BE01- BE01-

Lecture Objectives
!
Epidemiology
Sam Asgarian, M4
Tulane University
1
BE01-
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
Epidemiology advice
2
Epidemiology advice
BE01-
FA 2012: 54.1 FA 2011: 52.1 FA 2010: 54
ME 3e: 34
3
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.

a. Attack rate: a type of incidence rate in which the denominator is further
reduced for some known exposure
b. Focus on acute conditions
# of new events in a specific period of time
# at risk of having a new event in the specific time period
Incidence =
BE01- 4
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.

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

# of individuals with disease/attribute
Total population at risk
FA 2012: 54.1 FA 2011: 52.1 FA 2010: 54
ME 3e: 34
BE01-
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 5
Clinical Trials
Clinical Trials
BE01-
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 FA 2010: 52
ME 3e: 35
6
Case-control and Cross-sectional studies
Case-control and Cross-sectional studies
BE01- 7
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 FA 2010: 52
ME 3e: 34
BE01- 8
Difference between studies by time
Difference between studies by time
Differentiating Study Types by Time
FA 2012: 52.1 FA 2011: 50.1 FA 2010: 52
ME 3e: 35
BE01-
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 9
Twin and Adoption Studies
Twin and Adoption Studies
BE01- FA 2012: 53.1 FA 2011: 51.1 FA 2010: 53 10
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):
BE01-
FA 2012: 53.1 FA 2011: 51.1 FA 2010: 53
ME 3e: 34
11
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.
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
TP
TP+FN
BE01- 12
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.
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
TN
TN+FP
FA 2012: 53.1 FA 2011: 51.1 FA 2010: 53
ME 3e: 34
BE01- 13
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 =

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)
TP
TP+FP
FA 2012: 53.1 FA 2011: 51.1 FA 2010: 53
ME 3e: 34
BE01- 14
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 =

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)
TN
TN+FN
FA 2012: 53.1 FA 2011: 51.1 FA 2010: 53
ME 3e: 34
BE01-
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 15
Meta-analysis
Meta-analysis
BE01-
FA 2012: 55.1 FA 2011: 52.3 FA 2010: 54
ME 3e: 34
16
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 =

(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
TP + TN
TP + FP + TN + FN
BE01-
FA 2012: 54.2 FA 2011: 52.2 FA 2010: 54
ME 3e: 35
17
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






Odds Ratio = =

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
Disease Present
(+)
Disease Absent
(-)
Exposed group (risk factor +) A B
Nonexposed group (risk factor -, control) C D
A/B
C/D
AD
BC
BE01- 18
Relative Risk
Relative Risk
Relative risk (RR): comparative probability asking How much more likely?






Relative risk (RR) =

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
Disease Present
(+)
Disease Absent
(-)
Exposed group (risk factor +) A B
Nonexposed group (risk factor -, control) C D
A/(A+B)
C/(C+D)
FA 2012: 54.2 FA 2011: 52.2 FA 2010: 54
ME 3e: 35
BE01- 19
Attributable Risk
Attributable Risk
Attributable risk (AR): comparative probability asking How many more cases in
one group?






Attributable risk (AR) = !

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.
Disease Present
(+)
Disease Absent
(-)
Exposed group (risk factor +) A B
Nonexposed group (risk factor -, control) C D
A
A+B
C
C+D
FA 2012: 54.2 FA 2011: 52.2 FA 2010: 54
ME 3e: 35
BE01-
FA 2012: 56.1 FA 2011: 53.1 FA 2010: 55
ME 3e: 35
20
Types of Bias in Research
Types of Bias in Research
BE01- 21
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 FA 2010: 55
ME 3e: 35
BE01-
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

22
Bias: Lead-time, Recall, Late-look, Confounding
Bias: lead-time recall late-look confounding
FA 2012: 56.1 FA 2011: 53.1 FA 2010: 55
ME 3e: 35
BE01-
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


23
Design Bias
Design Bias
FA 2012: 56.1 FA 2011: 53.1 FA 2010: 55
ME 3e: 35
BE02- BE02-
Lecture Objectives
!
Biostatistics
Sam Asgarian, M4
Tulane University
1
BE02-
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 FA 2010: 56
ME 3e: 35
Hypothesis Testing
2
Hypothesis Testing
BE02-
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 FA 2010: 56
ME 3e: 35
3
Type I and Type II Errors
Type I and Type II Errors
BE02-
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 FA 2010: 56
ME 3e: 35
4
Power
Power
BE02-
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 FA 2010: 55 5
Skewed vs. Normal curves
Skewed vs. Normal curves
BE02-
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 FA 2010: 57
ME 3e: 36
6
T-test
T-test
BE02-
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
7
ANOVA
ANOVA
FA 2012: 58.4 FA 2011: 55.2 FA 2010: 57
ME 3e: 36
BE02-
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)

8
Chi-Squared
Chi-squared
FA 2012: 58.4 FA 2011: 55.2 FA 2010: 57
ME 3e: 36
BE02-
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 9
Disease Prevention
Disease Prevention
BE02-
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 10
Reportable Diseases & Leading Causes of Death
Reportable Diseases & Leading Causes of Death
BE02-
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 11
Suicide
Suicide
BE02-
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 12
Medicare and Medicaid
Medicare and Medicaid
BE03- BE03-
Lecture Objectives
Ethics
Sam Asgarian, M4
Tulane University
1
BE03-
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 FA 2010: 59
ME 3e: 30
2
Physicians Ethics
Physicians Ethics
BE03-
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 FA 2010: 59
ME 3e: 32
3
Informed Consent
Informed Consent
BE03-
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 FA 2010: 59
ME 3e: 32
4
Exceptions to Informed Consent
Exceptions to Informed Consent
BE03-
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 FA 2010: 59
ME 3e: 32
5
Emancipated Minors
Emancipated Minors
BE03-
Children younger than 18 years are minors and are legally incompetent
Exceptions:
Substance drug treatment
Prenatal care
Sexually transmitted disease treatment
Birth control
6
Special Cases for Minor Competency
Special Cases for Minor Competency
FA 2012: 59.5 FA 2011: 57.4 FA 2010: 59
ME 3e: 32
BE03-
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 FA 2010: 60
ME 3e: 33
7
Patient Confidentiality
Patient Confidentiality
BE03-
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 FA 2010: 60
ME 3e: 33
8
Physicians Duty to Warn and Protect
Physicians duty to warn and protect
BE03-
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 FA 2010: 60
ME 3e: 33
9
Malpractice
Malpractice
BE03-
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 FA 2010: 61
ME 3e: 30
10
Situational Testing: Only 1 Right Answer
Situational Testing: only 1 right answer
BE04- BE04-
Lecture Objectives
Development and Physiology
Sam Asgarian, M4
Tulane University
1
BE04-
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 FA 2010: 63
ME 3e: 29
Elderly Development
2
Elderly Development
BE04-
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 FA 2010: 63
ME 3e: 21
3
Grief
Grief
BE04-
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 FA 2010: 61
ME 3e: 6
4
Infants: APGAR Score and Birth Weight
BE04-
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 FA 2010: 62
ME 3e: 7
5
Milestones: Infant, Toddler, Preschool
BE04-
Tanner Development
FA 2012: 535.3 FA 2011: 60.4 FA 2010: 62
ME 3e: 9
6
Tanner Development
1. Childhood
2. Pubic hair and breast buds
3. Pubic hair darkens, increased secondary sexual characteristics
4. More development
5. Fully adult
BE04-
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
7
Sexual Dysfunction, Stress, BMI
BE04-
Circadian rhythm and Sleep
FA 2012: 64.1, 65.2 FA 2011: 62.1, 63.2
FA 2010: 64 ME 3e: 10
8
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 O
2
, erections
NE reduces REM
Alcohol and other depressants reduce REM and sleep stages 3-4
ACh is main neurotransmitter in REM sleep
BE04-
Narcolepsy and dreams vs terrors
FA 2012: 65.1, 3 FA 2011: 63.1, 3 FA 2010: 64
ME 3e: 12
9
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