Monday, October 19, 2009

And Now for Something Completely Different

Following the long tradition which I have only just now created, and given that it is the end of the term here at the Palmer Davenport campus, I have decided that this last post of the term shall be dedicated to a series of fun and interesting video clips rather than to a discrete educational topic. It has, in reality, been a long and difficult term for those of us here, so as we get set for break- and as those at Palmer West and Palmer Florida do not- here are a collection of completely unrelated, funny, or novel clips from youtube. They are of no educational import whatsoever, but are just some serious fun. When I return to this blog in a couple of weeks, I’ll be back to posting on education, scholarship and research, but for today, enjoy!

1. This first clip is from the late and lamented comedy show “Whose Line is It? The show often featured a skit where the comedic improvisers had to riff on some outlandish occupation, and in this one they skewer chiropractic.

2. This second clip features one of the most incredible musical engineering machines I have ever seen. I thought it was real, but recently learned it is a computer animation. Nonetheless, it still inspires awe in me.

3. This clip is entitled “little girl catches big fish.” Boy, does she ever. Who doesn’t love a little girl catching a big fish, especially when she just picks it up out of the water?

4. And who doesn’t love crazy basketball shots. These guys are masters at this game, and no one has ever shown these are not real. This is their “summer camp” version. You will see why, and I am guessing at the camp they are seen as kings.

5. I have an interest in extreme musical instruments. I figure you should as well. Here is something you have never seen before, a subcontrabass flute; in fact, this is the world’s largest flute.

6. And here is a contrabass saxophone. I’ve actually seen one played in concert, by the jazz musician Anthony Braxton, and all I can say is it sounds like an elephant. In heat.

7. As long as our current theme is music, I also find appealing people who find new ways to play their instrument. Working in a traditional medium, the guitarist Stanley Jordan uses two-hand tapping to create interlocking counterpoint, as he does here on the jazz standard “Autumn Leaves.”

8. And here is another guitarist, with a different method of doing two-hand tapping, here to create percussion counterpoint. This is Preston Reed, performing “Rainmaker.”

9. No amount of humor can ever get enough of Monty Python. I consider this clip the funniest clip the Pythons ever did, and it features John Cleese as the Minister of Silly Walks.

10. Hey, it’s my blog, so we get a Buffy clip; this time, of outtakes. Watch carefully for the one where Charisma Carpenter forgets she is supposed to be in character as Cordelia Chase and actually introduces herself as… herself.

And that's all folks. For now. PCCD, enjoy the break. PCCW and PCCF, enjoy the work. Soon enough, it'll be your turn again. Best wishes to all of you!

Monday, October 12, 2009

The Belmont Report

In the annals of research ethics within the United States, the importance of the Belmont Report ( cannot be overstated. It was an outgrowth of the National Research Act of 1974, which came about because of a series of events that had occurred in the 30 years leading up to the implementation of the Act. While the initial impetus came from the discovery of the Nazi atrocities in World War II, the fact was that even in the US there were research ethics violations, including the Willowbrook hepatitis study (involving retarded children), the Jewish Chronic Disease Hospital study (involving chronically ill but demented patients), the Tuskegee syphilis study (involving elderly Black sharecroppers), the thalidomide crisis, and other events. The Belmont Committee was charged with developing a framework for the ethical conduct of research, protecting those people who would be willing to participate as research subjects. Three principles emerged from the conference: (1) Respect for persons; (2) Beneficence; and (3) Justice.

Respect for Persons: Two issues arise with regard to respect to persons. One is that individuals are to be treated as autonomous agents, and the second is that those with diminished autonomy would require additional protection. This makes sense in that some of the most egregious violations that had occurred involved vulnerable populations- the poor, children, the elderly. Thus, the issue here is autonomy, or the right of people to self-determination. Embedded in this precept is the concept of informed consent. That is, no one should consent to being a research participant without being informed about the risks and benefits of that involvement. For a competent person, this requires disclosure of information and then an ability to make a decision to participate free from any force or coercion. In the case of someone with diminished competency or who is not competent (such as children, who are not legally competent), a surrogate (such as a parent) must make that decision.

Beneficence: This means more than simply do no harm; it means that efforts must be taken to reduce the risks for participation while doing what you can to enhance the benefits, if any are there. Today, the leading ethical framework for bioethics (1)- principlism- has broken the harm aspect out from the benefit aspect, so that one might talk about beneficence and nonmaleficence, to do good and to do no harm, but they are obviously different sides of the same coin. One of the issues that arises in clinical research is known as the therapeutic misconception, which occurs when patients confuse the goals of research (generalizable knowledge) with the goals of clinical practice (doing all you can to help the patient). Researchers are constrained by research protocols which they must follow, meaning that they cannot do all they can for a specific patient, something most patients initially do not grasp.

Justice: This relates to more than simply how we disburse health care resources. In the context of research, it also addresses the need that everyone share equally in risk if everyone will end up sharing in the benefit. Thus, we should not always look to local impoverished populations as research subjects because we know they are easily available and likely to find a small enticement more desirable than a wealthier potential research base. Our research should not systematically select specific classes or types of individuals because they have a compromised position in society.

The Belmont Report was an influential development in research ethics, and one that is very much a part of today’s research environment. Anyone considering conducting research should familiarize themselves with its precepts.

1. Beauchamp TL, Childress JF. Pricniples of biomedical ethics, 6th edition. New York, NY; Oxford University Press, 2009

Monday, October 5, 2009

Epidemiological and Clinical Research Strategies and Designs

As a reminder, note that the single most important hallmark of a scientific theory is that its hypotheses are capable of being disproved. Experimental studies, when done, can be excellent tests of hypotheses that we could not otherwise examine were we to simply try to observe naturally occurring events. But it is equally important to note that the kind of questions we ask in research cannot all be answered using the same exact research design; the design we use when trying to understand the factors that lead to, say, low back pain is very different from the design we use when trying to see which of two interventions is more effective at decreasing the pain seen with that same low back pain. Thus, knowing a bit about design is very helpful when you read journal articles, because the design of the study is a key to looking at what the study is about.

Generally speaking, we can classify research designs into two broad categories: descriptive (or analytic) designs and experimental. This is a broad classification, because there are also quasi-experimental designs, and non-experimental designs which can be used in clinical research, but this larger classification breaks the study designs down nicely. Descriptive studies are done when for whatever reason we cannot have control over the independent variable. For example, we might look to see if vibration from driving a truck leads to a higher incidence of low back pain- but the interval to do so here might run into years between exposure and outcome, and we would not want to set this up as a clinical trial where we expose some people to vibration over the course of a year and compare them to controls who were not exposed. In experimental designs, the intervention is under the control of the researcher, and this helps limits threats to validity.

The following is by no means all-inclusive, but is an introduction to common research designs. Descriptive designs include cross-sectional studies, case-control studies and cohort studies. Experimental designs include randomized clinical trials and cross-over designs.

Cross-Sectional: This assesses health status and exposure levels of individuals within a population at one point in time. By this, I mean that we are collecting this from each person at one point in time, not that we gather all the data at a single point in time. The classic example of a cross-sectional study is a survey. What we are looking for is a potential association between some causal factor and a condition of interest. For example, we might ask to see if people who have more than 3 drinks per day have higher rates of liver disease than those who do not. We cannot say if one causes the other, only that they are associated with one another.

Case-Control: In a case-control study, we look backward in time (retrospectively) to examine exposure factors between a group of people with the condition of interest (the cases) and those without (the controls). So we are likely looking at patient records in doing so, and we are trying, as much as possible, to ensure our populations are matched on all factors save for the presence of the condition of interest. These kinds of studies cannot determine the risk of developing a disease, but can determine the odds of doing so. An odds ratio can be calculated providing this information- this was discussed in an earlier blog post. Here, the OR is simply the ratio of odds of the cases being exposed divided by the odds of the controls being exposed to some factor.

Cohort: In a cohort study we follow patients forward in time and compare outcomes after one group is exposed to some suspected factor of disease while the other group is not. Such studies can last for many years, and the benefit of this design is that it is capable of detecting whether an exposure precedes an outcome; that is, does drinking 3 glasses of alcohol per day lead to a higher rate of liver disease? Thus, in a cohort study, we can determine a risk level, in this case a relative risk of developing the condition of interest between the group exposed and the group not so exposed. This is a particularly strong epidemiological design to use.

Randomized Clinical Trial: This is the classic pre-test/post-test randomized experimental design used in clinical trial research. It begins with two groups that are as similar in all important demographics as possible, and then subjects one to an intervention the other does not get, and finally compares the outcomes between the two groups. This design permits the statistical comparison of the two groups. It can be set as a factorial design when there are several explanatory variables involved.

Cross-Over: This design provides a treatment to one group while the other receives either a placebo or alternative treatment, and then switches those assignments at some specified point in time. There is usually a wash-out period involved to allow for time so that the initial treatment does not influence the alternative treatment. This is a complicated design that carries a high risk for drop-outs due to the time necessary to conduct the study.

As always, the idea is to use the proper design to answer the question, the best tool for the job, so to say. This is but an overview of the topic, but may help you as you read journal articles.