Lecture Objectives

Epidemiology

Sam Asgarian, M4
Tulane University

BE01- 1
!"

Epidemiology advice

Epidemiology advice
Easy section = easy to overlook

Points here can add up: make sure to prep as you do for any
Step 1 section and do not cram ! get all these points on Test
Day!

Become more ingrained in the test

FA 2012: n/a

FA 2011: n/a

FA 2010: n/a

BE01- 2

Incidence

Incidence
Incidence rate: the rate at which new events occur in a population.The
numerator is the number of NEW events that occur in a defined period; the
denominator is the population at risk of experiencing this new event during the
same period.

Incidence =

# of new events in a specific period of time

# at risk of having a new event in the specific time period

a. Attack rate: a type of incidence rate in which the denominator is further

reduced for some known exposure

b. Focus on acute conditions

FA 2012: 54.1

FA 2011: 52.1
ME 3e: 34

FA 2010: 54

BE01- 3

Prevalence

Prevalence
Prevalence rate: all persons who experience an event in a population. The
numerator is ALL individuals who have an attribute or disease at a particular
point in time (or during a particular period of time); the denominator is the
population at risk of having the attribute or disease at this point in time or
midway through the period.

# of individuals with disease/attribute

Total population at risk

Prevalence =

Point prevalence: prevalence at a specified point in time

Period prevalence: prevalence during a specified period or span
of time
Focus on chronic conditions

FA 2012: 54.1

FA 2011: 52.1
ME 3e: 34

FA 2010: 54

BE01- 4

Clinical Trials

Clinical Trials

Clinical Trials
1. Control group: subjects who do not receive the intervention under
study; used as a source of comparison to be certain that the
experiment group is being affected by the intervention and not by
other factors. In clinical trials, this is most often a placebo group.
2. For Food and Drug Administration (FDA) approval, three phases of
clinical trials must be passed.
a. Phase One: testing safety in healthy volunteers
b. Phase Two: testing protocol and dose levels in a small group
of patient volunteers
c. Phase Three: testing efficacy and occurrence of side effects in
a larger group of patient volunteers. Phase III is considered
the definitive test.
d. Post-marketing Survey: collecting reports of drug side effects
when out in common usage (post-FDA approval)

FA 2012: 52.2

FA 2011: 50.2

FA 2010: 52

BE01- 5

Case-control and Cross-sectional studies

Case-control and Cross-sectional studies

STUDIES:
Case-control study: identifies a group of people with the disease and
compares them with a suitable comparison group without the disease.
Almost always retrospective (e.g., comparing cases of treatment-resistant TB
with cases of nonresistant TB)
a. Cannot assess incidence or prevalence of disease
b. Can help determine causal relationships
c. Very useful for studying conditions with very low incidence or prevalence

Cross-sectional study: the presence or absence of disease and other

variables are determined in each member of the study population or in a
representative sample at a particular time. The co-occurrence of a variable
and the disease can be examined.
a. Disease prevalence rather than incidence is recorded
b. The temporal sequence of cause and effect cannot usually be determined in a
cross-sectional study
c. Example: who in the community now has treatment-resistant TB

FA 2012: 52.1

FA 2011: 50.1
ME 3e: 35

FA 2010: 52

BE01- 6

Cohort Study

Cohort Study
Cohort study: population group of those who have been exposed to risk factor
is identified and followed over time and compared with a group not exposed to
the risk factor. Outcome is disease incidence in each group (e.g., following a
group of individuals forward in time and comparing the development of lung
cancer in those who smoke and in those who dont smoke).

Prospective; subjects tracked forward in time

Can determine incidence and causal relationships

Must follow population long enough for incidence to appear

FA 2012: 52.1

FA 2011: 50.1
ME 3e: 34

FA 2010: 52

BE01- 7

Difference between studies by time

Difference between studies by time

Differentiating Study Types by Time

FA 2012: 52.1

FA 2011: 50.1
ME 3e: 35

FA 2010: 52

BE01- 8

Twin and Adoption Studies

Twin and Adoption Studies

Measuring inheritance of a genetic disease/disorder:
Twins: monozygotic and dizygotic
Adoption: nature vs. nurture

FA 2012: 52.1

FA 2011: 50.1

FA 2010: 52

BE01- 9

Diagnostic Tests

Diagnostic Tests
Diagnostic Tests
Will be covered on the exam
Pregnancy test example (dont want false positive, but really dont want a
false negative ! will take risks, etc)
Know this table (Table 1-4):

FA 2012: 53.1

FA 2011: 51.1

FA 2010: 53

BE01- 10

Sensitivity

Sensitivity
Sensitivity: the probability of correctly identifying a case of disease. Sensitivity
is the proportion of truly diseased persons in the screened population
who are identified as diseased by the screening test. This is also known
as the true positive rate.

TP
TP+FN

Sensitivity =

true positives/(true positives + false negatives)

Measures only the distribution of persons with disease

Uses data from the left column (Table 1-4)
Note: 1-sensitivity = false negative rate

FA 2012: 53.1

FA 2011: 51.1
ME 3e: 34

FA 2010: 53

BE01- 11

Specificity

Specificity
Specificity: the probability of correctly identifying disease-free persons.
Specificity is the proportion of truly nondiseased persons who are identified as
nondiseased by the screening test. This is also known as the true negative
rate.

TN
TN+FP

Specificity =

true negatives/(true negatives + false positives)

Measures only the distribution of persons who are disease-free

Uses data from the right column (Table 1-4)
Note: 1-specificity = false positive rate

FA 2012: 53.1

FA 2011: 51.1
ME 3e: 34

FA 2010: 53

BE01- 12

Positive Predictive Value

Positive Predictive Value

Positive predictive value: the probability of disease in a person who receives a
positive test result. The probability that a person with a positive test is a true
positive. (i.e., has the disease) is referred to as the predictive value of a
positive test.

Positive predictive value =

TP
TP+FP

true positives/(true positives + false positives)

Measures only the distribution of persons who receive a positive test

result
Uses data from the top row of the (Table 1-4)

FA 2012: 53.1

FA 2011: 51.1
ME 3e: 34

FA 2010: 53

BE01- 13

Negative Predictive Value

Negative Predictive Value

Negative predictive value: the probability of no disease in a person who
receives a negative test result. The probability that a person with a negative
test is a true negative (i.e., does not have the disease) is referred to as the
predictive value of a negative test.

Negative predictive value =

TN
TN+FN

true negatives/(true negatives + false negatives)

Measures only the distribution of persons who receive a negative test

result
Uses data from the bottom row (Table 1-4)

FA 2012: 53.1

FA 2011: 51.1
ME 3e: 34

FA 2010: 53

BE01- 14

Meta-analysis

Meta-analysis

Meta-analysis:
a. A statistical way of combining the results of many studies to
produce one overall conclusion
b. A mathematic literature review
Highest level of clinical evidence used to make an argument for
or against something

FA 2012: 58.2

FA 2011: 50.3

FA 2010: 52

BE01- 15

Accuracy and Precision

Accuracy and Precision

Accuracy: total percentage correctly selected; the degree to which a
measurement, or an estimate based on measurements, represents the true
value of the attribute that is being measured.

Accuracy =

TP + TN
TP + FP + TN + FN

(true positives + true negatives)/total screened patients

Precision: ability of a test to measure something consistently, either across

testing situations (test-retest reliability), within a test (split-half reliability), or
across judges (inter-rater reliability)
Reliability: think of the clustering of rifle shots at a target

FA 2012: 55.1

FA 2011: 52.3
ME 3e: 34

FA 2010: 54

BE01- 16

Odds Ratio

Odds Ratio
Odds ratio: looks at the increased odds of getting a disease with exposure to a
risk factor versus nonexposure to that factor
Disease Present
(+)

Disease Absent
(-)

Exposed group (risk factor +)

Nonexposed group (risk factor -, control)

Odds Ratio = A/B

C/D

AD
BC

Odds of having disease in exposed group divided by odds of having

disease in nonexposed group
The odds that a person with lung cancer was a smoker versus the odds
that a person without lung cancer was a smoker
Odds ratio does not so much predict disease as estimate the strength of a
risk factor
FA 2012: 54.2

FA 2011: 52.2
ME 3e: 35

FA 2010: 54

BE01- 17

Relative Risk

Relative Risk
Relative risk (RR): comparative probability asking How much more likely?
Disease Present
(+)

Disease Absent
(-)

Exposed group (risk factor +)

Nonexposed group (risk factor -, control)

Relative risk (RR) = A/(A+B)

C/(C+D)
Incidence rate of exposed group divided by the incidence rate of the
unexposed group
How much greater chance does one group have of contracting the
disease compared with the other group?
For statistical analysis, yields a p-value

FA 2012: 54.2

FA 2011: 52.2
ME 3e: 35

FA 2010: 54

BE01- 18

Attributable Risk

Attributable Risk
Attributable risk (AR): comparative probability asking How many more cases in
one group?
Disease Present
(+)

Disease Absent
(-)

Exposed group (risk factor +)

Nonexposed group (risk factor -, control)

Attributable risk (AR) =

A
A+B
!

C
C+D

Incidence rate of exposed group minus the incidence rate of the

unexposed group
Note that both relative risk and attributable risk tell us if there are
differences, but do not tell us why those differences exist.

FA 2012: 54.2

FA 2011: 52.2
ME 3e: 35

FA 2010: 54

BE01- 19

Types of Bias in Research

Types of Bias in Research

FA 2012: 56.1

FA 2011: 53.1
ME 3e: 35

FA 2010: 55

BE01- 20

Bias: Selection Measurement Experimenter Expectancy

Bias: Selection, Measurement, Experimenter

Expectancy
Selection: sample selected is NOT representative of the population
Heart disease study with participants from health club
AKA: Berksons bias ! used hospital records to estimate population
prevalence

Measurement: info gathered is distorted

You dont like your doctor, do you? as a leading question for
patient satisfaction
Hawthorne effect: being studied changes the behavior (similar to
being recorded)

Experimenter expectancy: experimenter communicates (verbal or non-verbal)

to the subjects who then produce the desired effects (Pygmalion Effect)
FA 2012: 56.1

FA 2011: 53.1
ME 3e: 35

FA 2010: 55

BE01- 21

Bias: lead-time recall late-look confounding

Bias: Lead-time, Recall, Late-look, Confounding

Lead-time bias:
False estimate of survival rates
Seem to live longer with a disease after a positive screening test
Dz discovered sooner, so patients SEEM to live longer

Recall bias:
Fail to accurately recall events in the past (retrospective studies)

Late-look bias:
Survey doesnt uncover patients with SEVERE disease; uses mild and
moderate cases to come to a conclusion; persons with AIDS report mild
symptoms (the severe ones are not alive to be counted in the survey)

Confounding bias:
Factor examined is related to other factors; heart disease in exercise;
if one group is young, the other is old ! heart dz could be due to age,
not exercise

FA 2012: 56.1

FA 2011: 53.1
ME 3e: 35

FA 2010: 55

BE01- 22

Design Bias

Design Bias
Design bias:
Parts of the study do not fit together; non-comparable control
group; measuring anti-hypertensive drug effect between those
with high blood pressure and those with normal blood pressure

FA 2012: 56.1

FA 2011: 53.1
ME 3e: 35

FA 2010: 55

BE01- 23

Lecture Objectives

Biostatistics

Sam Asgarian, M4
Tulane University

BE02- 1
!"

Hypothesis Testing

Hypothesis Testing

Hypothesis Testing:
a. Define the research question: what are you trying to show?
b. Define the null hypothesis, generally the opposite of what you hope to
show
i. Null hypothesis says that the findings are the result of chance or
random factors. If you want to show that a drug works, the null
hypothesis will be that the drug does NOT work.
We never accept the null hypothesis. We either reject it or fail
to reject it. Saying we do not have sufficient evidence to reject
it is not the same as being able to affirm that it is true.
ii. Alternative hypothesis says what is left after defining the null
hypothesis. In this example, that the drug does actually work.

FA 2012: 57.2

FA 2011: 54.1
ME 3e: 35

FA 2010: 56

BE02- 2

Type I and Type II Errors

Type I and Type II Errors

Errors:
i.

Type I error (alpha error): rejecting the null hypothesis when it is really
true (i.e., assuming a statistically significant effect on the basis of the
sample when there is none in the population, e.g., asserting that the
drug works when it doesnt). The chance of type I error is given by the
p-value. If p = 0.05, then the chance of a type I error is 5 in 100, or
1 in 20.

ii. Type II error (beta error): failing to reject the null hypothesis when it is
really false (i.e., declaring no significant effect on the basis of the
sample when there really is one in the population, e.g., asserting the
drug does not work when it really does). The chance of a type II error
cannot be directly estimated from the p-value.

FA 2012: 57.3

FA 2011: 54.2
ME 3e: 35

FA 2010: 56

BE02- 3

Power

Power

Power is directly related to type II error: 1 ! = Power

Just as increasing the power of a microscope makes it easier to
see what is going on in histology, increasing statistical power allows
us to detect what is happening in the data.
There are a number of ways to increase statistical power. The most
common is to increase the sample size.

FA 2012: 58.1

FA 2011: 54.3
ME 3e: 35

FA 2010: 56

BE02- 4

Skewed vs. Normal curves

Skewed vs. Normal curves

Skewed curves: not all curves are normal

Normal is when mean = median = mode (bell curve)

Sometimes the curve is skewed either positively or negatively
A positive skew has the tail to the right and the mean greater than
the median
A negative skew has the tail to the left and the median greater than
the mean
For skewed distributions, the median is a better representation of
central tendency than is the mean

FA 2012: 57.1

FA 2011: 53.2

BE02- 5

FA 2010: 55

T-test

T-test

T-test
Comparing the means of two groups from a single nominal variable,
using means from an interval variable to see whether the groups
are different
Used for two groups only (i.e., compares two means, e.g., do
patients with MI who are in psychotherapy have a reduced length of
convalescence compared with those who are not in therapy?)

FA 2012: 58.4

FA 2011: 55.2
ME 3e: 36

FA 2010: 57

BE02- 6

ANOVA

ANOVA

ANOVA (Analysis of variance)

One-way: compares means of many groups (two or more) of a single
nominal variable using an interval variable; significant p-value means
that at least two of the tested groups are different

FA 2012: 58.4

FA 2011: 55.2
ME 3e: 36

FA 2010: 57

BE02- 7

Chi-squared

Chi-Squared

Chi-Squared
Tests to see whether two nominal variables (NOT MEAN) are
independent (e.g., testing the efficacy of a new drug by comparing the
number of recovered patients given the drug with those who are not)

FA 2012: 58.4

FA 2011: 55.2
ME 3e: 36

FA 2010: 57

BE02- 8

Disease Prevention

Disease Prevention

Disease Prevention
3 stages of prevention
1)Prevent occurrence
Condoms and HIV
2)Early detection
Saliva swab, blood test, etc.
3)Reduce disease effects
Anti-retroviral therapy (prevent HIV ! AIDS)

FA 2012: 58.6

FA 2011: 55.4

FA 2010: 57

BE02- 9

Reportable Diseases & Leading Causes of Death

Reportable Diseases & Leading Causes of Death

Speaking of AIDS"
Reportable diseases:
AIDS is reportable everywhere, HIV varies
Hep A, B and C; measles, mumps, rubella (MMR)
Salmonella, TB, chickenpox
Leading causes of death
Infant = congenital (NOT same as genetic), respiratory
Age 1-14 = injuries, cancer, homicide
Age 15-24 = injuries, homicide, suicide
Ages 25-64 = cancer, heart dz, injuries
Ages 65 and older = heart disease, cancer, stroke

FA 2012: n/a

FA 2011: 56.1

FA 2010: 58

BE02- 10

Suicide

Suicide

Leading causes of death" suicide

Between 10 and 20 suicide attempts for every one that succeeds
Men commit suicide four times as often as women
Women attempt suicide three times as often as men
Firearms are the most likely method by which either men or women
commit suicide. Pills/poisons most likely method for women to
attempt suicide
Suicides outnumber homicides in the U.S.

FA 2012: n/a

FA 2011: 56.2

FA 2010: 58

BE02- 11

Medicare and Medicaid

Medicare and Medicaid

Medicare and Medicaid

Care for elderly, no one aids the young"
Resident salaries/stipends come from Medicare/Medicaid

FA 2012: 59.1

FA 2011: 56.3

FA 2010: 58

BE02- 12

Lecture Objectives

Ethics

Sam Asgarian, M4
Tulane University

BE03- 1

Physicians Ethics

Physicians Ethics

Physicians Ethics:
1) Beneficence = Do good
2) Nonmaleficence = Do no harm
3) Justice = Equality
4) Autonomy (wins out) = Not paternalistic

FA 2012: 59.2

FA 2011: 57.1
ME 3e: 30

FA 2010: 59

BE03- 2

Informed Consent

Informed Consent

Informed Consent
Risks/benefits/alternatives
Alternative includes: do nothing

Full, informed consent requires that the patient has received and understood
five pieces of information:
1. Nature of procedure (What)
2. Purpose or rationale (Why)
3. Risks
4. Benefits
5. Alternatives

FA 2012: 59.3

FA 2011: 57.2
ME 3e: 32

FA 2010: 59

BE03- 3

Exceptions to Informed Consent

Exceptions to Informed Consent

Four exceptions to informed consent:

1. Emergency
2. Waiver by patient
3. Patient is incompetent
4. Therapeutic privilege (unconscious, confused, physician deprives
patient of autonomy in interest of health)
Consent can be oral
A signed paper the patient has not read or does not understand does
NOT constitute informed consent
Written consent can be revoked orally at any time

FA 2012: 59.4

FA 2011: 57.3
ME 3e: 32

FA 2010: 59

BE03- 4

Emancipated Minors

Emancipated Minors

Children younger than 18 years are minors and are legally incompetent.
Exceptions: emancipated minors
If older than 13 years and taking care of self (i.e., living alone, treat
as an adul).
Marriage makes a child emancipated, as does serving in the
military
Pregnancy or giving birth, in most cases, does not
Partial emancipation
Many states have special ages of consent: generally age 14 and
older

FA 2012: 59.5

FA 2011: 57.4
ME 3e: 32

FA 2010: 59

BE03- 5

Special Cases for Minor Competency

Special Cases for Minor Competency

Children younger than 18 years are minors and are legally incompetent
Exceptions:
Substance drug treatment
Prenatal care
Sexually transmitted disease treatment
Birth control

FA 2012: 59.5

FA 2011: 57.4
ME 3e: 32

FA 2010: 59

BE03- 6

Patient Confidentiality

Patient Confidentiality

Physicians cannot tell anyone anything about their patient without the
patients permission.
Physician must strive to ensure that others cannot access patient
information.
Getting a consultation is permitted, as the consultant is bound by
confidentiality, too. However, watch the location of the consultation.
Be careful not to be overheard (e.g., do not discuss in elevator or
cafeteria).
If you receive a court subpoena, show up in court but do not divulge
information about your patient.

FA 2012: 60.4

FA 2011: 58.1
ME 3e: 33

FA 2010: 60

BE03- 7

Physicians duty to warn and protect

Physicians Duty to Warn and Protect

If patient is a threat to self or other, the physician MUST break

confidentiality
Duty to warn and duty to protect (e.g.,Tarasoff case + (DWI))
A specific threat to a specific person (including self)
Tarasoff decision: duty to warn and duty to protect
A student visiting a counselor at a counseling center in California states that he
is going to kill someone. When he leaves, the counselor is concerned enough to
call the police but takes no further action. The student subsequently kills the
person he threatened. The court found the counselor and the center liable
because they did not go far enough to warn and protect the potential victim.
The counselor should have called the police and then should also have tried in
every way possible to notify the potential victim of the potential danger. In similar
situations, first try to detain the person making the threat, next call the police,
and finally notify and warn the potential victim. All three actions should be taken,
or at least attempted.

FA 2012: 60.5

FA 2011: 58.2
ME 3e: 33

FA 2010: 60

BE03- 8

Malpractice

Malpractice

Malpractice:
Civil, not criminal
Duty
Breach (dereliction)
Harm done (damage)
Breach caused the harm (direct)
Most common cause of lawsuit is poor communication
Least friendly physicians sued more often

FA 2012: n/a

FA 2011: 58.3
ME 3e: 33

FA 2010: 60

BE03- 9

Situational Testing: only 1 right answer

Situational Testing: Only 1 Right Answer

Situational Testing
1 right answer; many misleading answers
Choose BEST
Dating
Family wants info
Child wants to know more (needs parents permission)
Child pregnant, wants abortion (need consent)
Child pregnant, wants to keep but parents want adoption ! child wins
Physician-assisted suicide = no go
Pharmaceutical company bonus = no go, but still use the company
Unneccessary procedures: delve deeper, dont refer away

FA 2012: 61.1

FA 2011: 59.1
ME 3e: 30

FA 2010: 61

BE03- 10

Lecture Objectives

Development and Physiology

Sam Asgarian, M4
Tulane University

BE04- 1

Elderly Development

Elderly Development

Development and Physiology

Development
Elderly
Sexual changes
Men: longer refractory, slower erection
Women: vaginal dryness
Sleep
Decreased REM, slow-wave, increased wakening
Increased suicide rate
Decreased muscle mass, increased fat
Decreased organ function

FA 2012: 63.1

FA 2011: 61.1
ME 3e: 29

FA 2010: 63

BE04- 2

Grief

Grief
Can last 2 months
Pathologic (treat it) if greater than 2 months, excessively
strong, or delayed/inhibited/or denied
Kubler-Ross
Denial
Anger
Bargaining
Depression
Acceptance
Not in order, can be overlapping

FA 2012: 63.2

FA 2011: 61.2
ME 3e: 21

FA 2010: 63

BE04- 3

Infants: Apgar score and birth weight

Infants: APGAR Score and Birth Weight

Apgar score ! pediatrician assesses newborn

5 areas (each scored 0-2)
APGAR ! Appearance, Pulse, Grimace, Activity, Respiration

Birth Weight
Defined as LOW if < 2500g
Increased risk of infection and complication

FA 2012: 62.1

FA 2011: 60.1
ME 3e: 6

FA 2010: 61

BE04- 4

Milestones: infant toddler preschool

Milestones: Infant, Toddler, Preschool

Milestones:
Infant (0-12 months old): reflexes (rooting, startle, etc.)
Sits
Crawls
Walks
Toddler (1-3 yrs old)
Climbs, stacks blocks, talks
Preschool (2.5-4 yrs old)
Toilet trained
Rides tricycle, hops, simple drawings

FA 2012: 62.3

FA 2011: 60.3
ME 3e: 7

FA 2010: 62

BE04- 5

Tanner Development

Tanner Development
1. Childhood
2. Pubic hair and breast buds
3. Pubic hair darkens, increased secondary sexual characteristics
4. More development
5. Fully adult

FA 2012: 535.3

FA 2011: 60.4
ME 3e: 9

FA 2010: 62

BE04- 6

Sexual dysfunction stress BMI

Sexual Dysfunction, Stress, BMI

Sexual dysfunction
Keep in mind
1) Drugs
2) Diseases
3) Psychological (e.g. fear after MI)

Stress
Fatter (lipids, cholesterol, cortisol)
Decreased immune system

BMI
Weight over height squared
Know ranges of underweight, normal, overweight, obese, morbidly obese

FA 2012: 63.3, 4, 5 FA 2011: 61.4, 5, 6

FA 2010: 63 ME 3e: 29

BE04- 7

Circadian rhythm and Sleep

Circadian Rhythm and Sleep

Circadian rhythm
Suprachiasmatic nucleus of hypothalamus
Prolactin, melatonin, NE

Sleep stages
1) Light sleep
2) Deeper sleep
3 and 4) Deepest sleep (slow wave)
5) REM: dreaming, paralyzed, increased brain O2, erections
NE reduces REM
Alcohol and other depressants reduce REM and sleep stages 3-4
ACh is main neurotransmitter in REM sleep

FA 2012: 64.1, 65.2 FA 2011: 62.1, 63.2

FA 2010: 64 ME 3e: 10

BE04- 8

Narcolepsy and dreams vs terrors

Narcolepsy and Dreams vs Terrors

Narcolepsy:
Excessive daytime sleepiness
Not necessarily asleep, just tired
Tx: give stimulants
Dreams are REM, terrors are Stages 3-4
Night terror! screaming in middle of night
Common in children
No memory

FA 2012: 65.1, 3

FA 2011: 63.1, 3
ME 3e: 12

FA 2010: 64

BE04- 9