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Behavioral Outcomes In Patients With Metopic Craniosynostosis: Relationship With Radiographic Severity, Mariana Almeida

Yale Medicine Thesis Digital Library

Children with metopic nonsyndromic craniosynostosis have been found to have more neurocognitive and behavioral difficulties, when compared to other types of nonsyndromic craniosynostosis. These neurocognitive and behavioral difficulties can be apparent later in life even following surgical correction of the cranial dysmorphology at infancy. The factors that may be contributing to these difficulties have not been fully elucidated. In metopic craniosynostosis, radiographic severity can be measured using computed tomography imaging. Pre-operative radiographic severity has been demonstrated to be associated with worse reading abilities at school age. However, these studies have had limited sample sizes. Furthermore, the impact of radiographic severity …

Refractory Neurogenic Cough Management: The Non-Inferiority Of Soluble Steroids To Particulate Suspensions For Superior Laryngeal Nerve Blocks, Hisham Abdou

Yale Medicine Thesis Digital Library

Purpose: Superior laryngeal nerve (SLN) block utilizing triamcinolone (TA) or methylprednisolone acetate (MP) has been described as an efficacious treatment for refractory cough (RC). Particulate corticosteroid injection in the neck carries a risk of large-particle embolization and devastating neurologic sequela in the event of inadvertent intravascular injection. Herein, we compare the efficacy of a soluble steroid (dexamethasone, SS) with particulate steroids (PS) in reducing cough severity in RC-patients.Materials and Methods: Patient charts for those receiving SLN blocks by fellowship-trained laryngologists for the sole indication of RC were reviewed. Drug/dose, timing/laterality, and adjuvant treatments were compared using chi-squared test. A paired …

Radiology Education For U.S. Medical Students In 2024: A State-Of-The-Art Analysis, Ryan Bahar

Yale Medicine Thesis Digital Library

Radiology is essential to the practice of clinical medicine, with ever-increasing volumes of diagnostic imaging studies and image-guided procedures across the U.S. healthcare system. Yet, radiology education has received criticism for its under-representation in formal U.S. medical school curricula, coupled with variable requirements and offerings among institutions. Recent national calls for medical education reform (e.g., the 2010 Carnegie report) and the emergence of new teaching tools (e.g., e-learning, simulation) have led to paradigm shifts in medical education delivery that have been further accelerated by the unprecedented alterations to educational environments catalyzed by the COVID-19 pandemic. In this landscape of profound …

Predictors Of Adverse Outcomes Following Surgical Intervention For Cervical Spondylotic Myelopathy, Samuel Craft

Yale Medicine Thesis Digital Library

As hospital costs associated with spine surgeries continue to climb, length of stay(LOS) and discharge disposition have been utilized as proxies through which these increasing costs can be assessed. Cervical spondylotic myelopathy (CSM) is the most common spinal pathology among older adults. As a result, studies assessing drivers of increased costs, LOS, and discharge disposition following surgery for CSM are needed. Two factors of interest are psychiatric comorbidities and safety net hospital (SNH) status. Psychiatric disorders are common and can have a profound impact on health, while SNHs serve a large proportion of patients with Medicaid or without insurance. However, …

Bringing Large Language Models To Ophthalmology: Domain-Specific Ontologies And Evidence Attribution, Aidan Gilson

Yale Medicine Thesis Digital Library

Background: In the landscape of medical innovation, Large Language Models (LLMs) represent a groundbreaking advancement, holding substantial promise for reshaping healthcare practices. These models demonstrate remarkable proficiency in assimilating and processing extensive medical literature, facilitating rapid information retrieval. Nevertheless, when applied to the specialized domain of ophthalmology, LLMs encounter significant hurdles owing to the intricacies inherent in this field. Ophthalmology, characterized by the intricate interplay of ocular anatomy, diverse disease manifestations, and nuanced diagnostic subtleties, poses considerable challenges for these generalized models. Compounding these challenges is the inherent limitation of the ophthalmological corpus itself, which remains notably narrower compared to …

The Evolving Landscape Of Academic Plastic Surgery: Understanding And Shaping Future Directions In Diversity, Equity, And Inclusion, Sacha C. Hauc

Yale Medicine Thesis Digital Library

Purpose: This study aims to comprehensively delineate gender and racial disparities in academic plastic and reconstructive surgery by analyzing publication authorship and leadership in academic plastic surgery. We also aim to evaluate the impact of mentorship on diverse representation, examine gender distribution in sub-specialties, and explore the influence of race and sex of plastic surgery leadership on resident/faculty composition. Methods: A comprehensive cross-sectional study investigated sex representation in academic PRS, covering editorial boards, faculty, and leadership positions. The study included 1,918 data points from notable journals and societies, examining names and sex of editorial board members, faculty in PRS residency …

Medicaid Coverage For Undocumented Children In Connecticut: A Political History, Chinye Ijeli

Yale Medicine Thesis Digital Library

In the US, undocumented immigrants are barred from receiving coverage from the federal government for healthcare other than emergency services. States can offer government-funded health insurance to undocumented immigrants, but as of 2021, only six had. Forces standing in the way of other states implementing such coverage include nativism, racism, and fears about immigrants taking scarce jobs during economic downturns.In 2021, Connecticut passed S.B. 956, a bill extending Medicaid coverage to all low-income children up to the age of eight—regardless of immigration status—starting in 2023. This policy was the culmination of a twelve-year-old grassroots movement started by Connecticut Students for …

Janus Kinase Inhibition In Granuloma Annulare: Two Single-Arm, Open-Label Clinical Trials, Erica Hwang

Yale Medicine Thesis Digital Library

Granuloma annulare (GA) is an inflammatory cutaneous granulomatous diseasethat lacks satisfying and effective targeted therapies. Janus kinase (JAK) inhibitors are of interest as they inhibit upregulated cytokines in GA including IFN-γ, IL-4, IL-13, IL-15, IL-21, and oncostatin M. Further investigation is needed to establish the safety profile, optimal route or formulation, and efficacy of JAK inhibitors for GA. We conducted single-arm, open-label clinical trials of abrocitinib, a JAK1-specific inhibitor, and AC- 1101, a topically applied JAK inhibitor, in patients with GA and hypothesized that each medication would be safe, tolerable, and effective at treating GA. In the first study, adult …

The Hardships Of Healthcare Among People With Lived Experiences Of Homelessness In New Haven, Ct, Brandon James Hudik

Yale Medicine Thesis Digital Library

Objectives: People with lived experiences of homelessness encounter barriers to accessing and maintaining appropriate healthcare. This project aims to: 1) identify how these barriers manifest in New Haven, CT; 2) examine the negative health and healthcare impacts such barriers may incur, including when people adapt to or try to overcome them; 3) examine the characteristics of positive experiences in accessing healthcare in order to inform future approaches to healthcare for this vulnerable population.

Methods: This study is a subanalysis of the Justice, Health, and Housing Study (JustHouHS) and draws on longitudinal, qualitative interviews with low-income New Haven residents who experienced …

Population Attributable Fraction Of Reproductive Factors In Triple Negative Breast Cancer By Race, Rachel Jaber Chehayeb

Yale Medicine Thesis Digital Library

Age-adjusted incidence rates of triple negative breast cancer (TNBC) are higher in Black women than in non-Hispanic White (White) women. The disproportionate incidence of TNBC in Black women partially drives the 40% higher mortality rate from breast cancer in Black women compared to White women. Several studies have identified lack of breastfeeding and younger age at first birth as risk factors for TNBC. There are large differences in breastfeeding uptake, breastfeeding duration, and the distribution of age at first birth across racial groups in the US: only 44% of Black women breastfeed for 6 months or longer, compared to 60% …

Evaluation Of Gastroesophageal Reflux And Hiatal Hernia As Risk Factors For Lobectomy Complications, Michael Kaminski

Yale Medicine Thesis Digital Library

Up to 40% of lobectomies are complicated by adverse events. Gastroesophageal reflux disease (GERD) and hiatal hernia have been associated with cardiopulmonary pathology across a range of clinical scenarios, yet their relation to complications after pulmonary resection is understudied. We hypothesized GERD and hiatal hernia are predictors of complications after lobectomy for lung cancer. Lobectomy patients at Yale-New Haven Hospital between January 2014 and April 2021 were evaluated for predictors of 30-day post-operative complications, pneumonia, atrial arrhythmia, readmission, and mortality. Multivariable regression models included sociodemographic characteristics, BMI, surgical approach, cardiopulmonary comorbidities, hiatal hernia, GERD, and acid suppressive therapy as predictors. …

Health Status Changes After Stenting For Stroke Prevention In Carotid Artery Stenosis, Jonathan Kluger

Yale Medicine Thesis Digital Library

Background: Clinical trials for carotid artery stenosis treatments have focused primarily on mortality, stroke, and myocardial infarction (MI), but less is known about the effects of carotid revascularization on health status. Our three aims were (1) to establish minimal clinically important differences (MCIDs) as thresholds for meaningful patient-reported clinical improvement for those undergoing transfemoral carotid artery stenting (TF- CAS), (2) to study the distribution of changes in health status 30 days after TF-CAS, and (3) to describe the clinical characteristics of patients who improved significantly after treatment.Methods: Using the Stenting and Angioplasty with Protection in Patients at High Risk for …

“Teen Health” Empowers Informed Contraception Decision-Making In Adolescents And Young Adults, Christina Lepore

Yale Medicine Thesis Digital Library

Adolescents and young adults (AYAs), here defined as aged 13-25 years, face uniquechallenges in accessing sexual and reproductive health information. Interactive internet resources provide a free, private and personalized opportunity to help AYAs make informed contraception choices. We designed an original website called “Teen Health” to provide age-appropriate and evidence-based SRH education to AYAs, as well as an interactive contraception education tool (CET). We introduced “Teen Health” to AYAs in a clinical setting and observed trends in contraception preference after website exposure. We hypothesized that “Teen Health” would support informed contraception decision-making.

A convenience sample of AYAs were recruited from …

Colonoscopy Withdrawal Time And Dysplasia Detection In Patients With Inflammatory Bowel Disease, Chandler Julianne Mcmillan

Yale Medicine Thesis Digital Library

Compared to the general population, patients with inflammatory bowel disease (IBD) are more at risk for developing colorectal dysplasia and neoplasia in their lifetime. Given this increased risk, current guidelines recommend that patients with IBD involving at least one-third of the colon undergo routine surveillance colonoscopy exams every one to five years to monitor disease activity and severity. Colonoscopy withdrawal time (CWT) is considered an important predictor of adenoma detection and a quality metric of colonoscopy within the general population. Society organizations including the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology have proposed a minimum average …

Regulation And Payment Of New Medical Technologies, Osman Waseem Moneer

Yale Medicine Thesis Digital Library

Our health care system should promote the development and useof innovative medical products, while simultaneously discouraging the marketing and adoption of unsafe or unnecessary products. In the United States, two federal agencies within the Department of Health and Human Services are responsible for administering policies directed toward these aims. The Food and Drug Administration (FDA) evaluates safety and effectiveness for market authorization of medical technologies while the Centers for Medicare & Medicaid Services (CMS) determines whether coverage is “reasonable and necessary” for its beneficiaries. Through a series of three investigations, this thesis evaluates federal policies for the regulation and payment …

Dermatologic Infectious Complications And Mimickers In Cancer Patients On Oncologic Therapy, Jolanta Pach

Yale Medicine Thesis Digital Library

Dermatologic infections affecting the skin, hair, mucosae, and nails are common complications of systemic cancer therapy and can impact cancer patients’ quality of life; however, studies investigating these complications are largely lacking. We aimed to characterize dermatologic infectious complications secondary to oncologic therapy and the management of these complications in the outpatient and inpatient settings. We sought to identify how dermatologic infections differ in patients undergoing novel classes of cancer therapy, including targeted therapy and immunotherapy, compared to those on traditional cytotoxic chemotherapy. Second, we aimed to investigate non-infectious dermatologic complications of oncologic therapy which may mimic infectious complications. Here, …

Distressed Community Index In Patients Undergoing Carotid Endarterectomy In Medicare-Linked Vqi Registry, Carmen Pajarillo

Yale Medicine Thesis Digital Library

IntroductionThe association between community socioeconomic distress and carotid endarterectomy (CEA) outcomes is understudied. We therefore analyzed the association between the Distressed Community Index (DCI), a zip-code level measure of community distress, with 36-month post-CEA mortality and readmission.

MethodsWe thus examined patients undergoing CEA between 2015-2019 in the Vascular Quality Initiative database linked with Medicare claims outcomes data. Patients’ DCI ranged from 0 (not distressed) to 100 (distressed). The 36-month mortality was assessed by DCI quintiles using the Kaplan-Meir cumulative incidence function (CIF) and for linear DCI, using Cox regression stratified on site. For 90-day readmission, we used CIF curves and …

Volumetric Assessment Of Imaging Response In The Pnoc Pediatric Glioma Clinical Trials, Divya Ramakrishnan

Yale Medicine Thesis Digital Library

Response assessment in neuro-oncology relies on radiographic assessment of tumor burden on magnetic resonance (MR) imaging. The most widely used criteria were developed by the Response Assessment in Neuro-Oncology (RANO) group. The RANO criteria rely on bidimensional (2D) measurements of tumor on MR images. The RANO criteria were originally developed to assess response in adult high-grade glioma. However, the heterogeneous appearance of pediatric low-grade gliomas make application of RANO criteria challenging. Volumetric assessment of pediatric gliomas may offer a more comprehensive method for characterizing response.

The goal of this thesis was to compare 2D and volumetric assessment methods in two …

Outcomes Following Hypofractionated Radiotherapy For Patients With Thoracic Tumors In Predominantly Central Locations, Alexander Sasse

Yale Medicine Thesis Digital Library

Hypofractionated radiation therapy (HFRT) is emerging as a preferred treatment for lung cancer patients ineligible for stereotactic body radiotherapy (SBRT). Normally, a standard-dose (SD-HFRT) hypofractionation regimen administers 60 Gy across 15 fractions, equating to a biologically effective dose (BED10) of 84.0, which is less than that of ablative SBRT. The first part of this thesis contrasts the clinical outcomes of patients receiving a high-dose (HD-HFRT) protocol, delivering 72 Gy in 18 fractions with a BED10 of 100.8, against those on SD-HFRT. Our research examines whether HD-HFRT enhances local control (LC) and overall survival (OS) rates while maintaining comparable rates of …

Machine Learning And Risk Prediction Tools In Neurosurgery: A Rapid Review, Josiah Sherman

Yale Medicine Thesis Digital Library

INTRODUCTION: Artificial intelligence (AI) and machine learning (ML) techniques have become highly visible in society and medicine, with some AI/ML-enabled devices receiving approval by the Federal Drug Administration for use in direct patient care. In neurosurgery, ML algorithms have been developed for clinical outcome prediction, many of which have achieved higher predictive ability than standard statistical analysis techniques. However, few have synthesized the ML literature in neurosurgery and its subspecialties. Given the rapid rate at which ML algorithms for outcome prediction and prognostication have developed in neurosurgery, additional synthesis of the current ML landscape in this area is necessary. The …

Somatic Mutations In Aging, Paroxysmal Nocturnal Hemoglobinuria, And Myeloid Neoplasms, Tho Tran

Yale Medicine Thesis Digital Library

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal blood disorder frequently associated with bone marrow failure that in rare instances can progress to leukemia. PNH clones of varying sizes occasionally present even in patients with hematologic malignancies and no known history of classical PNH, particularly in myelodysplastic neoplasms (MDS). Curiously, somatic driver mutations considered to be pathogenic and likely pathogenic in myeloid leukemias can be found in phenotypically normal, elderly individuals, as well as those with clonal disorders such as PNH, clonal hematopoiesis of indeterminate potential (CHIP), and age-related clonal hematopoiesis (ARCH). These mutations may be the critical link between PNH …

Advances In Keratin 17 As A Cancer Biomarker: A Systematic Review, Robert Tseng

Yale Medicine Thesis Digital Library

Background: In an era where tumor heterogeneity leads to widely variable cancer treatment outcomes, there is an unmet need for biomarkers that can characterize tumor subtypes, inform prognosis, and guide clinical decision-making for therapy. As an oncofetal monofilament that is only expressed in embryonic and cancer tissue, keratin 17 (K17) has been demonstrated as an effective biomarker in a wide variety of cancer types, detection methods, and clinical purposes. In order to guide and inform future investigations on K17, we performed a systematic review of clinical studies assessing the effectiveness of K17 as a cancer biomarker.

Methods: We performed a …

Regionalization Strategy To Optimize Inpatient Bed Utilization And Reduce Emergency Department Crowding, Ragini Luthra Vaidya

Yale Medicine Thesis Digital Library

Aims:Pooling inpatient bed resources for more efficient bed management is a promising solution to the pervasive problem of Emergency Department crowding. This study aims to characterize a regionalization protocol in place for ED-to-inpatient disposition between a tertiary academic medical center (AMC) and an urban community teaching hospital in an integrated health system, overseen by a single Bed Management Department. An additional purpose of this study is to investigate transfer decisions from a health equity perspective.

Methods:This is a retrospective observational study utilizing electronic admissions records from the two hospitals’ Emergency Departments to general medicine floors between January 1, 2020 and …

The Presence Of Mood And/Or Anxiety Disorders Does Not Affect Success Of Weight Management Therapies In Metabolic Dysfunction- Associated Steatotic Liver Disease, Bryan Bollinger

Yale Medicine Thesis Digital Library

Metabolic dysfunction-associated steatotic liver disease (MASLD) and resultant steatohepatitis (MASH) have been linked to psychiatric comorbidities. The treatment of MASLD/MASH primarily relies upon weight loss, where achieving a 7% total body weight loss is recommended to improve steatohepatitis. We aimed to determine whether likelihood of achieving a 7% total body weight loss (TBWL) in MASLD/MASH patients was significantly different in the presence of a mood and/or anxiety disorder in an interdisciplinary clinic that integrates weight management and hepatology care.We conducted a single center retrospective cohort study of MASLD/MASH patients segregated into those with an ICD-10 diagnosis of a mood and/or …

Social Determinants Of Health & Barriers To Care In Diabetic Retinopathy Patients Lost To Follow-Up, Thomas Chang

Yale Medicine Thesis Digital Library

SOCIAL DETERMINANTS OF HEALTH & BARRIERS TO CARE IN DIABETIC RETINOPATHY PATIENTS LOST TO FOLLOW-UP

Thomas L. Chang, Akua Frimpong, Kristen Nwanyanwu. Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, CT.

Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. More than a quarter of patients are lost to follow-up (LTFU) after they receive anti-vascular endothelial growth factor (anti-VEGF) injections as treatment. This study utilized a mixed-methods approach with both a quantitative and qualitative analysis. The specific aims of the quantitative analysis were to identify any potential factors or …

Association Of Vigorous Physical Activity With Psychiatric Disorders And Participation In Treatment, John L. Havlik

Yale Medicine Thesis Digital Library

This study aimed to compare annual levels of vigorous activity and minutes per episode of vigorous activity among adults with non-substance use psychiatric disorders, especially those participating in treatment, those with no history of psychiatric disorders, prior-to-past-year histories only, or current disorders but no past-year treatment. We used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III; n=36,309), a nationally representative survey of US adults. Adjusted means testing was used to evaluate differences between groups in annual frequency of vigorous physical activity and mean minutes per session of vigorous activity, with and without adjustment for …

Health-Related Social Needs Before And After Critical Illness Among Medicare Beneficiaries, Tamar A. Kaminski

Yale Medicine Thesis Digital Library

Health-Related Social Needs (HRSNs), such as financial strain, food insecurity, social isolation, and transportation disadvantage, are unmet social needs associated with poor health outcomes and increased healthcare utilization. In qualitative work, survivors of the intensive care unit (ICU) report financial strain; however, little is known about food insecurity, social isolation, and transportation disadvantage after critical illness. The objectives of this study were twofold: (1) to ascertain changes in three HRSNs—food insecurity, social isolation, and transportation disadvantage—from the year before critical illness to the year following discharge among older adult survivors of critical illness, and (2) to evaluate demographic, pre-admission, and …

A Cost-Effectiveness Analysis Of Oropharyngeal Cancer Post-Treatment Surveillance Practices, Rema Shah

Yale Medicine Thesis Digital Library

Post-treatment surveillance imaging for oropharyngeal squamous cell carcinoma (OPSCC) is guided by the National Comprehensive Cancer Network (NCCN) and often is routinely performed beyond the suggested guidelines. With the advent of biomarker-based disease surveillance, there may be an alternative option that can reduce the cost-burden of post-treatment imaging for OPSCC. This study investigates the comparative cost-effectiveness of a hypothetical miRNA biomarker test for specifically HPV-negative (HPV-) OPSCC post-treatment surveillance and also investigates whether the extra imaging practices that are often employed for both HPV+ and HPV- OPSCC are truly cost-effective in order to inform evidence-based decision making after OPSCC treatment. …

Prevalence Of Metabolic Comorbidities And Viral Infections In Monoclonal Gammopathy, Mansen Yu

Yale Medicine Thesis Digital Library

Monoclonal gammopathy (MG) encompasses a spectrum of related diseases, with monoclonal gammopathy of undetermined significance (MGUS) being the most prevalent, serving as a precursor of smoldering and clinical multiple myeloma. While the association between gammopathies, metabolic conditions and antigenic stimulation has long been recognized, the precise mechanism remains unclear. Prior research has shown that a subset of MGUS and MM is driven by chronic antigenic stimulation of B cells by endogenous lipids and exogenous microbial antigens. The aim of this study is to assess the prevalence of metabolic comorbidities and viral infections in a large population with monoclonal gammopathy, providing …

Racial Disparities In Behavioral Crisis Care: Investigating Restraint Patterns In Emergency Departments, Erika Chang-Sing

Yale Medicine Thesis Digital Library

AbstractImportance: Black patients were more likely than White patients to be brought to the hospital by police, and they were also more likely to be restrained and sedated during behavioral crises in emergency departments (EDs). Although the perils of policing mental health conditions for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the relationship between Black race and physical restraint use in emergency departments. Hispanic/Latino patients were less likely than White patients to be restrained in Emergency departments but more likely to be brought to the hospital by police. They were also less …