Medicine and Health Sciences Commons^™

New Persistent And Chronic Opioid Use In Cancer Survivors After Curative Intent Radiation, Elena V. Fernández

Theses and Dissertations

Background: Emerging evidence suggests that as more patients are surviving cancer, new persistent opioid use (no prior exposure to opioids before cancer therapy but requiring opioid prescriptions after curative intent treatment; NPOU) is of greater concern. In patients receiving curative intent radiation (definitive radiation therapy and as treatment for cure; CIR), the extent to which patients develop NPOU or continue opioid use (COU) following CIR is not known. Neither are factors associated with NPOU or COU, opioid doses, or time to discontinuation (TTD) of opioids in 5CS known. Objectives: Describe longitudinal trends opioid use in cancer survivors who received CIR, …

The Impact Of The Fda Warning On Post-Tonsillectomy Opioid Prescribing In Publicly And Privately Insured Children, Dianna J. Soelberg

Theses and Dissertations

Due to reports of significant adverse events, the U.S. FDA placed a Boxed Warning on the opioid codeine in February 2013 – contraindicating its use in pediatric patients undergoing tonsillectomy and/or adenoidectomy. Studies conducted in privately insured children showed a reduction in codeine prescribing and a slight increase in alterative opioid prescribing following the FDA warning, yet the extent to which the FDA warning impacted prescribing in publicly insured children is unknown. Using a quasi-experimental interrupted time series design, this study evaluated codeine and alternative opioid prescribing before and after the FDA warning in both publicly and privately insured children …

Development Of A Torque-Based Device For The Quantification Of Arm Rigidity In Patients With Parkinson’S Disease, Georgina O. Miller

Theses and Dissertations

Parkinsonian rigidity is caused by the inability of the muscles to relax and extend properly, due to reduced dopamine levels and often begins on one side of the body before spreading contralaterally. The current standard for determining joint rigidity in a clinical setting is a test completed by the clinician based on the feel of the relaxed wrist and elbow joints as they are passively flexed and extended and a series of ordinal rating scales, the Movement Disorder Society’s – Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Hoehn and Yahr Scale (H&Y), and Parkinson’s Disease Questionnaire-39 (PDQ-39). These methods are used …

Perceived Impact Of Ambient Operating Room Noise By Certified Registered Nurse Anesthetists, Marianne S. Cosgrove

Theses and Dissertations

It is widely acknowledged that elevated levels of noise are commonplace in the healthcare environment, particularly in high acuity areas such as the operating room (OR). Excessive ambient noise may pose a threat to patient safety by adversely impacting provider performance and interfering with communication among perioperative care team members. With respect to the certified registered nurse anesthetist (CRNA), increased ambient OR noise may engender distractibility, diminish situation awareness and cause untoward health effects, thereby increasing the possibility for the occurrence of error and patient injury.

This research project analytically examines the perceived impact of ambient noise in the operating …

Factors Associated With Hospital Readmissions Among United States Dialysis Facilities, Amber B. Paulus

Theses and Dissertations

Hospital readmissions are a major burden for patients with end stage renal disease (ESRD). On average, one in three hospital discharges among patients with ESRD are followed by a readmission within 30 days. Currently, dialysis facilities are held accountable for readmissions via the ESRD Quality Incentive Program standardized readmission ratio (SRR) clinical measure. However, little is known about facility-level factors associated with readmission. Additionally, unlike other standardized measures of quality in the dialysis setting, incident patients within their first 90-days of dialysis are included in the performance calculation. This study analyzed CMS Dialysis Facility Report data from 2013 to 2016 …

Diuretic, Natriuretic, And Vasodepressor Activity Of A Lipid Fraction Enhanced In Medium Of Cultured Mouse Medullary Interstitial Cells By A Selective Faah Inhibitor, Zdravka P. Daneva

Theses and Dissertations

The relationship between the endocannabinoid system in the renal medulla and the long-term regulation of blood pressure is not well understood. To investigate the possible role of the endocannabinoid system in renomedullary interstitial cells, mouse medullary interstitial cells (MMICs) were obtained, cultured and characterized for their responses to treatment with a selective inhibitor of fatty acid amide hydrolase (FAAH), PF-3845. Treatment of MMICs with PF-3845 increased cytoplasmic lipid granules detected by Sudan Black B staining and multilamellar bodies identified by transmission electron microscopy. HPLC analyses of lipid extracts of MMIC culture medium revealed a 205nm-absorbing peak that showed responsiveness to …

The Dna Methyltransferase Inhibitor, Guadecitabine, Targets Tumor-Induced Myelopoiesis And Recovers T Cell Activity To Slow Tumor Growth, Andrea J. Elkovich

Theses and Dissertations

Myeloid Derived Suppressor Cells (MDSC) represent a significant hurdle to cancer immunotherapy because they dampen anti-tumor cytotoxic T cell responses. Previous studies have reported on the myelo-depletive effects of certain chemotherapies. Using guadecitabine, a next-generation DNA methyltransferase inhibitor (DNMTi), we observed significantly reduced tumor burden in the 4T1 murine mammary carcinoma model. Guadecitabine treatment prevents excessive tumor-induced myeloid proliferation and systemic accumulation, and skews remaining MDSCs toward a beneficial antigen-presenting phenotype. Together, this alters the splenic environment to improve T cell activation and interferon-gamma (IFNg) production. Additionally, guadecitabine enhances the therapeutic effect of adoptively transferred antigen-experienced lymphocytes to diminish tumor …

The Role Of Sphingosine Kinase 2 In Alcoholic Liver Disease, Eric K. Kwong

Theses and Dissertations

Alcoholic liver disease (ALD) is one of the most common liver diseases worldwide characterized by the accumulation of lipids within the liver, inflammation and the possibility of progressing to cirrhosis and liver failure. More importantly, there are currently no effective treatments for ALD and liver transplantation remains the only therapeutic option for end-stage liver disease. Previous studies have shown that ALD is a result of a combination of endoplasmic reticulum (ER) stress, lipid metabolism dysregulation and inflammation. It has been previously reported that alcohol disrupts gut microbiota homeostasis and causes increased endotoxins that contribute to the pathology of ALD. However, …

Adaptation And Validation Of The Situation Awareness Global Assessment Technique For Student Registered Nurse Anesthetists, Deniz Dishman

Theses and Dissertations

Anesthesia is a health care specialty fraught with high workload demands, stressful work environments, increased production pressure, work areas with many distractions, an increasing use of advanced technology, and the constant need to prioritize work actions. Effective clinical judgment in this dynamic environment necessitates that the provider demonstrate the ability to project what may occur secondary to actual or potential condition changes. These key elements operationalize situation awareness (SA).

High level SA is an important characteristic for the successful development of student registered nurse anesthetists (SRNAs). With Endsley’s “Theory of Situation Awareness” as the foundation, the goal of this study …

Incidence And Predictor Variables Of Pressure Injuries In Patients Undergoing Ventricular Assist Device And Total Artificial Heart Surgeries: An Eight-Year Retrospective Review, Christopher T. Brindle

Theses and Dissertations

BACKGROUND

Cardiac surgery patients have some of the highest reported incidence and prevalence of pressure injuries (PI). A growing subset of cardiac surgery include patients with end-stage heart failure who undergo ventricular assist device (VAD) or total artificial heart (TAH) surgery. The risk of PI and their natural history of development in this population are unknown and the specific risk factors for PI development remain unexplored.

OBJECTIVES

To perform a systematic review of the literature to identify the incidence and risk factors of PI development in patients undergoing VAD-TAH surgery and thereby inform study design and variables in an eight-year …

Advances In Dual-Energy Computed Tomography Imaging Of Radiological Properties, Dong Han

Theses and Dissertations

Dual-energy computed tomography (DECT) has shown great potential in the reduction of uncertainties of proton ranges and low energy photon cross section estimation used in radiation therapy planning. The work presented herein investigated three contributions for advancing DECT applications. 1) A linear and separable two-parameter DECT, the basis vector model (BVM) was used to estimate proton stopping power. Compared to other nonlinear two-parameter models in the literature, the BVM model shows a comparable accuracy achieved for typical human tissues. This model outperforms other nonlinear models in estimations of linear attenuation coefficients. This is the first study to clearly illustrate the …

Estimating The Respiratory Lung Motion Model Using Tensor Decomposition On Displacement Vector Field, Kingston Kang

Theses and Dissertations

Modern big data often emerge as tensors. Standard statistical methods are inadequate to deal with datasets of large volume, high dimensionality, and complex structure. Therefore, it is important to develop algorithms such as low-rank tensor decomposition for data compression, dimensionality reduction, and approximation.

With the advancement in technology, high-dimensional images are becoming ubiquitous in the medical field. In lung radiation therapy, the respiratory motion of the lung introduces variabilities during treatment as the tumor inside the lung is moving, which brings challenges to the precise delivery of radiation to the tumor. Several approaches to quantifying this uncertainty propose using a …

The Relationship Between Central Venous Catheter And Post-Operative Complications In Patients Undergoing Hepatic Resection, David C. O'Connor

Theses and Dissertations

The Relationship Between Central Venous Catheter and Post-operative Complications in Patients Undergoing Hepatic Resection

David C. O’Connor, Ph.D., DNAP, CRNA

A dissertation submitted in partial fulfillment of the requirements for the degree of

Doctor of Philosophy at Virginia Commonwealth University

Virginia Commonwealth University, 2018

Dissertation Chair: Clarence J. Biddle, Ph.D., CRNA

Hepatic resection is indicated for primary and secondary malignancies. Use of a low central venous pressure technique is associated with decreased blood loss in these cases. This technique has evolved; central venous catheters and high dose morphine are no longer used, and patients are extubated earlier. The purpose of …

Predicting Arterial Oxygen Desaturation Events Via Patient Journal And Pulse Oximetry Data In Postoperative Ambulatory Surgery Patients, Charles R. Elam Iv

Theses and Dissertations

Associations between patient and procedural factors on the nature and quality of the immediate in-home recovery from anesthesia following ambulatory orthopedic surgery are unknown. Further, there is a paucity of outcomes research quantitatively categorizing in-home

patient recovery and safety following discharge from same-day orthopedic procedures. Tools are available, however, to shed light on outcomes in this population, and integration of such available measures is critical.

Ambulatory orthopedic surgery is a burgeoning specialty, with growth expected over the foreseeable future. The expected increased patient caseload subsequent to implementation of the Affordable Care Act and aging Baby Boom generation suggests greater morbidity …

Shared Genetic And Environmental Influences On Fear, Anxiety, Posttraumatic Stress, And Brain Morphometry, Chelsea Sawyers

Theses and Dissertations

Anxiety disorders (ADs) and stress-related disorders are some of the most common psychiatric disorders in the United States. Like other c0mplex psychiatric illness, genetics and neuroimaging research has focused on understanding their underlying neurobiology. Areas within the fear-network play important roles in threat perception, fear conditioning/learning, cognitive processing, and modulation of fear responses including contextual modulation and extinction and have been implicated in ADs as well as stress disorders such as posttraumatic stress disorder (PTSD). The primary gap in the current search for underlying biological mechanisms is in whether biomarkers associated with disorders share genetic influences with the disorders they …

Assessing Baseline And Post-Discharge Risk Factors In Subjects With And Without Sleep Apnea Undergoing Endoscopy With Deep Sedation, Mercedes E. Weir

Theses and Dissertations

ABSTRACT

ASSESSING BASELINE AND POST-DISCHARGE RISK FACTORS IN SUBJECTS WITH AND WITHOUT SLEEP APNEA UNDERGOING ENDOSCOPY WITH DEEP SEDATION

Background: Outpatient procedures encompass over 60% of all surgeries in the United States, and the prevalence of obstructive sleep apnea (OSA) remains high among adult surgical ambulatory patients. Ambulatory surgery poses problems for patients with OSA because narcotics and anesthetics used during surgery can complicate the negative effects of OSA, leading to cardiac events, brain hypoxia, and even death. This study was designed to evaluate the prevalence of cardiopulmonary risk factors among post endoscopic patients with diagnosed and undiagnosed sleep apnea. …

"To Conceive With Child Is The Earnest Desire If Not Of All, Yet Of Most Women": The Advancement Of Prenatal Care And Childbirth In Early Modern England: 1500-1770, Victoria E.C. Glover

Theses and Dissertations

This thesis analyzes medical manuals published in England between 1500 and 1770 to trace developing medical understandings and prescriptive approaches to conception, pregnancy, and childbirth. While there have been plenty of books written regarding social and religious changes in the reproductive process during the early modern era, there is a dearth of scholarly work focusing on the medical changes which took place in obstetrics over this period. Early modern England was a time of great change in the field of obstetrics as physicians incorporated newly-discovered knowledge about the male and female body, new fields and tools, and new or revived …

Effects Of The Na-Cl Co-Transporter (Ncc) In Western Diet Induced Metabolic And Cardiac Dysfunction, Zachary S. Cutter

Theses and Dissertations

Interleukin-18 (IL-18) is a pro-inflammatory cytokine known to be involved in maintaining metabolic homeostasis; however, also capable of inducing cardiac dysfunction. Additionally, IL-18, has been shown to bind to a novel receptor, the Na-Cl Co-transporter (NCC). We hypothesized that NCC mediates IL-18 metabolic and cardiac signaling in mice. Using male C57BL/6J mice, we compared the metabolic and cardiac function changes after at least 8 weeks of high-saturated fat high sugar diet (Western Diet) in NCC knockout (NCCKO), IL-18 knockout (IL-18KO), and wild-type mice. We show that NCCKO mice have significantly increased body weight gain from baseline, no difference in fasting …

Reducing Uncertainty In Head And Neck Radiotherapy With Plastic Robotics, Mark R. Ostyn

Theses and Dissertations

One of the greatest challenges in achieving accurate positioning in head and neck radiotherapy is that the anatomy at and above the cervical spine does not act as a single, mechanically rigid body. Current immobilization techniques contain residual uncertainties that are especially present in the lower neck that cannot be reduced by setting up to any single landmark. The work presented describes the development of a radiotherapy friendly mostly-plastic 6D robotic platform for positioning independent landmarks, (i.e., allowing remote, independent positioning of the skull relative to landmarks in the thorax), including analysis of kinematics, stress, radiographic compatibility, trajectory planning, physical …

Development Of Novel Models To Study Deep Brain Effects Of Cortical Transcranial Magnetic Stimulation, Farheen Syeda

Theses and Dissertations

Neurological disorders require varying types and degrees of treatments depending on the symptoms and underlying causes of the disease. Patients suffering from medication-refractory symptoms often undergo further treatment in the form of brain stimulation, e.g. electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), or transcranial magnetic stimulation (TMS). These treatments are popular and have been shown to relieve various symptoms for patients with neurological conditions. However, the underlying effects of the stimulation, and subsequently the causes of symptom-relief, are not very well understood. In particular, TMS is a non-invasive brain stimulation therapy which uses time-varying magnetic …

Motion-Induced Artifact Mitigation And Image Enhancement Strategies For Four-Dimensional Fan-Beam And Cone-Beam Computed Tomography, Matthew J. Riblett

Theses and Dissertations

Four dimensional imaging has become part of the standard of care for diagnosing and treating non-small cell lung cancer. In radiotherapy applications 4D fan-beam computed tomography (4D-CT) and 4D cone-beam computed tomography (4D-CBCT) are two advanced imaging modalities that afford clinical practitioners knowledge of the underlying kinematics and structural dynamics of diseased tissues and provide insight into the effects of regular organ motion and the nature of tissue deformation over time. While these imaging techniques can facilitate the use of more targeted radiotherapies, issues surrounding image quality and accuracy currently limit the utility of these images clinically.

The purpose of …

Evaluation And Adaptation Of Live-Cell Interferometry For Applications In Basic, Translational, And Clinical Research, Kevin A. Leslie

Theses and Dissertations

Cell mass is an important indicator of cell health and status. A diverse set of techniques have been developed to precisely measure the masses of single cells, with varying degrees of technical complexity and throughput. Here, the development of a non-invasive, label-free optical technique, termed Live-Cell Interferometry (LCI), is described. Several applications are presented, including an evaluation of LCI’s utility for assessing drug response heterogeneity in patient-derived melanoma lines and the measurement of CD3+ T cell kinetics during hematopoietic stem cell transplantation. The characterization of mast cells during degranulation, the measurement of viral reactivation kinetics in Kaposi’s Sarcoma, and drug …

Relationship Between Patient-Health Coach Interactions And Changes In Markers Of Glucose Homeostasis, Jason P. Nagy

Theses and Dissertations

Diabetes and insulin resistance are on the rise in the United States. Early detection and deployment of therapies has allowed for the reversal of pancreatic beta cell damage. Unfortunately, not all providers can offer the support to facilitating the required life style modifications. The introduction of clinical health consultants (CHC) as supplemental care has improved patient health for a variety of chronic diseases. Missing in the literature are studies investigating the correlation between the number of CHC interactions and improvement in biomarkers.

The study utilized a non-experimental, retrospective study design to evaluate the relationship between the use between the use …

Understanding The Role Of Phosphoinositide 3-Kinase And Its Function As A Driving Force Behind The Er Stress Response In Fibrostenotic Crohn’S Disease-Affected Ileal Smooth Muscle Cells, Prashant Yadav

Theses and Dissertations

Crohn’s disease (CD) affects about 780,000 people in the United States alone, and it is estimated that 6-15 per 100,000 persons will receive a diagnosis of this disease each year. There currently is no cure for Crohn’s disease, and available medical therapies simply serve to alleviate the inflammation. This does not help treat fibrostenosis that Crohn’s disease patients may develop, which can only be treated surgically. Finding alternatives to treat CD requires an understanding of mechanisms at the biochemical level. In this thesis, we attempted to gain a better understanding of certain pathways found to be active in Crohn’s disease-affected …

Economic Burden Of Renal Cell Carcinoma (Rcc) And Treatment Patterns, Overall Survival And Healthcare Costs Among Older Metastatic Rcc Patients, Hrishikesh P. Kale

Theses and Dissertations

Background

Renal cell carcinoma (RCC) is the most common type of kidney cancer. Patients diagnosed with metastatic RCC (mRCC) have shorter overall survival compared to those diagnosed at earlier stages. Several targeted therapies, which cost from $7,000 - $16,000 per month have been approved since 2005 to treat mRCC. In addition, there is a growing interest in the use of cytoreductive nephrectomy (CN) with targeted therapies among mRCC patients. However, little is known regarding the economic burden of RCC and role of CN and prescribing patterns of targeted therapies among older mRCC patients.

Objectives

1) To assess the economic burden …

Influence Of Muscle Strength On Mobility In Critically Ill Adult Patients On Mechanical Ventilation, Audrey R. Roberson

Theses and Dissertations

Patients in the intensive care unit (ICU) setting are prone to develop muscle weakness and the causes are multi-factorial. Muscle strength in adult, critically ill patients on mechanical ventilation decreases with immobility. The influence of muscle strength on different muscle groups and its influence on progressive mobility in the adult, critically ill patient on mechanical ventilation has not been examined. Identifying muscle strength in this patient population can benefit overall muscle health and minimize muscle deconditioning through a progressive mobility plan. The objective of this dissertation was to describe muscle strength in different muscle groups and to describe the influence …

Impaired Cardiorespiratory Fitness Following Thoracic Radiotherapy, Justin M. Canada

Theses and Dissertations

Cancer (CA) is the second leading cause of death in the United States preceded only by cardiovascular disease (CVD). Over the past 30 years, the 5-year survival rate for all cancers combined has increased by more than 20%. This improved survival rate is due to early diagnosis and advances in treatment involving a multimodality treatment approach that includes radiotherapy [RT] with about half of all CA patients receiving some type of RT sometime during the course of their treatment. Cardiotoxicity is one of the most important adverse reactions of RT and leads to a meaningful risk of CVD-related morbidity and …

Implementing Integrated Care In Family Medicine: Description And Outcomes In An Underserved Population, Zach Radcliff

Theses and Dissertations

Introduction: Family physicians provide access to medical and behavioral healthcare for many underserved populations. Integrating behavioral health clinicians into primary care practices has been proposed as one of the most effective ways to increase access to necessary behavioral health services for many Americans. Integrated behavioral healthcare (IBHC) has begun to be implemented in family medicine practices but there is limited research examining the impact for patients and clinic staff. This study begins to fill this gap in the literature by examining the effects of implementing integrated behavioral healthcare in an urban family medicine clinic in a medically underserved area.

Objective: …

Thyroid Hormone As A Method Of Reducing Damage To Donor Hearts After Circulatory Arrest, William P. Adams

Theses and Dissertations

There is a chronic lack of donor hearts to meet the need for heart transplant both in the US and worldwide. Further, the use of available hearts is limited by the short period between collection and implantation during which the heart can be safely preserved ex vivo. Using mid-thermic Langendorff machine perfusion, we have been able to preserve the metabolic function of a healthy heart for up to 8 hours, twice the limit for current static cold storage. We have also been able to preserve the metabolic function of a damaged DCD Heart collected 30 minutes after cardiac arrest …

Investigation On Genetic Modifiers Of Age At Onset Of Major Depressive Disorder, Huseyin Gedik

Theses and Dissertations

Major Depressive Disorder (MDD) is a complex multifactorial disorder, which would lead to disability. Environmental and genetic factors are involved in MDD etiology. The aim of this project was to identify loci modifying age at onset (AAO) of MDD using survival models after adjusting for Childhood Sexual Abuse (CSA). To achieve this aim, a dataset was made available by the China Oxford and VCU Experimental Research on Genetic Epidemiology (CONVERGE) consortium. The study population had 5,220 controls and 5,282 cases with MDD. We performed two univariate association analyses using Cox Proportional Hazard (Cox PH) models. These two are Full Sample …