Digital Commons Network^™

Level Of Evidence And Cost Considerations In United States Clinical Practice Guidelines, 2019-2023, Omar Qureshi

Yale Medicine Thesis Digital Library

BackgroundClinicians rely on clinical practice guidelines (CPGs) to fulfill a dual mandate: practicing evidence-based medicine and ensuring cost-conscious stewardship of resources. However, it remains unclear whether modern CPGs provide the guidance necessary to meet these goals. Specifically, the extent to which recommendation strengths align with evidence quality and the prevalence of cost-related guidance within U.S. medical society CPGs remains unknown.

Research Aimsa) To examine the distribution of SOR and LOE ratings for recommendations offered by United States medical societies through CPGs and evaluate concordance between SOR and LOE ratings for CPG recommendations. Additionally, assess whether there are recommendation-level, guideline-level, or …

Clinical And Pathologic Factors Associated With Poor Outcomes In Cutaneous Sarcomas, Jennifer Rodriguez

Yale Medicine Thesis Digital Library

Background:Cutaneous sarcomas exhibit a broad spectrum of clinical behavior, ranging from indolent tumors to lesions with significant metastatic potential. In atypical fibroxanthoma, pleomorphic dermal sarcoma, and cutaneous leiomyosarcoma predictors of recurrence and metastasis are not always apparent at initial diagnosis. Improved understanding of clinicopathologic features associated with adverse outcomes is needed to guide risk stratification and management.

Objectives:To identify clinical and pathologic factors associated with poor outcomes in AFX, PDS, and cutaneous leiomyosarcoma and to evaluate the relationship between initial biopsy, definitive excision findings, and clinical outcomes.

Methods:This thesis comprises three retrospective cohort studies conducted at a single academic institution. …

Automated Cerebral Autoregulation Monitoring With Machine Learning, Matteo Rosati

Yale Medicine Thesis Digital Library

Background - Current methods of identifying patients in the neurological intensive care unit (NeuroICU) with disrupted cerebral autoregulation rely on statistical methods that require significant time to produce predictions. There is a need for faster algorithms that can minimize the secondary damage caused by disrupted autoregulation in these patients.

Research Aims - We aim to develop a machine learning (ML) model that determines whether a patient is outside optimal autoregulatory limits using continuously recordable and minimally invasive physiologic data gathered in the NeuroICU.

Hypothesis - We hypothesize we can use ML techinques to ingest physiologic data in short time windows …

Predictive Modeling Of Transfusion After Cranial Vault Remodeling For Pediatric Craniosynostosis, Paul Serrato

Yale Medicine Thesis Digital Library

Background: Cranial vault remodeling (CVR) for pediatric craniosynostosis is associated with postoperative blood transfusion, yet determinants of transfusion risk remain incompletely defined. Estimating transfusion risk preoperatively could support more personalized blood management planning for this population.Research Aims: To evaluate whether supervised machine learning models can reliably predict postoperative transfusion risk following CVR compared to traditional logistic regression and to identify the most informative predictors of those models. Hypothesis/Question: We hypothesized that ensemble machine learning approaches (e.g. random forest, extreme gradient boosting) would match or outperform logistic regression in predicting transfusion by leveraging nonlinear associations and higher-order interactions across patient, procedural, …

Leveraging Large Language Models To Augment Emergency Department Chest Pain Decision-Making, Conrad Safranek

Yale Medicine Thesis Digital Library

Background - Large language models (LLMs) can convert unstructured clinical text into structured, computable signals, creating a new class of clinical decision support (CDS) that is tightly coupled to real documentation workflows. This is especially relevant in emergency medicine, where decisions must be made rapidly under uncertainty, often with key information scattered across notes, reports, and prior encounters. Emergency department (ED) chest pain evaluation is a prototypical setting for this problem: it is high-volume, high-stakes, operationally costly, and driven by pathway-based triage and risk stratification, yet care remains heterogeneous across clinicians and teams. As health systems and electronic medical record …

Comparison Of Clinical Outcomes By Tube Type And Size Following Percutaneous Radiologic Gastrostomy: A 10-Year Retrospective Study, Diane Zhao

Yale Medicine Thesis Digital Library

PurposeTo compare the complication rate and time to the first reintervention of pull-type and push-type gastrostomy tubes placed under radiologic fluoroscopy guidance in adults. Materials and Methods During a 10-year period (2012-2022), 2341 adult patients underwent percutaneous radiological gastrostomy at our institution, and their charts were reviewed. 896 (39%) procedures were done with the push method, and 1393 (61%) were done with the pull method. Results Rates of significant hemorrhage at the surgical site, leakage at the site, and malplacement of the g-tube were not found to be statistically different between the two groups. However, push g-tubes were significantly more …

The Strength Of Association Between Surrogate Markers And Clinical Outcomes Used By The Fda For Chronic Disease Indications, Samuel Yoon

Yale Medicine Thesis Digital Library

The U.S. Food and Drug Administration (FDA) has traditionally required the use of clinical outcome measures as clinical trial endpoints to support the approval of new drugs. However, clinical outcome trials are typically large, lengthy, and expensive. To expedite this process, Congress has enacted several regulatory programs to facilitate FDA approval of new drugs on the basis of surrogate markers, endpoints that are reasonably likely to predict clinical benefit, as trial endpoints. However, the evidence demonstrating the validity and reliability is mixed, creating uncertainty for patients and physicians about the true clinical benefits of new drugs approved on the basis …

Prevalence, Reporting, And Management Of Interstitial Lung Abnormalities And Incidental Findings On Lung Cancer Screening, Tian Wei Yu

Yale Medicine Thesis Digital Library

Background: Low dose computed tomography for lung cancer screening frequently identifies incidental findings. The most frequent and consequential thoracic and upper abdominal incidental findings include interstitial lung disease (ILD), interstitial lung abnormalities (ILA), emphysema, coronary artery calcification, aortic calcification, aortic aneurysm, and adrenal lesions. Many of these abnormalities carry prognostic and therapeutic implications. However, the prevalence of these findings, variation in reporting practices, and downstream management within integrated health systems remain incompletely characterized, particularly for ILA and ILD.

Research Aims: We aimed to quantify the prevalence of selected incidental findings on lung cancer screening CT across a large multi-hospital health …

Reducing 30-Day Readmission Rates In Patients With Heart Failure, Charles Mccoy

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Abstract

Globally, heart failure affects approximately 54 million individuals and has reached pandemic levels, contributing to elevated 30-day readmission rates (Sa et al., 2024). Background: In the United States, 30-day readmission rates range from 18% to 20%, with similar rates across all states. The current rate was documented as 29% at the study setting hospital. Objective: Implement a Quality Improvement project based on education, evidence-based order sets, and referral to palliative care to reduce 30-day readmission rates among adults with heart failure. Methods: Nursing staff completed education specific to heart failure, and patients received the American Heart Association Self-Check assessment. …

Starting Strong: Improving Mmr Vaccination Rates In Kindergartners, Regina Bryan

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Abstract

Introduction

During the 2023–2024 academic year, measles, mumps, and rubella (MMR) vaccination coverage among kindergarten students in this school district did not meet the Healthy People 2030 target, thereby elevating the risk of disease outbreaks. This quality improvement project aimed to improve MMR vaccination initiation and completion through coordinated, school-based interventions.

Methods

Guided by the Plan-Do-Study-Act framework, an eight-week immunization bundle was implemented across 14 elementary schools in South Texas. Interventions included reminder calls, multilingual education, districtwide communication, and a partnership with a nonprofit clinic that provides free or reduced-cost vaccines through on-site and community clinics. Pre- and post-intervention …

Ambient Listening: Using Artificial Intelligence To Transcribe Provider Office Visits, Odia Russette

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: Electronic health record (EHR) documentation burdens contribute to increased “pajama time” or after–hours charting, reduced job satisfaction, and provider burnout. Provider burnout leads to provider and critical access point losses. Ambient–listening artificial intelligence (AI) technologies have emerged as a possible tool to reduce charting burdens; however, evidence from outpatient wellness settings remains limited.

Local Problem: At an urban adult wellness clinic in Texas with limited resources for completing tasks, in-clinic and after-hours “pajama time” charting burdens contributed to provider fatigue, job dissatisfaction, and burnout.

Methods: A quality improvement (QI) project using the Plan-Do-Study-Act (PDSA) framework implemented an AI ambient …

A Quality Improvement Project To Decrease Medication Prior Authorization Approval Times, Amena Guinn Babers

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: Medication prior authorization requirements add to administrative burden, increase labor costs, and delay patient access to treatment in outpatient specialty settings. This bottleneck directly influences nursing workload and economic performance.

Purpose: To evaluate the fiscal and performance significance of implementing an electronic prior authorization (ePA) process, standardized tracking tools, and staff education in a small orthopedic clinic.

Methods: A pre–post quality improvement design was used. Descriptive statistics and inferential analyses (independent‑samples t tests and Mann–Whitney U tests) were conducted to compare time to approval, staff hours worked, satisfaction scores, and medication pickup timeframes.

Results: Significant reductions were observed in …

Inpatient Stroke Quality Improvement, Briyawna N. Wyatt

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Inpatient nursing documentation for stroke care is essential for meeting quality metrics, maintaining continuity, and supporting timely decisions. Gaps can lead to inconsistent care, metric failures, and reduced staff confidence. This quality improvement initiative aimed to improve metric compliance, documentation consistency, and nursing knowledge and satisfaction. A three-part intervention included targeted education, a standardized documentation verification form, and ongoing feedback from stroke champions. Outcomes measured were metric compliance, knowledge (pre/posttests), documentation completeness (Venous Thromboembolism (VTE), education, Modified Rankin Scale), and staff satisfaction. Results showed significant improvement in nursing knowledge (p < .005), reduced metric fallouts, and better documentation across all indicators. Staff satisfaction increased by about 20%. Overall, combining education, standardized tools, and continuous feedback improved documentation practices, enhanced compliance with stroke metrics, and increased nursing knowledge and satisfaction, supporting better care processes and patient outcomes.

A Questionnaire Assessing Attitudes And Readiness For Hiv Pre-Exposure Prophylaxis Therapy For Community Members At-Risk For Hiv Acquisition In Liberia, Yishak Bedaso

Yale Medicine Thesis Digital Library

AbstractA Questionnaire Assessing Attitudes And Readiness For HIV Pre-Exposure Prophylaxis Therapy For Community Members At-Risk For HIV Acquisition In Liberia Yishak Bedaso;1 Jessica Tuan, MD, MS;2 Yassah M. Barclay-Korboi;3 Onyema Ogbuagu MBBCh, FACP, FIDSA4 Affiliation: 1. Yale School of Medicine, New Haven, CT, USA 2. Columbia University Vagelos College of Physicians and Surgeons, Department of Infectious Diseases, New York, NY, USA 3. JFK Memorial Hospital, Monrovia, Liberia. 4.Yale Antivirals & Vaccines Research Program, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; Despite how effective Pre-exposure prophylaxis (PrEP) is in preventing HIV, uptake among women in sub-Saharan …

Epidermal Differentiation Disorders Across The Lifespan: Growth, Ophthalmologic, And Perinatal Manifestations, Caroline Echeandia-Francis

Yale Medicine Thesis Digital Library

Epidermal differentiation disorders (EDDs) are a heterogeneous group of inherited skin diseases characterized by impaired epidermal barrier function, scaling, and erythema. Although substantial progress has been made in identifying the genetic causes of EDD, long-standing clinical observations—including impaired growth, ectropion, and increased rates of preterm birth—remain poorly characterized across genotypes. The prevalence, severity, and clinical significance of these manifestations have not been systematically evaluated in large, genotype-stratified cohorts, limiting the ability to provide anticipatory guidance and tailored clinical care. This thesis seeks to (1) characterize growth trajectories in children with EDD and determine genotype-specific patterns of growth impairment; (2) assess …

Prevalence Of K13 Mutant Malaria Parasites In Busia, Uganda, Ahmed Elzamzami

Yale Medicine Thesis Digital Library

Artemisinin derivatives form the backbone of all antimalarial combination therapies usedworld-wide. Resistance to this critical drug class is a growing problem in the highest malaria transmission regions of the world. First detected in southeast Asia, independent mutations conferring partial resistance to artemisinin’s have now emerged in East Africa.27, 32 Retrospectively, these mutations have been detected as early as 2016 in Uganda.36 Previous work by the Parikh lab highlights the efficacy of 3-day vs 5-day artemether-lumefantrine treatment regimen for uncomplicated malarial episodes in Busia, Uganda in 2019.41 Infections were followed and classified as recrudescent, a reinfection, SBP1 slow clearing, or an …

Repurposing Ezetimibe As A Therapeutic For Parkinson's Disease: Evaluating The Therapeutic Potential And Probing For A Mechanism, Brian Hilton

Yale Medicine Thesis Digital Library

Neurologic disease is the leading cause of disability globally and Parkinson’s disease (PD) has been the fastest growing neurologic brain disease over the last several decades. Despite the immense burden of PD on patients and society, there has yet to be an efficacious disease-modifying therapy. Investigation of candidate pharmaceuticals that have already been approved by the FDA for other conditions might provide an expedited path to the advent of disease-modifying therapy. There is a rich history of drug repurposing for symptomatic therapy for PD, with amantadine as the preeminent example. In order to identify candidate therapeutics for possible repurposing, an …

Rns-Based Early Prediction Of Antiseizure Medication Efficacy, Joshua Hobbs

Yale Medicine Thesis Digital Library

Drug-resistant focal epilepsy accounts for a significant portion of patients with epilepsy. These patients many times experience persistent seizures despite several ASM (anti-seizure medication) trials. RNS (Responsive neurostimulation) has demonstrated efficacy in reducing seizure frequency in patients that are resistant to drug trials, and provide continuous intracranial electroencephalographic monitoring. This longitudinal data may offer an opportunity to identify potential early biomarkers of ASM trial effectiveness, which could lead to quicker optimization of pharmacological therapy. This study in particular evaluated whether early changes in RNS-detection of seizure activity can predict a clinical response to ASMs in patients with drug-resistant focal epilepsy. …

Facial Harmony And Gender Congruence: Patient-Reported Outcomes Of Gender-Affirming Facial Surgery Using The Gender-Q And Gpsq, Helia Hosseini

Yale Medicine Thesis Digital Library

Background:Gender-affirming facial surgery (GAFS) addresses gender dysphoria by aligning facial features with gender identity, with historical emphasis on refining the upper facial third to render patients more attractive and feminine. The GENDER-Q, a novel patient-reported outcome measure (PROM), evaluates aesthetic, functional, and psychosocial outcomes, complementing the Gender Preoccupation and Stability Questionnaire (GPSQ) to assess effects of GAFS in this study. Methodology: Survey data from 86 patients was analyzed using GENDER-Q and GPSQ scores. Higher GENDER-Q scores indicated improved outcomes, whereas lower GPSQ scores reflected reduced gender dysphoria. Pre- and post-operative outcomes were compared using paired and unpaired t-tests. Spearman’s correlation …

A Spatial Transcriptomic Atlas And Cellular Lineage-Based Analysis Of Chondroblastoma, Will Jiang

Yale Medicine Thesis Digital Library

Chondroblastoma is a benign primary bone tumor with controversial cellular origin. Although bearing the name “chondroblastoma”, this musculoskeletal tumor has faced controversy as to whether chondroblasts are chondrocytes. Moreover, its cellular composition can make it difficult to distinguish amongst its mimics including giant cell tumor of bone, chondrosarcoma, and chondromyxoid fibromas.

This thesis aims to characterize the transcriptomic expression atlas of human chondroblastoma to better define the gene expression profile and diagnostic expression markers of chondroblastoma. Secondarily, this thesis aims to identify the lineage progression and cellular composition of chondroblastoma using spatial and temporal patterning analysis.

Histologically confirmed samples of …

Trends, Predictors, And Cerebrovascular Outcomes Of Vertebral Artery Injury In Cervical Fractures, Rahul Jayaram

Yale Medicine Thesis Digital Library

Background and Scientific Premise: Cervical spine trauma is a common emergencydepartment presentation, and vertebral artery injury (VAI) is a potentially occult but serious complication associated with posterior circulation stroke. Identification of patients at risk remains challenging due to subtle presentations, variable screening practices, and limited prior data. Research Aims: The aims of this study were to characterize temporal trends in VAI detection among adult patients presenting to the emergency department with cervical spine fractures between 2010 and 2022, identify independent demographic, clinical, and injury-related predictors of VAI, and evaluate the association between VAI and ischemic stroke within ninety days of …

Prevalence, Predictors, And Consequences Of Postoperative Dysphagia After Aortic Surgery, Andrew Joseph Johnson

Yale Medicine Thesis Digital Library

Prevalence, Predictors, and Consequences of Postoperative Dysphagia After Aortic SurgeryAndrew Johnson and Ronny Munoz-Acuna, M.D., Department of Anesthesiology, Yale School of Medicine, New Haven, CT 06510. Abstract Background: Postoperative dysphagia is an underrecognized complication following cardiothoracic surgery and is associated with aspiration, prolonged hospitalization, and adverse clinical outcomes. Patients undergoing complex aortic surgery may be at particularly high risk due to prolonged mechanical ventilation, extensive airway instrumentation, and neurologic vulnerability. Data describing the prevalence, predictors, and clinical consequences of postoperative dysphagia in this population remain limited. Research Aim: This study consisted of three aims: first, to determine the prevalence and …

Cross-Sectional Analysis Of The Hepatitis C Care Cascade Among People Who Use Drugs In New Haven, Ct, Thomas Shaifer Jones

Yale Medicine Thesis Digital Library

People who use drugs (PWUD) are at high risk of contracting Hepatitis C Virus (HCV) and often face significant barriers in accessing healthcare. Treatment of HCV is highly effective, but previous studies show low rates of successful treatment in practice due to multiple points of failure along the treatment cascade. Harm reduction and outreach programs such as syringe services programs (SSPs) and drug treatment programs including medication for opioid use disorder (MOUD) have emerged as possible points of leverage in advancing people through the cascade of care. To better understand how people who use drugs access HCV treatment and elucidate …

Tone Matters: Advancing Equity Through A Pilot Intervention To Increase Exposure Of Clinical Findings In Skin Of Color, Lamley Amanuah Lawson

Yale Medicine Thesis Digital Library

Background: The ability to accurately recognize cutaneous manifestations of disease is a foundational clinical skill. However, current undergraduate medical education heavily relies on lighter skin tone prototypes, leaving trainees underprepared to diagnose conditions in patients with melanin-rich skin.Research Aims: This study aimed to evaluate the efficacy of a brief, targeted, visually comparative digital intervention by measuring its impact on medical students' immediate diagnostic accuracy and self-reported clinical confidence in identifying dermatologic conditions across a diverse range of skin tones. Hypothesis: We hypothesized that a brief, targeted digital educational intervention featuring side-by-side visual comparisons of dermatologic conditions across a range of …

Frailty And Functional Decline After Elective Endovascular Abdominal Aortic Aneurysm Repair, Judy Li

Yale Medicine Thesis Digital Library

Background: Frailty can be used to estimate perioperative and long-term mortality risk in octogenarians undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). Its association with functional decline, an important surrogate of quality of life in older adults, has not been well studied in this population. We aimed to evaluate whether preoperative factors such as frailty are associated with one-year functional decline after elective EVAR in octogenarians and to compare the performance of three different frailty assessments.

Methods: The Vascular Quality Initiative (VQI) database was queried for octogenarians who underwent elective EVAR for an asymptomatic infrarenal abdominal aortic aneurysm (AAA) (2014 …

Neurophysiologic Responses To Endovascular Interventions For Delayed Cerebral Ischemia Management, Rafael Seth Maarek

Yale Medicine Thesis Digital Library

Background/Scientific Premise: Delayed cerebral ischemia (DCI) continues to be a leading cause of poor outcomes in hospitalized aneurysmal subarachnoid hemorrhage (aSAH) patients. In addition to cerebral vasospasm, a growing constellation of pathophysiologic processes has been implicated in the development of DCI, including impaired autoregulation, micro-thrombosis, inflammation, and cortical spreading depolarizations. However, management options for patients showing signs of emerging DCI have largely remained spasmolytic in nature, and it remains unclear if reversing cerebral vasospasm in patients with signs of emerging DCI will reliably improve underlying neurophysiology. To our knowledge, no group has reliably shown postprocedural improvements in quantitative EEG metrics …

Passive Communication Across Diverse Swarm Formations And Scales Utilizing Wake Signatures For Messaging And Object Inference, Bryan Varela

Open Access Master's Theses

Passive wake signatures in fluid flows can support perception and low-rate communication in swarms. In cluttered or contested underwater environments, conventional acoustic, radio, and optical links can be power-hungry, intermittent, or undesirable when low observability is required. Wake-mediated cues offer a local, directional channel that does not require line of sight because each agent naturally sheds coherent vortices that persist downstream and can be sampled by followers with only a small number of probes.

This study evaluates whether sparse downstream probes are sufficient to infer agent attributes and decode simple messages from wakes generated by established source shapes. Computational fluid …

Sauce For The Gander: The False Symmetry Of Myths And Stereotypes Against The Accused In Sexual Assault Trials, Janine Benedet

Dalhousie Law Journal

As sexual assault laws evolved to be expressed in sex-neutral language, so too have arguments relating to myths and stereotypes in the context of sexual offences. This article evaluates the argument that myths and stereotypes, traditionally a reflection of systemic discrimination against female complainants in rape trials, also operate against male accused. Understood correctly, this trend repackages anti-feminist backlash to early equality reform efforts, ultimately working to revive the belief that women’s accusations of sexual assault are often false. The Supreme Court of Canada’s decision in R v Kruk affirms that this historical context matters when it comes to claims …

Lost At Sea: The Managerial Exclusion After Casinos Du Québec, Brian Langille

Dalhousie Law Journal

Is the managerial exclusion constitutionally dead or alive? In Casinos du Québec the Supreme Court of Canada somehow managed to make this a mind-boggling question. The Court also managed to bizarrely but blithely establish a higher threshold test for freedom of association violations than for unconstitutional intrusions upon other Charter freedoms. This comment addresses both of these shocking results but also seeks to go further and show how the Court’s entire freedom of association adventure is not only scary, but also unnecessary.

L’exclusion des postes de direction est-elle constitutionnellement morte ou vivante? Dans l’affaire Casinos du Québec, la Cour suprême …

Chapter 2 - Outline And Flow-Chart Of A Criminal Case, Anthony G. Amsterdam, Randy A. Hertz

Trial Manual for the Defense of Criminal Cases

Most jurisdictions have two or more distinct sets of criminal procedures to govern charges of differing degrees of gravity. The jurisdictions vary regarding the number of sets of procedures employed (usually two or three), the charges governed by each set, and the particular courts, stages, and practices involved in each set. Local statutes, rules, and customs must be consulted. (In federal practice, for example, criminal prosecutions in the United States District Courts are governed by Rules 1-57 and 59-61 of the Federal Rules of Criminal Procedure; Rule 58 provides a somewhat different set of rules for proceedings in petty-offense and …