Childhood disorders

I. Down syndrome
II. Mental retardation:
-

Its sub-average level of general intellectual functions + limitation of adaptive

functions, start before 18 yrs of old.
Mild (50-55 70), moderate (35-40 50-55), severe (20-25 35-40),
profound (< 20-25).
Causes: genetic syndromes (ex, downs syndrome, fragile X syndrome),
maternal infections, trauma, malnutrition, ionizing radiation.

III. Autism:
-

symptoms: dont show need of contact/affection, flat affect, self-stimulation,

limited or absence of speech, impaired intellectual & cognitive functions
(moderate mental retardation).
Causes: MMR, infections (TB), obstetric complications, toxins, CNS involvement.
Role of MD: detect protodeclarative pointing, gaze monitoring, pretend play, In
well-baby check ups, school screening programs, vaccination appointments.
Autistic child should be place in specialized program, integrated in society and
rise awareness and education about autism.

Coping strategies for families with

disabled children

The CHALLENGE is that; Families became exhausted by the relentless performance of challenging behavior of their
disabled child
BLAMING THE VICTIM to assume we are different from those who are ill and to believe in a predictable world.
INTERNAL CONFLICTS; Approach-Approach (2 desirable choices), Avoidance-Avoidance (2 undesirable choices),
Approach-Avoidance (1 desirable and the other isnt).
SOLVING THE PROBLEM;
a.
Emotion-focused coping: concentrate on the emotions the disability has caused to the family people
need to talk to; make terms and sense of it and decide what to do about it.
b.
Problem-focused coping: the steps depend on the type of problem (pressing one time decision, continuous
difficulty or anticipated event), once the problem is identified the coper can learn more about the problem
and have feel of control and speeds the recovery.

Regarding coping with unavoidable problems in life:

Reappraising the situation: rethink differently of the problem with convert anger to sympathy,
worry into determination and feeling of loss to feeling of opportunity that improves wellbeing, soften negative emotions and lowers cortisol.

Learning from experience: come up with newly acquired skills + discover previously unkown
sources of courge and strength.

Making social comparisons; with those less fortunate and that help in coping and
management.
SUPPORT GROUP; give sense of meaning, purpose and belonging +ve psychological well-being.
SELF-HEALING PERSONALITY: Control ( dont feeling powerless in the face of external challenges) +
Commitment ( feel committed to something important and meaningful) + Challenge ( respond to life with
excitement and energy) + Trust ( believe that world is understandable and meaningful.
.
Understanding Self-Healing: growth orientation/ self-actualization, and identity, morality and purpose.
.
types:
1.
2.

The active healthy: function best in stressful environment, outgoing and spontaneous.
The relaxed healthy: functions best in a low-stress environment.

INCREASE CHILDS ABILITY TO SEEK ASSISTANCE, children express their feeling while playing.
REDUCING VULNERABILITIES THAT PUT CHILD AT RISK OF DEVELOPING EMOTIONAL PROBLEMS; child
advocacy programs, long-term institutions, educational institutions, mainstreaming, targeted areas (hygiene,
social behavior, basic academic and simple occupational skills).
PERMANENT PLANNING; parents should be advised to seek assistance from early intervention programs to get

Family Health
Def. of family: the basic unit of society, two members or more than live together and
depend on each other socially, physically and economically.
Def. of family health: promotion and maintenance of physical, spiritual, social and mental
health of the family as a unit and each family member.
Types of families:
-

Nuclear (father + mother + children).

Extended (nuclear family + relatives).
Composite ( husband + >1 wife + children).
Single parent (father Or Mother + children)
Blended (father/mother or both had previously married + children from previous marriage).

Functions of family:
-

Management (decision making)

Socialization
Boundary
Communication
Education
Reproduction
Emotional support
Economic
Health care

Family stress and crisis

Def. of stress: a state of tension produced by stressor or actual/ perceived demands that arent managed yet.
Def. of stressor: any factor that cause stress or alter body equilibrium.

Family stressors:
Interpersonal (ex; divorce)
Environmental (ex; pollution)
Economic (ex; retirement)
Political (ex; war)
Socio-cultural
Sources of family stress:
Stressful contact of one member/ whole family with extra-familiar forces (ex; legal problem, poverty,etc)
Transitional stressor (ex; new baby, adolescent period).
Situational stressor ( ex; hospitalization)

Def. of Adaptation: adjustment to change and interaction with environmental demands that promote integrity of the
individual.
Strategies of adaptation:
Defense mechanisms.
Coping mechanisms; to find a balance between acceptance and action of taking control.
Mystery; end result of coping, where repeated successful problem solving efforts were done.
Time phases of stress and coping; Ante-stress actual stress post-stress period.
CRISIS: family failure of use of adaptive strategies with stress.
Types of Crisis: developmental/maturational + Situational (sudden external stressful events).
Phases of Crisis: shock defensive retreat acknowledgement (face reality) adaptation and change.
Principles of crisis intervention; Help them to ACCEPT the crisis CONFRONT it FIND the facts (know the truth is
better than unknown), and DONT GIVE them false reassurance or ENCOURGE them to blame others, also GIVE them
every day task not at once so they feel they are incompetent.

Telling the family of a disability

International classification of impairment, disability and handicap:
Pathology (disturbance @ cellular level) Disability (disturbance @ organ/system level, ex; limb paralysis)
impairment ( disturbance @ personal functional performance) handicap ( at social & environmental level,
ex; having less work opportunities due to paralysis).
Epidemiology; 0.5 billion of world population are disabled, 1/3 of them are children, and 80% in developing countries.
Reactions to bad news: Denial & shock Anger bargaining depression & stress acceptance.
Factors affecting family responses to disability:
-Nature of disability (severity, progression, mental involvement?)
-Information base
-Family psychological status (coping)
-Medical & social attitude
-Support networks.
family concerns: is it their fault?? Could they do something to prevent it?? Can they afford ttt??? Will the child ever
have a normal life??
consequences affect siblings & parents
-Marital relationship disturbance.
-Anxiety & depression
-Exaggerated response to medical discussions
-Hyper-attention sate.
Role of GP: identify, diagnose & intervention ( by therapeutic, prosthetic approaches).

Educating the family;

-Give accurate info. (what is it? causes? Ttt choices, prognosis)
-Accelerate recovery of grieving
-Reduce guild and anxiety
-Strengthen family support
-Develop cooperation with medical & support team

Patient safety
Def. of pt. safety: actions taken individuals or organizations to protect health care recipient from being
harmed by the health care services. WHO; avoidance, prevention and amelioration of adverse outcomes
or injures from processes of health care.
Def. of Near miss: An event that almost or did happen but no one know about it.
Traditional methods of pt. safety:
-

Well structured systems

Explicit processes
Professional standards of practice
Individual competences reviews

Human errors occur due to; inattention, memory lapse, failure to communicate, poorly designed
equipment, exhaustion, ignorance, noisy working environment.
How pt. safety be improved?
- Make mistakes impossible (ex; auto-shut off heating devices, ready-to-administer medications, over-write protected
computer disks, circuit breakers)
- Design safer processes (ex; barriers can prevent untoward events as door alarms, or surgical site confirmation)
- Reduce harm caused by mistakes (quick recognize of adverse effects and take an action).

How we reduce risk processes?

- Reactive (sentinel events): investigate pt. incidents by Root Cause Analysis (RCA).
Steps of RCA; gather facts choose team determine sequence of events identify contributing factors select root cause
develop corrective actions & follow-up plan.
Causes of medication related sentinel events: lack of staff training, inadequate supervision, staff distraction, improper labeling,
communication failure.

- Proactive: monitor pt. safety to prevent sentinel events from occurring, by;
gather & analyze info. About risk-prone processes and redesign high- risk processes;
Examine safety of processes by; failure mode, effects and criticality analysis (FMECA) that its steps are: flow chart the process,
brainstorm potential failures, determine [Criticality = frequency x severity x detectability] and discover causes of critical failures.
To redesign the process; eliminate the chance of failure, make it easier for people to do the right thing, identify/correct failure before
he is harmed then test it by FMECA, stress & pilot test document the process, train people, monitor it

Evidence Based Medicine

EBM

Benefits of EBM:
Doctor:
postgraduate continuous education & generic skills in appraising knowledge.
to plan more efficient research strategies & recognize an answer > quickly & use ur limited
time > efficiently.
Help to face misguided experts or drug company hype.
Patients : better info. Of prognosis & only proven medicine is applied on them, can make difficult
decisions.
Institutions: reduced cost, improved resource utilization and efficient care.
EBM is 1-2-3-4-5; 1 major aim best care, 2 major principles evidences, 3 components 3 Es, 4
Pillars RV-RA system, 5 steps 5As
Basis of evidence: (1&4 answer forward /basics Qs, while 2&3 background/ clinical Qs)
Likelihood ratiosare used for assessing

Experience latest bad experience bias, out of sight & the

outvalue
of mind,
non random
loss test.
of performing
a diagnostic
They
use
thesensitivity
and
specificityof
to follow up of unsatisfied pt., inability to combine out come data for multiple pt.
the test to determine whether a test result

Pathophysiology
usefully changes the probability that a

Textbooks
condition (such as a disease state) exists.
RL+
= sensitivity/(1-specificity)

Research what type? Appraising it? knowledge explosion,

finding
it.
RL- = (1-sensitivity)/specificity
EBM (3Es) = Expertise + Evidence + Expectation/patient preference.
RV-RA system (Relevance, Validity-Results clinical significance, Applicability)* applicability criteria
are intervention, population, and preferences.*for results; magnitude and precision.*validity;
diagnostic tests (population + blindness)
5As: Ask answerable Q Acquire the evidence Appraise it Apply the best one Assess ur
performance.
in other words; Hierarchy of Evidence: meta-analysis of RCTs individual RCT observational
studies clinical experience.
o The Structure of ur clinical question is Focused and well articulated PICO:
- Patient &/or Problem being addressed (i.e assess ur patient)
- The Intervention/exposure being considered (ask clinical Qs)

Cont. of EBM

EBM results into information Mastery: control the information, PBL, and this equation [usefulness =
(relevance x validity)/work] concentrate on High-yield journals with favorable POEM:DOE ratio (i.e
patient-oriented, common to practice & require change of practice).
Relevance = POEM (pt.-oriented evidence that matter, ex; mortality/morbidity) + DOE (Diseaseoriented evidence, ex; pathophysiology).
just in case info.; found in databases/libraries, have Much detailed info. For all needs but require
time.
just in time info.; highly filtered focused info. Sources like Cochrane library , with rapid access but
may lead to reliance on the filtering mechanism.
Difficulties in EBM:
Financial disincentives
Medical training
Opinion leaders
Standards of practice
Patient expectations
Competence
Information overload
Drug companies
Perception of liability
Organizational constraints
Barriers & solutions in EBM:
Difficult to find evidence
Isnt applicable on patients goal of medicine is to try whats most likely to work most of the time.
Tradition
Perceived loss of Autonomy EBM provides best info. For one to form the best decisions not providing
the decisions themselves.
It scoffs al clinical experience clinical jazz = science (EBM) + art (experience) of medicine.
Fear from statistics

Medical Confidentiality
Def.: the foundation of trust in doctor-patient relationship to keep patients information as a secret.
Confidentiality of child = elderly = mental retarded = dead people.
Benefits:
-

Respect patients privacy, dignity, autonomy and individuality.

Fear of social embarrassment, disapproval, discrimination, or stigmatization.
Avoid information misused against patient.
Open communication and free exchange of critical information.
Demonstrate doctors fidelity to patient
Effective medical intervention
Prevent harm to others
Public health efforts

When its needed? Sexual Hx and STIs, Adolescent sexual Hx, Alcohol and drug abuse, Psychiatric
patients, Marginalized people.
Principles of disclosure:
- With patients consent (Autonomy) get it whenever its possible ONLY from the pt., valid written, pt. should understand
nature and effect of it, and 3 rd parties and reason should be written in it, hand doc. To pt.
- For benefit of patient (Beneficence) in emergency, incompetent, to prevent harm to pt. (ex; epilepsy/child abuse), only
necessary info. Is shared between professionals taking care of the pt.
- Prevent harm to others (Nonmaleficence) the harm out weights doctors duty to pt., seriousness of harm, know to
whom & how to tell.
- When required by Law (Justice) order of court, drug abuse, public health risk (ex; infectious), factories regulations, or
enlistment act for national services.
- Medical research, audit, registries approved by ethical committee, where feasible get patients informed consent,
dislink patients identifiable data, ensure no harm to pt., operated under medical confidentiality principles
Medical certificates; dr. hand it to pt., & pt. is responsible to pass the information, its for claiming benefits. Special
situations: Company/Managed care, Occupational physicians, Maids Employment examination, Armed Forces Medical
Officer, Police & Prisons Doctor, Electronics Medical Records

Occupational Health

Def. of occupational Health: The promotion and maintenance of the highest degree of physical, mental, social well-being
of workers in all occupations-total health for all workers by studying the adverse environmental factors and stresses
arising at the work place and their effects on the health of workers.
Occupational medicine: It is the branch of medicine dealing with the study, prevention, and treatment of workplace
injuries and occupational diseases and with promotion of optimal health and safety in the workplace.
Occupational health team (multidisciplinary):
occupational health physician:
- Administrative role.
- preventive role:
* pre-employment medical examination to choose suitable employee and exclude those with incompatible
health status
with the job, record those with need of regular check ups and for medico legal issues and compensation to
those get
occupational diseases.
* periodic medical examination for early detection of occupational and non-occupation disease, assess efficacy
of
environmental control measures. The frequency and type of tests depend on type of exposure (ex; every 2
yrs dusts,
1yrchemicals, 6monthslead fumes, after each exposure of atomic reaction.
* special medical examination chronic disease ex; HT/DM, after sick leave, pregnant women, work promotion.
* health education
* prevention of non-occupational diseases,
curative rule:
occupational hygienist to detect and evaluate environmental hazards at work which is needed 4 environmental
control measures, and to preparation and maintenance of personal protective equipments.
Others; occupational health nurse, psychologist, physiotherapist, ergnomist, epidemiologist, sageryl engineer,
toxicologist, microbiologist, chemist, work organization specialist, health promotion specialist.
Hazards: is any source of potential damage, harm or adverse health effects on something or someone under certain
conditions at work.

Cont. Occupational Health

Examples of Hazards and possible diseases it cause:

Physical (ex; extreme temp. Heat stroke/exshuation/collapse/fatigue/cramps, unsatisfactory
noise occupational deafness, light poor lighting cause eye discomfort, miners nystygmus &
burning and headache, ionizing radiation x-ray + cancer, gama-ray + leukemia/aplastic anemia, but
effect depend on time, distance and sheilding non-ionized radiation Infrared +cataract, UV +skin
burns, laser + eye damage, electromagnatic, or pressure air embolism, vibration Rayounds
syndrome)
Chemical (particulates [dust, fumes, smoke, mist] occupational asthma, restrictive lung diseases
as farmers lung/asbestosis/silicosis/anthracosis or even cancer in asbestosis, non-particulates [gases,
vapors], liquids [acids, alkalis, solvents]. The effect depend on; the route of entry, rate of excretion
and biological factors, chemical toxicity and dose local as contact dermatitis or skin cancer, systemic
. ACUTE effects Asphyxiation, necrosis, irritation CHRONIC effects CNS/Kidney/liver/bone
damages, blood changes, cancer.Biological monitoringcontrol at source, path and worker sites.
biological (parasitic/bacterial infections)
psychosocial (tension, no support, unsatisfaction, loss of control) HT, peptic ulcer.
mechanical (tools) ex; bursitis, tendinosynovitis, blisters.
Due to Non-application ergonomic principles carpel tunnel syndrome, cervical strains,
thoracic outlet syndrome.
accidental.
Classification of occupational diseases:
-

Type I: only occupational origin, ex; silicosis.

Types II: occupation/non-occupational origin, ex; broncogenic carcinoma.
Type III: non-occupational origin but aggravated by occupation, ex; endogenous eczema.

Safety: It is the degree to which risk is absent. It is a concept covering hazard identification, risk
assessment and accident prevention
Occupational Hx.: type of work? Exposed hazards in details? Symptoms variation at work and outside it?
other diseased co-workers?

Medical Ethics

Def. of ethics: a moral system or set of principles for particular group, person or community, morals are principles
of right and wrong, good and evil, Moral isnt related to law. Includes; bioethics (medical+ eviromental), clinical,
medical ethics.
Def. of Autonomy: peoples ability to make rational choices based on their own beliefs and values, free from the
controlling influence of others.
Def. of competence: Whether a patient is mentally or physically well enough to make an informed Decision. Is taskspecific. ABOVE 18 yrs old
Def. of consent: A patients valid agreement to be treated.
Types: Explicit: writing/oral, Tacit: non-verbal ex; opening mouth for tongue inspection.
Contents: purpose, side effects, alternatives
Def. of paternalism: The deliberate overriding or non-consultation of a Patients wishes with intention of benefiting
the Patient or avoiding him harm.
Minors (new born, young child/school-age, adolescents) & ethics: decision made on child best interests that parents
share in determining it Parents give the consent.Beneficence is most important value.BUT mature minor can
give legal valid consent.
Value system: The Person Making a decision to Undergo/Refuse Treatment NOW is the Same Person who will have to
live with the Consequences of the decision later.
1. Beneficence: to value prevention or elimination of HARM and doing GOOD.
2. Non-malificence: disvaluing HARM.
3. Autonomy
4. Justice: Valuing fair, equitable, and appropriate treatment in light of what is due or owed to persons.
5. Trustworthiness: Valuing being able to be counted on to act with integrity, to be honest and truthful and to
keep ones promises.
-. In clinical ethics; medical or patient value point of view 1& 2, patient preference 3, contextual features 4.
If pt. refused a treatment and he is in his full CAPACITY then his decision should be respected but a legal document
showing that should be written. An Autonomous person is considered to be the Best Judge of their own Interests. A
woman has a right to refuse treatment even if this may result in the death of viable fetus. In case of a child, parents
decision is respected when they refuse not major treatment, as child has rights, and the best interest of the child is
determined by help of doctors.
Clinical decision cannot lawfully be taken to withdraw/withhold artificial nutrition and hydration in the Case of a
competent patient who expresses the wish to remain alive.
Abortion; The pregnancy has Not exceeded 24 weeks. Two doctors are of opinion, formed in Good faith that the

Types of Research Bias

Selection Bias: Selection bias occurs when individuals or groups being compared are different. Two main
factors that can contribute to selection bias are self selection, when the sample selects itself, and
convenience sampling, when individuals are selected because they are easy to obtain. To help insure
external validity, subjects in the study should be very similar to the population in which study results will
be applied.
Detection Bias is a form of selection Bias, refers to systematic inconsistency in outcome assessment.
Measurement Bias: The research design should accurately and truthfully measure the research question.
Measurement bias occurs when the research design does not match the research question; for example, a
questionnaire aims to assess the learning objectives of a training session but measures only the learners
satisfaction with the session. A diagnostic or measurement tool that is not accurate could cause instrument
bias. For example, an unbalanced weight scale would skew the results of a study.
Interviewer Bias: The interviewers opinions, prejudices, and even non-verbal cues, when displayed
during the interview process, can bias or influence study results.
Response Bias: Subjects may shape their responses in order to please the interviewer. Subjects may also
believe they know the expected findings and change behaviors to match. Finally, subjects may believe
they are thecontrolorexperimental groupwhich is often called theplacebo effect.
Theobserver-expectancy effect: is a form ofreactivityin which aresearcher'scognitive biascauses
them to unconsciously influence the participants of an experiment. It is a significant threat to a
study'sinternal validity, and is therefore typicallycontrolledusing adouble-blind experimental design.
Lead time biasis the bias that occurs when two tests for a disease are compared, and one test (the new,
experimental one) diagnoses the disease earlier, but there is no effect on the outcome of the diseaseit
may appear that the test prolonged survival, when in fact it only resulted in earlier diagnosis when
compared to traditional methods. It is an important factor when evaluating the effectiveness of a specific
test.
Performance bias is introduced during the treatment or exposure phases of a study and occurs when
subjects in comparison groups are systematically given different care in ways other than the intervention
under investigation. To minimize performance bias in randomized controlled trials, the subjects, physicians,
and those collecting the data should be blinded to the designated intervention status of each group.
Attrition bias relates to patient dropout or exclusion from a study. High dropout rates or systematic