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Characterization Of The Macular Choriocapillaris In Dry Age-Related Macular Degeneration Using Swept-Source Optical Coherence Tomography Angiography, Phillip X. Braun

Yale Medicine Thesis Digital Library

The purpose of this study was to characterize further, using swept-source (SS-) optical coherence tomography angiography (OCTA), the relationship between dry age-related macular degeneration (AMD) and the macular choriocapillaris (CC), which may have pathophysiologic and therapeutic implications. It included (1) a topographic analysis to determine if there is a significant relationship between dry AMD stage and macular CC perfusion, and (2) an investigation of the predictive value of macular CC perfusion with respect to geographic atrophy (GA) growth rate.

Study design was retrospective and cross-sectional. A database of 6x6 mm fovea-centered swept-source OCTA images of the CC from eyes with …

Exploring The Role Of Racial Associations Within Life And Psychiatry: The Dissociation Of Explicit And Implicit, Dervin Junior Cunningham

Yale Medicine Thesis Digital Library

Objective: In the past decade there has been increased interest in understanding racial

disparities throughout the world. In doing so, racial associations and biases have been

found to be one potential etiology of these disparities. Particularly in the medical field,

trainings and institutions often have providers rely on self-reported racial associations as

a means to understanding their biases. However, there is little known on how

explicit/self-reported associations relate to implicit associations and clinical behavior,

specifically within mental healthcare. This study aims to understand the relationship

between explicit/self-reported statements and psychiatric providers’ implicit racial

associations.

Methods: Psychiatric providers were asked to …

The Cost-Effectiveness Of Culture Vs Naat Based Screening Of Pregnant Women For Group B Streptococcus To Reduce Early-Onset Sepsis Of The Newborn, Bertie Geng

Yale Medicine Thesis Digital Library

While great progress has been made to reduce its incidence, group B streptococcus (GBS) is still a leading cause of neonatal disease. Current standard of care recommends antepartum rectovaginal GBS culture of all pregnant women at 36 weeks of gestation in order to identify candidates for intrapartum prophylaxis to reduce vertical transmission. The purpose of the study is to assess three alternative nucleic acid amplification (NAAT) screening strategies for GBS: antepartum NAAT at 36 weeks, intrapartum NAAT, or a combined intrapartum and antepartum approach in which patients with penicillin allergies undergo antepartum culture screening and all other patients undergo intrapartum …

External Validation Of An Electronic Phenotyping Algorithm To Detect Attention To Elevated Bmi And Weight-Related Comorbidities In Pediatric Primary Care., Anya Golkowski Barron

Yale Medicine Thesis Digital Library

Pediatric obesity is a growing national and global concern with nearly 1 in 5 children in the U.S. affected [1].The American Academy of Pediatrics endorsed expert committee recommendations in 2007 to assist clinicians in pediatric weight management; however, adherence to these recommendations among primary care providers is suboptimal, and measuring adherence in feasible and pragmatic ways is challenging[2-4]. Commonly used quality measures that rely on billing data alone are an inadequate measure of provider attention to weight status in pediatric populations as they do not capture whether providers communicate about elevated body mass index (BMI) and associated medical risks with …

Antidepressant Treatment Of Major Depressive Disorder In Patients With Comorbid Alcohol Use Disorder: Two Meta-Analyses Of Randomized Placebo-Controlled Trials, Isaac Nathan Smullin Johnson

Yale Medicine Thesis Digital Library

Objective:

Aim 1: To examine the efficacy of antidepressant agents compared with placebo in reducing depressive symptoms in subjects with comorbid Alcohol Use Disorders (AUD).

Aim 2: To examine the efficacy of antidepressant agents compared with placebo on measures of alcohol consumption.

Data Sources:

Aim 1: PubMed was searched for randomized, placebo-controlled trials that examined the efficacy of antidepressant medications for treating depression symptoms with comorbid AUD.

Aim 2: Ovid MEDLINE (1946 to September 23, 2016) and CENTRAL (Issue 8, August 2016) were searched with no language limits for randomized placebo-controlled trials that examined the effects of antidepressant medications on …

Decline In Medication Affordability Despite Closure Of The Medicare Part D Coverage Gap, Matthew Jordan Klebanoff

Yale Medicine Thesis Digital Library

The original Medicare Part D benefit included a gap in coverage, commonly known as the “doughnut hole,” where beneficiaries were responsible for 100% of drug costs. The Affordable Care Act included provisions to gradually close this gap, beginning in 2011, in order to reduce the financial burden of drug spending for Part D enrollees. Using a nationally representative survey of Medicare beneficiaries, we examined the effect of this policy on out-of-pocket drug spending and medication affordability. We found that the policy was associated with a decrease in out-of-pocket spending. However, this trend was limited to relatively healthy enrollees in stand-alone …

Discipline, Diagnose & Punish: A Critical Analysis Of Ptsd Diagnostication Amongst Syrian Migrants In Jordan, Erik Kramer

Yale Medicine Thesis Digital Library

This qualitative project seeks to explore sociopolitical factors influencing post-traumatic stress disorder (PTSD) diagnostication in Syrian migrants living in Jordan. Interviews were performed with twenty-three key informants, comprised of clinicians, organizational staff, and scholars, using semi-structured techniques which were analyzed with grounded theory analytic approaches. The results illuminate the complex social forces governing the practice of PTSD diagnostication in the Syrian migrant population in Jordan, with a focus on the effects of financial pressures. This is the first study to report extensively on the financial pressures affecting PTSD diagnostication in this setting. These data served as rooted substrate for a …

Developing Normal Placental Growth Curves Using 2-D Ultrasound In A Zimbabwe Maternity Hospital, Belinda Juliana Nhundu

Yale Medicine Thesis Digital Library

The placenta aids in providing nutrients and oxygen from the mother to the developing fetus. Using a validated tool to measure Estimated Placenta Volume (EPV) prior studies have shown a small EPV predicts low birthweight in pregnant women in US institutions. The aim of this study was to develop Estimated Placental Volume (EPV) normative curves for a population of women in Zimbabwe across a range of gestational ages. Additionally, to determine if low EPV measurements were predictive of IUFD or stillbirth. From January to June of 2019 a total of 150 women at Mbuya Nehanda Maternity Hospital in Harare Zimbabwe …

Cerebral Autoregulation-Based Blood Pressure Management In The Neuroscience Intensive Care Unit: Towards Individualizing Care In Ischemic Stroke And Subarachnoid Hemorrhage, Andrew Silverman

Yale Medicine Thesis Digital Library

The purpose of this thesis is to review the concept of cerebral autoregulation, to establish the feasibility of continuous bedside monitoring of autoregulation, and to examine the impact of impaired autoregulation on functional and clinical outcomes following subarachnoid hemorrhage and ischemic stroke. Autoregulation plays a key role in the regulation of brain blood flow and has been shown to fail in acute brain injury. Disturbed autoregulation may lead to secondary brain injury as well as worse outcomes. Furthermore, there exist several methodologies, both invasive and non-invasive, for the continuous assessment of autoregulation in individual patients. Resultant autoregulatory parameters of brain …

Obstructive Sleep Apnea And Pain Intensity In Young Patients, Wardah Athar

Yale Medicine Thesis Digital Library

Obstructive sleep apnea and pain intensity in young patients

Wardah Athar; Mary E. Card; Antonios Charokopos; Kathleen Akgün; Eric C. DeRycke; Sally G Haskell; Henry K. Yaggi; Lori A. Bastian. Yale University School of Medicine, New Haven, CT.

Objective: This study aims to examine whether young patients who are diagnosed with obstructive sleep apnea (OSA) are more likely to report higher pain intensity when compared to young patients without OSA.

Design/Participants: To do so, we conducted a cross-sectional analysis of a cohort study of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans who had at least one clinical encounter …

Understanding Costs Of Healthcare: Patient Perspectives And Beyond, Edwin Yirong Chan

Yale Medicine Thesis Digital Library

Introduction: Healthcare spending in the US is among the highest in the world and continues to grow year-over-year despite outcomes comparable to or worse than other nations. This spending has translated to extensive patient burden and high out-of-pocket costs for many individuals. Despite high costs to both systems and individuals, patients continue to pursue expensive care options such as emergency department care over other appropriate alternatives. Here, we assess patient understanding of emergency room costs and influences on their decisions to pursue emergency department care.

Methods: Adult patients presenting to the emergency department for conditions not meriting hospital admission or …

Approaches To Fracture Healing Under Inflammatory Conditions: Infection And Diabetes, Sean Vincent Cahill

Yale Medicine Thesis Digital Library

Non-union is a devastating complication of fracture and can be precipitated by abnormal

inflammatory states including infection and diabetes.

This thesis focuses on four related research problems that are addressed through original

scientific investigation and literature review. In addressing these questions, this dissertation

presents evidence for the following conclusions through in vivo animal models and using methods

including bacterial cell culture and counting, histology, radiography, and micro-computed

tomography:

1. Rifampin-loaded hydrogels decrease bacterial load and improve fracture healing in

a MRSA-infected open fracture model.

2. MRSA-infected nonunion is characterized by impaired chondrocyte maturation and

is associated with IL-1 and NF-KB …

Shifts In Micromobility-Related Trauma In The Age Of Vehicle Sharing: The Epidemiology Of Head Injury, Joshua Richard Feler

Yale Medicine Thesis Digital Library

Shared micromobility programs (SMPs) provide access to a distributed set of shared vehicles – mostly conventional bicycles, electronic bicycles, and electronic scooters – and are increasingly common in domestic and global cities, with riders completing an estimated 84 million trips using an SMP vehicle. There is heterogeneity in these programs in size, vehicle types offered, and distribution model. The impact of SMP introduction on the epidemiology of traumatic injury is largely unknown, and the relative safety of different shared vehicle types has not been evaluated; these effects are the subject of this study.

Considered as a whole, the annual number …

Meat Consumption, Cooking Practices, And Blood Harmane Concentrations In Essential Tremor: A Population-Based, Environmental Study In The Faroe Islands, Monica Ferrer Socorro

Yale Medicine Thesis Digital Library

Background: Essential tremor (ET) is among the most prevalent neurological disease, yet potential modifiable environmental factors contributing to its etiology are poorly understood. Harmane [1-methyl-9H-pyrido(3,4-b)indole], is a potent neurotoxin, of which elevated levels may be linked to ET. Possible etiologies for this elevation include increased dietary consumption, impaired metabolism, or increased endogenous production. Harmane is particularly abundant in meats and long cooking times can increase its concentrations. One previous study provided preliminary data of a dietary difference between male ET cases and controls. To clarify the relationship between ET and harmane we conducted a population-based, case-control study, in the Faroe …

Development And Validation Of A Predictive Model For Oncology Hospital-At-Home, Keval Niraj Desai

Yale Medicine Thesis Digital Library

Background:

Hospital-at-Home (HaH) is a unique care model that allows for the provision of inpatient level care in the patient’s home. HaH has been used to facilitate early discharge from inpatient care or to substitute entirely for an inpatient admission. Hospital-at-Home has been shown to have similar clinical outcomes to inpatient care, while reducing cost and complications associated with inpatient admission. Application of the HaH model to patients with oncologic disease is a promising avenue to reduce healthcare costs while improving patients’ quality of life by increasing time spent at home. A major challenge to implementing a Hospital-at-Home program for …

Aging With Hiv: Biomarkers Of Inflammation And Incident Rheumatologic Disease, Jennifer Leslie Simon Hanberg

Yale Medicine Thesis Digital Library

Chronic Human Immunodeficiency Virus (HIV) infection results in multimorbidity and shortened lifespan. Inflammation and immune dysfunction contribute to these outcomes. The aim of this thesis is (1) to investigate the utility of two inflammatory biomarkers evaluated in other settings (neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)) for prognostication in patients living with HIV (PLWH) and comorbid inflammatory states; and (2) to compare the frequency and severity with which rheumatologic disease states occur in PLWH to demographically and behaviorally similar uninfected individuals (“controls”).

Three cohorts were created from the Veterans Aging Cohort Study. In each cohort, patients were stratified by presence …

Genetic Investigation Reveals Novel Pathways For Disease Pathogenesis In Inherited And Mosaic Skin Disorders, Shayan Cheraghlou

Yale Medicine Thesis Digital Library

Introduction

Genetic mosaicism underlies many inherited and acquired cutaneous disorders. Despite the barriers to genetic analysis of mosaic disorders, next generation sequencing has led to substantial progress in understanding their pathogenesis, which has significant implications for clinical management and genetic counselling. Advances in paired and deep sequencing technologies in particular have made study of mosaic disorders more feasible. In this study, we aim to utilize next generation sequencing technologies in order to evaluate the genetic cause of three mosaic cutaneous disorders: epidermolytic acanthoma (EA), progressive symmetric erythrokeratodermia (PSEK), and mosaic childhood acantholytic dyskeratosis.

Methods

Using genomic DNA extracted from paraffin-embedded …

Identification Of A Novel Disorder With Cholestasis, Liver Fibrosis And Congenital Diarrhea Due To Organic Solute Transporter Alpha Deficiency, Emily Gao

Yale Medicine Thesis Digital Library

BACKGROUND: Much of our understanding of normal liver pathophysiology comes from studying patients with liver disease who remain undiagnosed after a comprehensive workup. Searching for diagnoses among such cohorts has benefits both for the underserved patients with idiopathic liver disease, but also for science as a whole. Unbiased genomic analysis of patients with undiagnosed disease has yielded remarkable results, including clinically actionable diagnoses in children and adults, as well as the discovery of novel genetic diseases. Thus, we posit that among pediatric patients with undiagnosed liver disease, there may be previously unrecognized Mendelian causes.

METHODS: We report a 2.5 year …

Statin Therapy Associated With Improved Thrombus Resolution In Patients With Deep Vein Thrombosis, Charles Hsu

Yale Medicine Thesis Digital Library

Objectives: Statin therapy has been associated with a decreased incidence of venous thromboembolism (VTE) in clinical trials and enhanced thrombus resolution in animal models. The effect of statins on thrombus resolution has not been reported clinically. This study investigates the association of statins with thrombus resolution or improvement in patients with deep vein thrombosis (DVT).

Methods: A retrospective study of the electronic medical records of consecutive adult patients presenting with lower extremity DVT was performed. Patients were divided into two groups based on statin therapy (statin group) or lack thereof (non-statin group). The two groups were compared with respect to …

Inference Of Natural Selection In Human Populations And Cancers: Testing, Extending, And Complementing Dn/Ds-Like Approaches, William Meyerson

Yale Medicine Thesis Digital Library

Heritable traits tend to rise or fall in prevalence over time in accordance with their effect on survival and reproduction; this is the law of natural selection, the driving force behind speciation. Natural selection is both a consequence and (in cancer) a cause of disease. The new abundance of sequencing data has spurred the development of computational techniques to infer the strength of selection across a genome. One technique, dN/dS, compares mutation rates at mutation-tolerant synonymous sites with those at nonsynonymous sites to infer selection. This dissertation tests, extends, and complements dN/dS for inferring selection from sequencing data. First, I …

Reversal Of Warfarin-Associated Coagulopathy: Prothrombin Complex Concentrates Versus Fresh Frozen Plasma In Elderly Patients Presenting With Intracranial Hemorrhage, Shunella Grace Lumas

Yale Medicine Thesis Digital Library

Background: Patients on warfarin with traumatic intracranial hemorrhage (ICH) often require pharmacological reversal of warfarin-induced coagulopathy. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP) or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage on warfarin.

Study Design: This was a retrospective analysis of 150 patients on preinjury warfarin. Data was abstracted from the electronic medical record (EMR) of an academic level 1 trauma center for patients age 65 years and greater on warfarin therapy admitted with a traumatic ICH between January 2013 and December …

Do Associated Mri Findinds Improve The Detection Of Elusive Encephaloceles?, Lovemore Makusha

Yale Medicine Thesis Digital Library

Objective: Encephaloceles are difficult to detect on imaging, leading to missed diagnosis for many years. Herein, we aim to describe encephalocele MR characteristics to enhance detection and interpretation of an abnormality that underlies intractable temporal lobe epilepsy of approximately 10% of patients. We postulate that some MR features that are easier to visualize than encephaloceles, such as CSF clefts or cortical distortions, along with MR signs of increased ICP such as empty sella and Meckel’s cave dilation, should raise neuroradiologists’ suspicion of potential encephaloceles, and hence improve their detection.

Subjects and Methods: We performed a retrospective study on consecutive patients …

Writing The Gap: The Role Of Clinician-Authored Narratives In Building Structural Competence And Situated Knowledge In Service Of Marginalized Patient Populations, Anusha Singh

Yale Medicine Thesis Digital Library

This thesis analyzes clinician-authored narratives about mental illness. Through this lens, it argues that the writing and reading of medical narratives can facilitate the development of key clinical skills such as structural competence and situated knowledge – terms that this thesis will define and discuss at length. It will argue that clinicians who write about structural barriers to health do so to develop a deeper understanding about their vulnerable and marginalized patient populations. It will assert that clinicians who pursue situated knowledge can positively impact health outcomes. Ultimately, this thesis will compare what clinician-authored narratives can achieve with what patient …

Cbpr 2.0 - A Community-Based Participatory Research Approach To Program Scaling In Maternal Mental Health: Responding To Community Risk Factors For Maternal Depression While Replicating New Haven Moms To Bridgeport And New York City, Sonia Taneja

Yale Medicine Thesis Digital Library

“Community-Based Participatory Research 2.0” refers to a methodologic framework describing the process of scaling the New Haven MOMS Partnership, an existing participatory intervention, to new sites in Bridgeport, Connecticut and New York City.

Following a community-based participatory approach to the process of program differentiation within implementation science, informal team canvassing identified core components of the program: neighborhood hub sites, community mental health workers, and utilization of incentives. Community needs assessments were prepared, distributed, and analyzed to identify flexible program components. Assessments were tailored to specific communities and included the Center for Epidemiologic Studies-Depression Scale (CES-D), the Oslo-3 perceived social support …

Characterization Of Temperature Curves In The Intensive Care Unit, Patricia Lourdes Valda Toro

Yale Medicine Thesis Digital Library

Fevers are extremely common in hospitalized patients, particularly in those admitted to the intensive care unit (ICU). Up to 50% of fevers in the ICU are non-infectious in origin. Yet, the development of a fever commonly prompts extensive, costly and invasive infectious workups. Patients with persistent fevers are usually treated with antimicrobials long after infectious workups prove unrevealing. While this is viewed as a ‘safe’ approach, inappropriate antibiotic use has shown to be harmful to patients – even effecting an increase in mortality – in addition to contributing to the spread of antibiotic resistance. The purpose of this study is …

The Development And Validation Of A Novel Ichthyosis Severity Assessment Instrument, Qisi Sun

Yale Medicine Thesis Digital Library

Abstract: THE DEVELOPMENT AND VALIDATON OF A NOVEL ICHTHYOSIS SEVERITY ASSESSMENT INSTRUMENT. Qisi Sun, Amy Paller, Keith A. Choate. Department of Dermatology, Genetics & Pathology, Yale University School of Medicine, New Haven, CT.

Ichthyosis clinical trials require reliable, validated severity assessments to identify appropriate subjects and quantify treatment outcomes. There is no validated scale to measure ichthyosis severity across the entire body. We aim to create and validate a comprehensive and user-friendly instrument to measure total body ichthyosis severity in adults and children.We divided the body into 10 regions to score special regions of interest. Likert scales (0-4) were established …

Context Of Injury Among Abusive And Accidental Injuries In Children, Lindsay Eysenbach

Yale Medicine Thesis Digital Library

Child physical abuse is a significant public health challenge with an incidence of approximately 6.4 hospitalized cases per 100,000 children. Many abused children, however, will go undiagnosed by physicians evaluating these injuries. Assessing whether a child has been abused is a high-stakes decision: a missed case leaves a child vulnerable to future injury, but an inaccurate diagnosis of abuse may be greatly disruptive and stigmatizing to children and their families. Previous research has established key physical examination and radiographic findings that are associated with abusive injury. A gap in the literature, however, is the role of additional injury circumstances and …

Trust And Healthcare: A Qualitative Analysis Of Trust In Spanish And English Language Group Well-Child Care, Nicolas Muñoz

Yale Medicine Thesis Digital Library

Trust and healthcare: a qualitative analysis of trust in Spanish and English language group well-child care

Nicolas Muñoz, Patricia Nogelo, Benjamin Oldfield, Ada Fenick, Marjorie Rosenthal

Yale Pediatric Primary Care Center and Yale Clinic for Hispanic Children,

Department of Pediatrics

Yale University School of Medicine, New Haven, CT

Background: Trust, in the healthcare setting, is defined as the optimistic belief that providers and systems serve patient’s best interest. It is a multidimensional concept including competence, and value congruence, and exists due to patient vulnerability. Trust has been demonstrated to impact healthcare utilization. In pediatric patients, trust is key for strong …

How Exposure To Mass Incarceration Is Associated With The Wellbeing Of Individuals And Families, Ram Sundaresh

Yale Medicine Thesis Digital Library

Mass incarceration in America has far-reaching effects on individuals and their families. Although a large body of evidence has described the effects of incarceration on specific physical and social outcomes, there is almost no research on its effects on broader wellbeing, a more holistic measure of lived experience that can more sensitively reflect social welfare and structural vulnerability. The goal of this thesis is to assess the association between exposure to the American system of mass incarceration and wellbeing. We examine individual-level exposure to the broader criminal legal system (CLS), including police stops, arrests, and incarceration, and family-level exposure to …

Immunologic Analysis Of Non-Small Cell Lung Cancer In People Living With Hiv, Ramsey Yusuf

Yale Medicine Thesis Digital Library

Among people living with HIV (PLWH), non-small cell lung cancer (NSCLC) has emerged as the most common non-AIDS defining cancer and a leading cause of death. PLWH with NSCLC are diagnosed at younger ages and demonstrate worse outcomes compared to the general population. Global immune dysregulation in the setting of HIV infection may account for these disparities, however little is known about the immunobiology of HIV-associated NSCLC. The goal of this study was to investigate the clinical and pathology of NSCLC in PLWH. This retrospective cohort study examined HIV-associated and uninfected NSCLC cases within Yale-New Haven Hospital between 2000-2016. Medical …