Medicine and Health Sciences Commons^™

Decision Making In Patients With Initial Positive Deep Margins On Diagnostic Biopsy Of Melanoma, Ana Eliza Souza Cunha

Yale School of Medicine Physician Associate Program Theses

Background: Current guidelines recommend SLN biopsy (SLNB) among patients with initial Breslow Thickness (BRES) ≥0.8mm at initial screening. However, there is limited guidance regarding SLNB among patients who have deeper final depth after initial biopsy.

Methods: We conducted a retrospective cohort study of 62 thin melanoma patients with primary lesions with initial Breslow Thickness (BRES)

Results: Approximately 55% of patients (n = 34) included in our study underwent SLNB. After adjustment, there was no association between SLNB status and recurrence. Immunosuppressive drug use was associated with higher odds of local (OR= 28.56 CI 1.87- 435.53; p =0.016) and regional recurrence …

Differences In Predicted Risk Of Mortality After Coronary Artery Bypass Graft Between Black And White Patients With Identical Clinical Profiles Using The Society Of Thoracic Surgeons Calculator: An In-Silico Cohort Study, Kiara Marmolejos

Yale School of Medicine Physician Associate Program Theses

Abstract/Summary:

Background: “The Society of Thoracic Surgeons mortality risk calculator”, which includes a race variable, is recommended for estimating Short- term (30 day) predicted risk of mortality after isolated coronary artery bypass graft, with a risk estimate of 3-4% stratifying patients into intermediate risk, a risk estimate above 5% stratifying patients into high risk for surgery and a risk estimate above 8% stratifying patients into the very high-risk category. We compared differences between Black and White individuals in Society of Thoracic Surgeons-predicted risk of mortality across various plausible risk factor combinations with the aim of evaluating if using the predictive …

Narrative Therapy And Quality Of Life In Functional Neurological Disorder, Amber Wilder

Yale School of Medicine Physician Associate Program Theses

Functional Neurological Disorder is a severely disabling and stigmatized condition in which motor or sensory neurological symptoms cannot be attributed to a known neurological condition and are considered to be psychological in nature. Cognitive behavioral therapy improves depression and neurological symptoms for some patients, but many do not respond to therapy, and treatment adherence is extremely low. Narrative therapy is a psychotherapeutic model based in reframing one’s life story, and it is associated with decreased self-stigma and improved treatment adherence and engagement, but it has not been studied in Functional Neurological Disorder. In this randomized controlled trial, we will compare …

Telemedicine Slashes ‘No Show’ Rates And Achieves Comparable Outcomes In Diabetes Care, Jay Gandhi

Yale School of Medicine Physician Associate Program Theses

Abstract

Telemedicine Slashes ‘No-Show’ Rates and Achieves Comparable Outcomes in Diabetes Care

Jay Gandhi, PA-SII, and Jonathan Weber, MA, PA-C, DFAAPA, Yale Medicine Diabetes Center at Yale-New Haven Hospital, Yale Physician Associate Program

Background

Patients with type 2 diabetes (T2D) require continuous management to achieve optimal outcomes. Patients confronting barriers to care face higher risks of complications. Socioeconomic barriers including inability to afford transportation, work release, childcare or parking fees are factors affecting patient attendance. During the Covid-19 pandemic, telemedicine likely reduced common barriers affecting patient attendance compared to in-person visits. This study investigated the impact of telemedicine on no-show …

Use Of A Decision Aid In Medication Initiation Among Patients With Opioid Use Disorder And Hiv, Katrina Gateley

Yale School of Medicine Physician Associate Program Theses

Opioid use disorder refers to the maladaptive use of prescribed or illicit opioids. This condition can be treated using pharmacotherapy referred to as medications for opioid use disorder (MOUD), but they are underutilized. Opioid use disorder is more prevalent among people living with HIV (PLH), highlighting a target population for interventions to increase treatment. Patient decision aids have been successful in affecting decision-making in other populations. However, no decision aid for medication for opioid use disorder has been utilized among patients with comorbid HIV and OUD. In this randomized cluster trial, we will determine whether a patient decision aid affects …

Effect Of Intranasal Insulin For Anosmia And Hyposmia In Parkinson’S Patients, Eden Anonye

Yale School of Medicine Physician Associate Program Theses

Olfaction impairment is one of the earliest nonmotor symptoms of Parkinson’s disease. Olfaction disorders in patients with Parkinson’s disease can range from hyposmia, a reduction in smell ability, to anosmia, a complete loss of smell. Regardless of severity, olfaction loss can result in decreased well-being and mood disorders. However, there is no approved management for anosmia or hyposmia secondary to Parkinson’s disease. Insulin is hypothesized to modulate olfactory neuron regeneration in patients with post-infectious hyposmia, but its effects have not been studied in Parkinson’s patients. Using a randomized controlled trial design, we seek to determine whether eight weeks of daily …

Brief Interventions In Adult Roux-En-Y Gastric Bypass Patients With At-Risk Alcohol Use, Ruth Seok

Yale School of Medicine Physician Associate Program Theses

Bariatric surgeries are the most effective treatment for severe obesity. However, despite the benefits, patients who undergo bariatric surgery, especially Roux-en-Y Gastric Bypass, are at a higher risk of developing alcohol use disorders compared to the general population. There is currently limited research that evaluates interventions to decrease unhealthy alcohol use in at-risk bariatric patients. This study aims to investigate whether an intervention strategy known as Brief Intervention can reduce alcohol consumption in Roux-en-Y patients who screen positive for at-risk alcohol use. We will randomize adult post-operative patients who screen positive to either receive brief interventions or usual care. Alcohol …

Linkage To Outpatient Treatment In Inpatients With Alcohol Use Disorder Started On Naltrexone, Stephanie Stamatis

Yale School of Medicine Physician Associate Program Theses

Naltrexone is a full opioid antagonist approved for the treatment of alcohol use disorder that can effectively reduce alcohol consumption. There are few studies that study the impact of starting naltrexone for alcohol use disorder in the inpatient setting. We propose to compare rates of outpatient treatment follow-up for alcohol use disorder in hospitalized patients who are referred to treatment without initiating naltrexone versus those initiated on oral naltrexone or injectable naltrexone. Using an open-label, randomized clinical trial design, we will enroll 75 adults aged 18 to 55 with alcohol use disorder admitted to a general medicine inpatient service and …

Efficacy Of Psychotherapy-Supported Mdma In The Treatment Of Complex Posttraumatic Stress Disorder, Danielle Dubois

Yale School of Medicine Physician Associate Program Theses

Complex Posttraumatic Stress Disorder is a debilitating psychiatric disorder with no approved treatment options despite the high symptom burden and diminished quality of life. Randomized controlled trials have shown robust attenuation of posttraumatic stress disorder symptomatology using treatment with 3,4-Methylenedioxymethamphetamine (MDMA) plus psychotherapy, but individuals with complex traumatization have not been studied explicitly. Prior trials primarily utilized an inactive placebo group, undermining the interpretation of the results due to concern for unblinding of subjects. The proposed study is the first to utilize an active comparator to test a key hypothesis related to MDMA’s mechanism of action and to preserve blinding. …

Comparison Of Oral Carotene Supplementation And Oral Polypodium Leucotomas In Preventing Photodamage, Jazmin Martinez

Yale School of Medicine Physician Associate Program Theses

Skin exposure to ultraviolet (UV) irradiance is the major cause of skin disorders, such as sunburn and nonmelanoma cancer. The current standard of care for photoprotection is the daily use of sunscreen, although patient adherence and adequate application continues to be an issue. Current data show systemic photoprotection can be added to sunscreen use to reduce the risk of cutaneous diseases. This randomized controlled study will investigate whether supplementation with Polypodium leucotomas versus carotenoid supplementation versus the standard of care, provide increased photoprotection in adults with Fitzpatrick skin types II-IV. Outcomes will be measured by comparing the minimal erythema dose …

Managing Refractory Status Epilepticus With Early Ketamine Administration, Ashlyn Shavers

Yale School of Medicine Physician Associate Program Theses

Status epilepticus is a time-sensitive neurological emergency that can be associated with severe disability and mortality. Approximately 20% of patients with status epilepticus will fail to respond to existing first and second-line therapies that act on similar receptors. There is a need for additional therapeutic options. One candidate drug, ketamine, has a novel mechanism of action and may work synergistically to terminate seizures. This study seeks to examine whether ketamine administration along with other second-line medications can reduce seizure burden in patients with status epilepticus. Using an open-label randomized clinical trial of 436 patients, we will examine the proportion of …

Providing Trauma Informed Care For Individuals On Opioid Agonist To Increase Contraception, Devon Knight

Yale School of Medicine Physician Associate Program Theses

Individuals with opioid use disorder report having less reproductive and sexual health knowledge and are at greater risk of unintended pregnancy than their peers. This has led to increased neonatal opioid withdrawal syndrome and an increased healthcare burden, yet providing contraception and trauma informed care at treatment centers for individuals engaging in medication treatment has not been emphasized. Co-locating trauma informed reproductive and sexual health education and contraception access at substance use treatment centers provides a unique opportunity to improve knowledge and access to care for this population. We propose a randomized control trial to determine whether trauma informed care …

Spinal Fusion For Adult Degenerative Scoliosis: Rct Of Robot-Assisted Versus Navigation Guidance, Kyle Hanks

Yale School of Medicine Physician Associate Program Theses

Adult degenerative scoliosis is characterized by the side-to-side curvature of the spine due to the degeneration of facet joints and intervertebral discs. Life-limiting cases of adult degenerative scoliosis are corrected by spinal fusion, the success of which is determined by pedicle screw accuracy. Robot-assisted guidance has become more commonly used in spinal surgery to ensure pedicle screw placement. However, there is limited evidence for the role of robot-assisted guidance in the correction of adult degenerative scoliosis. Here, in this randomized controlled trial, we aim to investigate whether robot-assisted guidance can more consistently produce accurate pedicle screw placement than neuronavigation …

The Effect Of Neurologic Music Therapy On Speech Intelligibility In Children With Cerebral Palsy, Paulina Perez-Curiel

Yale School of Medicine Physician Associate Program Theses

Cerebral palsy is the most common motor disability in children and is caused by abnormal development of or damage to the brain. Children with cerebral palsy often have speech disorders, most commonly dysarthria, due to deficits in speech-motor control. The inability to communicate effectively can lead to needs not being met, self-isolation, and an overall decrease in self-perception and quality of life. In this randomized control trial, we will evaluate whether Neurologic Music Therapy improves word-level speech intelligibility in children with Cerebral Palsy. Fifty children will be exposed to Neurologic Music Therapy and fifty children will receive standard speech therapy. …

Auricular Acupressure On Depression And Anxiety In Mothers With Peripartum Depression, Jane Chan,

Yale School of Medicine Physician Associate Program Theses

Peripartum depression is a prevalent mental health disorder characterized by clinically significant depressive symptoms that can markedly impair maternal functioning, mother-infant bonding, and infant development. Current treatments for peripartum depression include pharmacotherapy and psychotherapy, but cost, time investment, and potential adverse effects limit their effectiveness. Auricular acupressure has been shown to improve a variety of conditions, however, there is a lack of application in peripartum depression. In this study, we propose to determine whether magnetic bead auricular acupressure reduces symptoms in mothers with peripartum depression. Using a randomized controlled trial, we will assign patients to either acupressure or sham acupressure …

Sensor-Monitored Compliance Following Rcr And Effects On Postoperative Prognosis, Phillip Westbrook

Yale School of Medicine Physician Associate Program Theses

Rehabilitation in the immediate postoperative period after surgical rotator cuff repair is critical for long-term patient outcomes. This rehabilitation typically consists of six weeks of immobilization with a sling following surgery to optimize tendon-to-bone healing, but the benefit of this has been debated in recent years. The optimal immobilization period is difficult to determine because patient compliance with immobilization protocols varies. Subjective measures from patients regarding compliance are often unreliable, suggesting a need for a more objective approach. In this prospective cohort study, we will use temperature sensors to monitor sling wearing times and assess the effect of patient compliance …

Dichloroacetate As A Metabolic Treatment For Glioblastoma, Megan Macia

Yale School of Medicine Physician Associate Program Theses

Glioblastoma is the most common aggressive primary brain tumor in adults, and there is no current standard of care for progression. The Warburg effect is a known part of cancer’s metabolic reprogramming and has been studied as a possible target for limiting tumor growth. Dichloroacetate, a pyruvate dehydrogenase kinase inhibitor, has been proposed as a treatment for glioblastoma, and the drug has had success in phase 1 trials. The proposed study is an open-label, randomized phase 2 clinical trial. Participants will be randomized to oral dichloroacetate, with dosing based on genetic testing, or to a control group treated with lomustine. …

A Cross Sectional Review: Effects Of Dehydration On Subdural Hematoma Risk In Athletes, Lina Nguyen

Yale School of Medicine Physician Associate Program Theses

Subdural hematomas are precedent to nearly all catastrophic head injuries in athletics, and are a leading cause of death and morbidity in sports. While known risk factors exist, cases still occur in young, healthy athletes without clear predisposition– occasionally without a precipitating traumatic event. Athletes are at increased susceptibility for dehydration, and the effects of inadequate fluid status on subdural risk is unknown. This study aims to elucidate the relationship between dehydration during athletic activity and subdural hematoma formation. We propose a cross-sectional study utilizing Yale New Haven Hospital electronic medical records, where we compare hydration status at emergency room …

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 …

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 …

Analyzing Pediatric Department Documentation Of Patient Social Needs With Icd-10 Z-Codes, 2019-2020, Oluwatofunmi Jummie Akinwunmi

Public Health Theses

The 10th revision of the International Classification of Diseases (ICD-10) allows healthcare professionals to document social needs with ICD-10 Z-codes. Data derived from documentation of ICD-10 Z-codes can be leveraged to identify at-risk populations for targeted intervention. However, there remains concern for underutilization of these codes particularly in the pediatric population. We sought to examine the documentation of ICD-10 Z-codes in the pediatric outpatient setting of the largest Connecticut hospital network by specialty type and age group. We examined deidentified electronic health records of pediatric outpatient patients from 2019-2020. We used descriptive statistics to measure the proportion of patients with …

Does Environmental Testing Of C. Difficile Predict Whether A Patient Is Positive With C. Difficile?, David Caccese

Public Health Theses

Clostridioides difficile is a major public health threat and frequent cause of healthcare-associated infections. Hospitals have struggled to control C. difficile due in part to the challenge of identifying asymptomatic C. difficile carriers and because of C. difficile’s ability to survive on environmental surfaces for long periods. Asymptomatic carriers and environmental surfaces can contribute to C. difficile transmission. Screening of all patients for C. difficile upon hospital admission is not feasible and asymptomatic patients may not be accepting of surveillance testing. Thus, this study examines whether sampling the patient’s room environment once they have been admitted can indicate a patient …

A Dna-Extraction-Free Method For The Molecular Detection Of Streptococcus Pneumoniae Carriage In Saliva, Tzu-Yi Lin

Public Health Theses

Pneumococcal carriage is a prerequisite for pneumococcal disease and surveillance of carriage is crucial for evaluating and informing vaccination strategies. In recent years, molecular methods have improved the sensitivity of pneumococcal carriage detection as compared to the gold standard culture-based method. However, nucleic acid extraction from samples collected is resource-intensive, limiting scalability for extensive surveillance, particularly in low-resource settings. We previously developed a saliva-based PCR test for SARS-CoV-2, having identified that nucleic acid extraction can be omitted and replaced with a simple enzymatic lysis or heat treatment step without compromising the accuracy and efficiency of testing. Here, we compared pneumococcus …

Interrupted Time Series Analysis To Evaluate Regional Greenhouse Gas Initiative Health Impacts, Julia Sweatman

Public Health Theses

Abstract

Background & Aims: Fossil fuel combustion emits a spectrum of ambient air pollutants, with the most harmful health effects seen from particulate matter 2.5 μm or less in diameter (PM2.5). Pricing carbon can reduce PM2.5 emissions and yield co-benefits for public health. The Regional Greenhouse Gas Initiative (RGGI) is a cooperative carbon pricing initiative among twelve states aiming to curb carbon dioxide emissions from the power sector. This preliminary analysis explores methodological approaches to quantify the health benefits associated with PM2.5 changes after RGGI was first implemented in 2009.

Methods: An interrupted time series analysis was performed to compare …

A Retrospective Cohort Study: Association Of Sex And Race Differences On 30-Day Retention In Addiction Treatment For Substance Use Disorders After Discharge, Bingning Wang

Public Health Theses

Objective: Little is known about the association of sex and racial differences in accessing SUD treatment. little is known whether these disparities continue despite hospitalization. The main objective was to determine the association of race and sex differences on 30-day retention in addiction treatment for all substance use disorders after discharge. Design: A Retrospective Cohort Study using the Yale Addiction Medicine Consult Service databaseSubjects: Patients with SUD who were hospitalized at Yale New Haven Hospital from Oct 26th, 2018 to Jun 30th, 2021 are eligible, which has 2557 observations. Methods: Mixed effect multivariable logistic regression for sex and racial differences …

Recommendations For Climate Adaptation To Preserve Connecticut Drinking Water Quality And Quantity, Matthew Salvatore Di Vitto

Public Health Theses

Climate change impacts drinking water both directly and indirectly. Increases in temperature, drought frequency, and precipitation are among the climate impacts which currently and are projected to affect water quality and quantity in the continental United States. These impacts limit access to clean and abundant water sources by damaging habitat, spreading toxic substances via runoff and favoring the growth of harmful algal blooms. States can learn from one another to adopt best practices and policies to increase water resilience around the country. This paper explores how Connecticut can employ strategies from the States of New York, New Jersey, Massachusetts, Minnesota, …

Psychological Resilience In U.S. Military Veterans: Results From The 2019-2020 National Health And Resilience In Veterans Study, Michael Georgescu

Public Health Theses

Psychological resilience is the most common response following exposure to traumatic life events. To date, most research has focused on factors associated with adverse post-trauma mental health outcomes rather than understanding those associated with psychological resilience. In particular, little is known about factors associated with resilience in veterans, despite their high rates of trauma exposure, such as combat and military sexual trauma. To address this gap, we used a discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalize resilience and to identify modifiable health and psychosocial factors associated with resilience in a nationally representative sample of U.S. veterans (N = 4,069). …

Cleft Lip And Depression In Adults: A Multi-Ancestry Mendelian Randomization Study, Anne Lyon Havlik

Public Health Theses

Background: Clefting of the lip with or without cleft palate (CLP) is the most common congenital craniofacial abnormality globally, affecting one in 700 live births. Traditional observational studies suggest an increased risk of adult depression among subjects with CLP, but these studies are subject to residual confounding.Objective: We aimed to address residual confounding by evaluating the association between the genetically-predicted risk of CLP on the risk of adult depression in a Mendelian randomization framework. Methods: We used single-nucleotide polymorphisms strongly associated with CLP as genetic instruments. Genetic associations with adult depression were extracted from separate studies. Three ancestry groups were …

For “Them”, Not Us: A Qualitative Study Of Asian American Pacific Islander Perceptions Of Substance Use And Harm Reduction, Winnie Ho

Public Health Theses

Background: Asian American Pacific Islander (AAPI) substance use data is typically aggregated in a way that not only produces overly generalized results, but also potentially perpetuates stereotypes created by the Model Minority Myth (MMM). This has mutually reinforced a lack of representation and understanding of AAPI substance use experiences and needs. This presents a public health concern that is both excluding them from consideration by the field of harm reduction, but also themselves from considering harm reduction. Disaggregated data shows rising rates of substance use and associated harms that are often hidden or not taken as seriously as a public …

"Hair-Esteem Toolkit For Black Girls": The Development Of A Self-Esteem Toolkit For Black Adolescent Girls Centering Hair As A Tool For Empowerment, Sydney Hussett-Richardson

Public Health Theses

Background: For Black adolescent girls, hair is a strong staple of gender and ethnic identity, influencing intrapersonal and interpersonal interactions. Gendered racism and Eurocentric beauty standards pathologize Black girls and their hair, leading them to experience high rates of hair harassment and discrimination. These experiences negatively impact the self-esteem of Black girls, which has important implications for a host of health behaviors. The purpose of this study was to explore the relationship between self-esteem and hair among Black girls and integrate findings into a culturally relevant digital toolkit to promote and develop hair-esteem and self-esteem among Black girls.Methods: This study …