Medicine and Health Sciences Commons^™

The Role Of Physician Assistants And Nurse Practitioners In Increasing Access To Buprenorphine, Yeon Sun Kim

Yale School of Medicine Physician Associate Program Theses

Opioid use disorder results in increasing mortality every year and is a growing concern in the United States. Buprenorphine is a safe and effective evidence-based medication to treat opioid use disorder. However, despite this evidence, there are a disproportionately low number of providers with the requisite Drug Enforcement Agency registration to prescribe buprenorphine, resulting in a significant barrier to access. In 2016, the Comprehensive Addiction and Recovery Act extended buprenorphine prescription privileges to physician assistants and nurse practitioners; however, these efforts have been restricted by state regulations. We hypothesize that access to buprenorphine is improved in areas where PA/NPs have …

Checkpoint And Cyclooxygenase Inhibition In Microsatellite Stable Metastatic Colorectal Cancer, Angela Preda

Yale School of Medicine Physician Associate Program Theses

Traditionally, metastatic colorectal cancer has been treated using cytotoxic chemotherapy but the development of immunotherapeutic agents has afforded higher durable remission rates and more tolerable side effect profiles in a small subset of patients. Immunotherapy treatments are currently approved for the treatment of microsatellite instability high subgroup that comprises four percent of metastatic colorectal cancer. However, immunotherapy treatments have little clinical activity in the microsatellite stable subgroup, which encompasses the majority of colorectal cancers. In this phase II trial, we propose to study the efficacy and safety of a three-drug regimen comprised of two immunotherapy treatments, programmed death 1 and …

Group Videoconferencing To Reduce Fear Of Falling, A Randomized Non-Inferiority Trial, Alan Vlieg

Yale School of Medicine Physician Associate Program Theses

A fear of falling has a significant impact on the life of an elderly person. Over half of people over the age of sixty-five admit to a fear of falling, which is an independent risk factor for falling and several other poor health outcomes. Interventions have been successful in reducing fear of falling among participants, however there are significant barriers to participation among an older population. Delivering the intervention at home would reduce several barriers. Teleconferencing has been an effective tool among an elderly population and delivery of an established intervention through videoconferencing has been shown to be comparable to …

Randomized Controlled Trial Examining Ticagrelor Versus Placebo On Coronary Flow Reserve, Sabrina Puvalowski

Yale School of Medicine Physician Associate Program Theses

Non-obstructive coronary artery disease is prevalent in the United States and is associated with acute coronary syndrome and heart failure. Despite its prevalence and morbidity, no standard therapy exists for non-obstructive coronary artery disease. The development of non-obstructive coronary artery disease involves coronary microvascular dysfunction, which is primarily driven by endothelial dysfunction. Therefore, exploring therapies to improve endothelial function could benefit patients with coronary microvascular dysfunction. Ticagrelor is a P2Y12 inhibitor that is used for its anti-platelet effects and is also thought to improve endothelial function. Therefore, we propose to investigate the effects of ticagrelor versus placebo on coronary flow …

Early, Proactive Palliative Care In Hospitalized Patients With Advanced Dementia: A Research Proposal, Tori Viveen

Yale School of Medicine Physician Associate Program Theses

Dementia is a chronic, progressive and fatal neurodegenerative disease with no curative treatment options. The number of Americans living with dementia is expected to triple between 2018 and 2050. Access to palliative care for patients living with dementia and other chronic diseases like cancer improves quality of life and may even prolong life. However, the optimal timing for a palliative care consult is not yet clear. This study seeks to determine whether early initiation of palliative care in dementia patients admitted to the hospital with acute illness benefits patient clinical outcomes (non-institutionalized days at home, readmissions, location of death) and …

Initiating Buprenorphine In Patients Hospitalized With Intravenous Drug-Use-Related Endocarditis, Naiska Y. Cheung

Yale School of Medicine Physician Associate Program Theses

During the current opioid crisis, hospitalizations for the treatment of intravenous drug use-related infective endocarditis have increased. Despite this, opioid use disorder is inadequately treated resulting in continued drug use, higher surgical intervention, recurrence and mortality rates relative to non-drug use-related endocarditis. Buprenorphine* is a safe and effective medication-assisted addiction treatment in outpatient settings; however, buprenorphine remains underutilized, particularly among patients hospitalized for infective endocarditis. Emergency department-initiated buprenorphine combined with referral to ongoing treatment is associated with improved rates of addiction treatment engagement. Therefore, our objective is to investigate whether hospital-initiated buprenorphine combined with referral in patients with opioid use …

Psilocybin-Assisted Therapy: A Double-Blind Randomized Controlled Trial, Katherine Gruppo

Yale School of Medicine Physician Associate Program Theses

Alcohol use disorder is one of the most prevalent mental health disorders worldwide, treatment options are limited, and relapse rates are high. There remains an urgent need for effective treatments. Research involving the therapeutic potential of classic hallucinogens has reemerged in recent decades and the hallucinogen psilocybin has shown some promise in early studies. We aim to assess the efficacy of psilocybin in treating alcohol use disorder with a 10-week double blind randomized double dummy crossover control trial comparing psilocybin-assisted psychotherapy to ketamine-assisted psychotherapy in individuals with alcohol use disorder. Our primary outcome will be the mean percent heavy drinking …

Effectiveness Of Telepsychiatry Among Geriatric Participants With Age-Related Hearing Loss, Stephanie Mock

Yale School of Medicine Physician Associate Program Theses

Presbycusis (hearing loss that occurs with age) affects 30% of adults aged 65 to 74, yet hearing loss is rarely considered when developing novel treatment deliveries. For example, research shows that telepsychiatry improves depression symptoms among geriatric patients similarly to traditional forms of therapy, however, there is no literature on effectiveness of telepsychiatry in geriatrics with presbycusis. The objective of this study is to assess whether, compared to face-to-face psychotherapy, telepsychiatry produces superior outcomes assessed by the Beck Depression Inventory II, among depressed geriatric patients suffering from presbycusis. We will conduct a randomized controlled trial among elderly individuals with depressive …

Ketamine Plus Exercise For Major Depressive Disorder: A Randomized Controlled Trial, Sean J. Mccarthy

Yale School of Medicine Physician Associate Program Theses

Major Depressive Disorder is the leading cause of disability among mental illnesses worldwide, but existing therapies fail to adequately treat approximately 30-50% of depressed patients. Ketamine has promising rapid antidepressant effects, but these effects are of short duration. Exercise yields moderate antidepressant effects both as a primary treatment and as an adjunct to standard therapies, but has not been investigated as an adjunct to ketamine. This study seeks to determine whether the addition of regular aerobic exercise regimens to ketamine therapy will potentiate or prolong ketamine’s antidepressant effects. We propose a single-blind, randomized controlled trial in which patients will be …

Outcomes Among Patients With Chronic Critical Limb Ischemia With No Revascularization Option And Deep Vein Arterialization As A Novel Revascularization Approach: A Systematic Review And Meta-Analysis, Mohammed Imran Riaz Ghare

Yale Medicine Thesis Digital Library

Objective: To quantify the 6- and 12-month amputation-free survival (AFS) in patients with “no-option” Rutherford category 5/6 critical limb ischemia (CLI) in current clinical practice and to characterize outcomes and methods for deep vein arterialization as a possible means for revascularization in patients who are not candidates for conventional surgical or endovascular revascularization. We also sought to determine if there was any trend in amputation-free survival before and after 2003 which was the year of publication for the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).

Background:

The natural …

A Report Of Us Physicians’ Beliefs About Physician-Assisted Suicide And A Bioethical Analysis Of The Practice, Peter Theodore Hetzler

Yale Medicine Thesis Digital Library

A REPORT OF US PHYSICIANS’ BELIEFS ABOUT PHYSICIAN-ASSISTED SUICIDE AND A BIOETHICAL ANALYSIS OF THE PRACTICE.

Peter T. Hetzler III, James Nie, Amanda Zhou, and Lydia S. Dugdale. Department of Internal Medicine, Yale University, School of Medicine, New Haven, CT.

The goals of this work were two fold. The first was to assess the beliefs of US physicians about the national legalization of physician-assisted suicide (PAS). The second was to determine the moral permissibility of PAS through a bioethical analysis. For the former, we sent a survey to 1000 randomly chosen physicians from around the US. For the last, we …

Home Visits In Internal Medicine Graduate Medical Education, Amitte Rosenfeld

Yale Medicine Thesis Digital Library

Home-based care training is largely absent from internal medicine (IM) graduate medical education, and home-based care program evaluation largely focuses on resident attitudes and satisfaction, rather than impact on practice or the patient experience. In the 2015-16 academic year, the Yale Primary Care Internal Medicine residency program (YPC) incorporated required home visits for all PGY-1s and PGY-2s. These visits are intended to build unique clinical skillsets, enhance education about the role of psychosocial determinants of health, and potentially impact resident wellbeing. A qualitative method was used to evaluate this program with the goal of characterizing the impact of one-time home …

Methods For The Visualization Of Placental Vasculature In Fetoscopic Surgery, Praneeth Sadda

Yale Medicine Thesis Digital Library

Twin-to-twin transfusion syndrome is a potentially fatal disease of placental vasculature in twin pregnancies. It is treated with fetoscopic laser photocoagulation surgery, a procedure in which a surgeon uses an endoscope to find and cauterize abnormal vascular anastamoses on the placental surface. However, even after surgery, mortality remains as high as twenty to forty-eight percent, largely due to anastamoses being missed during the operation. Many technical challenges contribute to anastamoses being missed, including poor endoscopic image quality and a limited field of view. Any tools capable of addressing these challenges would be clinically valuable. This thesis presents the design and …

Drumming To Communicate Emotion: Dual-Brain Imaging Informs An Intervention In A Carceral Setting, Rahil Rojiani

Yale Medicine Thesis Digital Library

Drumming is an ancient nonverbal communication modality for expression of emotion. However, there has been limited exploration of its possible applications in clinical settings. Further, the underlying neural systems engaged during live communication with drumming have not been identified. We investigated the neural response to live, natural communication of emotion via drumming using a novel dual-brain neuroimaging paradigm to discover its unique neurophysiological mechanisms related to drum behavior and cross-brain coherence, and as compared to talking. We then investigated the application of a drumming intervention in an incarcerated, halfway house population to characterize intervention feasibility, elucidate the phenomenology of social …

Identifying Interactions Between Chikungunya Virus And Aedes Aegypti Salivary Gland Proteins, Alfred Jiang

Public Health Theses

Chikungunya virus (CHIKV), an emerging threat to global health, has been responsible for extensive arboviral epidemics in Southeast Asia and the Americas in recent years. In order to develop effective therapeutics and preventative measures, we must first gain a deeper understanding of both the host and vector factors that define the pathogen’s life cycle and transmissibility. Currently, the entry receptor and potential co-factors that facilitate CHIKV infection in the arthropod vector are unknown, highlighting a critical knowledge gap in our understanding of the viral life cycle. Furthermore, while secreted mosquito salivary proteins have been shown to modulate host infection through …

Nicotine Dependence And Alternative E-Cigarette Use Behaviors: Dripping And Vape Tricks, Harmanpreet Bhatti

Public Health Theses

Background: E-cigarette use among youth is concerning due to the risk of exposure to hazardous chemicals and future combustible cigarette use. Alternative e-cigarette use behaviors, or dripping (i.e., applying drops of e-liquids directly onto heated coils) and vape tricks (i.e., blowing shapes or large clouds of visible exhaled aerosol), may also increase this risk. However, little is known about the risk of nicotine dependence among adolescents who engage in these behaviors. Therefore, the aim of this study was to determine the association between these alternative e-cigarette use behaviors and nicotine dependence among adolescents.

Research Design: Cross-sectional data were collected from …

So You Think You Can Exercise: The Gap Between Exercise Confidence And Physical Activity Among Samoan Adults, Diksha Brahmbhatt

Public Health Theses

Samoa is experiencing one of the highest prevalence of overweight and obesity in the world, placing its population at increased risk of developing several noncommunicable diseases including type 2 diabetes and cardiovascular disease. The role of physical activity in reducing the burden of these diseases and overweight is well-established. Exercise self-efficacy or confidence is a predictor, if not determinant, of recreational physical activity. The purpose of this study, therefore, is to assess the relationship between exercise confidence and levels of recreational physical activity among Samoan adults. We confirm that exercise confidence is correlated with time spent exercising. However, despite considerable …

Postpartum Weight Trajectories In A Cohort Of 127 Samoan Women: Does Breastfeeding Protect Against Postpartum Weight Retention?, Grace Castillo

Public Health Theses

Rising global obesity rates impact every aspect of health, including maternal-fetal health. Samoa has a disproportionate burden of obesity, with more than half of Samoan women entering pregnancy obese. Given Samoan women’s high parity (4), postpartum weight retention (PPWR) may be a significant source of weight gain over women’s lifetimes. Little is currently known about PPWR among Samoan women, so this analysis sought to document PPWR trajectories, assess factors – like breastfeeding -- associated with PPWR. Data of 127 mother-infant dyads from the 2017 Foafoaga O le Ola cohort were used in analysis. Researchers collected demographic and lifestyle data, as …

Attachment Security And Psychological Health In Adult Child Caregivers And Their Parents With Alzheimer’S Disease And Related Dementias, Wei Aiko Chang

Public Health Theses

Objective: Attachment theory is a helpful framework for examining one of the most fundamental needs in parent-child dyads across the lifespan and how attachment security might protect both dyad members’ psychological health, especially in times of crisis. In this study of adult child caregivers and their parents with early stage Alzheimer’s disease and related dementias (ADRD), we examined the associations between both dyad members’ attachment security, the adult child’s depressive symptoms, and quality of life of the parent with ADRD.

Method: Thirty-four individuals (parents) with ADRD and their 34 adult-child caregivers each completed the 12-item Experiences in Close Relationship Scale …

Evaluation Of A Patient Navigation Program For Vulnerable Families, Hillary Chisholm

Public Health Theses

Abstract

Objectives: Low-income and minority children experience worse health outcomes for reasons that are complex and multifactorial. The aims of this study were to examine the experiences of caregivers and providers who participated in a patient navigation program designed to address these disparities, and to understand how the program was impactful to participants.

Methods: As part of a larger pilot-stage intervention, we conducted a qualitative study using a modified Realist Evaluation approach. Between April and October 2018, we conducted semi-structured interviews of a group of caregivers who were enrolled in the intervention, and the providers who cared for these children. …

Persistence Of Ebola Virus In Survivors & Risks Of Sexual Transmission: A Systematic Review, Allison Cheung

Public Health Theses

Background: Longitudinal cohort studies of Ebola virus disease (EVD) survivors from the 2014-2016 West African outbreak have found evidence of Ebola virus (EBOV) and EBOV RNA persistence in the bodily fluids of survivors, particularly in semen. This new evidence has raised the possibility of sexual transmission of EBOV by EVD survivors. The current interim guidance issued by the World Health Organization (WHO) recommends safer sex practices for at least 12 months after acute disease onset (ADO). However, based on new evidence, these recommendations may require revision.

Objective: The main aim of this article is to present and evaluate evidence on …

Estimating Mortality After Natural Disasters In Low- And Middle-Income Countries: A Systematic Review, Joseph Clingerman

Public Health Theses

Background

The outcomes of natural disasters produce many complex uncertainties and statistics, many of which have no metrics to assess how accurate they are. In particular, mortality estimates in low- and middle-income countries encompass many variables in their inherently challenging physical, political, and logistical landscapes. Given that there has been no known systematic review of assessing mortality estimation methodologies, the author aimed to provide a systematic review of known methodologies and provide a framework to assess mortality estimation methodologies.

Methods

The author performed a systematic search of electronic databases from the past two decades up to January 2019. In addition, …

Quantifying Influenza Exposure Within Hospitals And Nursing Homes, Drew Taylor Dickinson

Public Health Theses

Abstract

Background: Influenza acquisition in hospitals and nursing homes (NHs) highlights the need for infection prevention to protect patients from contagious diseases while under the care of a healthcare facility. We quantified influenza exposure in both settings and compared facility-onset influenza rates in order to determine if risks of acquiring influenza differed by type of healthcare facility since infection prevention practices are less standardized and less rigorous in NHs.

Methods: We conducted a retrospective cohort study of California hospital and NH inpatients during the 2015-2016 influenza season, defined as the peak influenza month, plus the two adjacent months, using claims …

Older Adult Spouses’ Emotional Responses To Reminiscing About Their First Encounter: Associations With Mental Health, Marital Satisfaction, And Cardiovascular Reactivity, Hanzhen Lan

Public Health Theses

Objectives: While there has been growing interest in how close relationships affect older adults’ health, not much research has examined how emotional experiences in older married couples’ positive interactions relate to individual and relational well-being and physical health. The present study hypothesizes that positive emotional responses to older couples reminiscing about first encounter are associated with each spouse’s higher marital satisfaction, fewer depressive symptoms, and healthier cardiovascular reactivity (blood pressure and heart rate variability).

Method: One hundred and one couples completed a background questionnaire at home and then participated in a laboratory session in which they discussed how they first …

Gaps In Mental Healthcare Use And Perceived Quality Between Privately Insured Lgb And Heterosexual Individuals In The United States, Yuki Hayashi

Public Health Theses

Previous research has identified significantly heightened levels of mental health issues and psychological distress among lesbian, gay, and bisexual (LGB) individuals in the U.S., as well as greater mental health service utilization among this population. Using a nationally representative sample of privately insured adults in the U.S., we investigate differences in mental healthcare utilization, characteristics of mental healthcare received, and perceived quality of care between LGB and heterosexual individuals. Key results find that privately insured LGB men and women are significantly more likely than their heterosexual counterparts to have used outpatient mental healthcare as well as out-of-network (OON) outpatient mental …

Evaluating Fda Generic Approval After 2017 Agency Initiatives, Kuo Jiao

Public Health Theses

Importance: Generic drugs play an essential role in the US healthcare system, providing less costly alternatives to branded drugs that are equally effective and safe. The US Food and Drug Administration (FDA) regulatory policies influence the standards for generic drug approval. In 2017, the FDA instituted several initiatives to promote generic drug approval, particularly focused on those with limited competition.

Objective: To determine whether the initiatives begun by FDA in 2017 were associated with greater numbers of approvals of generic drugs with limited generic competition and histories of drug shortage.

Study Sample and Design: We conducted a cross-sectional study of …

Proximity To Nearest Major Road And Time To Pregnancy In The Early Pregnancy Study, Nina Hatch

Public Health Theses

Purpose: Current literature suggests that air pollution may affect reproductive outcomes, but little research has evaluated the association between air pollution and fertility. Our aim is to further examine the relationship between distance to major roadway, a proxy for traffic-related air pollution, and fecundability.

Methods: Our analysis was conducted within the North Carolina Early Pregnancy Study (n=221). Our outcome was pregnancy attempt time, an estimate of fecundability, or the per cycle probability of conception. Our primary definition of conception included early pregnancy loss, spontaneous miscarriage, ectopic and molar pregnancy, and singleton or twin pregnancies. In a secondary analysis, we defined …

A Review On Antibiotic Stewardship In Pediatric Primary Care, Paulina Kaminski

Public Health Theses

Background. Misuse of antibiotics for upper respiratory tract infections (URTIs) in pediatric primary care settings persists despite growing concern over antibiotic resistance. Interventions aimed at improving prescription use, coined Antibiotic Stewardship Programs (ASPs) often target clinicians for improved clinical decision-making. More recently, ASPs have begun educating patients to antibiotic needs, and for pediatric cases, parents who might pressure clinicians into prescribing unneeded antibiotics. While many reviews have targeted adult patients or emergency settings, few evaluate practices for pediatric populations. For this reason, we performed a review of the literature to summarize common strategies used to reduce antibiotic overprescribing for pediatric …

Multi-State Analysis Of Unconventional Oil And Gas Development And Rates Of Sexually Transmitted Infections In The United States, Nicholaus Peter Johnson

Public Health Theses

Background

Advances in unconventional oil and gas development (UOGD), including hydraulic fracturing and horizontal drilling, have helped position the United States as a world leader in the production of both crude oil and natural gas hydrocarbons. This significant increase in production would not have been possible, however, without the assemblage of a workforce that is predominantly young, male, and mobile. This is significant given that a number of studies have associated similar types of mobile workforces – especially those employed by resource extractive industries – with impacts on the sexual health of the host communities in which these workers operate …

Evaluating The Feasibility And Effectiveness Of Self-Monitoring Of Health – A Pilot Study Among Samoan Women, Erica Kocher

Public Health Theses

Background:

Samoa, like many low- and middle-income countries, faces a high burden of obesity and non-communicable disease. Self-monitoring technologies to help individuals track their health have proven effective in high-income countries, but have not generally been tested in low-income settings. To investigate the feasibility and potential effectiveness of using step-counters and digital scales in Samoa, we conducted a pilot randomized controlled trial.

Methods:

The trial enrolled 44 Samoan women (31-40 years) without chronic conditions (non-hypertensive, non-diabetic, etc.) and who reported motivation to become more active. After a 1-week baseline period to measure physical activity in the absence of any feedback, …