trans ambiguity, only see what is sequenced, cannot detect low-level mosaicism or allele burden, cannot detect whole exon deletions or duplications, not quantitative
advantages and disadvantages of next gen sequencing
advantages - massive amount of sequence data, quantitative, can detect rare events, no cis v. trans ambiguity
disadvantages - complex, still requires target enrichment, requires software and bioinformativs to analyze
explain the advantages and disadvantages of Sanger sequencing v. gene panel sequencing v. whole exome/ whole genome sequencing
types of probability
objective probability - based on experiments or a theoretical model
subjective probability - a person’s opinion, hunch or best guess about whether an outcome will occur
conditional probability
the probability of an event occurring given that another event has already occurred
p(A|B)
unconditional probability
assumes no prior knowledge about event B
joint probability
the probability that two simultaneous events occur
p(A or B) when not mutually exclusive events
p(A) + p(B) - p(A and B)
complementary events
if event A and event B are mutually exclusive, and together account for all possible events, then they are complementary
p(A) + p (B) = 1
p(A) = 1 - p(B)
probability of A and B for non-independent events
p(A and B) = p(A|B)p(B)
p(A|B) = p(A and B)/p(B)
internal validity
A study is internally valid if the results are not biased with respect to the study sample
external validity
A study is externally valid if the results are generalizable to the population for which the study question is relevant
spectrum bias (sampling bias)
systematic differences between target population and subjects chosen for study
cumulative incidence
number who developed outcome/total number followed
**for studies of a fixed population and equal follow-up times
incidence density
the number of people who developed the outcome/number of person years of follow-up
2x2 table
sensitivity
given the presence of disease, the probability that a test will be positive
Sensitivity = TP/(TP + FN)
specificity
given the absence of disease, the probability that a test will be negative
specificity = TN/(FP + TN)
ROC curve
posttest probability positive
if your patient has a positive test result, the probability that disease is present
predictive value (+) = posttest prob (+)
posttestprobability negative
if your patient has a negative test result, the probability that disease is still present but your test missed it
predictive value negative
the probability of not having the disease, given a negative result
psttest prob (-) = 1 - predictive value (-)
uses of genetic testing
diagnosis, prognosis, risk, pharmacogenomics, obstetrical
analytic validity
the ability to accurately and reliably measure the genotype of interest
includes analytic sensitivity, specificity, reliability, and assay robustness
clinical validity
the ability to accurately and reliably predict the disorder of interest, encompasses clinical sensitivity and clinical specificity
may be affected by variability in allele/genotype frequencies in racial/ethnic subpopulations
clinical utility
the evidene of improved measureable clinical outcome, and its usefulness and added value to decision-making compared with current strategies without genetic testing
if a test has clinical utility, the results provide information of value to the person, or to the family, in making decisions about effective treatment or preventive measures
biopsychosocial model
psychosocial factors play into the biology of disease and must be addressed alongside
biochemical model of PKU
defect in phenylalanine hydroxylase, prevents conversion of phenylalanine to tyrosine
leads to a buildup of phenylalanine and byproducts in the blood, which causes intellectual disability
can be treated with dietary means
autosomal recessive
