Joslin Diabetes Center is the world’s foremost institution for diabetes research, clinical care and education. A useful site for up to date research on Diabetes
over 6 years ago
NIH VideoCast - (1) Sickle Cell Anemia: Yesterday, Today, and Tomorrow (2) Epidemiology of Type 2 Diabetes Mellitus: Its History and Contributions to Treatment and Prevention
(1) Sickle Cell Anemia: Yesterday, Today, and Tomorrow (2) Epidemiology of Type 2 Diabetes Mellitus: Its History and Contributions to Treatment and Prevention
over 6 years ago
over 6 years ago
This course equips students with the knowledge and statistical skills to make valuable contributions to medical research as well as public health in low-, middle- and high-income countries. Epidemiological methods underpin clinical medical research, public health practice and health care evaluation to investigate the causes of disease and to evaluate interventions to prevent or control disease.
over 6 years ago
Global Epidemiology of HIV Infection among Men Who Have Sex with Men | The New York Academy of Sciences
At the NYAS March 2011 Music, Science and Medicine conference, Assistant Professor of Psychiatry and Neuroscience at Mount Sinai School of Medicine and 2010 Blavatnik Award winner, Daniela Schiller, talks to Roger Bingham about how she got into science and reviews research in modifying fear memories.
over 6 years ago
Introduction to Epidemiology and public health Epidemiology is the study of the patterns, causes, and effects of health and disease in defined populations. It is the cornerstone of public health, and informs policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive medicine. Epidemiologists help with study design, collection and statistical analysis of data, and interpretation and dissemination of results (including peer review and occasional systematic review). Epidemiology has helped develop methodology used in clinical research, public health studies and, to a lesser extent, basic research in the biological sciences. Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" (1920, C.E.A. Winslow). It is concerned with threats to health based on population health analysis. The population in question can be as small as a handful of people or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", as defined by the United Nations' World Health Organization. Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health, behavioral health, health economics, public policy, insurance medicine and occupational health (respectively occupational medicine) are other important subfields. From Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Epidemiology
over 6 years ago
Tutorial teaching sensitivity vs. specificity, including SPIN and SNOUT mnemonics. Learn the difference between sensitive and specific tests, for medical health science students. Please SUBSCRIBE: More cool stuff coming as we get more HippoHelpers! Further tutorials and flashcards at http://www.helphippo.com Our epidemiology playlist at: http://www.youtube.com/playlist?list=PLIPkjUW-piR24nWuDMiXPB0DcUl-1qUzr http://www.helphippo.com - for more video tutorials organized by topic/year.
over 6 years ago
In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992
Dr Emad Sidhom
over 6 years ago
"One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong" Sir William Osler Well, it's almost Christmas. I know it's Christmas because the animal skeleton situated in the reception of my University's Anatomy School has finally been re-united with his (or her?) Christmas hat, has baubles for eyes and tinsel on its ribcage. This doesn't help with my trying to identify it (oh the irony if it is indeed a reindeer). This term has probably been one of the toughest academic terms I've had, but then when you intercalate that is sort of what you choose to let yourself in for. I used to think that regular readings were a chore in the pre-clinical years. I had ample amounts of ethics, sociology and epidemiology readings to do but this is nothing compared to the world of scientific papers. The first paper I had to read this term related to Glycosaminoglycan (GAG) integrity in articular cartilage and its possible role in the pathogenesis of Osteoarthritis. Well, I know that now. When I first started reading it felt very much like a game of boggle and highly reminiscent of high school spanish lessons where I just sat and nodded my head. This wasn't the end. Every seminar has come with its own prescribed reading list. The typical dose is around 4-5 papers. This got me thinking. We don't really spend all that much time understanding how to read scientific papers nor do we really explore our roles as 'scientists' as well as future clinicians. Training programmes inevitably seem to create false divides between the 'clinicans' and the 'academics' and sometimes this has negative consequences - one simply criticises the other: Doctors don't know enough about science, academics are out of touch with the real world etc... Doctors as scientists... The origins of medicine itself lie with some of the greatest scientists of all time - Herophilus, Galen, Da Vinci, William Harvey (the list is endless). As well as being physicians, all of these people were also respected scientists who regularly made contributions to our understanding of the body's mechanics. Albeit, the concept of ethics was somewhat thrown to the wind (Herophilus, though dead for thousands of years, is regularly accused of performing vivisections on prisoners in his discovery of the duodenum). Original sketches by William Harvey which proved a continuous circuit of blood being supplied and leaving the upper limb. He used his observations to explain the circulatory system as we know it today What was unique about these people? The ability to challenge what they saw. They made observations, tested them against their own knowledge and asked more questions - they wanted to know more. As well as being doctors, we have the unique opportunity to make observations and question what we see. What's causing x to turn into y? What trends do we see in patients presenting with x? The most simple question can lead to the biggest shift in understanding. It only took Semmelweiss to ask why women were dying in a maternity ward to give rise to our concept of modern infection control. Bad Science... Anyone who has read the ranting tweets, ranting books and ranting YouTube TED videos of academic/GP Ben Goldacre will be familiar with this somewhat over used term. Pseudoscience (coined by the late great Karl Popper) is a much more sensible and meaningful term. Science is about gathering evidence which supports your hypothesis. Pseudoscience is a field which makes claims that cannot be tested by a study. In truth, there's lots and lots of relatively useless information in print. It's fine knowing about biomarker/receptor/cytokine/antibody/gene/transcription factor (insert meaningless acronym here) but how is it relevant and how does it fit into the bigger picture? Science has become reductionist. We're at the gene level and new reducing levels of study (pharmacogenetics) break this down even further and sometimes, this is at an expense of providing anything useful to your clinicial toolbox. Increasing job competition and post-graduate 'scoring' systems has also meant there's lots of rushed research in order to get publications and citations. This runs the danger of further undermining the doctors role as a true contributor to science. Most of it is wrong... I read an article recently that told me at least 50% of what I learn in medical school will be proven wrong in my lifetime. That might seem disheartening since I may have pointlessly consumed ample coffee to revise erroneous material. However, it's also exciting. What if you prove it wrong? What if you contributed to changing our understanding? As a doctor, there's no reason why you can't. If we're going to practice evidence-based medicine then we need to understand that evidence and doing this requires us to wear our scientist hat. It would be nice to see a whole generation of doctors not just willing to accept our understanding but to challenge that which is tentative. That's what science is all about. Here's hoping you don't find any meta-analyses in your stockings. Merry Christmas.
almost 7 years ago