Digital Commons Network^™

Incorporating Genomic Analysis In The Clinical Practice Of Hepatology, David Hun Chung

Yale Medicine Thesis Digital Library

In the past two decades, whole-exome sequencing has been successfully demonstrated as an indispensable instrument in uncovering the genetic etiology underlying numerous types of unexplained liver disease. Characterization of these illnesses into distinct molecular disease entities has revolutionized understanding of pathophysiology and has translated into improved guidance on management, treatment and prognosis for patients. However, hepatologists have been slow to welcome the technology into their mainstream clinical practice, largely due to inadequate training in genomic medicine. There thus remains a pressing need to create various forums through which clinicians can gain better appreciation for the value of genetic analysis in …

Clinical Trials Related To The Spine & Shoulder/Elbow: Rates, Predictors, & Reasons For Termination, Dennis Louis Caruana

Yale Medicine Thesis Digital Library

Clinical trials are key to the advancement of products and procedures related to musculoskeletal conditions. Unfortunately, many trials are terminated prior to completion. ClinicalTrials.gov is a registry and results database maintained by the National Library of Medicine that catalogs trial characteristics and tracks overall recruitment status (e.g., ongoing, completed, terminated) for each study as well as reasons for termination. Reasons for termination have not been specifically evaluated for musculoskeletal trials and those related to the spine and shoulder/elbow were selected for characterization and assessment of independent predictors of termination by comparing characteristics of completed and terminated trials.

The ClinicalTrials.gov database …

An Examination Of Honor Society Membership, Mistreatment, And Discrimination By Medical Student Demographics, Katherine Ann Hill

Yale Medicine Thesis Digital Library

Purpose: To determine whether the prevalence of honor society membership and self-reported mistreatment and discrimination differs by medical student demographic group.Methods: This cross-sectional study analyzed data from Association of American Medical Colleges data collection instruments and included all students who graduated from LCME-accredited US medical schools and completed the Graduation Questionnaire in 2016-2019 (for honor society membership) or 2016-2017 (for self-reported mistreatment and discrimination). Results: In a sample of 50,384 graduating medical students, membership disparities were found in both Alpha Omega Alpha (AOA) and Gold Humanism Honor Society (GHHS). However, disparities in AOA existed across more identities, were often larger, …

Utility Of Shear Wave Elastography In Breast Cancer Diagnosis: A Systematic Review And Meta-Analysis, Aishwarya Pillai

Yale Medicine Thesis Digital Library

In the United States, breast cancer is one of the most diagnosed cancers in women. Early detection, often via mammography, and intervention have been shown to reduce mortality. However, not all cancers are mammographically evident in early stages, if at all. As a result, ultrasound has been increasingly used to supplement mammography for breast cancer detection and assessment, particularly in dense breasts. Recent advancements in ultrasonography include the ability to characterize the stiffness of biological tissues. Shear Wave Elastography (SWE) is one such development used to quantify tissue stiffness within a region of interest.

The resistance of soft tissue to …

Surgical Outcomes Following Posterior Spinal Fusion For Adolescent Idiopathic Scoliosis, Wyatt Benajmin David

Yale Medicine Thesis Digital Library

Surgical Outcomes Following Posterior Spinal Fusion for Adolescent Idiopathic ScoliosisWyatt B. David and Michael DiLuna. Section of Pediatric Neurosurgery, Department of Neurosurgery, Yale University, School of Medicine, New Haven, CT. Hospital size has previously been shown to impact outcomes in adult spine surgery. However, there is a paucity of studies assessing the impact of hospital size on outcomes in adolescent spine surgery. Furthermore, gender-based differences have been suggested in disease progression and outcomes of adolescent idiopathic scoliosis (AIS), though only a few studies have investigated these disparities. The aim of this study was to determine the impact of hospital size …

International Academic Partnerships In Orthopaedic Surgery, Michael Jesse Flores

Yale Medicine Thesis Digital Library

Abstract: INTERNATIONAL ACADEMIC PARTNERSHIPS IN ORTHOPAEDIC SURGERY. Michael J. Flores. Department of Orthopaedics & Rehabilitation, Yale University, School of Medicine, New Haven, CT.

Introduction: Orthopaedic-related disease (ORD) is one of the leading health challenges faced worldwide and is a significant cause of global morbidity and mortality, especially in low- and middle-income countries (LMICs). In recent years, international orthopaedic outreach to address the global burden of ORD has received greater attention due to initiatives such as the Lancet Commission on Global Surgery (LCGS). Many strategies have been considered to address the global burden of ORD, most commonly though volunteer trips by …

Incarcerated Patients Have Higher Mortality After Trauma: An Unreported Healthcare Disparity, Harry Newmanplotnick

Yale Medicine Thesis Digital Library

While the U.S. has the highest incarceration rate in the world, at nearly 1% of the adult population, or over 2 million people, insight regarding health disparities in this population remains limited, particularly for traumatic injuries and surgical care. Our aims with this paper were two-fold. First, we sought to perform the largest national database analysis of criminal-justice system involved (CJI) trauma patients (specifically incarcerated patients). Second, we planned to investigate if incarceration status was associated with differences in a variety of outcomes after trauma for U.S. adults.To accomplish these aims we analyzed data from the National Trauma Data Bank …

Almajiri Health; A Scoping Review On Disease, Health Literacy And Space For Participatory Research, Muzzammil Imran Muhammad

Yale Medicine Thesis Digital Library

Introduction

Almajirai are male children who leave the care of their parents to learn the Qur’an and study Islam under the tutelage of a Mallam or Imam at a Tsangaya. Almajiranci refers to the system of education based on this relationship between almajiri and mallam, and which was the dominant mode of education in precolonial Hausaland – Northern Nigeria and Southern Niger. This system remains widespread and popular in both countries. In recent years, discourse around almajirai has featured prominently in media from and about this region, and has associated almajiranci with non-participation in formal education, abuse, poverty, and underdevelopment. …

More Than Meets The Eye: Improving Recognition Of Child Abuse In Emergency Departments, May Shum

Yale Medicine Thesis Digital Library

Background: Child abuse guidelines exist to help emergency department (ED) providers evaluate injured children for suspected child abuse. Little is known about the impact of these guidelines on provider decision-making in pediatric (PED) and community EDs (CEDs). Objective: To evaluate the impact of a child abuse guideline in pediatric and community EDs through three primary studies: 1. To examine guideline adherence and the appropriateness of decision-making by CED providers. 2. To determine the impact of the guideline on differences in evaluations of infants for abuse between a PED and three CEDs. 3. To implement and assess the use of a …

Sex Differences In Patients With Deep Vein Thrombosis, Shin Mei Chan

Yale Medicine Thesis Digital Library

Objective: Sex differences in short-term outcomes of patients with deep vein thrombosis (DVT) have been reported but differences in long-term outcomes remain poorly characterized. This study aims to evaluate sex differences in long-term mortality, venous thromboembolism (VTE)-related mortality, and bleeding-related mortality in patients with DVT at a tertiary care center.

Methods: A retrospective chart review from 2012 – 2018 of all consecutive patients diagnosed with DVT was performed. Patients were grouped by sex, and baseline characteristics and treatment modalities were compared. Long-term outcomes of recurrent VTE, bleeding, and related mortalities were analyzed. Multivariable regression analysis was performed to determine factors …

Applying Deep Learning To Identify Imaging Biomarkers To Predict Cardiac Outcomes In Cancer Patients, Aishwarya Kishore Nene

Yale Medicine Thesis Digital Library

Cancer patients are a unique population with increased mortality from cardiovascular disease, however only half of high-risk patients are medically optimized. Physicians ascertain cardiovascular risk from several risk predictors using demographic information, family history, and imaging data. The Agatston score, a measure of total calcium burden in coronary arteries on CT scans, is the current best predictor for major adverse cardiac events (MACE). Yet, the score is limited as it does not provide information on atherosclerotic plaque characteristics or distribution. In this study, we use deep learning techniques to develop an imaging-based biomarker that can robustly predict MACE in lung …

Improving Cancer Classification With Domain Adaptation Techniques, Juliana Veira

Yale Medicine Thesis Digital Library

Background: As the quantity and complexity of oncological data continue to increase, machine learning (ML) has become an important tool in helping clinicians better understand malignancies and provide personalized care. Diagnostic image analysis, in particular, has benefited from the advent of ML methods to improve image classification and generate prognostic information from imaging collected in routine clinical practice [1-3]. Deep learning, a subset of ML, has especially achieved remarkable performance in medical imaging, including segmentation [4, 5], object detection, classification [6], and diagnosis [7].

Despite the notable success of deep learning computer vision models on oncologic imaging data, recent studies …

An Ultrasound Based Femoral Artery Calcification Score Predicts Amputation Free Survival, Ethan Maahs

Yale Medicine Thesis Digital Library

Objectives: Duplex ultrasound (DUS) of the lower extremities is commonly used to assess patients with lower extremity atherosclerosis. Arterial calcification can often be visualized in these images, however efforts to quantify its extent have been limited. We thus sought to develop a new scoring system to measure calcification on duplex US studies of the femoral artery and correlate it with standard CT-based methods. We then made preliminary attempts to correlate US-based femoral artery calcification scores with limb-specific outcomes in patients with peripheral artery disease. Methods: Patients who underwent CT scan evaluation of the lower extremities and arterial duplex US of …

Toll-Like Receptors 2/4 Directly Co-Stimulate Arginase-1 Induction Critical For Macrophage-Mediated Renal Tubule Regeneration, Natnael Beyene Doilicho

Yale Medicine Thesis Digital Library

Background: Following kidney injury, macrophages that have infiltrated the kidney undergo a transition from an initial proinflammatory state to a pro-reparative one characterized by the expression of arginase-1 (Arg 1), mannose receptor (Mrc1) and macrophage scavenger receptor-1 (Msr1). Granulocyte-macrophage colony-stimulating factor (GM-CSF) is an essential tubular-cell-derived determinant of the pro-reparative phenotype. However, it remains unclear what additional, if any, signals macrophages are integrating to maximally induce arginase-1.

Hypothesis: (1) The addition of cellular debris as a tubular cell cast mimetic will augment Arg1 expression in GM-CSF stimulated bone marrow derived macrophages; (2) Toll-like-receptors 2/4 transduce the debris signal from (1) …

The Impact Of Peer Interventions On Physical Activity For Individuals Living With Mental Illness, Julia Wolfe

Yale Medicine Thesis Digital Library

Individuals living with mental illness have significantly reduced physical health compared to the general population, leading to a significantly decreased life expectancy. Physical activity has been shown to be an effective strategy to address many of the conditions contributing to this disparity. However, many people with mental illness do not meet the recommended levels of daily physical activity. Peer support has been shown to be effective in some aspects of recovery for individuals living with mental illness, but its effectiveness in increasing engagement with physical activity in that population is not well established. The specific aim of this report is …

Leveraging Electronic Health Records To Examine Blood Pressure Patterns Preceding Stroke Events, Dana Lee

Yale Medicine Thesis Digital Library

Background: Hypertension (HTN) is the primary modifiable risk factor for stroke, with blood pressure (BP) control being paramount. Yet only one-fourth of patients with HTN who are receiving medical care have controlled BP. Accordingly, we aimed to elucidate patterns of BP control prior to incident stroke.Methods: We analyzed electronic health record data from patients who were hospitalized for a first stroke within the Yale New Haven Health system between 2015 and 2021. Patients were included if they had ≥2 outpatient visits in the 2 years prior to stroke to capture those regularly seeking care. BP measurements for all ambulatory visits …

The Association Between Social Needs Care Coordination And Social Needs Status Amongst Patients In A Federally Qualified Health Center, Autumn Nobles

Yale Medicine Thesis Digital Library

Social needs screenings within healthcare systems have grown more common with increasing discourse around the contribution of systemic determinants to health outcomes. These screenings have been used to describe the prevalence of social needs within communities but have not been evaluated for the impact that they and the interventions to which they are attached may have on health outcomes. Here we evaluate social needs screenings and their potential impact on patient health at a federally qualified health center in New Haven, Connecticut. We describe the baseline needs at the facility, evaluate change in reported social needs among patients undergoing screening, …

Understanding Perceptions Of New-Onset Type 1 Diabetes Education In A Pediatric Tertiary Care Center, Gabriel Betancurvelez

Yale Medicine Thesis Digital Library

Background: Youth newly diagnosed with type 1 diabetes (T1D), and their families, require intensive education on the management of this chronic condition during this overwhelming period. Traditionally, our center conducts training in person during a hospital admission.

Methods: We studied family perceptions of our current patient education methods in an effort to elucidate strategies to augment education in the post-pandemic environment, where provider time in the room and visitation rules may limit face-to-face encounters.

Results: 25 families completed the survey (distributed to 156 in total, with approximately 21% response rate). The mean age at diagnosis was 9.52 ± 4.29 years …

Factors Influencing Decision For Contralateral Prophylactic Mastectomy Versus Unilateral Mastectomy, Julian Huang

Yale Medicine Thesis Digital Library

Background: Rates of contralateral prophylactic mastectomy (CPM) are increasing despite falling rates of contralateral breast cancer and controversy over survival benefit of the procedure. We investigated why and how patients choose to undergo CPM, with focus on the roles of financial burden, decision-making resources, and active participation in decision-making.

Methods:Female unilateral breast cancer patients older than 18 years old who had undergone mastectomy (with or without CPM) coming in to the Yale Breast Center for a follow-up or post-operative visit between June and August 2017 were approached with an opportunity to participate in this survey study. Chart review was completed …

Family Dyads, Emotional Labor, And The Theater Of The Clinical Encounter: Co-Constructive Patient Simulation As A Reflective Tool In Child And Adolescent Psychiatry Training, Isaiah Thomas

Yale Medicine Thesis Digital Library

Patient simulation has been used in medical education to provide a safe and supportive learning environment for learners to practice clinical and interpersonal skills. However, simulation involving pediatric medicine and child psychiatry is rare and generally does not reflect the child-caregiver dyad or the longitudinal aspects of this care and does not provide learners an opportunity to engage with and reflect on these dynamics. We organized a series of 7 observed patient simulation sessions with a cohort of 7 senior child and adolescent psychiatry fellows as an educational opportunity. In these sessions, we utilized the previously described co-constructive patient simulation …

Characterization Of Cutaneous Immune-Related Adverse Events Due To Immune Checkpoint Inhibitors, Annika Belzer

Yale Medicine Thesis Digital Library

Immune checkpoint inhibitors (ICI) have been associated with a multitude of immune-related adverse events (irAE), which affect multiple organ systems in the setting of increased immune activation. Cutaneous immune-related adverse events (cirAE) are among the most common irAE, occurring in up to 50% of patients treated with an ICI. The most common cirAE are maculopapular eruption, pruritus (with or without primary cutaneous eruption), lichenoid dermatitis, eczematous dermatitis, psoriasiform eruption, and vitiligo. cirAE are of concern to oncologists and dermatologists alike, as cirAE can necessitate interruption or discontinuation of life-prolonging therapy. There is a paucity of data regarding cirAE in specific …

Perspectives On Emergency Department-Initiated Buprenorphine Among Clinical Pharmacists, Marissa Justen

Yale Medicine Thesis Digital Library

Clinical pharmacists are well positioned to enhance efforts to promote Emergency Department (ED)-initiated buprenorphine to treat opioid use disorder (OUD). Among clinical pharmacists in urban EDs, we sought to characterize barriers and facilitators for ED-initiated buprenorphine to inform future implementation efforts and enhance access to this highly effective OUD treatment.

This study was conducted as a part of Project ED Health (CTN-0069, NCT03023930), a multisite effectiveness-implementation study aimed at promoting ED-initiated buprenorphine that was conducted between April 2017 and July 2020. Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) framework to …

Examination For Independent Predictors Of Seasonality Of Birth Across Forty-Nine Low- And Middle-Income Countries: Analyses Of The United States Agency For International Development Demographic And Health Survey Data, Jehanzeb Kayani

Yale Medicine Thesis Digital Library

Although seasonal patterns in the distribution of live births have been well described across distinct populations for centuries, little is known about determinants of birth seasonality, particularly among low- and middle-income countries. Knowledge of determinants of birth seasonality may assist in the timely implementation and distribution of maternal and child health resources that may morbidity and mortality. In this study we examined for maternal and household sociodemographic determinants of birth seasonality in a sample of 3,260,238 live births across 49 nations that are included in the United States Agency for International Development Demographic and Health Survey Program. Our findings demonstrate …

Barriers To Identifying Learning Disabilities: A Qualitative Study Of Clinicians And Educators, Lauren Stone

Yale Medicine Thesis Digital Library

The estimated prevalence of learning disabilities (LDs) is nearly 8% of all children. Yet fewer than 5% of all children are diagnosed in public schools — jeopardizing remediation. The specific aims of this study were as follows: 1) To perform a qualitative study involving individual interviews with front-line child-facing professionals to identify barriers to detecting school-aged children with LDs and 2) To utilize results to suggest improvements to pediatric clinical care, as pediatricians are often initial responders for families when children experience academic difficulties.

We conducted a qualitative study with individual interviews of 40 professionals from different areas of the …

"Come On. I Need An Answer." A Mixed-Methods Study Of Barriers And Disparities In Diagnostic Odysseys, Zeyu Tang

Yale Medicine Thesis Digital Library

Background: The boom of next generation DNA sequencing over the past decade has improved our ability to provide accurate genetic diagnoses for children with previously undiagnosed diseases, in turn leading to important advances in management and prognostication. Even given this progress, two areas of ongoing need are the accurate definition of further novel genetic diseases and to make genetic expertise and diagnostics widely available to children and families who have frequently endured grueling diagnostic odysseys. The Pediatric Genomics Discovery Program (PGDP) at Yale is an advanced genomics program focusing on both these areas, enrolling over 700 patients since its inception …

Beta-Catenin Nuclear Transport In Wnt Signaling: Kap-Beta2/Transportin Mediates Nuclear Import Of Beta-Catenin Via A Py-Nls Motif In A Ran Gtpase Dependent Manner, Woong Y. Hwang

Yale Medicine Thesis Digital Library

Wnt signaling is essential for embryonic development and adult tissue homeostasis; mutations in Wnt pathway components are major drivers of multiple diseases especially cancer. β-catenin is a key effector in this pathway that translocates into the nucleus and activates Wnt responsive genes. However, due to our lack of understanding of β-catenin nuclear transport, therapeutic modulation of Wnt signaling has been challenging. Here, we took an unconventional approach to address this long-standing question by exploiting a heterologous model system, the budding yeast Saccharomyces cerevisiae, which contains a conserved nuclear transport machinery. In contrast to prior work, we demonstrate that β-catenin accumulates …

“I Was Reaching Out For Help And They Did Not Help Me”: Mental Healthcare In The Carceral State, Anna Grace Preston

Yale Medicine Thesis Digital Library

Background: Despite the limitations the carceral environment may impose on mental wellness, mental healthcare is increasingly becoming a carceral endeavor. Over the course of the last several decades, prisons and jails have become the de facto mental healthcare provider for thousands of incarcerated individuals. Furthermore, practices like mandated mental healthcare for supervised individuals further broaden the population experiencing mental healthcare within the criminal legal system at large. This study examines the perspectives of nine individuals who experienced mental healthcare within the carceral state, whether in prison or on parole or probation, with a special focus on how attributes of the …

Analysis Of Prices And Outcomes For Common Hospitalized Conditions In 2021, Lina Vadlamani

Yale Medicine Thesis Digital Library

Our study seeks to use newly disclosed hospital price transparency data to understand associations between average payer-negotiated prices, outcomes and hospital characteristics. Data on prices, outcomes and hospital characteristics for 4 commonly hospitalized conditions - Acute Myocardial Infarction (AMI), Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD) and Hip/Knee Replacements (THR/TKR) - were acquired from publicly available hospital chargemasters and Medicare’s Hospital Compare database. Mann-Whitney U and ANOVA tests were conducted comparing prices and key hospital characteristics (geography, urban/rural location, Medicare percentage, Medicaid percentage, and ownership). Linear regressions were conducted exploring the effect of outcomes (mortality, readmissions) and hospital characteristics …

Multi-Omic Differences Between Right And Left Sided Colorectal Cancer Liver Metastases, Montana Tremaine Morris

Yale Medicine Thesis Digital Library

Colorectal cancer (CRC) is the second leading cause of cancer-related death both in the United States and worldwide, making it an urgent area of investigation for the oncology community. The inferior survival of patients with right-sided colon cancer (RCC) compared to left (LCC), particularly in metastatic disease, as well as the resistance of RCC to certain targeted systemic therapies, represent clinically important features relevant to the development of improved targeted therapies for CRC. Given the high probability that there is a biological component underpinning the differing clinical behaviors of CRC across anatomic laterality, we conducted a multi-omic analysis on frozen …

Baseline Skin Cytokine Profiles Determined By Rna In Situ Hybridization Correlate With Response To Dupilumab In Patients With Eczematous Dermatitis, Katelyn Singh

Yale Medicine Thesis Digital Library

Dupilumab, a monoclonal antibody that inhibits IL4 and IL13, has revolutionized the treatment of atopic dermatitis (AD). However, not all patients respond optimally, and this may relate to underlying molecular heterogeneity. Yet, clinically useful and accessible methods to assess such heterogeneity have not been developed. Additionally, As the number of targeted medications continues to expand, the choice of which specific therapy to initiate in any individual patient will become increasingly difficult. Currently, there are no biomarkers that can be used to guide treatment selection in common inflammatory diseases such as atopic dermatitis (AD) and psoriasis. This study aims to determine …