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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 …

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 …

Hearts With Cardiac Arrest History Safe For Transplant In The Context Of Donor And Recipient Factors, Aditi Balakrishna

Yale Medicine Thesis Digital Library

Background: Cardiac arrest, or downtime, can result in ischemic damage to myocardial tissue, which prompts caution in accepting hearts with such a history for transplant. Our aim is to provide guidance about whether these hearts are suitable and which among them confer optimal outcome.

Methods: We analyzed all first-time adult cardiac transplantations in the United States between 1988 and 2010 as reported in the United Network of Organ Sharing (UNOS) database. Stratification was between donors with downtime history prior to brain death versus those without such a history for univariate and multivariate analyses.

Results: Of 17,941 donors that met inclusion …

Non-Small Cell Lung Cancer In The National Cancer Database, Jacquelyn Gayle Hancock

Yale Medicine Thesis Digital Library

BACKGROUND

The National Cancer Database (NCDB) is the largest clinical database resource available. Using this remarkable tool, we completed two studies with the goal of answering two questions about non-small cell lung cancer (NSCLC) in the United States: 1) How is clinical stage IIIA-cN2 NSCLC managed? and 2) What is the survival and optimal treatment approach following incomplete resection of NSCLC?

Clinical stage IIIA (cStage IIIA) NSCLC that results from mediastinal lymph node disease (stage IIIA-cN2) represents a difficult lung cancer scenario. In addition to the disappointing prognosis, the accuracy of mediastinal staging is uncertain, the optimal treatment approach is …

Thoracentesis In Cardiac Surgery Patients With Non-Specific Pleural Effusion: A Case-Control Study, David Russell Kull

Yale Medicine Thesis Digital Library

Non-specific pleural effusion is common in patients after cardiac surgery. Thoracentesis for non- specific pleural effusion is being used more frequently with informal observations of improved dyspnea, shorter length of inpatient stay (LOS), reduced need for escalation of care, and less postoperative atrial fibrillation (AF). Our hypothesis is that the majority of cardiac surgery patients who undergo thoracentesis for non-specific pleural effusion have improvements in dyspnea, reduced days in AF, and reduced escalation of care compared to similar patients who do not have procedural intervention.

Our study population includes patients with evidence of pleural effusion on chest x-ray during a …

Limitations Of Administrative Databases In Orthopaedic Surgery Research: A Study In Obesity And Anemia, Nicholas Golinvaux

Yale Medicine Thesis Digital Library

The use of national inpatient databases for orthopaedic surgery research has been increasing. However, large databases that rely on administrative data, such as International Classification of Diseases Ninth Revision (ICD-9) codes, may misrepresent patient information, thus affecting the results of studies using this data.

The present study uses easily quantified and objective variables of obesity and anemia as example comorbidities to assess the accuracy of ICD-9 codes in the setting of their continued use in orthopaedic surgery database studies.

For each study arm, a large inpatient population was obtained from the Yale-New Haven hospital. Each patient's medical record was reviewed, …

A Model For Short-Term Medical Service Trip Evaluation: Impact Of A Hand Surgery Trip To Honduras, Kyle Ragins

Yale Medicine Thesis Digital Library

A MODEL FOR SHORT-TERM MEDICAL SERVICE TRIP EVALUATION: IMPACT OF A HAND SURGERY TRIP TO HONDURAS.

Kyle T Ragins and J Grant Thomson. Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, CT.

This study evaluates the impact of a hand-surgery-focused short-term medical service trip (MST) to Honduras on the upper extremity morbidity and health-related quality of life of its patients. The aim of the study is to provide a quantitative measurement of patient impact, while providing a model for how other MSTs can evaluate their outcomes to eventually determine best practices for …

Outcomes Following Lumbar And Cervical Spinal Surgery In The Obese: An Acs-Nsqip Database Study, Rafael Antonio Buerba

Yale Medicine Thesis Digital Library

Prior studies on the impact of obesity on spine surgery outcomes have focused mostly on lumbar fusions, do not examine lumbar discectomies or decompressions, and have shown mixed results regarding complications. There is also a paucity of literature regarding the effect of obesity on cervical spinal fusion outcomes. The purpose of this thesis was therefore to analyze whether obesity as measured by BMI influences the complication rates, operation times, and lengths of stay in patients undergoing lumbar or cervical spine surgery.

To this end, we conducted a retrospective cohort analysis of prospectively collected data on lumbar and cervical surgeries using …

Antidepressants And Melanoma: Is There A Link?, Stephanie Douglas

Yale Medicine Thesis Digital Library

ANTIDEPRESSANTS AND MELANOMA: IS THERE A LINK? Stephanie R. Douglas, Deepak Narayan. Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.

Cutaneous melanoma is the sixth most common cancer in the United States, and its incidence continues to rise steadily at a rate of 2-3% per year. Meanwhile nearly 11% of the general population is treated with antidepressant medication. Laboratory studies suggest a number of theoretical links between antidepressants and melanoma. Serotonin is a growth factor for melanocytes, and antidepressants upregulate components of the Wnt/beta-catenin, mTOR, and MAP kinase signaling pathways, all …

Idiopathic Normal Pressure Hydrocephalus: A Review And A Proposed Role For, Conor Grady

Yale Medicine Thesis Digital Library

Despite nearly five decades of experience treating idiopathic normal pressure hydrocephalus (iNPH), there is still no consensus amongst care providers as to how to reliably identify patients with suspected iNPH who will benefit from shunt surgery, or how to measure post-operative symptom improvement. We performed a selective review of the literature, focusing especially on the role of neuroimaging in aiding in the diagnosis of iNPH, and the various clinical scales that have historically been used to assess outcome. Further, we tested the hypothesis that patient-reported outcomes (PROs) will demonstrate effectiveness of shunt surgery for the relief of iNPH symptoms consistent …

Mechanism For Eph-B4 Regulation Of Vein Graft Adaptation, Daniel Lu

Yale Medicine Thesis Digital Library

Introduction

Vein graft adaptation to the arterial circulation entails many changes at the cellular/molecular levels, including both cell proliferation and extracellular matrix (ECM) deposition/remodeling, resulting in thickening of the vein wall, and in excessive cases, pathological neointimal hyperplasia. Eph-B4 is a receptor tyrosine kinase and embryonic determinant of veins that, when stimulated, has been shown by our lab to decrease vein graft wall thickening. We hypothesize that among other mechanisms, Eph-B4 exerts this effect through modulating extracellular matrix production and/or degradation, and that Eph-B4 interacts directly with eNOS to mediate some of its downstream effects.

Methods

Mouse Embryonic Fibroblasts (MEFs) …

Assessing The Survival And Functional Outcomes Of Patients With Supraglottic Squamous Cell Carcinoma, Graeme Michael Rosenberg

Yale Medicine Thesis Digital Library

The objective of this project is to report oncologic and functional outcomes for a cohort of patients with supraglottic squamous cell carcinoma (SSCC) treated in a multidisciplinary setting including the use of transoral laser microsurgery (TLM).

A retrospective observational study at Yale New Haven Hospital, academic teaching hospital was performed. A total of 56 patients without evidence of distant metastasis at presentation treated for SSCC between January 1, 2003 and December 31, 2007 were identified. The main outcome measures include overall survival (OS), locoregional and distant recurrence, and the incidence of tracheostomy and gastrostomy tube requirement.

Of the 56 patients, …

The Genetic Basis Of Dupuytren's Disease, Gloria Sue

Yale Medicine Thesis Digital Library

Dupuytren's disease is a common heritable connective tissue disorder of poorly understood etiology. It is thought that oxidative stress pathways may play a critical role in the development of Dupuytren's disease, given the various disease associations that have been observed. We sought to sequence the mitochondrial and nuclear genomes of patients affected with Dupuytren's disease using next-generation sequencing technology to potentially identify genes of potential pathogenetic interest. Additionally, we sought to compare the genomes between diseased tissue and blood to look for potential somatic mutations in the diseased tissue. Upon sequencing and subsequent bioinformatics analysis, no differences were observed in …

Eph-B4 Activation Reduces Neointimal Hyperplasia In Human Saphenous Vein, Daniel James Wong

Yale Medicine Thesis Digital Library

Despite the rise in percutaneous interventions, bypass surgery is an essential therapy for patients with advanced coronary and peripheral artery disease. Nearly half of the saphenous vein grafts used in these operations are eventually complicated by pathologic remodeling known as neointimal hyperplasia (NIH). Recent work in animal models has shown that the development of NIH can be reduced by stimulation of the receptor tryrosine kinase Eph-B4 by systemic injections of its ligand ephrin-b2. The purpose of this study was to determine whether the reduction of intimal hyperplasia observed with Eph-B4 stimulation in animal models translated into human tissues. Specifically we …

Predictors And Potential Mechanisms Of Improvement
 In Asthma Control In Children Following Adenotonsillectomy, Maria Koenigs

Yale Medicine Thesis Digital Library

Recent small observational studies suggest that asthmatic children receive clinical benefit in asthma control following adenotonsillectomy (TA), but little is known about which clinical and biological characteristics impact improvement. We enrolled 213 children undergoing TA, including 136 children with asthma and 78 controls, in a longitudinal observational cohort study (YCAAD). An asthma questionnaire, Asthma Control Test (ACT) scores, and serum asthma biomarkers levels were obtained at baseline and at six-months. Interim analysis compared patient characteristics to a historical cohort (CT-Kids) of 49 children with asthma who underwent TA. Urgent care visits (P < 0.001), oral steroid courses (P < 0.001), and ACT scores (P < 0.001) all improved in children with asthma following TA. Serum Th2 inflammatory markers, including IL-4 (P = 0.022) and IL-5 (P = 0.002), decreased following TA. Decreased IL-5 levels following surgery correlated with improvement in urgent care visits (P = 0.021), decreases in oral steroids (P = 0.02), and overall improvement in asthma control (P = 0.008). Children who were low or healthy weight, younger, female, had a history of sinusitis, and/or had a history of persistent asthma were more likely have improvement in their asthma following surgery. Elevations of serum IL-2, IL-4, IL-5, IL-13, IFN-γ, TNF-α, and GM-CSF levels were found in children whose asthma improved after TA. These clinical characteristics and biomarkers may help predict which children will receive maximum benefit in asthma control following TA.

Treating Very Large Non-Small Cell Lung Cancers: A Survival Analysis Using National Cancer Databases, Amy Moreno

Yale Medicine Thesis Digital Library

Very large primary non-small cell lung cancers (NSCLC), defined as those >7 cm, remain a therapeutic challenge due to known survival disadvantage compared to smaller tumors and lack of specific studies in this population. This study compares the effect of various treatment modalities on survival of patients with large NSCLC with none or positive hilar lymph node involvement (T3>7cmN0 and T3>7cmN1, respectively).

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients undergoing a lobectomy or pneumonectomy for T3>7cmN0 NSCLC from 1999 to 2008. Patients were categorized into groups based on type of surgery …

Extracorporeal Membrane Oxygenation (Ecmo) In Adults In The United States From 2006-2011, Christopher Mark Sauer

Yale Medicine Thesis Digital Library

Objective:

Recent studies have shown the benefits of extracorporeal membrane oxygenation (ECMO) in supporting adults with severe respiratory or cardiac failure refractory to conventional treatments. The purpose of this investigation was to analyze the utilization of ECMO in adults to identify recent trends within the United States.

Methods:

In a serial cross-sectional study, the utilization rate of ECMO in adults in the United States from 2006 to 2011, as well as the survival rates and costs of hospitalization were analyzed using the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). The survival rates were further analyzed …

Evaluation And Characterization Of The Biomechanical Properties Of Tissue Engineered Vascular Grafts Implanted In The Arterial Circulation, Brooks Van Udelsman

Yale Medicine Thesis Digital Library

We used a murine model to assess the in vivo evolving biomechanical properties of tissue engineered vascular grafts (TEVGs) implanted in the arterial circulation. The initial polymeric tubular scaffold was fabricated from (poly)lactic acid (PLA) and coated with a 50:50 copolymer of (poly)caprolactone and (poly)lactic acid (P[PC/LA]). Following seeding with syngeneic bone marrow derived mononuclear cells, the TEVGs (n=50) were implanted as aortic interposition grafts in wild-type mice and monitored serially using ultrasound. A custom biaxial mechanical testing device was used to quantify in vitro the circumferential and axial mechanical properties of grafts explanted at 3 or 7 months. At …

Central Lymph Node Dissection In Patients With Papillary Thyroid Cancer: A Population Level Analysis Of 14257 Cases, Chineme Enyioha

Yale Medicine Thesis Digital Library

CENTRAL LYMPH NODE DISSECTION IN PATIENTS WITH PAPILLARY THYROID CANCER: A POPULATION LEVEL ANALYSIS OF 14,257 CASES. Chineme Enyioha, Sanziana Roman and Julie Ann Sosa. Department of Surgery, Yale School of Medicine, New Haven, CT.

The role of prophylactic central lymph node dissection (CLND) in patients with differentiated thyroid cancer has been controversial. This study analyzes the impact of patient demographic factors and tumor size on surgery with CLND in patients with papillary thyroid cancer (PTC) in the U.S.

All patients >/= 18 with PTC and follicular variant-PTC, who underwent thyroidectomy with or without CLND in SEER, 2004-08, were included. …

Radiation Therapy And Expander-Implant Breast Reconstruction: Analysis Of Timing And Complications, Rachel Lentz

Yale Medicine Thesis Digital Library

The optimal timing of expander-implant exchange in the setting of post mastectomy radiation remains unclear with prior reports yielding inconsistent and variable results. The purpose of this study was to characterize complications associated with the sequencing of expander-implant breast reconstruction before or after radiation therapy and to compare the outcomes between early (< 4 months) and late (>4 months) expander-implant exchange in the subset of patients who received radiation prior to exchange.

The medical records of all patients receiving post-mastectomy radiation therapy in the setting of tissue expander-implant breast reconstruction between June 2004 - June 2011 at Yale-New Haven hospital were reviewed retrospectively. Patients …

Targeted Sirna Directed Therapy To Increase Chemosensitivity In Drug Resistant Bladder Cancer Cells, Jerry Trejo

Yale Medicine Thesis Digital Library

Chemoresistance is a common problem encountered by patients with advanced urothelial carcinoma. Recent studies have investigated the mechanisms of drug resistance in cancer, particularly agents of the DNA damage repair pathway. One major player in this pathway is Ataxia-Telangiectasia Mutated and Rad3-Related protein (ATR), a kinase that becomes activated during nuclear damage yielding a single-stranded DNA break. Due to the fact that many traditional chemotherapeutic agents induce cytotoxicity by initiating DNA damage, ATR is an attractive target for investigating the mechanism behind multidrug resistant urothelial carcinoma.

Using two bladder cancer cell lines, MMCR (a drug-resistant cell line) and RT4 (a …

Dysmorphology And Dysfunction In The Brain And Calvarial Vault Of Nonsyndromic Craniosynostosis, Joel Stanley Beckett

Yale Medicine Thesis Digital Library

Craniosynostosis is a premature pathologic fusion of one or more sutures in the calvarial vault. The six calvarial sutures are growth sites between adjacent intramembranous bones, which allow for flexibility during passage through the birth canal and accommodation for the growing brain. Premature fusion results in obvious cranial morphologic abnormality and can be associated with elevated intracranial pressure, visual dysfunction, mental retardation and various forms of subtler learning disability.

A category of disease called isolated nonsyndromic craniosynostosis (NSC) represents nearly 85% of cases. It results in prototypical skull deformities and has newly-discovered correlations with poor neuropsychologic and visual functioning. Herein …

Correlations Between Intracranial Aneurysms And Thoracic Aortic Aneurysms, Gregory Kuzmik

Yale Medicine Thesis Digital Library

This project investigates the clinical occurrence of concurrent thoracic aortic aneurysms (TAA) and intracranial aneurysms (ICA). We hypothesized that patients with a TAA have an increased risk of harboring a concurrent ICA, and likewise that patients with an ICA have an increased risk of harboring a concurrent TAA relative to the general population. In a separate arm of this project, we hypothesized that a pre-defined gene expression profile, based on the expression levels of 41 specific genes measured in peripheral blood cells, will exhibit a characteristic expression pattern in ICA patients and thereby have utility in detecting the presence of …

Walk This Way: Predicting Postoperative And Discharge Outcomes Among Ambulatory Surgical Patients, Charles Odonkor

Yale Medicine Thesis Digital Library

Within the ambulatory surgical setting, existing risk prediction models focus predominantly on postoperative factors of nausea, vomiting, and pain, but do not uniformly specify preoperative predictors of outcomes across multiple surgical specialties. Identification of preoperative markers, specifically those that are reversible, is key to improving risk stratification and designing patient-specific clinical interventions. Recent work shows that preoperative gait speed is a promising marker of postoperative morbidity and mortality within the inpatient surgical population. However, it remains to be explored whether gait speed is sensitive enough to delineate discharge and postoperative outcomes within the ambulatory surgical population.

We sought to determine …

Patient Assessment In Orthopedics: Spine And Trauma, Ferrin Katarina Ruiz

Yale Medicine Thesis Digital Library

In many areas of orthopedics, it is important to have the tools to adequately evaluate a patient. It is sometimes challenging to obtain and quantify both objective and subjective data that contribute to the entire picture of a patient. The goal of this research was to work toward improvement in the quality of different aspects of patient assessment in orthopedics.

The first project focused on the use of outcomes measures in reference to low back pain and mobility. Pain and disability were assessed using patient-report surveys, including the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). Mobility was …

Leptin: A Novel Hormone Of The Parathyroid Gland, Don Hoang

Yale Medicine Thesis Digital Library

Purpose: To investigate the expression and exogenous effect of Leptin hormone in diseased parathyroid glands at a basic science and clinical level.

Introduction: Hyperparathyroidism (HPTH) is a common endocrine problem affecting 1 in 500 individuals who are typically female and over the age of 60. Combined effects of low calcium and vitamin D stimulating parathyroid activity and excess PTH secretion are well established, especially in secondary HPTH. Unclear is the mechanism behind the development of hyper secreting parathyroid adenomas, responsible for nearly 90% of primary HPTH. Discovered in 1994 as a class 1 cytokine receptor, leptin has mounted considerable interest …

Obstacles To Bariatric Surgery Provision In Adolescents In England & Scotland, Kristel Carrington

Yale Medicine Thesis Digital Library

Obesity is an epidemic of global proportions and contributes significantly to the burden of chronic disease and disability. Bariatric surgery is the only effective treatment for morbid obesity. Patients not only lose weight but see vast improvement in obesity related comorbidities. Childhood obesity is one of the most serious public health challenges of the 21st century. England, Scotland and the US have some of the highest rates of childhood obesity, with increasing rates of obesity related comborbidities seen in this population. In adolescents, bariatric surgery has been shown to be safe and effective. England and Scotland have significantly lower rates …

Epigenetic Events Suggest A Distinct Molecular Pathogenesis In Braf-Associated Papillary Thyroid Cancer, Ogechukwu Eze

Yale Medicine Thesis Digital Library

EPIGENETIC EVENTS SUGGEST A DISTINCT MOLECULAR PATHOGENESIS IN BRAF-ASSOCIATED PAPILLARY THYROID CANCER.

Ogechukwu Eze, Lee Starker, William Long, Robert Udelsman, Peyman Björklund, and Tobias Carling. Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

Papillary thyroid cancer (PTC) associated with a somatic V-raf murine sarcoma viral oncogene homolog B1 (BRAF) V600E mutation has been associated with a more aggressive phenotype (i.e. extrathyroidal extension, lymph node metastasis, high TNM stage and recurrence) than those with wildtype (WT) BRAF. The underlying molecular mechanism for this association is incompletely clarified. Epigenetic alterations, such as DNA methylation participate with genetic abnormalities …

Surgical Patients With Do-Not-Resuscitate Orders: An Analysis Of Characteristics And Short-Term Outcomes Among 8256 Patients, Hadiza Shu'aib Kazaure

Yale Medicine Thesis Digital Library

Surgical Patients with Do-Not-Resuscitate (DNR) Orders: An Analysis of Characteristics and Short-term Outcomes Among 8256 Patients

Hadiza S. Kazaure, Sanziana A. Roman, Julie Ann Sosa

Section of Endocrine Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT

Objective: Using data obtained from more than 120 hospitals participating in the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP, 2005-08), the characteristics and outcomes of patients who underwent surgery with a DNR order were examined.

Methods: Patients with a DNR order were matched by age and procedure, to those without a DNR order. The main outcomes of interest …

3d-Fse Isotropic Mri Of The Lumbar Spine: New Application Of An Existing Technology, Daniel John Blizzard

Yale Medicine Thesis Digital Library

Daniel J. Blizzard, Andrew H. Haims, Andrew W. Lischuk, Rattalerk Arunakul, Joshua W. Hustedt, and Jonathan N. Grauer. Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT.

The purpose of this study was to assess the diagnostic performance of three-dimensional, isotropic fast/turbo spin-echo (3D-TSE) in routine lumbar spine MR imaging.

Conventional 2D-FSE MRI requires independent acquisition of each desired imaging plane. This is time consuming and potentially problematic in spine imaging, as the plane of interest varies along the vertical axis due to lordosis, kyphosis, or possible deformity. 3D-TSE provides the capability to acquire volumetric datasets …