Medicine and Health Sciences Commons^™

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 …

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 …

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 …

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 …

“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 …

"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 …

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 …

Predictors Of Very Late Onset Infection In Kidney Transplant Recipients At Least Ten Years Post Transplant, Harry Cheung

Yale Medicine Thesis Digital Library

Although there have been improved outcomes for kidney transplant recipients, infection is still a leading cause of morbidity and mortality for long-term kidney transplant survivors (LTKS). This thesis and study aims to investigate the epidemiology of very late onset infections (>10 years post-transplant), or VLOI and clinical markers that can predict these infections.

A single-center, retrospective study of a cohort of patients (≥18 years old) who underwent kidney transplantation between 2003-2009 and survived for at least 10 years post transplantation was conducted. The primary outcome studied was the occurrence of VLOI. The data collected included transplant data, patient co-morbidities, …

Comorbid Pad And Mvd: A Retrospective Nrd Analysis Of Trends, Outcomes, And Readmissions, Miguel Algara

Yale Medicine Thesis Digital Library

ABSTRACTBackground: Previous studies on select populations have shown worsened limb outcomes among patients with comorbid Peripheral artery disease (PAD) and Microvascular disease (MVD), however this connection has not been studied in larger populations. Using a national database, we aimed to analyze the frequency of Major Adverse Limb Events (MALE), as well as Major Adverse Cardiac Events (MACE), Mortality, and other comorbidities for patients with comorbid PAD/MVD, as compared to patients with PAD or MVD alone. Methods: Using 2011 to 2018 National Readmission Database (NRD) data, we identified the frequency of PAD and MVD-related admissions based on ICD-9/10 codes. The primary …

The Real Cause Of The Broken Rib: Developments In Pediatricians' Approach To Child Abuse; 1960 - 2020, Sofia Charania

Yale Medicine Thesis Digital Library

In 1962, C. Henry Kempe published his landmark work, The Battered Child Syndrome, and set into motion a new discourse on child abuse within the American pediatrics community. This paper discusses the tension pediatricians felt between longstanding assumptions of parental virtue and the implications of the emerging conversation on child abuse started by Kempe. It also discusses the resistance shown by some pediatricians to accepting the reality of abuse and the slow process by which that resistance was overcome, aided by factors such as pediatricians’ involvement in adoption procedures. As pediatricians began confronting and understanding child abuse more deeply, their …

Primary Care Characteristics And Medication Management Among Patients Receiving Office Based Opioid Treatment With Buprenorphine, Xinxin Du

Yale Medicine Thesis Digital Library

AbstractBackground: Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients. Objective: To characterize medical conditions, medications, and treatment outcomes among patients receiving office-based opioid treatment (OBOT) with buprenorphine for OUD, and to describe differences among patients by age and by time in care. Methods: This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within …

Impact Of Single-Family-Room Nicu Design On Infant Neurodevelopment And Breast Milk Provision, Lucille Kohlenberg

Yale Medicine Thesis Digital Library

NEONATAL INTENSIVE CARE UNIT DESIGN IMPACTING INFANT OUTCOMES AND BREAST MILK PROVISION.

Lucille Kohlenberg and Angela Montgomery, MD, MSEd. Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine. New Haven, CT.

Single-family room (SFR) NICUs have gradually replaced open-bay (OB) units over the last three decades. Compared to OB units, SFR units provide increased opportunities for parental rooming and maternal breast milk (MBM) provision; however, they may also present fewer sensory exposures and parental learning opportunities. Due to the presence of potentially beneficial and detrimental effects, it remains uncertain whether the SFR design offers aggregate advantages over the …

Assessment Of Emergency Care Services In Nigerian Hospitals: A Cross-Sectional Study, Kelechi Herbert Umoga

Yale Medicine Thesis Digital Library

The Accident and Emergency (A&E) unit in Nigeria is a key entry point to access health care for patients with various diseases. Currently there are limited data assessing the functionality of these units and their capacity for care. This study aims to evaluate the functional capacity of A&Es in Nigeria and to identify factors impeding optimal care.We conducted a cross-sectional study of seven hospitals in Nigeria, randomly selecting one hospital from each of the six geopolitical zones, and purposively including National Hospital Abuja. We used a universal sampling technique interviewing all doctors and nurses identified as routine A&E staff. We …

Changing Selection And Epistasis On Drivers Over Tumorigenesis In Primary And Metastatic Prostate Cancer, Alexander Yang

Yale Medicine Thesis Digital Library

Background: Many attempts have been made to characterize and describe the driver genes and mutations responsible for prostate cancer tumorigenesis. We have quantified the cancer effect size—a direct measurement of the survival advantage a mutation confers—for 2699 primary and metastatic prostate tumor samples. Our measure of cancer effect treats tumorigenesis as an evolutionary process, subject to positive and negative selective pressures. We have applied this metric in a stage-specific manner to elucidate which mutations are selected for as prostate cancer develops.Methods: We analyzed 2699 prostate cancer tumor exomes, genomes, and panel sequences (1648 primary tumors and 1051 metastatic samples). The …

Is Risk Compensation Real? The Effect Of Perceived Level Of Hiv Acquisition On Risk Behavior In A Pilot Pre-Exposure Prophylaxis Demonstration Project In Men Who Have Sex With Men In Malaysia, Kelsey Rankin

Yale Medicine Thesis Digital Library

Pre-exposure prophylaxis (PrEP) is highly effective in human immunodeficiency virus (HIV) prevention for key populations, including men who have sex with men (MSM). In Malaysia, human immunodeficiency virus (HIV) prevalence among MSM is 22%, and is even higher in key urban areas, including Kuala Lumpur. Despite nationwide campaigns committed to address HIV, scale-up of PrEP for MSM in Malaysia has been suboptimal. This limitation can be attributed partially to concerns that PrEP will lead to increased sexual risk behaviors, based on the controversial theory of risk compensation.

A 2018 PrEP demonstration study of MSM in Malaysia (n=150) was used to …

Temporal And Geographic Trends Analysis Of American Academy Of Ophthalmology Political Action Committee (Ophthpac), Jun Hui Lee

Yale Medicine Thesis Digital Library

The purpose of study was to examine the trends in both the incoming donations from American Academy of Ophthalmology members and outgoing political contributions to U.S. House of Representative candidates by OPHTHPAC. This retrospective, observational analysis included all of OPHTHPAC’s large donations and campaign contributions between 1989 and 2018. Data on U.S. congress members were combined with the financial records to tabulate the results of campaigns that received OPHTHPAC contribution. Ordinary linear regression was used to assess temporal trends in the amount and number of financial transactions as well as the election results and political characteristics of candidates. The donations …

Characteristics, Motivations, And Experiences Of Women Using Nitrous Oxide During Childbirth, Gwendolyn Towers

Yale Medicine Thesis Digital Library

CHARACTERISTICS, MOTIVATIONS, AND EXPERIENCES OF WOMEN USING NITROUS OXIDE IN CHILDBIRTH

Gwendolyn Towers, Michelle Telfer, Jessica L. Illuzzi. Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT

Nitrous oxide labor analgesia is growing in popularity in the United States, with little known regarding the factors driving this trend or about women’s experiences with the method. This study, which includes both a quantitative and a qualitative component, contributes to our understanding of the use of nitrous oxide labor analgesia in the US by exploring the following: (1) who uses the method and how these women …

Somatic Gja4 Mutation In Vascular Malformations Reveals A Novel Pathway For Vascular Neoplasia, Nelson C. Ugwu

Yale Medicine Thesis Digital Library

The term “cavernous hemangioma” has been used to describe vascular anomalies with histology featuring dilated vascular spaces, vessel walls consisting mainly of fibrous stromal bands lined by a single layer of flattened endothelial cells, and a variably irregular outer rim of interrupted smooth muscle cells. Hepatic hemangiomas (HH) and cutaneous venous malformations (cVM) share this histologic pattern, and we examined lesions in both tissues to identify genetic drivers. Paired WES of lesional tissue and normal liver in HH subjects revealed a recurrent GJA4 c.121G>T, p.Gly41Cys somatic mutation in four of five unrelated cases, and targeted sequencing in paired tissue …

The Future Of Global Interventional Radiology, Austin-Marley Windham-Herman

Yale Medicine Thesis Digital Library

Interventional Radiology (IR) has become an integral component of modern, developed healthcare systems. The minimally invasive, image-guided procedures that the field offers are highly effective and often lead to significantly less morbidity than alternative surgical options. The growth of IR globally is in an early phase; however, patients and healthcare systems stand to benefit from its rapid expansion and integration around the world.

Globally, billions of people are without access to safe surgery and diagnostic imaging. However, the democratization of radiology resources such as portable ultrasound and low-cost medical devices is making IR more accessible than ever before. Global healthcare …

The Role Of Knowledge In End-Of-Life Decision-Making By Older Persons, Laura Van Dyck

Yale Medicine Thesis Digital Library

As physicians, we aim to support our patients to engage in and make end-of-life medical decisions. Ideally, patients engage in advance care planning (ACP) to direct their care if they become incapable of participating in decision-making. For many patients, however, their first encounter with end-of-life care—e.g. code status—occurs at hospital admission. This thesis describes two studies: the ACP Study and Code Status Study. The ACP Study examines ACP knowledge and its relationship to engagement. This study utilizes baseline data from 921 participants age 55 years enrolled in the STAMP randomized controlled trial, including a knowledge scale consisting of 7 questions …

Same-Day Referral Of Patients With Elevated Preoperative Blood Pressure To Primary Care Providers, Shaunte Butler

Yale Medicine Thesis Digital Library

SAME-DAY REFERRAL OF PATIENTS WITH ELEVATED PREOPERATIVE BLOOD PRESSURE TO PRIMARY CARE PROVIDERSShaunte Butler, Natalie Holt, Feng Dai, Catherine Quick, Jeffrey D. Kravetz, Albert Perrino Jr., Robert B. Schonberger. Department of Anesthesiology, Yale University, School of Medicine, New Haven, CT.

Although recent studies show that elevated blood pressures as measured during the preoperative evaluation are often predictive of true hypertension, it is not yet known what interventions during the preoperative evaluation may result in modifications of longitudinal blood pressure trajectories. We herein report the results of a quality improvement project at a preoperative evaluation clinic that aimed to improve hypertension …

A Comprehensive Study Of Comorbidities And Treatments Including Tnf-⍺ Inhibitors In Patients With Acute Scleritis, Ahmad Abdel-Aty

Yale Medicine Thesis Digital Library

Scleritis is a highly symptomatic inflammatory disease of the sclera. We conducted a retrospective study to identify demographic factors and comorbidities associated with resolution of scleritis, to compare patient outcomes on different treatments for scleritis, and to compare treatment utilization by the different medical specialties that manage scleritis. The medical records of all patients with a CPT code for scleritis seen at a tertiary care center from January 1, 2013 to January 1, 2020 were reviewed. Data was collected on demographic factors, comorbidities, and treatment. The primary outcome measures were time until resolution of disease, defined as quiescence of inflammation …

Associations Between Cardiac Manifestations Of Noonan Syndrome And Adverse Pregnancy Outcomes, Christopher Chow-Parmer

Yale Medicine Thesis Digital Library

ASSOCIATIONS BETWEEN CARDIAC MANIFESTATIONS OF NOONAN SYNDROME AND ADVERSE PREGNANCY OUTCOMESChristopher Chow, Katherine Campbell, and Robert Elder Yale University School of Medicine, New Haven, CT The goal of this study was to characterize a population of woman with Noonan syndrome who had been pregnant in order to determine the safety and feasibility of pregnancy. We performed a retrospective chart review of patients evaluated at Yale-New Haven Hospital from 2012-2020 with a diagnosis of Noonan syndrome and pregnancy. We identified 5 women with Noonan syndrome who had a total of 10 pregnancies. In terms of maternal cardiac disease, 3/5 patients had …

Evaluating Clinician Features And Reporting Decisions On Performance In The Merit-Based Incentive Payment System, Christopher Robert Han

Yale Medicine Thesis Digital Library

The Merit-Based Incentive Payment System (MIPS) is the largest change to physician reimbursement in decades. We sought to examine clinician participation and performance of clinicians to better understand the relationship between clinician features and reporting decisions on MIPS scores and payment adjustments.

Using publicly available data from the Centers for Medicare and Medicaid Services (CMS), we examined 2018 clinician participation and performance in the MIPS. We analyzed aggregate MIPS score performance as well as payment adjustment results stratified by clinician specialty, reporting affiliation, practice size, and the CMS special status designating rural or health profession shortage area (HPSA). Using linear …

Preauthorizations In Orthopaedic Surgery: An Analysis Of A Single Institution’S Spine Center, Kareem Jamal Kebaish

Yale Medicine Thesis Digital Library

Introduction

Preauthorizations are frequently required by commercial insurers before patients can undergo magnetic resonance imaging (MRI) of the spine. In addition to the administrative burden, such processes can lead to delays in care. The current study assessed the rates and eventual disposition of preauthorizations required prior to spine MRIs ordered from an academic spine center.

Methods

Patients from a single academic institution’s spine center who were covered by commercial insurance and referred for a spine MRI between January 2013 and December 2019 were included in the analysis. The requirement for preauthorization and eventual disposition of each of these studies was …