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Partial And Total Tonsillectomy For Pediatric Sleep-Disordered Breathing: The Role Of The Cas-15, Jacob Garn Mabey

Yale Medicine Thesis Digital Library

The Clinical Assessment Score-15 (CAS-15) is an office-based tool for assessing the riskof sleep disordered breathing (SDB), a relatively common condition in the pediatric population. Change in CAS-15 following total tonsillectomy (TT) has been shown to have a large effect size, but it is unclear how it varies following partial intracapsular tonsillectomy (PIT). Thus, the objective of the present study is to evaluate the utility of the CAS-15 score in assessing the effectiveness of PIT and how this compares to change after TT. Children ages 2-18 undergoing PIT (N=16) or TT (N=8) with or without adenoidectomy for SDB completed the …

Colonoscopy Withdrawal Time And Dysplasia Detection In Patients With Inflammatory Bowel Disease, Chandler Julianne Mcmillan

Yale Medicine Thesis Digital Library

Compared to the general population, patients with inflammatory bowel disease (IBD) are more at risk for developing colorectal dysplasia and neoplasia in their lifetime. Given this increased risk, current guidelines recommend that patients with IBD involving at least one-third of the colon undergo routine surveillance colonoscopy exams every one to five years to monitor disease activity and severity. Colonoscopy withdrawal time (CWT) is considered an important predictor of adenoma detection and a quality metric of colonoscopy within the general population. Society organizations including the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology have proposed a minimum average …

Dermatologic Infectious Complications And Mimickers In Cancer Patients On Oncologic Therapy, Jolanta Pach

Yale Medicine Thesis Digital Library

Dermatologic infections affecting the skin, hair, mucosae, and nails are common complications of systemic cancer therapy and can impact cancer patients’ quality of life; however, studies investigating these complications are largely lacking. We aimed to characterize dermatologic infectious complications secondary to oncologic therapy and the management of these complications in the outpatient and inpatient settings. We sought to identify how dermatologic infections differ in patients undergoing novel classes of cancer therapy, including targeted therapy and immunotherapy, compared to those on traditional cytotoxic chemotherapy. Second, we aimed to investigate non-infectious dermatologic complications of oncologic therapy which may mimic infectious complications. Here, …

Distressed Community Index In Patients Undergoing Carotid Endarterectomy In Medicare-Linked Vqi Registry, Carmen Pajarillo

Yale Medicine Thesis Digital Library

IntroductionThe association between community socioeconomic distress and carotid endarterectomy (CEA) outcomes is understudied. We therefore analyzed the association between the Distressed Community Index (DCI), a zip-code level measure of community distress, with 36-month post-CEA mortality and readmission.

MethodsWe thus examined patients undergoing CEA between 2015-2019 in the Vascular Quality Initiative database linked with Medicare claims outcomes data. Patients’ DCI ranged from 0 (not distressed) to 100 (distressed). The 36-month mortality was assessed by DCI quintiles using the Kaplan-Meir cumulative incidence function (CIF) and for linear DCI, using Cox regression stratified on site. For 90-day readmission, we used CIF curves and …

Somatic Mutations In Aging, Paroxysmal Nocturnal Hemoglobinuria, And Myeloid Neoplasms, Tho Tran

Yale Medicine Thesis Digital Library

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal blood disorder frequently associated with bone marrow failure that in rare instances can progress to leukemia. PNH clones of varying sizes occasionally present even in patients with hematologic malignancies and no known history of classical PNH, particularly in myelodysplastic neoplasms (MDS). Curiously, somatic driver mutations considered to be pathogenic and likely pathogenic in myeloid leukemias can be found in phenotypically normal, elderly individuals, as well as those with clonal disorders such as PNH, clonal hematopoiesis of indeterminate potential (CHIP), and age-related clonal hematopoiesis (ARCH). These mutations may be the critical link between PNH …

Maternal And Donor Human Milk Support Robust Intestinal Epithelial Growth And Differentiation In A Fetal Intestinal Organoid Model, Lauren Smith

Yale Medicine Thesis Digital Library

Necrotizing enterocolitis (NEC) is a severe gastrointestinal complication of prematurity. Using small intestinal organoids derived from fetal tissue of a gestational age similar to an extremely preterm infant, this study aims to assess the effect of diet on intestinal epithelial growth and differentiation to elucidate the role nutrition type plays in intestinal development and modifies the risk for NEC.

Organoids were cultured for 5 days in organoid growth media and 5 days in organoid differentiation media supplemented 1:40 with four different diet conditions: maternal milk (MM), donor human milk (DHM), standard formula (SF), or extensively hydrolyzed formula (HF). 4x images …

Illness Perception And The Impact Of A Definitive Diagnosis On Women With Ischemia And No Obstructive Coronary Artery Disease: A Qualitative Study, Leslie Yingzhijie Tseng

Yale Medicine Thesis Digital Library

Background: Ischemia and no obstructive coronary artery disease (INOCA) disproportionately impacts women, yet the underlying pathologies are often not distinguished, contributing to adverse health care experiences and poor quality of life. Coronary function testing at the time of invasive coronary angiography allows for improved diagnostic accuracy. Despite increased recognition of INOCA and expanding access to testing, data lack on first-person perspectives and the impact of receiving a diagnosis in women with INOCA.Methods: From 2020 to 2021, we conducted structured telephone interviews with 2 groups of women with INOCA who underwent invasive coronary angiography (n=29) at Yale New Haven Hospital, New …

Advances In Keratin 17 As A Cancer Biomarker: A Systematic Review, Robert Tseng

Yale Medicine Thesis Digital Library

Background: In an era where tumor heterogeneity leads to widely variable cancer treatment outcomes, there is an unmet need for biomarkers that can characterize tumor subtypes, inform prognosis, and guide clinical decision-making for therapy. As an oncofetal monofilament that is only expressed in embryonic and cancer tissue, keratin 17 (K17) has been demonstrated as an effective biomarker in a wide variety of cancer types, detection methods, and clinical purposes. In order to guide and inform future investigations on K17, we performed a systematic review of clinical studies assessing the effectiveness of K17 as a cancer biomarker.

Methods: We performed a …

Survival Outcomes In T3 Laryngeal Cancer Based On Staging Features At Diagnosis, Vickie Jiaying Wang

Yale Medicine Thesis Digital Library

Stage T3 laryngeal cancer is defined by the presence of vocal cord fixation and/or invasion into any of the following: pre-epiglottic space, paraglottic fat, post-cricoid space, or inner cortex of the thyroid cartilage. These cancers are usually treated with chemoradiation rather than upfront total laryngectomy. To our knowledge, no studies have directly compared differences in survival among the varied features within the T3 staging category. This study aims to determine how the presence of each of these staging features impacts overall and laryngectomy-free survival.Patients with clinically-diagnosed T3 laryngeal squamous cell carcinoma seen at our institution between 2010-2021 were retrospectively identified. …

A Hero's Journey: Experiences Using A Therapeutic Comicbook In A Children’S Psychiatric Inpatient Unit, Idil Yazgan

Yale Medicine Thesis Digital Library

Children’s mental health care has been on the decline since the start of the century. The COVID-19 pandemic further unearthed this significant worsening of mental health in children with heightened levels of anxiety, depression, loneliness, anger, and fatigue leading to an increase in the number of emergency room visits and inpatient hospitalizations. Art and narrative-based interventions are known to improve patient outcomes and are a crucial component of pediatric inpatient psychiatric care. We discuss the process of adoption of a novel therapeutic comic book that was developed for children admitted to the hospital in a psychiatric inpatient unit at Yale-New …

Refractory Neurogenic Cough Management: The Non-Inferiority Of Soluble Steroids To Particulate Suspensions For Superior Laryngeal Nerve Blocks, Hisham Abdou

Yale Medicine Thesis Digital Library

Purpose: Superior laryngeal nerve (SLN) block utilizing triamcinolone (TA) or methylprednisolone acetate (MP) has been described as an efficacious treatment for refractory cough (RC). Particulate corticosteroid injection in the neck carries a risk of large-particle embolization and devastating neurologic sequela in the event of inadvertent intravascular injection. Herein, we compare the efficacy of a soluble steroid (dexamethasone, SS) with particulate steroids (PS) in reducing cough severity in RC-patients.Materials and Methods: Patient charts for those receiving SLN blocks by fellowship-trained laryngologists for the sole indication of RC were reviewed. Drug/dose, timing/laterality, and adjuvant treatments were compared using chi-squared test. A paired …

Behavioral Outcomes In Patients With Metopic Craniosynostosis: Relationship With Radiographic Severity, Mariana Almeida

Yale Medicine Thesis Digital Library

Children with metopic nonsyndromic craniosynostosis have been found to have more neurocognitive and behavioral difficulties, when compared to other types of nonsyndromic craniosynostosis. These neurocognitive and behavioral difficulties can be apparent later in life even following surgical correction of the cranial dysmorphology at infancy. The factors that may be contributing to these difficulties have not been fully elucidated. In metopic craniosynostosis, radiographic severity can be measured using computed tomography imaging. Pre-operative radiographic severity has been demonstrated to be associated with worse reading abilities at school age. However, these studies have had limited sample sizes. Furthermore, the impact of radiographic severity …

Ventilator Weaning Parameters Revisited: A Traditional Analysis And A Test Of Artificial Intelligence To Predict Successful Extubation, John James Andrews

Yale Medicine Thesis Digital Library

The prediction of which patients can be liberated successfully from mechanical ventilation and which patients require continued support remains a challenge for clinicians. While premature extubation comes with many risks, including respiratory distress, loss of airway, complications of reintubation, and increased mortality, delayed extubation comes with risks including ventilator-associated pneumonia, ventilator-induced lung injury, airway trauma, and unnecessary sedation. With such serious clinical implications, there is a strong and persistent interest among clinicians to identify better models to predict extubation success. Multiple respiratory parameters for predicting weaning success have been assessed over the past several decades, with particular attention to respiratory …

A Needs Assessment For Rural Health Education In United States Medical Schools, Kailey Carlson

Yale Medicine Thesis Digital Library

This study is a needs assessment for rural health education at United States medical schools. Health disparities between rural and urban populations are significant and worsening. Rural areas are home to 20% of Americans but just 11% of physicians, contributing to health inequity. Medical schools must produce more future rural physicians to meet the needs of the population. To understand the need for rural health education in medical schools, medical students were surveyed on attitudes toward living and working in rural areas and comfort with clinical competencies important in rural areas. The hypothesis was that medical students at schools focusing …

Genetic Contributions To Thoracic Aortic Disease, Ellelan Arega Degife

Yale Medicine Thesis Digital Library

AimsThoracic aortic aneurysms and dissections are significant yet under-recognized threats in cardiovascular health, often remaining undetected until catastrophic events occur. This study aims to explore the genetic landscape of thoracic aortic diseases, focusing on genetic mutations contributing to thoracic aortic aneurysm (TAA) and dissection. It also seeks to refine the size criteria for surgical intervention in TAA, aiding clinicians in decision-making and improving patient outcomes.

MethodsThe study employed a comprehensive literature review, focusing on the genetic aspects of thoracic aortic diseases. In addition to a systematic MEDLINE search, the investigation used the Genomics England PanelApp to identify genes associated with …

Patient Perceptions Of Machine Learning-Enabled Digital Mental Health, Clara Zhang Guo

Yale Medicine Thesis Digital Library

Objective: The mental health crisis is accelerating, with 55.8M American adults in treatment in 2022. Digital mental health is a growing field with implications for mental health care. The objective of this study was to understand patients’ mental health treatment experience and the relationship with their perspectives of a novel digital health product geared toward improving care quality.

Methods: In December 2023, an IRB-exempt questionnaire was sent to undergraduate and graduate students at campuses across the North-East United States, as well as healthcare-focused Slack® groups.

Results: Of the 1,127 respondents, 28% were actively in treatment for their mental health, 25% …

Association Of Vigorous Physical Activity With Psychiatric Disorders And Participation In Treatment, John L. Havlik

Yale Medicine Thesis Digital Library

This study aimed to compare annual levels of vigorous activity and minutes per episode of vigorous activity among adults with non-substance use psychiatric disorders, especially those participating in treatment, those with no history of psychiatric disorders, prior-to-past-year histories only, or current disorders but no past-year treatment. We used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III; n=36,309), a nationally representative survey of US adults. Adjusted means testing was used to evaluate differences between groups in annual frequency of vigorous physical activity and mean minutes per session of vigorous activity, with and without adjustment for …

Applying Deep Learning To Derive Noninvasive Imaging Biomarkers For High-Risk Phenotypes Of Prostate Cancer, Sajid Hossain

Yale Medicine Thesis Digital Library

Novel biomarkers can help guide management of Prostate Cancer (PCa) through the identification of high-risk phenotypes among similar patients in traditional National Comprehensive Cancer Network (NCCN) risk groups. We hypothesized that deep learning (DL) models which identified Extraprostatic Extension (EPE) and Seminal Vesicle Invasion (SVI), both pathologies associated with treatment failure, on Magnetic Resonance Imaging (MRI) could provide imaging biomarkers of PCa prognosis. In this study, two deep learning models were trained on axial T2-weighted (T2W) prostate MRI images (n=612) to derive imaging biomarkers of EPE and SVI. Area Under the Receiver Operating Characteristic Curve (AUC) was used to measure …

Janus Kinase Inhibition In Granuloma Annulare: Two Single-Arm, Open-Label Clinical Trials, Erica Hwang

Yale Medicine Thesis Digital Library

Granuloma annulare (GA) is an inflammatory cutaneous granulomatous diseasethat lacks satisfying and effective targeted therapies. Janus kinase (JAK) inhibitors are of interest as they inhibit upregulated cytokines in GA including IFN-γ, IL-4, IL-13, IL-15, IL-21, and oncostatin M. Further investigation is needed to establish the safety profile, optimal route or formulation, and efficacy of JAK inhibitors for GA. We conducted single-arm, open-label clinical trials of abrocitinib, a JAK1-specific inhibitor, and AC- 1101, a topically applied JAK inhibitor, in patients with GA and hypothesized that each medication would be safe, tolerable, and effective at treating GA. In the first study, adult …

Evaluation Of Gastroesophageal Reflux And Hiatal Hernia As Risk Factors For Lobectomy Complications, Michael Kaminski

Yale Medicine Thesis Digital Library

Up to 40% of lobectomies are complicated by adverse events. Gastroesophageal reflux disease (GERD) and hiatal hernia have been associated with cardiopulmonary pathology across a range of clinical scenarios, yet their relation to complications after pulmonary resection is understudied. We hypothesized GERD and hiatal hernia are predictors of complications after lobectomy for lung cancer. Lobectomy patients at Yale-New Haven Hospital between January 2014 and April 2021 were evaluated for predictors of 30-day post-operative complications, pneumonia, atrial arrhythmia, readmission, and mortality. Multivariable regression models included sociodemographic characteristics, BMI, surgical approach, cardiopulmonary comorbidities, hiatal hernia, GERD, and acid suppressive therapy as predictors. …

Barriers To Mental Health Care In Us Military Veterans, Connor Lewis

Yale Medicine Thesis Digital Library

BARRIERS TO MENTAL HEALTH CARE IN US MILITARY VETERANS. Connor Lewis, Ian Fischer, and Robert Pietrzak. Department of Psychiatry, Yale University, School of Medicine, New Haven, CT.

Objectives: The aims of this study were to analyze data from a nationally representative sample of US veterans to: (1) Determine the prevalence of barriers to mental health care among current US veterans spanning numerous conflicts and generations of service and who have no history of mental health treatment; and (2) Identify predisposing, enabling, and needs factors associated with barriers to care. Aims were examined in both the full sample of veterans and …

Radiology Education For U.S. Medical Students In 2024: A State-Of-The-Art Analysis, Ryan Bahar

Yale Medicine Thesis Digital Library

Radiology is essential to the practice of clinical medicine, with ever-increasing volumes of diagnostic imaging studies and image-guided procedures across the U.S. healthcare system. Yet, radiology education has received criticism for its under-representation in formal U.S. medical school curricula, coupled with variable requirements and offerings among institutions. Recent national calls for medical education reform (e.g., the 2010 Carnegie report) and the emergence of new teaching tools (e.g., e-learning, simulation) have led to paradigm shifts in medical education delivery that have been further accelerated by the unprecedented alterations to educational environments catalyzed by the COVID-19 pandemic. In this landscape of profound …

Imaging Markers Of Microstructural Development In Neonatal Brains And The Impact Of Postnatal Pathologies, Pratheek Sai Bobba

Yale Medicine Thesis Digital Library

Rapid changes in diffusion properties and white matter microstructural integrity in neonatal brains complicates the interpretation of advanced MRI techniques such as diffusion weighted (DWI) and diffusion tensor imaging (DTI). Thus, the goal of this work is to characterize age-related normative diffusion patterns in neonates and determine the impacts of postnatal growth trajectory, delivery method, and hypoxic ischemia on neonatal brain diffusion metrics. From a large cohort of neonates who had received brain MRI within 3 months of birth between January 2013 and March 2021, the following cohorts were identified for individual analyses: a cohort of neonates with no neurological …

Social Determinants Of Health & Barriers To Care In Diabetic Retinopathy Patients Lost To Follow-Up, Thomas Chang

Yale Medicine Thesis Digital Library

SOCIAL DETERMINANTS OF HEALTH & BARRIERS TO CARE IN DIABETIC RETINOPATHY PATIENTS LOST TO FOLLOW-UP

Thomas L. Chang, Akua Frimpong, Kristen Nwanyanwu. Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, CT.

Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. More than a quarter of patients are lost to follow-up (LTFU) after they receive anti-vascular endothelial growth factor (anti-VEGF) injections as treatment. This study utilized a mixed-methods approach with both a quantitative and qualitative analysis. The specific aims of the quantitative analysis were to identify any potential factors or …

Predictors Of Adverse Outcomes Following Surgical Intervention For Cervical Spondylotic Myelopathy, Samuel Craft

Yale Medicine Thesis Digital Library

As hospital costs associated with spine surgeries continue to climb, length of stay(LOS) and discharge disposition have been utilized as proxies through which these increasing costs can be assessed. Cervical spondylotic myelopathy (CSM) is the most common spinal pathology among older adults. As a result, studies assessing drivers of increased costs, LOS, and discharge disposition following surgery for CSM are needed. Two factors of interest are psychiatric comorbidities and safety net hospital (SNH) status. Psychiatric disorders are common and can have a profound impact on health, while SNHs serve a large proportion of patients with Medicaid or without insurance. However, …

Spinal Infections: Pathophysiology, Diagnosis, Prevention, And Management, Meera Madhav Dhodapkar

Yale Medicine Thesis Digital Library

Spine infections fall under one of two major categories, primary spinal infections as well as postoperative spine infections. Both of these events are rare but associated with significant morbidity and mortality, and the diagnosis as well as optimal intervention strategy utilized for management is not always clear. In particular, postoperative surgical site infection (SSI) is a rare but potentially devastating complication. Previous studies have assessed risk factors for postoperative spine SSI and one aimed to develop risk stratification tool to assess management options, but this tool has not been externally validated or regularly used.The current thesis had two primary aims: …

Implications Of Acute Brain Injury Following Transcatheter Aortic Valve Replacement, Daniel Grubman

Yale Medicine Thesis Digital Library

Stroke is a feared complication of transcatheter aortic valve replacement (TAVR), affecting 2–8% of patients at 30 days. Beyond clinically evident stroke, covert brain injury (CBI) defined as clinically silent evidence of brain injury on imaging is strikingly prevalent: 70–100% of patients have evidence of new infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI). The clinical significance of these lesions is unknown. Recent guidance has highlighted the importance of imaging in the assessment of cerebral embolic protection (CEP) devices that aim to counter the debris generated during TAVR. This work aims to a) determine the clinical significance of new ischemic lesions, …

Latent Health Status Trajectory Modelling In Patients With Symptomatic Peripheral Artery Disease, Scott Grubman

Yale Medicine Thesis Digital Library

For patients with peripheral artery disease (PAD) and symptoms of intermittent claudication, treatment is geared towards maximizing health status and minimizing disease progression. We aimed to phenotype health status trajectories over the first 12 months of specialty care and examine factors associated with nonresponsiveness to treatment. Adults with new or worsening exertional leg symptoms presenting to vascular clinics in the United States, Australia, and Netherlands 2011-2015 were included. Patients with non-compressible ankle-brachial index, critical limb ischemia, barriers to consent, or lacking at least one follow-up interview were excluded. The Peripheral Artery Questionnaire (PAQ; range 0-100, higher = better) was used …

Clinical Decision Support For Emergency Department-Initiated Buprenorphine For Opioid Use Disorder, Wesley Holland

Yale Medicine Thesis Digital Library

Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians’ unfamiliarity with this practice and perceptions that it is complicated and time-consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user-centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED-initiated BUP.An interrupted time series study was conducted in an urban, academic ED from April …

The Hardships Of Healthcare Among People With Lived Experiences Of Homelessness In New Haven, Ct, Brandon James Hudik

Yale Medicine Thesis Digital Library

Objectives: People with lived experiences of homelessness encounter barriers to accessing and maintaining appropriate healthcare. This project aims to: 1) identify how these barriers manifest in New Haven, CT; 2) examine the negative health and healthcare impacts such barriers may incur, including when people adapt to or try to overcome them; 3) examine the characteristics of positive experiences in accessing healthcare in order to inform future approaches to healthcare for this vulnerable population.

Methods: This study is a subanalysis of the Justice, Health, and Housing Study (JustHouHS) and draws on longitudinal, qualitative interviews with low-income New Haven residents who experienced …