A FIVE MINUTE MANAGEMENT COURSE!!

Lesson 1: The wife gets out of the shower and the husband gets in. Just then, the doorbell rings. The wife quickly wraps herself in a towel and runs downstairs. When she opens the door, there stands Bob, the next-door neighbor. Before she says a word, Bob says, 'I'll give you $800 to drop that towel.' After thinking for a moment, the woman drops her towel and stands naked in front of Bob, after a few seconds, Bob hands her $800 and leaves. The woman wraps back up in the towel and goes back upstairs. When she gets to the bathroom, her husband asks, 'Who was that?' 'It was Bob the next door neighbor,' she replies. 'Great,' the husband says, 'did he say anything about the $800 he owes me?' Moral of the story: If you share critical information pertaining to credit and risk with your shareholders in time, you may be in a position to prevent avoidable exposure. Lesson 2: A priest offered a Nun a ride. She got in and crossed her legs, forcing her gown to reveal a leg. The priest nearly had an accident. After controlling the car, he stealthily slid his hand up her leg. The nun said, 'Father, remember Psalm 129?' The priest removed his hand. But, changing gears, he let his hand slide up her leg again. The nun once again said, 'Father, remember Psalm 129?' The priest apologized 'Sorry sister but the flesh is weak.' Arriving at the convent, the nun sighed heavily and went on her way. On his arrival at the church, the priest rushed to look up Psalm 129. It said, 'Go forth and seek, further up, you will find glory.' Moral of the story: If you are not well informed in your job, you might miss a great opportunity. Lesson 3: A sales rep, an administration clerk, and the manager are walking to lunch when they find an antique oil lamp. They rub it and a Genie comes out. The Genie says, 'I'll give each of you just one wish.' 'Me first! Me first!' says the admin clerk. 'I want to be in the Bahamas, driving a speedboat, without a care in the world.' Puff! She's gone. 'Me next! Me next!' says the sales rep. 'I want to be in Hawaii , relaxing on the beach with my personal masseuse, an endless supply of Pina Coladas and the love of my life.' Puff! He's gone. 'OK, you're up,' the Genie says to the manager. The manager says, 'I want those two back in the office after lunch.' Moral of the story: Always let your boss have the first say. Lesson 4: An eagle was sitting on a tree resting, doing nothing. A small rabbit saw the eagle and asked him, 'Can I also sit like you and do nothing?' The eagle answered: 'Sure, why not.' So, the rabbit sat on the ground below the eagle and rested. All of a sudden, a fox appeared, jumped on the rabbit and ate it. Moral of the story: To be sitting and doing nothing, you must be sitting very, very high up. Lesson 5: A turkey was chatting with a bull. 'I would love to be able to get to the top of that tree' sighed the turkey, 'but I haven't got the energy.' 'Well, why don't you nibble on some of my droppings?' replied the bull. hey're packed with nutrients.' The turkey pecked at a lump of dung, and found it actually gave him enough strength to reach the lowest branch of the tree. The next day, after eating some more dung, he reached the second branch. Finally after a fourth night, the turkey was proudly perched at the top of the tree. He was promptly spotted by a farmer, who shot him out of the tree. Moral of the story: Bull Shit might get you to the top, but it won't keep you there. Lesson 6: A little bird was flying south for the winter. It was so cold the bird froze and fell to the ground into a large field. While he was lying there, a cow came by and dropped some dung on him. As the frozen bird lay there in the pile of cow dung, he began to realize how warm he was. The dung was actually thawing him out! He lay there all warm and happy, and soon began to sing for joy.. A passing cat heard the bird singing and came to investigate. Following the sound, the cat discovered the bird under the pile of cow dung, and promptly dug him out and ate him. Morals of the story: (1) Not everyone who shits on you is your enemy. (2) Not everyone who gets you out of shit is your friend. (3) And when you're in deep shit, it's best to keep your mouth shut! THUS ENDS THE FIVE MINUTE MANAGEMENT COURSE!!

Wife & Bridge

A man walking along a California beach was deep in prayer. Suddenly the sky >clouded above his head and, in a booming voice, the Lord said, "Because you have TRIED to be faithful to me in all ways, I will grant you one wish." >The man said, "Build a bridge to Hawaii so I can drive over anytime I want. >The Lord said, "Your request is very materialistic. Think of the enormous >challenges for that kind of undertaking. The supports required, to reach the >bottom of the Pacific! The concrete and steel it would take! It will nearly >exhaust several natural resources. I can do it, but it is hard for me to justify >your desire for worldly things. Take a little more time and think of something >that would honor and glorify me." >The man thought about it for a long time. Finally he said, "Lord, I wish that >I could understand my wife. I want to know how she feels inside, what she's >thinking when she gives me the silent treatment, why she cries, what she means >when she says nothing's wrong, and how I can make a woman truly happy." >The Lord replied, "You want two lanes or four on that bridge?"

Go not to the temple............

Go not to the temple............


A Lovely Poem by Shri Rabindranath Tagore
Go not to the temple to put flowers upon the feet of God,
first fill your own house with the Fragrance of love...
Go not to the temple to light candles before the altar of God, first remove the darkness of sin from your heart...
Go not to the temple to bow down your head in prayer,
first learn to bow in humility before your fellowmen...
Go not to the temple to pray on bended knees, first bend down to lift someone who is down-trodden. ..
Go not to the temple to ask for forgiveness for your sins, first forgive from your heart those who have sinned against you

PICTURE OF THE YEAR

China is ready for the Olympics !

Aisle , Altar , Hymn ( Funny )

Throughout the ages, men have been trying to unlock the mystery as towhy their wives who accepted them as they were before they gotmarried, begin the quest to change their behaviour and life-style oncetheir vows are exchanged.Finally, the riddle is solved. A social-scientist arrived at a simpleand logical explanation.When the bride, accompanied by her father, starts to walk slowly downthe long aisle, she sees the altar at the end and hears the choirsinging a hymn. Walking down the aisle, the conditioning process wherethe brain absorbs these three stimuli: aisle, altar, hymn, begins. Shebecomes mesmerized as she continually reinforces these perceptions:aisle, altar, hymn. . . aisle, altar, hymn. . . aisle, altar, hymn.And finally, as she stops beside the groom, the conditioning processis complete.She looks up at him smiling sweetly and keeps saying to herself...'I'll alter him.'

How to break a bad news...

> > A good technique especially for those>studing..........hehehe.....enjoyyyyyyyyyyy> > >> > >>


> > A letter by an young girl to her mom...> > >> > >> > > Dear Mom,> > >> > > I know I haven't written for three months, but I have been very >busy>and I've been having a very exciting time.>>Actually, I'm just back from the hospital, where I had spent a fortnight>about two months ago. It was nothing,really - just a>>concussion on the back of my head, a broken leg and a hairline fracture,>that I got while jumping out of the second floor of my>>hostel when it caught fire. In fact, I can now stand all by myself without>crutches, and can almost see everything perfectly,>>except for a slight blur. But don't worry. The doctor says there is a good>chance of me walking on my own again. Actually,it>> > > could have been worse, if not for that nice chai-walla who saw me >lying>there in a dead faint and rushed me to hospital.>>He was very helpful, really, and came to see me everyday in the hospital.>Now that I am out of hospital, I had nowhere to go,>>as the hostel is still under construction. So when he suggested that I move>in with him in his hut, I thought it was very kind! of>>him, and agreed. We are very much in love now, and I am sure that you and>Dad will sure!y like him and accept him in the>>family. I am sure the minor matter that he is fourteen years older than me>and that he is of a different caste and religion, will not>>matter at all to broadminded parents like you. He may be illiterate and>poor, but he has a heart of gold - really, Mom, you>>should see how he cares for both of us - me and his wife, that is. She is>quite sweet too, and so are her three children; so there>>is absolutely no problem. You must be wondering how you and Dad got>informed so late. Don't get angry, Mom. We just>>didn't have the time. You see, we decided to get married only recently>since we thought it would be unfair to let our baby>>into the world without a proper surname. Yes, Mom, you are going to be a>grandmother! Congratulations!>>> > > I am sure you and Dad are delighted, and will come to visit us in>his village in Mizoram after we shift there next week.>> OK Mom. All this did not really happen. There was no fire, no fracture,>no bigamous chai-walla and no legitimate>>pregnancy. But I did flunk in my Mathematics exam, and I wanted you to >view>this problem in the right perspective.>>> > > Your Darling Daughter,

Chect this out !

http://www.jacquielawson.com/viewcard.asp?code=ZS43976949

Nice ecard.

[ not funny ]

Is this Sachin Tendulkar ?

Click on the image to view it in actual size .
Post your comments ?
Sachin in a sari in college or a lame fake .
Post your comments !

Funny Slogans !

Sign on a Coffin Makers shop :

When you drop dead , drop in !

# Sign on a railway station at Patna :
Aana free, jaana free,
pakde gaye to khana free.

# Seen on a famous beauty parlor in Bombay :
Don't whistle at the girl going out from here.
She may be your grandmother!

# Seen on a bulletin board:
Success is relative
More the success, more the relatives.

# Sign at a barber's saloon in Juhu, Bombay :
we need your heads to run our business.

# A traffic slogan:
Don't let your kids drive if they are not old enough - or else they never will be.....

#THE BEST ONE :
Its God's responsibility to forgive the terrorist organizations
It's our responsibility to arrange the meeting between them and god."
- Indian Armed Forces -

Thanks : 1000 views for my video !

http://www.youtube.com/watch?v=yLaR1sHChXE

1000 views for my video : Pstylcho : Snake 2 high score ( 3883 on a nokia 3315 ) Which is the worlds highest score .

Thanks !

Thank You !

29 Posts . 500 Hits . Thanks !

Metal Gear Solid Name Generator !

http://www.metalgearnamegenerator.com/

For all you metal gear solid fans . Type in your name and you get your code name .

I got : Chainsaw Scorpion . Whats yours ?

Post your codenames : By clicking on comments .

Personality test !

*There is a very, very tall coconut tree, and there are 4 animals: King Kong, Ape, Orangutan and a Monkey passing by.


They have a competition to see who is the fastest to climb & get the banana.

Who do you guess will win?

Trust me your answer will reflect your personality.
Try and answer within 30 seconds
Got your answer? Scroll down to see the analysis

. . . . . .




. . . .



. . .


. . . . .



. . . . . . .


. . . . . . .







. . If your answer is any of these ....


Orangutan = dull/stupid

Ape = foolish

Monkey = idiot

King Kong = stupid

Why?????


Coconut tree, doesn't have bananas..... ....!!


**Obviously you're stressed and overworked. Take some time off and relax!! *

Word Count !

http://wordcount.org/main.php

Check out this website : Each and every word in english in the frequency its used .

The most commonly used word : The

Find out more ... check out the site !

Idiot !

I was having trouble with my computer. So I called Eric, the 11 year old next door, whose bedroom looks like Mission Control and asked him to come over. Eric clicked a couple of buttons and solved the problem.

As he was walking away, I called after him, 'So, what was wrong? He replied, 'It was an ID ten T error.'

I didn't want to appear stupid, but nonetheless inquired, 'An, ID ten T error? What's that? In case I need to fix it again.'

Eric grinned.... 'Haven't you ever heard of an ID ten T error before?'

'No,' I replied. 'Write it down,' he said, 'and I think you'll figure it out.'

So I wrote down: I D 1 0 T


I used to like Eric.............

Wrong Number !

'Hello?'

'Hi honey. This is Daddy.

Is Mommy near the phone?'

'No Daddy. She's upstairs in the bedroom with Uncle Paul.'

After a brief pause,

Daddy says, 'But honey, you haven't got an Uncle Paul.'

'Oh yes I do and he's upstairs in the room with Mommy, right now.'

Brief Pause.

'Uh, okay then, this is what I want you to do. Put the phone down on the

table, run upstairs and knock on the bedroom door and shout to Mommy

that Daddy's car just pulled into the driveway.'



'Okay Daddy, just a minute.'

A few minutes later the little girl comes back to the phone.

'I did it Daddy.'



'And what happened honey?'

'Well, Mommy got all scared, jumped out of bed with no clothes on and

ran around screaming. Then she tripped over the rug, hit her head on the

dresser and now she isn't moving at all!'

'Oh my God!!!

What about your Uncle Paul?'

'He jumped out of the bed with no clothes on, too. He was all scared and

he jumped out of the back window and into the swimming pool.

But I guess he didn't know that you took out the water last week to

clean it. He hit the bottom of the pool and I think he's dead.'



***Long Pause***



***Longer Pause***

***Even Longer Pause***





Then Daddy says, 'Swimming pool?



Is this 486-5731?'



No, this is 486-5713.... .





sorry wrong number

5 Lessons in Life

Lesson 1:

The wife gets out of the shower and the husband gets in.

Just then, the doorbell rings.

The wife quickly wraps herself in a towel and runs downstairs. When she opens the door, there stands Bob, the next-door neighbor. Before she says a word, Bob says, 'I'll give you $800 to drop that towel.'
After thinking for a moment, the woman drops her towel and stands naked in front of Bob, after a few seconds, Bob hands her $800 and leaves.

The woman wraps back up in the towel and goes back upstairs. When she gets to the bathroom, her husband asks, 'Who was that?' 'It was Bob the next door neighbor,' she replies.

'Great,' the husband says, 'did he say anything about the $800 he owes me?'

Moral of the story:
If you share critical information pertaining to credit and risk with your shareholders in time, you may be in a position to prevent avoidable exposure.

Lesson 2:
A priest offered a Nun a ride. She got in and crossed her legs, forcing her gown to reveal a leg.
The priest nearly had an accident. After controlling the car, he stealthily slid his hand up her leg.

The nun said, 'Father, remember Psalm 129?'
The priest removed his hand. But, changing gears, he let his hand slide up her leg again.

The nun once again said, 'Father, remember Psalm 129?'
The priest apologized 'Sorry sister but the flesh is weak.'
Arriving at the convent, the nun sighed heavily and went on her way.

On his arrival at the church, the priest rushed to look up Psalm 129. It said, 'Go forth and seek, further up, you will find glory.'

Moral of the story:
If you are not well informed in your job, you might miss a great opportunity.

Lesson 3:
A sales rep, an administration clerk, and the manager are walking to lunch when they find an antique oil lamp. They rub it and a Genie comes out. The Genie says, 'I'll give each of you just one wish.'

'Me first! Me first!' says the admin clerk. 'I want to be in the Bahamas, driving a speedboat, without a care in the world.'
Puff! She's gone.

'Me next! Me next!' says the sales rep. 'I want to be in Hawaii , relaxing on the beach with my personal masseuse, an endless supply of Pina Coladas and the love of my life.'
Puff! He's gone.

'OK, you're up,' the Genie says to the manager.
The manager says, 'I want those two back in the office after lunch.'

Moral of the story:
Always let your boss have the first say.

Lesson 4:
An eagle was sitting on a tree resting, doing nothing. A small rabbit saw the eagle and asked him, 'Can I also sit like you and do nothing?' The eagle answered: 'Sure, why not.'

So, the rabbit sat on the ground below the eagle and rested. All of a sudden, a fox appeared, jumped on the rabbit and ate it.

Moral of the story:
To be sitting and doing nothing, you must be sitting very, very high up.

Lesson 5:
A turkey was chatting with a bull.

'I would love to be able to get to the top of that tree' sighed the turkey, 'but I haven't got the energy.'

'Well, why don't you nibble on some of my droppings?' replied the bull. hey're packed with nutrients.'

The turkey pecked at a lump of dung, and found it actually gave him enough strength to reach the lowest branch of the tree.

The next day, after eating some more dung, he reached the second branch.
Finally after a fourth night, the turkey was proudly perched at the top of the tree. He was promptly spotted by a farmer, who shot him out of the tree.

Moral of the story:
Bull Shit might get you to the top, but it won't keep you there.

Lesson 6:
A little bird was flying south for the winter. It was so cold the bird froze and fell to the ground into a large field.

While he was lying there, a cow came by and dropped some dung on him. As the frozen bird lay there in the pile of cow dung, he began to realize how warm he was. The dung was actually thawing him out!

He lay there all warm and happy, and soon began to sing for joy..
A passing cat heard the bird singing and came to investigate. Following the sound, the cat discovered the bird under the pile of cow dung, and promptly dug him out and ate him.

Morals of the story:
(1) Not everyone who shits on you is your enemy.
(2) Not everyone who gets you out of shit is your friend.
(3) And when you're in deep shit, it's best to keep your mouth shut!

THUS ENDS THE FIVE MINUTE MANAGEMENT COURSE!!

Spectacles - With and without it !

Fart Joke !

From Reader Digest)

One day I met a sweet gentleman and fell in love. When it
became apparent that we would marry, I made the supreme
sacrifice and gave up eating beans.
Some months later, on my birthday, my car broke down on the
way home from work. Since I lived in the countryside I
called my husband and told him that I would be late because
I had to walk home. On my way, I passed by a small diner and
the odour of baked beans was more than I could stand. With
miles to walk, I figured that I would walk off any ill
effects by the time I reached home, so I stopped at the
dinner and before I knew it, I had consumed three large
of baked beans.

the way home, I made sure that I released all the gas.
Upon my arrival, my husband seemed excited to see me and
delightedly: "Darling I have a surprise for
dinner tonight." He then blindfolded me and led me to
chair at the dinner table. I took a seat and just as he
about to remove my blindfold, the telephone rang. He
made me promise not to touch the blindfold until he
returned and went to answer the call. The baked beans I had
consumed were still affecting me and the pressure was
most unbearable, so while my husband was out of
the room I seized the opportunity, shifted my weight to one
leg and let one go. It was not only loud, but it smelled
like a fertilizer truck running over a skunk in front of a
pulpwood mill.

took my napkin from my lap and fanned the air around me
vigorously.. Then, shifting to the other cheek, I ripped
off three more. The stink was worse than stinking cabbage.
my ears carefully tuned to the conversation in the
other room, I went on like this for another few minutes...
pleasure was indescribable. When eventually the
telephone farewells signaled the end of my freedom, I
quickly fanned the air a few more times with my napkin,
placed it on my lap and folded my hands back on it feeling
very relieved and pleased with myself. My face must have
been the picture of innocence when my husband returned,
apologizing for taking so long..

asked me if I had peeked through the blindfold, and I
him I had not. At this point, he removed the
blindfold, and twelve dinner guests seated around the table
chorused: "Happy Birthday!"!! I nearly died!!!

ZacBrowser - Browser for Autistic Kids(Free Browser)

ZAC is the first web browser developed specifically for children with autism, and autism spectrum disorders such as Asperger syndrome, pervasive developmental disorders (PDD), and PDD-NOS. We have made this browser for the children - for their enjoyment, enrichment, and freedom. Children touch it, use it, play it, interact with it, and experience independence through ZAC.

ZAC is the zone that will permit your child to interact directly with games (a LOT of games) and activities (focused on MANY interests) that cater specifically to kids who display the characteristics of autism spectrum disorders, like impairments in social interaction, impairments in communication, restricted interests and repetitive behavior. ZAC has been an effective tool for kids with low, medium and high functioning autism.

ZAC focuses on the children and their interaction - But we also provide an excellent forum for parents, caretakers, teachers, and others to share their experiences, tools and resources and to unite as a caring, compassionate, and extremely knowledgeable community. It is said that "it takes a village to raise a child", and that is exponentially true for raising a child with autistic spectrum disorders. The power of your experience yesterday is going to be instrumental in helping someone successfully tackle the circumstances of today.

http://www.zacbrowser.com
Download size : 6.25/5.95 Mb http://www.helpcd.com/zac/en/zacbrowser_e.exe

Lie Detector

John was a salesman's delight when it came to any kind of unusualgimmick. His wife Marsha had long ago given up trying to get him tochange. One day, John came home with another one of his unusualpurchases. It was a robot that John claimed was actually a liedetector. It was just about 5:30 that afternoon when Tommy, their 11year old son, returned home from school. Tommy was over 2 hours late.'Where have you been? Why are you over 2 hours late getting home?',they asked.Several of us went to the library to work on an extra credit project,said Tommy. The Robot then walked around the table and slapped Tommy,knocking him completely out of his chair.Son, this robot is a lie detector, now tell us where you went afterschool.' 'We went to Bobby's house and watched a movie.''What did you watch?' asked Marsha. ''The Ten Commandments.' answeredTommy. The Robot went around to Tommy and once again slapped him,knocking him off his chair. With lip quivering, Tommy got up, sat downand said, 'I am sorry I lied. We really watched a tape called SexQueen.'I'm ashamed of you Son,' said John. 'When I was your age, I never liedto my parents.' The robot then walked around to John and delivered aroundhouse right that nearly knocked him out of his chair.Marsha was bent double laughing, almost in tears. 'Boy, did you everask for that one! And you can't be too mad with Tommy. After all, heis your son!' The Robot immediately walked around to Marsha, and
slapped the shit out of her!

Google's I'm feeling lucky button !

Ever wondered what that button is ?

For the past few years Google has had a button called, "I'm Feeling Lucky" this button brings you to "the first website that Google comes up with for that search field. So what's the big deal? Well, there's some really funny ones that come up if you know the words to put in. The latest one I found, "failure." And here's what it leads to. See if anyone in the media bites this story. And I wonder what Google stocks would do if investors found out that they are quite basically bashing the man that has recovered the Economy since the Clinton/9-11 fallout

Some other funnier searches:

French Military Victories

elgooG

Elmer Fudd

Pickled Scuppernongs

and Formerly:

Weapons of Mass Destruction

Waffles

Source : http://gopandcollege.blogspot.com/2005/09/im-feeling-lucky-punk.html

Also try : Chuck Norris , Find Chuck Norris

P.s. Click on "I'm feeling lucky" not on "Google Search"

Chuck Norris Facts !!!

Check out this website. Its too funny ! http://www.chucknorrisfacts.com/

Here are a few :

When the Boogeyman goes to sleep every night, he checks his closet for Chuck Norris.
Chuck Norris doesn't read books. He stares them down until he gets the information he wants.
There is no theory of evolution. Just a list of creatures Chuck Norris has allowed to live.
Outer space exists because it's afraid to be on the same planet with Chuck Norris.
Chuck Norris does not sleep. He waits.
Chuck Norris is currently suing NBC, claiming Law and Order are trademarked names for his left and right legs.
Chuck Norris is the reason why Waldo is hiding.
Chuck Norris counted to infinity - twice.
There is no chin behind Chuck Norris’ beard. There is only another fist.
When Chuck Norris does a pushup, he isn’t lifting himself up, he’s pushing the Earth down.
Chuck Norris is so fast, he can run around the world and punch himself in the back of the head.
Chuck Norris’ hand is the only hand that can beat a Royal Flush.
Chuck Norris can lead a horse to water AND make it drink.
Chuck Norris doesn’t wear a watch, HE decides what time it is.
Chuck Norris can slam a revolving door.
Chuck Norris does not get frostbite. Chuck Norris bites frost
Remember the Soviet Union? They decided to quit after watching a DeltaForce marathon on Satellite TV.
Contrary to popular belief, America is not a democracy, it is a Chucktatorship.

Also try this : Go to google.com , Type : Find chuck norris , Click on "I'm feeling lucky " not on "Google Search" . Enjoy !

Nehru Family - Things you never knew

NEHRU FAMILY

Analytical Epidemiology ( Community Dentistry )

ANALYTICAL EPIDEMIOLOGY

What is epidemiology?
Englander (1962) defined epidemiology as “ the study of those factors which influence the occurrence and distribution of health , disease , defect , disability and death in populations .
Epidimiology as a science is organized into three distinct divisions which complement one another . they are as follows :
Descriptive Epidemiology
Analytical Epidemiology
Experimental Epidemiology
The descriptive and analytical studies are often called as “ Observational Studies . “

ANALYTICAL EPIDEMIOLOGY
In analytical epidemiology , the subject of interest is the individual within the population. The object is not to formulate , but to test hypothesis. Nevertheless , the inference is not to the population from which they are selected.
Analytical studies compromise 2 distinct types of observational studies :
Case control studies
Cohort studies
From each of these study designs, one can determine,
Whether or not a statistical association exists betmeen a disease and a suspected factor
If one exists the strength of the association
SCHEMATIC DIAGRAM OF THE DESIGNOF CASE CONTROL AND COHORT STUDIES
CASE CONTROL STUDY
Factors present Individuals with particular disease CASES
Or

Absent Individuals without particular disease CONTROLS

PROSPECTIVE ( COHORT ) STUDY
Individuals exposed to Presence
Particular factor(s) or
Absence
of
Individuals unexposed to particular
Particular factor(s) diseases

TIME

CASE CONTROL STUDIES
In recent years , the case control approach has emerged as a permanent method of epidemiological investigation . The case control method has 2 distinct features.
Both exposure and outcome(disease) have occurred before the start of the study
The study proceeds backwards from effect to cause
it uses a control or comparison group to support or refute an inference
By definition , a case control study involves 2 populations – cases and controls . The unit is the individual rather than the group . The controls are generally selected at an equal rate with the number of cases and should have matching characteristics with respest to general variables such as age ,sex , etc. if these variables themselves are not the suggested exposure characteristics.
Framework of a Case Control Study
( The 2 x 2 contingency table )
Suspected or Cases ( Disease Control (disease
Risk Factors Present ) absent )
Present a b
Absent c d
a + c b + d
Basic Steps
There are 4 basic steps in conducting a case control study :
Selection of cases and controls
Matching
Measurement of exposure
Analysis
Selection of cases and controls
Selection of cases
The following 2 specifications are crucial :
Diagnostic Criteria
Eligibility criteria
Sources of cases
Hospitals
general population
Selection of controls
The controls must be as similar to the cases as possible , except for the absence of the disease under study.
Sources of controls
Hospital controls
Relatives
Neighborhood controls
General population

2.Matching
It is defined as the process by which we select controls in such a way that they are similar to case with regard to certain pertinent selected variables ( e.g. age ) which are known to influence the outcome of disease and which if not adequately matched for compatibility , could distort or confound the results.

3.Measurement of exposure
Definitions and criteria about exposure are just as important as those used to define cases and controls. Thus information about exposure should be obtained.

Analysis
The final step is analysis , to find out
Exposure rates among cases and controls to suspected factors
Estimation of disease risk associated with exposure ( odds ratio )

Biases in case control studies
A bias is a systematic error in design , conduct or analysis of a study which leads us to an erroneous conclusion.
Biases in selection of cases
This is called selection bias or diagnostic bias where in diagnosis itself is more unlikely if the exposure is present in history.
Biases in investigating controls
Apart from the fact that the controls are less likely to recall exposure variables than the cases themselves , there are other sources of biases that can creep into case control studies. The investigations/tests/interviews etc. may lack depth in controls whereas the cases are thoroughly worked up. This obviously introduces a bias by inflating the exposure factor in cases.

3.Confounding Bias
This is the distortion of study effect mixed with another effect because of variables extraneous to the exposure disease association predictive of the disease . Specially when one has multiple isk factors which are related to each other , the confounding effect may appear. To reduce this effect one usually comes at matching between cases and controls .

4. Problems due to overmatching
Confounding factors are actually extraneous factors unequally distributed between exposure subgroups. One tries to reduce the confounding by matching the common ones such as age,sex,etc. At times investigations land up in table by overmatching where in potential confounder is matched among cases and controls. The study thus loses the power of proving an obvious association .

5.Bias in Analysis
The obvious result of presence of a confounder is at the time of analysis .The association observed entirely may be due to non-uniform distribution of the confounder among cases / controls. The remedy is the use of strtification but it is only possible in a larger study.

ADVANTAGES
Relatively easy to carry out.
Rapid and inexpensive ( compared with cohort studies )
Requires comparatively fewer subjects
Particularly suitable to investigate rare diseases or diseases about which little is known. But a disease whish is rare in general population may not be rare in special exposure groups
No risks to subjects
Allows the study of several different aetiological factors
Risk factors can be identified . Rational revention and control programmes can be identified.
Ethical problems minimal
No attrition problems , because case control studies do not require follow up of individuals into then future.

DISADVANTAGES
Problems of bias relies on memory or past records, the accuracy of which may be uncertain, validation of information obtained is difficult or sometimes impossible.
Selection of an appropriate control group may be difficult .
We cannot measure incidence , and can only estimate the relative risk.
Do not distinguish between cases and associated factors.
Not suited to the evaluation of therapy or prophylaxis of disease.
Another major concern is the representativeness of cases and controls.

COHORT STUDY
Cohort study is another type of analytical study which is usually undertaken to obtain additional evidence to refute or support the existence of an association between suspected cause and disease.
It is also known as
Prospective study
Longitudinal study
Incidence study
Forward looking study
The distinguishing features of cohort studies are
The cohorts are identified prior to the appearance of the disease under investigation
The study groups , so defined , are observed over a period of time to determine the frequency of disease among them
The study proceeds forward from cause to effect
Concept of cohort
In epidemiology, the term ‘cohort’ is defined as a group of people who share a common characteristic or experience within a defined time period.
e.g. age,occupation,exposure to a drug or vaccine, pregnancy , insured persons, etc.
The comparison group may be the general population from which the cohort is drawn , or it may be another cohort of persons thought to have had little or no exposure to the substance in question , but otherwise normal.
Indications of cohort studies
When there is good evidence of an association between exposure and disease , as deriver from clinical observations and supported by descriptive and case control studies.
When exposure is rare, but the incidence of disease is high among exposed e.g. special exposure groups like those in industries , exposure to x rays , etc.
When criterion of study population can be minimized e.g. follow up is easy, cohort is stable, co-operative and easily accessible.
When ample funds are available.
Framework of a cohort study
In contrast to case control studies which proceed from effect to cause , the basic approach in cohort studies is to work from cause to effect.
In cohort study, the exposure has occurred but the disease has not.
COHORT DISEASE TOTAL
YES NO
Exposed to putative a b a+b
Aetiological factor
Not exposed to putative c d c+d
Aetiological factor
In assembling cohorts , the following general considerations are taken into account:
The cohorts must be free from the disease under study. Thus if the disease under study is coronary heart disease , the cohort members are first examined and those who already have evidence of the disease under investigation are excluded.
Insofar as the knowledge of the disease permits, both the groups should be equally susceptible to the disease under study , or effectively reflect any difference in disease occurrence.
Both the groups should be comparable in respect of all the possible variable, which may influence the frequency opf the disease.
The diagnostic and eligibility criteria of the disease must be defined before hand, this will depend upon the availability of reliable methods for recognizing the disease when it develops .
A well designed cohort is considered the most reliable means of showing an association between a suspected risk factor and subsequent disease because it eliminates many of the problems of the case control study and approximates the experimental model of the physical sciences.
Types of cohort study
Prospective cohort study
Retrospective cohort study
Combination of retrospective and prospective cohort study
Prospective cohort study
A prospective cohort study or “current” cohort study is one in which the outcome has not yet occurred at the time the investigation begins. Most prospective studies begin in the present and continue into future.
Retrospective cohort study
A Retrospective cohort study is one in which the outcomes have all occurred before the start of the investigation.
It is also known as
Historical cohort study
Prospective study in Retrospective
Non-current prospective study
Combination of retrospective and prospective cohort study
In this type of study, both the retrospective and prospective elements are combined. The cohort is identified from past records and is assessed of date for the outcome. The same cohort is followed up prospectively into the future for further assessment of outcome.
Elements of a cohort study
Selection of study subjects
Obtaining data on exposure
Selection of comparison groups
Follow-up
Analysis
Selection of study subjects
The subject of a cohort study are usually assembled in one of 2 ways –
General population
When the exposure or cause of death is fairly frequent in the population , cohorts may be assembled from the general population, residing in well defined geographical, political and administrative areas.
Special groups
These may be special groups or exposure groups that can readily be studied

1.Select Groups
These may be preformed groups (e.g.doctors,nurses,lawyers,teachers,civil servants), insured persons, obstetric population, college alumni, govt. employees, volunteers, etc. These groups are usually a homogenous population.

2.Exposure Groups
If the exposure is rare, a more economical procedure is to select a cohort of persons known to have experienced the exposure.
Obtaining data on exposure
Information about exposure may be obtained directly from the
Cohort members – through personal interviews or mailed questionnaires
Review of records – certain kinds of information can be established only from medical records
Medical examination or special tests – Some types of information can only be obtained by Medical examination or special tests
Environmental surveys – This is the best source for obtaining information on exposure levels of the suspected factor in the environment where the cohort lived or worked.
Information about exposure should be collected in a manner that will allow classification of cohort members
According to whether or not they have been exposed to the suspected factor
According to the level or degree of exposure in the case of special exposure groups
Selection of comparison groups
Internal Comparisons
In some cohort studies , no outside comparison group is required. The comparisons are in built .
External comparisons
When information on degree of exposure is not available , it is necessary to put an external control to evaluate the experience of the exposed group.

C. Comparison with general population rates
If none is available , the mortality experience of the exposed group is compared with the mortality experience of the general population in the same geographic area as the exposed people.
The limiting factors in using general population rates for comparison are :
Non-availability of population rates for the outcome required
The difficulties of selecting the study and comparison groups which are representative of the exposed and non exposed segments of the general population
Follow up
One of the problems in cohort studies is the regular follow-up of all the participants . The procedures required compromise:
Periodic medical examination of each member of the cohort
Reviewing physician and hospital records
Routine surveillance of death records
Mailed questionnaires , telephone calls , periodic home visits – preferably all 3 on an annual basis .
Analysis
The data are analysed in terms of
Incidence rates of outcome among exposed and non-exposed
Estimation of risk
1.Incidence Rates

In a cohort study , we can determine incidence rates directly in those exposed and those not exposed.
2. Estimation of risk
Having calculated the incidence rates , the next step is to estimate the risk of outcome in the exposed and non exposed cohorts .
Relative risk
Attributable risk
Relative Risk
Relative risk ( RR ) is the ratio of the incidence of the disease among exposed and the incidence among non exposed.
RR = Incidence of disease ( or death ) among exposed
----------------------------------------------------------
Incidence of disease ( or death ) among non exposed
Estimation of relative risk is important in aetiological enquiries . It is a direct measure of the strength of association between suspected cause and effect .
Attributable risk
Attributable risk ( AR ) is the difference in incidence rates of disease ( or death ) between an exposed group and non exposed group.
It is often expressed as a parent .
AR = Incidence of disease rate among exposed minus incidence x 100 of disease rate among non exposed
-----------------------------------------------------------------------
Incidence rate among exposed
Attributable risk indicates to what extent the disease under study can be attributed to the experience.
Population attributable risk
It is the incidence of the diseases ( or death ) in the total po9pulation minus the incidence of disease ( or death ) among those who were not exposed to the suspected causal factor .
The concept of population attributable risk is useful in that it provides an estimate of the amount by which the disease could be reduced in that population if the suspected factor is eliminated or modified .
Relative Risk vs Attributable Risk
Relative risk is important in etiological enquiries . Its size is a better index than is attributable risk for assessing the aetiological role of a factor in disease . The larger the relative risk , the strength the association between cause and effect . But relative risk does not reflect the potential public health importance as does the attributable risk . Attributable risk gives a better idea than does relative risk of the impact of successful preventive or public health programme might have in reducing the problem .

Bias in cohort studies
There are 5 different bias types that are operative in a cohort study.
Selection bias
Follow up bias
Information bias
Confounding bias
Post Hoc bias
Selection Bias
Selection bias occurs when the group actively studied does not reflect the same distribution of characteristics like age , sex , etc. occurring in the general population .
Follow up bias
If the rate of disease is different among those lost to follow up , then internal validity of the study may be affected , that is , the relationship between exposure and outcome may be changed .
Information bias
This occurs when there is an error in the classification of 9ndividuals with respect to the outcome variable .
This may result measyrement errors , imprecise measurements and misdiagnosis os cases .
Confounding bias
It occurs when other factors that are associated with the outcome and exposure variables do not have the same distribution in the exposed anhd unexposed groups . The 2 common confounders in cohort studies are the factors of smoking and age . The risk of disease varies with age for almost all diseases .
Post hoc bias
It arised due to the use of data from o cohort study to make observations which were not part of the original study . Thus , interesting relationships are often observer in cohort studies which were not originally anticipated .

Advantages
Incidence can be calculated
Several possible outcomes related to exposure can be studied simultaneously i.e. we can study the association of the suspected factor with many other diseases in addition to the one under study .
Cohort studies provide a direct estimate of relative risk.
Dose-response ratios can also be calculated
Since comparison groups are formed before disease develops , certain forms of bias can be minimized like misclassifications of individuals into exposed and unexposed groups .

Disadvantages
Cohort studies involve a large number of people . They are generally unsuitable for investigating uncommon diseases or diseased with low incidence in the population .
It takes a long time to complete the study and obtain results by which time the investigators may have died or the participants may have changed their classification .
Administrative problems - loss of experienced staff , loss of funding,etc
The cohorts may migrate , lode interest or simply refuse to provide required information.
Those who volunteer may not be representative of all the individual with the characteristic of interest.
There may be changes in the standard methods or diagnostic criteria of the disease over prolonged follow up
Cohort studies are expensive
The study itself may alter peoples behaviour
Ethical problems
Practical considerations dictate that we must concentrate on a limited number of factors possible related to disease outcome
The main differences between case control and cohort studies are as follows :
Case control study Cohort Study
Retrospective Prospective
Disease has already occurred Disease is expected to occur in
the future
Presence of exposure in cases Development of disease in
And controls compared exposed and non exposed
Compared
Relatively easy to carry out Time consuming and difficult to
Carry out
Useful for rare cases with Suitable for common diseases
Smaller numbers with common exposure
Can have one outcome, but Can have multiple exposures
Can have multiple exposures
Only derives odds ratio Derives relative risk , attributable
Risk,etc.
Substantial biases can occur Biases are generally lower
Relatively less costly and no Expensive and dropout rate higher
Dropouts

References
Soben Peter
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