Medicine and Health Sciences Commons^™

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

Yale School of Medicine Physician Associate Program Theses

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

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

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

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

Yale School of Medicine Physician Associate Program Theses

Abstract/Summary:

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

Abstract

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

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

Background

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

Managing Refractory Status Epilepticus With Early Ketamine Administration, Ashlyn Shavers

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

Dichloroacetate As A Metabolic Treatment For Glioblastoma, Megan Macia

Yale School of Medicine Physician Associate Program Theses

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

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

Yale School of Medicine Physician Associate Program Theses

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

Computerized Cognitive Behavioral Therapy For Patients With Post-Treatment Lyme Disease Syndrome, Katherine Fry

Yale School of Medicine Physician Associate Program Theses

Lyme disease is the most common vector-borne illness in North America. Post-treatment Lyme disease syndrome is defined as a subset of patients appropriately treated for Lyme disease who continue to experience generalized symptoms, such as depression. However, treatment options for depressive symptoms in post-treatment Lyme disease syndrome largely remain unknown. The objective of this study is to examine whether computerized cognitive behavioral therapy, an internet-delivered form of traditional cognitive behavioral therapy, can reduce depressive symptoms in patients with post-treatment Lyme disease syndrome. Here, we conduct a parallel randomized controlled trial to evaluate whether computerized cognitive behavioral therapy can reduce depressive …

Cardiac Rehabilitation Adherence Rates In Elderly Patients Using A Mobile Application, Amanda Wilson

Yale School of Medicine Physician Associate Program Theses

Adherence to cardiac rehabilitation reduces cardiovascular disease mortality. Despite this, adherence rates remain suboptimal especially among older patients. Mobile applications are increasingly utilized to deliver virtual healthcare with similar health outcomes. However, no studies have determined whether cardiac rehabilitation delivered via mobile applications can increase adherence rates in elderly patients who may be limited by logistical barriers, such as difficulties with transportation. The aim of this study is to examine whether cardiac rehabilitation conducted via mobile application can increase adherence rates to cardiac rehabilitation in patients over 65 years old compared with traditional cardiac rehabilitation. We will conduct a randomized, …

The Effect Of Platelet-Rich Plasma On Recovery In Athletes With A Grade Iii Lateral Ankle Sprain, Matthew Attolino

Yale School of Medicine Physician Associate Program Theses

Lateral ankle sprains are the most common cause of missed athletic participation. One emerging therapy that has been used to hasten recovery from orthopedic injuries is injection with platelet-rich plasma. However, the effect of platelet-rich plasma on recovery from lateral ankle sprains has only been studied in the context of less severe injuries (grades one and two). We hypothesize that a platelet-rich plasma injection will decrease the mean days to return to play in athletes with a severe (grade three) lateral ankle sprain. We will conduct a multicenter randomized controlled trial to investigate the mean days to return to play …

Extracorporeal Membrane Oxygenation Facilitated-Resuscitation For Out Of Hospital Cardiac Arrest, Gloria Ho

Yale School of Medicine Physician Associate Program Theses

Survival rates for out-of-hospital cardiac arrest are abysmal and have largely remained unchanged over the last several decades. A recent single center study of patients with out-of-hospital cardiac arrest found that early cannulation with extracorporeal membrane oxygenation could improve mortality rates. It is unclear if these findings are generalizable to and reproducible at other hospitals. The goal of this study is to assess the rate of survival to hospital discharge for patients treated with early extracorporeal membrane oxygenation compared to standard advanced cardiovascular life support. To this end, we will conduct a multi-center, intention-to-treat, randomized controlled trial in adults with …

Efficacy Of Topical Silymarin In Melasma Treatment During Pregnancy And Breastfeeding, Warunee Nowak

Yale School of Medicine Physician Associate Program Theses

Melasma is a common hyperpigmentation disorder that negatively impacts quality of life. Melasma predominately affects women of reproductive age and is commonly acquired during pregnancy. Current treatment options focus on prevention with limited therapies available once melasma has developed for patients who are pregnant or breastfeeding. One potential therapy that has shown promise for the treatment of melasma is silymarin, a derivative of milk thistle. However, the effect of silymarin on melasma in the pregnant and breastfeeding population has never been investigated. This double-blind randomized placebo-controlled trial will investigate whether topical silymarin can improve the severity of melasma in pregnant …

The Effects Of Mindful Meditation Skills-Training For Healthcare Providers On Patient Satisfaction, Gaia Mohr-Tonachini

Yale School of Medicine Physician Associate Program Theses

Mindfulness-based interventions have become an increasingly popular and accepted approach to reducing burnout, depression, anxiety, and stress among healthcare professionals. However, the effects of how a mindfulness-based intervention might impact a clinician’s patient care and patient-provider relationship are not known. In this study, we aim to discover if providing healthcare professionals with a Mindfulness-Based Stress Reduction program will improve their patient-provider relationship as indicated by a statistically significant change in Press Ganey patient satisfaction scores. Providers recruited from Yale Health will be randomized into an intervention group or wait-list control group. Mean patient satisfaction scores will be analyzed for each …

Impact Of Acculturation In Mediating Barriers To Screening Mammography Among Arab American Women, Nour Ebid

Yale School of Medicine Physician Associate Program Theses

Breast cancer is the most common malignancy in women. Early detection and screening (including breast self-examination, clinical breast examination, and mammography) are vital for early identification and treatment, but there are established cultural differences in screening. Arab women have lower screening rates and are more likely to be diagnosed with late-stage disease. Cultural differences can be attributed to medical mistrust and inadequate knowledge. However, the extent to which they impact screening practices is not fully known. In this cross-sectional study, we assess the rate and regularity of screening mammography in the U.S., comparing Arab versus non-Arab/Hispanic White women. We will …

Topiramate For Weight Loss In Adults With Obesity And Loss Of Control Eating After Bariatric Surgery, Amanda Faxon

Yale School of Medicine Physician Associate Program Theses

Diagnostic criteria for binge eating disorder may preclude a diagnosis in post-bariatric surgery patients because they require consumption of abnormally large quantities. Loss of control eating is considered the salient feature of binge eating disorder in some eating disorder literature, and some of the field is moving towards excluding the quantity of food criterion. Loss of control eating is associated with poorer weight outcomes post-surgery. Topiramate, an anticonvulsant, has been shown to improve weight outcomes in patients with binge eating disorder after surgery, therefore its evaluation in patients with loss of control eating and obesity post-surgery is warranted. We aim …

Effects Of Dialectical Behavior Therapy On Body Modification In Borderline Personality Disorder, Tyler Godek

Yale School of Medicine Physician Associate Program Theses

Borderline Personality Disorder is a mood disorder characterized by emotional dysregulation, increased impulsivity, and increased self-harm. Recently, a positive correlation has been made relating number of body modifications (such as piercings, tattoos, and scarification) and severity of disease. Dialectical Behavior Therapy is the first-line treatment for Borderline Personality Disorder and has been found to significantly reduce engagement in another form of self-harming behavior (non-suicidal self-injury). However, the effects of Dialectical Behavior Therapy on body modification are not understood. In this randomized control study, we will compare the effects of Dialectical Behavior Therapy, pharmacotherapy, or non-treatment on the number of body …

Efficacy Of Quikclot Combat Gauze When Used By Immediate Responders In A Simulated Gunshot Wound, Brenden Feingerts

Yale School of Medicine Physician Associate Program Theses

Gunshot wounds sustained by civilians in the context of active shooter events are distressingly common in the United States. Current guidelines recommend the use of advanced hemostatic dressings as the first-line treatment for gunshot wounds sustained to anatomical areas in which a tourniquet cannot be effectively deployed. These guidelines have been informed by studies conducted in military and surgical settings by trained medical personnel, however, no studies have been conducted to assess their efficacy when utilized by untrained civilian bystanders. In this study, we will compare the efficacy of QuikClot Combat Gauze to standard gauze for achieving hemostasis when utilized …

Efficacy Of Rimegepant Plus Calcitonin Gene-Related Peptide Monoclonal Antibody For Migraine, Carina Leggio

Yale School of Medicine Physician Associate Program Theses

Migraine is a paroxysmal pain disorder managed with abortive therapy during a pain attack, prophylactic therapy to prevent attacks, and often a combination of both. Calcitonin gene-related peptide (CGRP) and its receptor have a role in the provocation of migraines, and therefore have been targeted in the development of both preventive and abortive therapies. However, there is limited research investigating concomitant use of the therapies. This study will examine the safety and efficacy of oral rimegepant when used for acute treatment concomitantly with a monoclonal antibody (mAb) targeting the CGRP ligand or receptor for the preventive treatment of migraine. A …

Sudarshan Kriya Yoga And Alteration In Depression Severity And Default Mode Network Connectivity, Elizabeth Togneri

Yale School of Medicine Physician Associate Program Theses

Major depressive disorder is one of the most common and burdensome psychiatric disorders. Many individuals still experience symptoms despite pharmacological treatment. Breathing techniques have shown potential for stress, depression, and anxiety reduction. A second promising treatment are mindfulness-based interventions, which have been shown to effectively decrease depression with fewer side effects than pharmacological agents. Both interventions are accessible via remote instruction. This study will investigate the effect of Sudarshan Kriya Yoga breathwork on depression symptoms. Using a prospective, randomized controlled trial, subjects will receive Sudarshan Kriya Yoga, Mindfulness Based Stress Reduction, or standard care for 8-weeks. We will measure changes …