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Preventive medicine
Statistics
Most important IM questions
Step 3 review
2015
Ahmed Koriesh
Screening
Step 3 review
Preventive Medicine
Vaccines:
MMR:
-
Screening
Step 3 review
Polio:
- Indications: travel to developing country, immunocompromised (IPV not OPV)
- Contraindications:
o OPV: contraindicated in immunosuppressed and household contacts of
immunosuppressed. Pregnancy is relative CI. Allergy to neomycin or streptomycin
o IPV: pregnancy, Allergy to neomycin or streptomycin
Varicella Varivax:
- Indicated for all adults without evidence if immunity (check AB, if ve vaccinate)
- Contraindications: pregnancy, immunocompromised, allergy to neomycin or gelatin
- Post exposure prophylaxis: give varicella vaccine, if vaccine CI give VZIG.
- NEVER give varicella vaccine and IG together (live attenuated vaccine will be inactivated).
Varicella-Zoster Zostovax:
- Live attenuated VZV, virus load is 14 times greater than Varivax.
- Indications: Elderly > 60 years to prevent zoster (50%) and to reduce post-herpetic neuralgia
(66%).
- Contraindications: pregnancy, immunocompromised, allergy to neomycin
HPV:
-
Routine vaccination for women 12-26 years. No benefit after 26. Ideally given before starting
sexual activity.
Capsid Ptn for HBV 6, 11 that cause Cx cancer and 16, 18 that cause genital warts.
Not given in pregnancy (no safety date yet)
HIV patients:
- Live vaccines that are CI: Varicella, OPV, oral typhoid, yellow fever
- Live vaccines that are indicated: MMR
- Non-live vaccines that are indicated: Penumovax, conjugated influenza, HAV in high risk
patients, HBV vaccine.
Pregnancy:
- Contraindicated: Measles, Mumps, Rubella, BCG, Small Pox, Varicella
- Should be avoided: Yellow fever, HPV
Post exposure prophylaxis HBV: Vaccine IG (if not vaccinated)
Post exposure prophylaxis HIV: 3-drug regimen.
Post exposure prophylaxis meningococcus: Rifampin 1st line (600mg bid for 2 days), Ciprofloxacin if
patient on OCP (rifampin increase OCP clearance)
Screening
Step 3 review
Disease screening:
Smoking cessation: Bupropion, nicotine replacement, Varenceline. Varenceline is partial agonist to
nicotinic receptor and avoided in patients with unstable psychiatric symptoms or suicidal ideation.
Dyslipidemia:
- Screen all men > 35
- Screen all women > 45 with increased risk for CAD (DM, FHx of premature CAD, FHx of
dyslipidemia)
- Repeat after 5 years if first test was normal.
DM:
-
Method: Screening with FBS > 126 on two separate times. RBS > 200 with symptoms, but needs
confirmation with FBS.
Indications: all patients with symptoms, all patients with HTN or dyslipidemia.
Osteoporosis:
- Method: DEXA scan
- Indications: all women > 65, women 60-65 with risk factors ( low BMI < 127lb, short, smokers,
drinking alcohol > 2 drinks/day, FHx of osteoporotic fr, steroid use > 3 months)
- Prevention:
o Post-menopausal women: start on Ca & VitD
o Chronic steroid use: Start on Ca & VitD, get baseline Dexa, repeat Dexa in one year.
o
- TTT: Bisphosphonates
AAA:
-
Risk factors: Age > 60, male sex, SMOKING, first degree relative with AAA
Screening: abdominal US for men 65-79 years (especially if smoker). No screening for women.
Follow up with US every 2 years (if < 4cm) or every 6 months (if 4-5.5 cm).
If patient has AAA and HTN: BB is the antiHTN of choice.
Cancer screening:
Test
Mammography
PAP smear
Colonoscopy
Flex sigmoidoscopy
FOBT
Starting age
40
21 or at 1st sexual
intercourse
50
50
50
Frequency
Yearly
Yearly for 3 years then
q 3yrs
10yrs
3-5yrs
Yearly
Ending age
70
65
None
None
None
Cancer colon:
- Routine for people > 50: FOBT yearly and endoscopy (either colonoscopy q10yrs or
sigmoidoscopy q5yrs)
Screening
Step 3 review
Moderate risk: FHx of cancer colon, adenomatous polyps, Cancer colon s/p resection
o FHx (1st degree < 60 or two 1st degree > 60): colonoscopy 10 yrs earlier than youngest
case or at age of 40, repeat q5yrs
o FHx (other relatives): only routine screening
o Polyp single adenomatous < 1cm: repeat colonoscopy within 3 yrs then routine (q10yrs)
o Polyp large or multiple: repeat colonoscopy after 3 years then q5yrs
o Polyp found to be malignant: repeat colonoscopy after 1yr then 3 yrs then q5yrs
High risk: FAP, HNPCC, IBD
o FAP: Colonoscopy starting at puberty, genetic testing (if positive total colectomy or
colonoscopy q 1-2 yrs)
o HNPCC: Colonoscopy starting at 21yrs, genetic testing (if positive colonoscopy q2yrs
till 40 then q1yr)
o UC: colonoscopy q1yr starting 8yrs (if pancolitis) or 15yrs (lt sided) after diagnosis. If
dysplasia colectomy
Cancer breast:
- Routine: Mammogram q2y starting at 50 yrs
- Family member with BRCA: Mammography q1y starting at 20
Genetic testing for breast cancer:
- 2 first degree relatives with breast cancer
- 3 first and 2nd degree relatives
- 1st degree relative with bilateral breast cancer
Cancer prostate:
- Not recommended to screen with PSA.
- Protein bound PSA is more associated with cancer, free PSA is more associated with BPH
Lung cancer
Cancer
prostate
Ovarian
cancer
Breast cancer
Cervical
cancer
Colon cancer
HBV
HCV
HIV
PSA
Screening
Step 3 review
Syphilis
VZ vaccine
AAA
US
Aspirin
Aspirin for preeclampsia
Lipid
Vision in
children
Vitamin D screening
Vitamin D supplements
Osteoporosis
GBS
Recto-vaginal
Culture
PPD Test:
PPD Positive if:
- > 5mm in immunocompromised (HIV, transolant, other), CXR suggestive of TB, recent contact
with TB patient.
- > 10mm in recent immigrant, residents & employee of high risk settings (healthcare, prisons,
shelters) , IV drug abuser
- > 15mm if no risk factors.
Effect of BCG vaccine on PPD:
- Rarely exceed 15mm induration, significantly decrease after 15 years. IFN gamma assay can
distinguish true positive PPD.
TTT of latent TB: (positive PPD, -ve Xray and sputum)
- INH for 9 months
HCW exposed to active TB patient: PPD now and repeat after 3 months. INH only if PPD conversion.
High intensity: if LDL > 190, Age < 75 with significant atherosclerosis (ACS, Stroke, TIA), DM with 10-year
ASCVD > 7.5%.
Moderate intensity: If Age >75, DM with 10-year ASCVED < 7.5%
Screening
Step 3 review
Prenatal:
o 3-drug HAART, HIV load monthly until undetectable then every 3 months
o If mother already on efavirenz then continue and dont change her regimen, if not
dont start efavirenz in first 8 weeks (neural tube defects) similar to valproate approach
in pregnancy
o Avoid amniocentesis until viral load undetectable
Intapartum:
o Avoid ROM, vacuum or foreceps.
o If mother not on HAART, start Zidovudine, if viral load > 1000 do C-section and start
Zidovudin
Postpartum:
o Mother continue 3-drug HAART
o Infant start Zidovudin for 6 weeks, serial HIV PCR. NO BREAST FEEDING
Ethics
Step 3 review
Ethics:
Parents cant withhold limb or lifesaving treatment from their children
Minors authorized to consent: (certain minors or certain events)
o Emancipated minors (married, pregnant, parents, military, financially independent)
o Certain services: (ER, prenatal care, contraception, abortion, STDs, infectious disease,
HIV testing/ttt, drug/alcohol abuse, sexual assault)
Consent for minors taken from legal guardians (parents). Sister and grandparents cant give consent
Treating family members and friends is ethically problematic. Only in acute care whne no other
physician is available.
ADHD ttt:
- in preschool children behavioral therapy is first line
- In older children, stimulants and atomoxetin are first line. Ask about cardiac hx before starting
on stimulants. Clonidine is a second line agent.
Mood disturbance and home problems can stand against organ transplantation
Pharmaceutical company: We can accept travel reimbursement, Honoria.
Firing patients: physician cant terminate relationship with a patient except after giving a reasonable
notice or providing a referral to another health care provider.
Domestic violence: If wife complain of domestic violence refer to domestic violence program. Child and
elderly abuse are the only reportable.
Neurology
Step 3 review
Palpable LN
Parotid gland
Neurology
Step 3 review
Patient with hashimoto thyroiditis and pyramidal signs, think of B12 deficiency due to pernicious
anemia.
Severe B12 deficiency treatment: patient may develop hypokalemia.
Contraception is required for patient on MS disease modifying therapy
MS good prognosis: sensory onset, CN onset, female, young age of onset.
Bad prognosis: Male, late age of onset, motor symptoms
Drugs that can cause IIH: isotretinone, tetracyclin, minocycline, steroids, danazole, tamoxifen,
thyroxine, lithium and nitrofurantoin.
Parinaud syndrome: loss of vertical gaze, optokinetic nystagmus, pupillary reaction and ataxia. Some
pineal gland tumors secrete HCG.
Carbamazepine side effects: neutropenia, SIADH with hyponatremia, anticholinergic (glaucoma and
urine retention).
Post stroke spasticity: dantrolene is the first line therapy, alike baclofen, it is not sedating
B12 deficiency cause hyperbilirubinemia due to ineffective erythropoiesis: cells die in bone marrow
before maturation.
Miller Fischer test: for NPH, assess gait before and after removal of 30cc of CSF.
Gastro
Step 3 review
Gastro
Step 3 review
Positive Anti HCV Ab: may be infected or cured from infection or false positive ELISA. Next step is HCV
RNA confirmation
Lactose breath hydrogen test for diagnosis of lactose intolerance: patient should be fasting 8 hours
before.
Colonoscopy excised polyp and biopsy showed adenocarcinoma in the head with free stalk:
polypectomy is enough, f/u colonoscopy in 3 years if < 2cm or 3 months if > 2cm
C diff relapse: continue with metronidazole after first relapse, then Vancomycine after 2nd relapse
Barrett esophagous f/u EGD with biopsy in 1-3 years
Patient with Celiac disease with persistent symptoms inspite strict gluten free diet: think of GI
lymphoma. A common complication of celiac disease
Hepatology
Step 3 review
Child-Turcot-Pough score:
Points
Bilirubin
Albumin
PT
Ascites
Encephalopathy
1
<2
>3.5
<15
Absent
None
2
2-3
2.8-3.5
15-17
Slight/responsive
Stage 1-2
Class A: score 6
Class B: score 7-9
Class C: score 10
Liver transplantation is considered in all cirrhotic with score >7
When to treat HCV with ribavirin and interferon:
- if ALT is persistently elevated
- liver biopsy shows moderate inflammation
- HCV RNA positive
3
>3
<2.8
>17
Moderate/Severe
3-5
General
Step 3 review
Drugs that can cause SIADH: Chlorpropamide, SSRI, Carbamazepine and cyclophosphamide
Hyponatremia:
Cause
SIADH
Sr Osmolarity
Polydepsia
Pseudohyponatremia
Volume depletion
Ur Osmolarity
> 100mosmol
Urine NA
> 40 meq
<100 mosmol
< 20 meq
Hemochromatosis: usually affects 2nd and 3rd MCP joints, Positive birefringent CPPD crystals present in
50% of patients. X-ray shows hook-shaped osteophytes and subchondral cysts.
Osteoarthritis: spares MCP joint
Gout: usually affect DIP and spares MCP. Negative birefringent crystals.
Pseudogout CPPD arthropathy: > 65 old, positive birefringent crystals.
MCP
Hemochromatosis
Rheumatoid arthritis
Pseudogout
DIP
Osteoarthritis
Psoriatic arthritis
Reactive arthritis
Suicide:
- High Imminent risk: (Intent and plan), hospitalize involuntary if necessary. Remove all self-harm
risk objects. Constant observation
- High non-imminent risk: treat depression, recruit family for support, secure firearms and
medications.
General
Step 3 review
Obsessions: recurrent thoughts, image or impulse that causes severe distress. Mother who has
recurrent thoughts of killing her children, and this makes her distressed
Compulsions: repetitive compulsive behavior in an attempt to alleviate anxiety by obsessions.
MCC of bleeding in old age: diverticulosis and angiodysplasia (associated with aortic stenosis)
Shoulder pain:
- Rotator cuff impringement: Pain with abduction & external rotation, subacromial tenderness,
normal range of motion, positive neer and Hawkins test.
- Rotator cuff tear: same + weakness with external rotation.
- Frozen shoulder (adhesive capsulitis): decreased passice & active range of motion. May be
idiopathic, secondry to stroke, DM or bursitis.
- Biceps tendinitis: anterior shoulder pain, pain with lifting or overhead reaching.
Acute HBV: treatment is supportive. Antiviral therapy (Lamivudin) only in patients with HCV,
immunosuppressed, severe disease.
DKA:
-
General
Step 3 review
General
Step 3 review
Disorder
PHP
HP
VDD
Calcium
Low
Low
Low
Phosphorus
High
High
Low
PTH
High
Low
High
General
Step 3 review
Effect of Estrogen on L-thyroxin: increase TBG formation which will bind more L-thyroxin. Patient will
need increase in her L thyroxin dose.
Subclinical hypothyroidism: mild elevation in TSH with normal free T4. No treatment if asymptomatic.
Screen for anti-thyroid AB.
Squamous cell carcinoma: Surgery is first line, Cryotherapy, electro surgery, radiotherapy are 2nd line
Extra-articular manifestations of ankylosing spondylitis: uveitis, aortic regurgitation, pulmonary
fibrosis, restrictive lung disease
Drug induced lupus: Hydralazine, procainamide, minocycline, anti-TNF (etanrecept, infliximab). ANA and
anti-histone is positive.
Patient with medullary thyroid cancer and REC proto-oncogene positive, next step?
- Next step screen for MENII.
All patient with medullary thyroid carcinoma: measure Sr calcitonin, CEA, neck US for metastasis, RET
mutation, evaluation for hyperparathyroidism and PCCs.
MEN I: hyperparathyroidism, pancreatic tumor, pituitary tumor (3P)
MEN IIA: Medullary thyroid Ca, Pheochromocytoma, hyperparathyroidism
MEN IIB: MTC, PCC, mucosal and intestinal neuromas, marfanoid features.
Evaluation of thyroid nodule:
1) TSH and thyroid US:
- Suspicious of cancer solid FNA
- Not suspicious:
2) TSH is normal or elevated: FNA
3) TSH is low (likely hot nodule) thyroid scan FNA if hypofunction
PCO: try weight loss first. If it fails to restore fertility Clomiphene citrate
Lichen planus: discrete, intensely pruritic violaceous papules on flexor surface of extremities. Diagnosed
with skin biopsy. Associated with HCV.
Asthma exacerbation: After short acting B agonist in ER:
- If PEF > 70% baseline discharge home on B agonists or steroids
- If PEF 40:69% admit to ward
- If PEF < 40% or PCO2 > 42 admit to ICU
Psoriasis: mild or moderate skin disease treated with UV-B, topical steroids. Arthritis or sever disease
treated with methotrexate. No oral steroids in psoriasis because it ppt pustular psoriasis.
OCD ttt: Cognitive behavioral therapy (exposure and response prevention), Clomipramine.
SLE activity: Anti-dsDNA and Complement levels.
SLE nephropathy: Biopsy is first line, type I,II require no treatment. Type III,IV require steroids.
General
Step 3 review
General
Step 3 review
Pain medication agreement: the patient sign that he will obtain pain meds from single physician and
single pharmacy and the medication may be discontinued if he violates the contract.
Rupture of chordae tendina: in Ehler dantos
Rupture of papillary muscle: in MI (usually 2-7 days after MI)
Viagra in pilots: Viagra causes blue hazed vision. Pilots have to wait 6 hours after Viagra before flying.
Breast Mass management:
- < 30 years: US then FNA if simple cyst & biopsy if solid or complex cyst.
- > 30 years: US & mammography then core biopsy if suspicious for cancer
Actinic keratosis results from long sun exposure. Has malignancy potential, ttt by excision or destruction
(cry or 4-FU cream)
After tPA, keep BP < 185/105 using IV labetalol
HRT should be avoided in patients with hx of thromboembolic disease.
Nelsons syndrome: after bilateral adrenalectomy in Cushings disease, patients develop pituitary
adenoma with suprasellar extension leading to bitemporal hemianopsia and high plasma ACTH.
Dont give bicarbonate in DKA, diesnt increase survival and may cause hypokalemia
Gall stones:
- Asymptomatic: no ttt
- Symptomatic: elective cholecystectomy
- Biliary colic without gall stones: cholecystokinin-stimulated cholecintigraphy to evaluate GB
functions, if low ejection cholecystectomy
Breast milk jaundice: continue breast feeding, resolve by 3 month. (Mech: high glucoronidase activity in
breast milk that unconjugated bilirubin in intestine and allow its absorption).
Bicuspid aortic valve: increased risk of aneurysm, dissection, IE. F/U echo q1y
Neonatal chlamydial infection: Conjunctivitis at 1 week and pneumonia (staccato cough & hyperinflated
chest) at 4-12 weeks. TTT with erythromycin.
PCP pneumonia: ttt with cotrimoxazole, add steroids if A-a > 35
Marfan: defect in fibrillin, MCC of death is aortic regurge, dissection or aneurysm.
Rosacea: erythema in central part of face. Ttt by topical brimonidine and avoid pdp factors, topical
metronidazole if popular lesions.
Graves disease ttt:
General
Step 3 review
Male Delayed puberty: If no testicular enlargement by age of 14, get x-ray to determine bone age. If
bone age older or equal to chronological age warrants further testing.
ADPKD: IMPORTANT: F/U plan is regular BP checks, not imaging. Screening in family members by Abd
US not genetics. Most common extra renal manifestation is hepatic cyst.
Bacterial conjunctivitis: return school after 24 hours of AB therapy.
Bacterial vaginosis ttt: ORAL metronidazole or clindamycin, if pregnant tell the patient the meds cross
the placenta but no known teratogenic effect.
Bullous skin disease:
- Bullous pemphigoid: TENSE bullae + itching
- Pemphigus vulgaris: Flaccid bullae + ORAL lesions
- Dermatitis herpetiformis: CELIAC disease + ITCHING, buttocks involved
Acute gout ttt:
- First line: NSAIDS
- 2nd line: Colchicine (if CI for NSAIDS)
- 3rd line: steroids (If colchicine CI in liver, renal disease)
Abscess ttt:
- I&D only: if < 5cm, no systemic signs of infection
- I&D + AB: if > 5cm, surrounding cellulitis, systemic signs of infection.
High Anion gap metabolic acidosis:
- Anion gap > 14 (Na (Cl+Hco3))
- MUDPILES: Methanol, Uremia, DKA, Propylene glycol, INH, Iron, Lactic acidosis, Ethylene glycol,
Salicylates.
HIT: start direct thrombin inhibitor, switch to warfarin only when Plt > 150k
Herpangina: caused by coxsackievirus
Ovarian cyst with pregnancy: if persists after 1st trimester and > 5cm surgical removal in 2nd trimester
to avoid complications (eg; twist)
Opsoclonus-Myoclonus: a paraneoplastic syndrome associated with malignancy, Pheochromocytoma
mg is a known cause.
Digoxin toxicity cause decreased appetite. Check digoxin level if suspected.
Women finished LMP ended 6 days ago: dont get HCG, she cant be pregnant.
Upper lib cancer is usually BCC, lower lip is usually Sqcc
General
Step 3 review
Surgery
Step 3 review
ID
Step 3 review
Gonococcal urethritis: develop 2-4 days postexposure, NGU develop 5-10 days post-exposure.
NGU: Azithromycin or Doxycyline (Azithromycin if hx of non-compliance). If not responsive to
therapy, treat with metronidazole (single dose of 2g) and erythromycin 500mg q6h for 7days.
IRIS: Self-limited, continue HAART and AB for the undergoing infection.
HIV post-exposure prophylaxis: 4 weeks of 2 reverse transcriptase inhibitor (zidovudine &
Lamivudin)
Rabies post-exposure prophylaxis: rabies vaccine only if vaccinated and both vaccine and IG if
not vaccinated before.
Gonorrhea treatment if cephalosporin allergic: Quinolones
Cryptococcal CSF findings: high opening pressure, low glucose, WBCs < 50, increased protein.
India ink preparation is diagnostic.
Adult Vaccination :
The most common vaccines in adults are influenza, pneumococcal and tetanus.
Influenza: people > 50, COPD, CHF, ESRD, pregnant, healthcare workers, residents of long-term
facilities and immunosuppressed.
Pneumococcal: people >65
Tetanus toxoid: only if patient is wounded and last vaccine >5years ago (if dirty) or >10 years (if
clean).
Latent syphilis: patient accidently was found to have syphilis, will need CSF analysis to rule
neurosyphilis in or out which will affect treatment decisions. .
HIV patient with syphilis: if no neurosyphilis, treat with benzathine penicillin for 2 weeks. If has
neurosyphilis treat with crystalline penicillin G IV for 2 weeks.
Necrotizing fasciitis:
Type 1
Type 2
in patients with DM or PVD
healthy individuals after a puncture wound
aerobic and anaerobic organisms
GAS
HIV test: cant be done without a formal consent.
Saliva, tears, sweat dont transmit HIV
Indications of corticosteroids in PJP treatment: A-a gradient > 35 or PaO2 < 75
Latent TB infection: Positive PPD with negative CXR, treat with INH for 9 months then stop.
If TB is suspected, order CXR if positive proceed with sputum analysis and culture, no PPD. (If
CXR is positive, no need for PPD).
PhAT: primary HIV associated thrombocytopenia: treatment with Zidovudin
Acute retroviral syndrome: Primary HIV infection chch by fever, maculopappular rash,
lymphadenopathy, pharyngitis, oral ulcer, leukopenia. ELISA is negative while HIV RNA and P24
Ag are positive.
Catheter associated infection:
o No leukopenia: Vancomycine
o Leukopenia: Vancomycine + Gram negative coverage (cefepime or zosyn)
Trypanosoma Cruzi: Ventricular aneurysm, mural thrombosis with emboli, heart block,
progressive dilation of esophagus and colon.
Cat scratch disease: Bartonella Hensele. Causes LN suppuration, retinitis, encephalopathy, HSM.
Pediatrics
Step 3 review
Sleep terrors usually resolve spontaneously in children. Give benzo if severe and recurrent
Bronchiolitis:
- Child < 2 years with upper respiratory symptoms, low grade fever, wheezing, crackles.
- Cause: RSV
- D: Clinical + RSV in respiratory secretions
- TTT: isolation, supportive measures (fluids, suction, humidified oxygen)
- Prevention: Palvizumab
o In preterm < 29 weeks gestation
o Chronic lung disease of prematurity
o Severe Congenital heart disease
Croup ttt:
Humidified air if mild.
- Steroids (oral, IM or IV), nebulized epinephrine if severe (stridor at rest)
Infants and children with tuberculous meningitis, milliary TB, and tuberculous osteomyelitis should
receive 12 months of ant tuberculous therapy.
The preferred antibiotic therapy for neonatal sepsis consists of a combination of ampicillin and
ceftriaxone or cefotaxime.
Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of
bilirubin.
Gyna/Obs
Step 3 review
Cervical Insufficiency:
- RF: Hx of cervical dilatation, laceration, conization or excision. Collagen abnormalities.
- Dx: Hx of cervical dilatation with 2nd trimester loss, current cervical dilatation or length < 25mm
in 2nd trimester.
- Tx: Serial US of cervical length and cerclage in 2nd trimester.
Gestational diabetes:
- Diagnosis: 1h after 50-gm glucose (screening) If > 140 100gm-glucose test (diagnosis):
o If Fasting > 95
o If 1 hour > 180
o If 2 hour > 155
o If 3 hour > 140
- Target blood sugar: Fasting <95, 1 hr postprandial <140, 2 hr postprandial < 120.
- Agents: Diet, exercise then insulin and oral agents.
GBS:
-
STATISTICS
Rates:
NNT= 1/incidence
Relative risk and Odds ratio:
- Risk means probability to occur in future. So Relative risk used for prospective cohort study
- In case control outcome is known from the start so we cant calculate risk so we calculate Odds
of exposure.
- Odds ratio compares the odds of exposure to a risk factor in cases and controls.
- Values: from 0 to infinity. Value of 1 indicates no difference
- Rare disease assumption: odds ration approximates relative risk
- Calculation:
o RR: Risk in exposed/ Risk in non-exposed (a/a+b) / (c/c+d)
o OR: Odds of exposure in diseased/Odds of exposure in non-diseased (a/c)/(b/d) = ad/bc
Correlation:
- Correlation coefficient: ranges from -1 to +1
- Correlation of determination (Percent of variability in outcome explained by predictor factor) =
square the coefficient. (How much of the homocysteine variability explained by folic a intake?)
Attributable risk:
- Attributable risk = Difference in incidence between exposed & non-exposed
- Attributable risk percent = percent attributed to risk factor in exposed= attributable risk/incidence in
exposed.
- Population attributable risk percent = percent attributed to risk factor in population = incidence in
exposed incidence in population/ incidence in exposed
Null hypothesis:
- P value represent the probability that null hypothesis is true. P 0.05 = 5% probability that null is true
Confidence interval:
- If includes 1, then there is > 5% chance that the association by chance and P value > 0.05
- Calculation:
o SEM = SD/n
o SEM * Z score (z=1.96 for 95% CI, z=2.58 for 99% CI)
o Mean (SEM * Z)
STATISTICS
Central tendency:
- Mean= sum of all values / number of observations
- Median= if observations are odd number (13), then median is the middle number. If observations are
even number (12) then median = adding the middle two values and divide by 2.
- Outlier is an extreme unusual value. It affects mean>median but doesnt affect mode.
Meta-analysis:
- Since it contains larger sample size than each study. The CI will be narrower than any other study.
Meta-analysis will be represented by a smaller vertical line compared with each study.
Diagnostic testing:
- Sensitivity Rule OUT, Specificity Rule IN
- Sensitivity = TP/(TP+FN)
- Specificity = TN (TN + FP)
- PPV = TP/(TP+FP)
- NPV = TN/(TN+FN)
- PPV and NPV If given prevalence, sensitivity and specificity:
o PPV = TP (sensitivity * prevalence)/ TP + FP (1-specificity * 1-prevalence)
o NPV = TN (specificity * 1-prevalence)/ TN + FN (1-sensitivity * prevalence)
- PPV and NPV other method:
o Apply prevalence to the numbers first then apply the short equation without prevalence.
o EX: test with 80% sensitivity, 90% specificity and disease prevalence is 10%.
o PPV: if population is 100, 10 are diseased, 90 are healthy. Test will see 80% of the 10 (TP 8)
and will miss 10% of the healthy (FP 9). PPD = 8/8+9 = 8/17 = 47%
- PPV is affected by specificity and prevalence
- NPV is affected by sensitivity and prevalence
- Likelihood ratio:
o Doesnt depend on disease prevalence
o Means probability of a given test result in patient with the disorder compared to patient
without.
o Positive LR = sensitivity / (1-specificity)
o Negative LR = (1-sensitivity)/ Specificity
People who test positive are . Likely to have the disease than those who tested negative.
Screening test bias:
-
Lead time: the time difference between detection of disease by screening test and diagnosis by prior
methods.
Lead time bias: apparent increase in survival is due to early diagnosis not successful treatment.
o EX: screening test for cancer stomach increased survival few weeks but no difference in rate of
radical gastrectomy.
Length time bias: apparent increase in survival due to screening test preferentially detects less
aggressive forms of the disease.
STATISTICS
Study Design:
- Case control is best for small infectious outbreaks and rare diseases
Selection Bias:
o Berkson: selecting control subjects from hospitalized patients.
o Referral: selecting patients from specialized medical centers.
o Loss of follow up
o Non response bias: if non-responders to survey are sicker than general population
o Prevalence bias (Neyman bias): if incidence is estimated based on prevalence.
If you compare MI in diabetics and non-diabetics by asking the patients. Diabetics will
be under-represented because DM patients more likely die from MI.
o Susceptibility: treatment regimen for patients depends on the severity of their condition.
STATISTICS
ACS patients, healthy patients undergo LHC while sicker patients undergo medical
treatment. LHC will appear superior to medical treatment.
Measurement bias:
o Recall bias
o Observer bias (ascertainment, detection, assessment bias)
Observer effect (Hawthorne effect): people change their behaviors when they are observed
How to limit confounding: Randomization, Matching.
Effect modification: confounding factors that cant be corrected or eliminated. Like family hx of cancer
breast. It is a natural phenomenon and should be mentioned in study discussion. Ex. Study to define
relation between OCP and breast cancer found increased breast cancer incidence in patients with FHx
while no relation in patients with no FHx.
What if patient change from placebo to active group, or patient in active group stop his treatment?
- Intention to treat: patient analyzed along with their original group preserve randomization
(patients were randomized in the beginning of the study)
- As treated: patients analyzed according to their new treatment.
Statistical distribution:
- In normal distribution: 68% of observations lie within 1 SD of the mean. 95% in 2 SD and 99% in 3SD.
Skewed distributions have a tail: positively skewed (tail to the RT), negatively skewed (tail to the
Lt). In Rt skewed; Mode is the peak, median is to the right, mean is further to Rt.
Comparing group:
- Both are Nominal: use Chi square
- Non-nominal:
o Two groups: t Test
o > 2 groups: ANOVA analysis of variance
o Same individual followed overtime: Paired t Test
Survival analysis:
-
Time to event:
o New chemotherapy is analyzed and 2 years survival is 80% and conventional therapy is 80%.
The new drug is effective, how? Although survival is the same but time to event may be
different. Survival time may be 3 months with conventional and 9 months with new drug.
Latent period:
o The period between exposure and development of outcome. Ex: vitamins effect in prevention of
CV disease starts after 3 years of vitamin supplements.
Probability of survival:
o Multiply the probability to survive each month. Ex: probability to survive 3 months =
(probability to survive 1st * probability to survive 2nd * probability to survive 3rd)
Statistical power:
- Type I error: concluding an association when there is none.
- Type II error: concluding no association when there is one.
- Probability of committing type I error is referred as Alpha and expressed as P value.
STATISTICS