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PBHE427 Epidemiology

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This is a randomized controlled trial to assess the effects of lifestyle modification and metformin in the prevention of diabetes in high risk individuals. The hypothesis was that lifestyle intervention or metformin would prevent or delay the development of diabetes. 3,234 persons with elevated fasting and post-load glucose concentrations were assigned to receive placebo, receive metformin, or participate in an intensive lifestyle modification program. The average follow up was 2.8 years. The study found that both metformin and lifestyle intervention did reduce the incidence of diabetes. Lifestyle intervention was significantly more effective than metformin.

Challenges of assessing risks and reduction measures used

According to Friis & Sellers (2014) there are 3 issues with controlled trials when assessing risks. The first is the diversity of the human subjects. This study boast that 68 percent are women and 45 percent were members of a minority group. The second issue is sample size. Studies that have larger sample in comparison to smaller samples have greater statistical power and reduced measurement error; of course, larger samples are more costly to collect than smaller, (Friis & Sellers, 2014, p. 403). This study has over 3,000 patients enrolled, though it is reported that there was a 10 percent rate of loss to followup per year. Which is the third issue. Noncompliance is a factor in experimental studies that can potentially nullify the effects of the intervention. The team did assess for adherence to medication compliance with pill counts and structured interviews. They also tried to mitigate adverse side effects of metformin by titrating the dose at a slower rate or decreasing the dose.

Risk for major adverse cardiac events in select surgical patients

Hawn et al. (2013) conducted a retrospective cohort study of patients undergoing noncardiac surgery to determine risk for major adverse cardiac events (MACE) within 30 days after surgery and the relationship to time from stent to surgery with adjustment for stent type, surgical characteristics, cardiac risk factors, and comorbid conditions. The cohort consisted of patients undergoing noncardiac surgery within 24 months following coronary stent placement who had MACE compared to those did not have MACE.
This study calculated odds ratios (ORs), which is a little confusing to me because Friis and Sellers (2014) describe ORs for case-control studies, not retrospective cohort studies. However, using ORs in this study makes sense because the researchers are trying to determine the odds of MACE given twelve variables. The study concluded that the top 3 variables that were most strongly associated with MACE were nonelective surgical admission, history of myocardial infarction in the 6 months preceding surgery, and a revised cardiac risk index greater than 2.
I think the challenges in assessing risk include the possibility of confounding variables. The researchers do not make any recommendations for risk reduction due to several limitations of the study. The do, however, acknowledge that the findings are hypothesis generating only and recommended randomized trials be conducted.
1a. What is the prevalence of TB in the community as of Dec 31, 2009? 60/50000, or 12 in 10000
b. What was the incidence of breast cancer in 2009? 5/50000, or 1 in 10000
c. If, of the 500 deaths in 2008, 89 were r/t Cardiovascular disease; what is the CV disease specific mortality? 89/50000, or almost 18 in 10000
d. What was the prevalence of diabetes for 2009? 2100/50000, or 42 in 10000

Calculate the % change in diabetes in Anytown for 2009. 2008 was 2000/5000 = 4%, 2009 was 2100/50000 = 4.2%. Diabetes went up by 0.2%.
What do the data mean? One could likely compare the Anytown data to national incidence/prevalence to get an idea of the towns overall health. One could also look at preceding years data to see if there are trends. The data give no information on adjusted rates, so disparities could be present.
2. What is the relative risk of being diagnosed with lung cancer in Somewhere for individuals who are smokers? 200 smokers/100 nonsmokers = 2:1
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