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The planning and design of a course for the inactive registered nurse desiring to return to active practice is reported in this practicum paper. Current literature was reviewed with emphasis on the needs in rural states, such as Vermont, and characteristics of the target group. The first three modules of the course were developed, entitled: The Nursing Process, The Endocrine System, and The Transport System. Other modules were identified for future development, including: Oxygen Deprivation; The Infectious Process; Neurological Problems; Skeletal Problems; Nutrition in Disease; Proliferation of Cells; Focus on Abnormal Behaviors; Common Maternal and Child Health Problems; and Legal Implications of Nursing. Various methods of print and non-print materials would be used. Evaluation of learning would be through pre- and post-tests. Recommendations include submitting the first three prepared modules to the Vermont State Board of Nursing for approval. If approved, the remaining modules would be completed and the course offered through the Department of Continuing Education to all inactive nurses within the state. Evaluation of the effect of the course would be through a follow-up study of the nurse and employer in six months. (Author/LBH)

The concept of precision medicine aims to provide additional context to patient data for healthcare providers. Precision medicine overlays three additional layers of patient data on top of standard patient information: environmental exposure, personal lifestyle and behavior patterns, and information gleaned from their genome. While precision medicine promises to provide physicians and their patients with increased levels of customization for preventative and primary care, there is evidence that preparation relating to the genomic pillar of precision medicine is not yet adequate to ensure successful deployment. Aim 1 in this dissertation explored the knowledge gap between primary care physicians and genetic experts via a validated survey instrument and compared these two group's ability to interpret genetic tests and their self-efficacy when working with genomic data. Results found the correct interpretation rates for the two groups were relatively high (74.4% for providers, 83.4% for specialists). Additionally, higher correct interpretation rates were associated with age, prior genetic test consultation experience, and level of trust assigned to the reports. Aim 2 mapped out the ideal educational techniques to help increase patient comprehension of genetic testing results by conducting a scoping review; 26 manuscripts were selected in this review. The papers were categorized into three themes that emerged: education interventions, curriculum development, and review papers. Finding from this review established that there is a need to develop web-based educational tools designed with active learning methodologies, additional randomized controlled trials are needed to develop more robust evidence, and clinical outcomes need to be linked with educational interventions. Aim 3 captured the development of a mhealth telehealth app; a proxy software solution to assist healthcare providers with a artificial intelligence driven clinical decision support as a method to assist with genetic data education and interpretation. AI driven CDSS was found to have some significant hurdles still yet to overcome. Precision medicine has moved from theoretical and planning stages into real world initiatives and there are now large amounts of resources being invested. It is critical to investigate solutions and continue identifying future roadblocks while they remain manageable. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]

This annotated bibliography lists almost 100 items. It focuses on materials on the social aspects of the history of medicine published after 1981 because there is no other bibliography that does so. The research design relies on the bibliographic method. The end-product is a systematic, enumerative bibliography. The guide includes 13 general reference works; 3 guides; 9 bibliographies; 12 biographies; 8 dictionaries and encyclopedias; 6 indexes and online services; 3 directories; 33 monographs on social aspects of medicine; 5 periodicals; and 5 associations. (KRN)

Although emergency departments (EDs) are often the only sites of care for patients with opioid use disorder (OUD), a proven medication, buprenorphine, is underutilized by community emergency physicians when patients present with OUD. To explore this further, we first performed a qualitative study of 30 community emergency physicians. We then conducted a quantitative analysis of a national database of emergency department visits based on one of our main qualitative findings. Finally, we evaluated the results of the quantitative study in the context of our other main qualitative findings, exploring the Familiarity Principle and how it explained our quantitative findings in light of our qualitative results. The integrative analysis demonstrates that it is not the population of patients with OUD but rather the disease of OUD towards which stigma exists.Our original model for community emergency physician (CEP) prescription of buprenorphine to patients with OUD suggested that four themes predominantly factored into decision-making: (1) physician professional identity; (2) the image of (and stigma towards) patients with OUD; (3) physician education and professional development; and (4) additional resources for care. While some of these findings had been described previously, the concept of stigma appeared to be novel and so formed the basis for a confirmatory quantitative study. To explore ideas further, we performed a quantitative analysis of a national database of 267 million ED visits over four years. We found that ED resource utilization for patients with OUD who presented because of typical ED complaints (chest and abdominal pain) was similar to ED resource utilization for patients without OUD. This finding suggested that any CEP bias towards this population did not translate into less care during ED visits for non-OUD concerns.To further understand the counterintuitive results, we returned to our qualitative findings. We analyzed them in the light of the Familiarity Principle and determined that the other three qualitative findings—physician identity, education, and resources—allowed CEPs to treat patients with OUD similarly when they presented with non-OUD concerns, given their overall comfort with the medical issues, if not the patients. This comfort appeared to override CEPs’ stigma towards this patient population. This finding may be the key to developing effective methods to increase the appropriate treatment of these patients when they present with OUD concerns.

The Medicare Improvements for Patients and Providers Act passed by Congress in 2008 has changed prescribing practices in the United States. Electronic prescriptions (e-prescriptions) have now become the most widely used form of prescriptions. The government in fact financially discourages the use of the older more traditional paper prescriptions. Many emergency medicine physicians fear that this blanket policy is not in the best interests of their unique patient population. It is the belief of many of these physicians that emergency patients are more likely to fill paper prescriptions than e-prescriptions. This theory is predicated on the knowledge that many emergency patients are less established in the system and their visits are frequently rushed, chaotic, and unplanned. For these reasons, the e-prescription system is not ideal for them and the theorized consequence is that many e-prescriptions go unfilled, leaving patients to go untreated. A retrospective analysis was conducted at the emergency department of the University of California, Irvine Medical Center to identify insured adult patients who were given a non-controlled substance prescription in either the paper or electronic form. Pharmacy claim data to insurances was used to determine whether these prescriptions were filled. 405 encounters were included, 218 of which included e-prescriptions and 187 of which included paper prescriptions. Our findings showed that paper prescriptions are filled at the same rate as electronic prescriptions (58.3% versus 57.8% p=1). These results were surprising as they contradicted what many physicians believe is the situation. More studies are needed in order to be able to broaden these results to the entire emergency medicine patient population, but these results may begin to alter prescription practices in emergency medicine.

Heart disease is the leading cause of death in men and women in the United States. Significant research into the risk factors for cardiovascular disease has been done, and the effect of hyperlipidemia on cardiovascular risk has been well documented. Recent research has shown that there is a lack of adherence to lipid guidelines by primary care providers. Failure to follow clinical guidelines for lipid disorders leads to increased cardiovascular morbidity and mortality. The objective of the project was to evaluate whether a simple, paper-based, lipid tracking form could improve provider adherence to current lipid guidelines. This descriptive study used a prepost test design. Baseline adherence to lipid guidelines was determined by chart review of a random sample of current practice patients. The lipid-tracking form was placed on the charts of all patients seen for routine office visits during a specified time frame. After the lipid-tracking form collection period was completed, a random sample of those patients was reviewed to reassess adherence to lipid guidelines. The post-implementation date was compared to the baseline data. The use of the lipid-tracking form did demonstrate an improvement in adherence to lipid guidelines as demonstrated by an increase in the number of patients who had a documented LDL goal (p=0.000). In practices without electronic medical records, this simple, inexpensive, paper-based tool can help providers improve adherence to lipid guidelines.

This portfolio thesis comprises three parts: a systematic literature review, an empirical study and a set of appendixes.Part one is a systematic literature review, in which the literature pertaining to factors that impact on the psychological wellbeing of parents of children with type 1 diabetes is reviewed. The review begins with an overview of the research relating to parents of diabetic children, which is followed by a rationale for why this review would be an interesting addition to the literature. The paper then describes the methods used to collect the relevant studies. The review synthesises the results in a way which makes it clear which factors impact on each measure of psychological wellbeing. An overview of the findings is then given. The paper closes with limitations of the review, suggestions for future research and conclusions.Part two is a preliminary pilot study in which empathy and sibling relationships are the focus. This cross-sectional study explores empathy and the quality of the sibling relationship as perceived by diabetic children, their healthy siblings and siblings in which both children are physically healthy. Based on Furman and Burhmester's (1985) model of the determinants of the quality of sibling relationships, the study moves on to explore the predictive effect of empathy on children's perceptions of their sibling relationship. The paper presents the findings and conclusions before discussing the clinical implications and the pilot study's limitations.Part three is a set of appendixes to support the work in the first two parts. It also contains a reflective account to explore the process of developing this portfolio thesis.

This portfolio thesis comprises of three parts: a systematic literature review, an empirical report and a reflective statement.Part one is a systematic review in which literature relating to the empirical paper is reviewed. Due to a paucity of literature about reasons to participate in male reproductive health trials (RHTs), the broader area of reasons to participate in clinical trials, from a non-clinical sample, was reviewed. The review attempts to determine reasons why ‘healthy’ people participate in clinical trials and compares the findings with literature on reasons why patients participate. Recommendations are then made for future clinical trial recruitment strategies.Part two is an empirical paper encompassing two studies. Study one aimed to test hypotheses about factors that influence male participation in RHTs, specifically masculinity and altruism. Comments from participants about their own idiosyncratic reasons were then used to triangulate findings. Study two aimed to complement study one by exploring experiences of men participating in a RHT. Thematic constructions of stigma, altruism and masculinity were considered within a decision-making framework.Part three comprises of ppendices, including a reflective summary drawing on all aspects of the research process.

This portfolio thesis comprises of four parts: a systematic literature review paper, an empirical paper, a reflective statement and appendices.Part one is a systematic literature review which examines whether personal therapy is an effective method of professional development for therapists. Quantitative and qualitative literature is critically reviewed. A model of the reported benefits of personal therapy for therapists is proposed. Implications for clinical practice are discussed.Part two is an empirical paper examining the relationship between stage of development and behaviour in clinical supervision for trainee clinical psychologists. Forty trainee clinical psychologists, from three years of a training course, completed a questionnaire (the SLQ-R[A]) measuring their stage of development as supervisees. A subsample submitted DVD-recordings of their supervision sessions which were coded using the Teacher's PET to analyse the supervision behaviours. Comparisons were made between the supervision behaviour of first (n = 8) and third (n = 3) year trainee clinical psychologists and their supervisors. Correlations between questionnaire responses and supervision behaviours were examined. Results are discussed in the context of the Integrated Developmental Model of Supervision. Implications for clinical practice are highlighted.Part three is a reflective statement which considers the process of conducting the research and developing this portfolio thesis.Part four is the appendices.

The portfolio has three parts. Part one is a systematic literature review, in which the empirical literature relating to self-defining memories is reviewed. The term 'self-defining memories' which was first coined by Singer and Moffitt (1991-1992), refers to a subcategory of autobiographical memories that are of important events in our personal histories that we believe define who we are (Singer, 2005). The systematic literature review presented in this portfolio examines which factors may affect the recollection of SDMs recall in terms of the types of memories recalled, but also the experience of recalling such poignant memories. Part two is an empirical paper, which explores the how changes in mood may affect the recollection of self-defining memories. This investigation uses laboratory induced changes in mood to examine how mood variation may affect the thematic content, and affective response to SDMs in a group of individuals with bipolar disorder, and nonclinical controls. The findings suggested partial support for the hypotheses that mood does influence the type of SDMs recalled, affective responses to memories, and perception of positive self when thinking of the memories. However, contrary to predictions, the effect of mood was not found to differ between individuals with bipolar disorder and non-clinical controls. Interestingly, this study found that individuals with bipolar disorder recalled memories that contained themes of a disrupted sense of identity, or acting out of character, when by their nature, SDMs are meant to reflect events that an individual feels defines who they are rather than who they are not. Part three comprises the appendices. This part contains additional information relating to the literature review and empirical paper, including information about ethical approval.

This research portfolio is divided into three parts: Part one is a systematic literature review titled 'Factors associated with relationship stability following brain injury: a systematic review of the literature'. Research frequently documents the negative effects of brain injury and the difficulties faced by survivors and their families. Couples in particular may experience a range of life changes and challenges, which have been shown to place considerable strain on the stability of their relationship. This systematic literature review explores the positive and negative factors associated with marital and relationship stability following acquired and traumatic brain injury, in order to examine what keeps couples together and what pushes them apart. The review process uncovered 18 studies that contained evidence relating to factors associated with relationship stability after brain injury. All studies were assessed for methodological quality and the strengths and weaknesses of papers are discussed. Findings revealed 20 different factors that may contribute to relationship stability following brain injury. Although the evidence for 14 of these factors appeared contradictory, six factors were identified with consistent evidence. The following may have important implications for the stability of relationships following brain injury: The extent of physical disability, particular neurobehavioural characteristics including mood swings and unpredictability, changes in communication between couples and finally, un-injured partners' difficulty understanding the effects of the brain injury. Part two is an empirical paper titled 'Discrepant illness perceptions in stroke survivorpartner dyads: Relationship to psychological adjustment and expressed emotion'. Previous research has shown that relationships between couples can become strained after brain injury and that those partners who adopt a carer role may be more likely to express negative or critical reactions towards the person they care for. This study explores a cognitive component that may underlie the extent of carers expressed emotions: The difference or discrepancy between carers understanding of their partners stroke and stroke survivors understanding of their stroke. Findings from the health research literature have shown that following an illness event, patients and carers create unique personal models or illness perceptions around five distinct components, these include identity, cause, time-line, consequences and cure-control. This study investigates whether couples differ in their illness perceptions and if so, whether this relates to carers level of negative or critical reactions towards their partner (expressed emotion) and stroke survivors level of psychological adjustment (anxiety and depression). A correlational design was used to explore the associations between discrepant illness perceptions, expressed emotion and anxiety and depression. A total of 51 couples participated in the research and results showed that although the correlations between variables were not statistically significant, there was a statistically significant correlation between stroke survivors' level of anxiety and partners' level of expressed emotion. The implications and possible avenues for further research are discussed. Part three contains the appendixes, which provide further information for the systematic literature review and empirical paper. A reflective statement on the process of carrying out the research is also provided.

This portfolio thesis comprises of three parts: a systematic review paper, an empirical report and appendices. Part one is a systematic review in which the literature relating to the empirical paper is reviewed. Literature concerning the prevalence of paternal distress within the first year postpartum is addressed. The review attempts to determine levels of severity and aims to stipulate when distress is more prevalent within the year. The usefulness of such epidemiological data is also considered. Part two is an empirical paper examining the discourses around the postpartum father. The study aimed to conceptualise how the father's discursive position may limit the acceptability of distress in this period. The paper outlines popular competing constructions of postpartum fatherhood and paternal affect drawn from the accounts of first-time parents, midwives and health visitors. The impact of such discursive inconsistency on the recognition of this clinical issue is discussed. Clinical implications are then described. Part three comprises the appendices. A reflective summary drawing on the overall research process is included.

Evidence Based Medicine (EBM) is the process of systematically finding, judging, and using research findings as the basis for clinical decisions and has become the standard of medical practice. There are countless new studies and research being published daily. Keeping track of each of them is impossible, not to mention needing to read and comprehend them. While search engines can help healthcare professionals search for a topic with suggesting relevant papers on the topic, healthcare professionals still need to go through the papers and extract relevant information themselves. This is a very time-consuming task as one study on Information Retrieval (IR) practices of healthcare information professionals that it takes on average 4 hours for healthcare information professionals to finish a search task. Moreover, a systematic review study on the barriers to medical residents' practicing of evidence-based medicine revealed that two of the most frequently mentioned barriers for residents were limitations in available time, knowledge, and skills. In this project, we address both problems by building a Medical Question Answering (QA) system that employees semi-supervised information extraction methods in Natural Language Processing (NLP) to construct a large scale Knowledge Graph (KG) from the extracted facts from a large repository of medical research publications. Then, the system translates a given user’s question in a natural language to the KG efficiently to extract relevant answers based on evidences to present in a user-friendly manner. The system returns a compilation of summaries for the related evidences with one sentence summary for each evidence relevant to the user’s question and the reference to the full publication. The system can help address the barriers of knowledge and skills by providing comprehensive summary of the evidences for a given question in a natural language that eliminates the need to formulate complex structured queries. The system was evaluated on a real-life test dataset collected from healthcare professionals, and the evaluation results showed performances comparable to the state-of-the-art Biomedical QA systems in the literature.

This thesis is submitted in partial fulfilment of the requirements for the Doctor of Clinical Psychology (Clin. Psy. D. ) at the University of Birmingham. It comprises clinical placement reports and a research project. Volume I contains the research component in two papers. The first is a review of the literature relating to Post-Traumatic Stress Disorder (PTSD) in Obstetrics. This paper is prepared for submission to the British Journal of Health Psychology. It examines how the DSM-IV diagnostic system for PTSD has been applied to traumatic stress reactions to childbirth. Post-partum PTSD is then compared and contrasted with PTSD in other fields, such as combat, civilian and health-related settings. The second paper is an empirical study of the psychological adjustment to the Implantable Cardioverter Defibrillator (ICD). It investigates the role of coping style and negative and positive affect in physical and psychological recovery. There is also an examination of whether ICD shock discharge is associated with poorer psychological and physical outcome and posttraumatic stress symptoms. This paper has been prepared for submission to the journal of Pacing and Clinical Electrophysiology. Instructions for submitting authors to the journals are included in the appendices to Volume I. The thesis follows APA required writing guidelines unless journal submission specifications are required. To facilitate ease of reading, tables and figures are included in the text, but will be included as appendices for journal submission. The appendices to Volume I also contain an executive summary of the empirical paper that is intended for submission to the public domain. Volume II comprises five reports of clinical practice that were submitted over the course of clinical training. These describe a range of issues pertinent to the clinical specialties of adult mental health, child and family, older adult and clinical health psychology. The reports are: a case of a woman with bulimia formulated from cognitive, psychodynamic and systemic perspectives; a short case study of a cognitive behavioural intervention with a woman experiencing phobic anxiety of public urinary incontinence; an evaluation of the quality of communication of a child and family mental health team to GP referrers; an extended single case study of the assessment and intervention with an older adult experiencing chronic grief and sleep disturbance, and; a written presentation describing the role of the clinical psychologist in the assessment of a patient requesting breast augmentation surgery. Relevant appendices are inserted after Clinical Practice Report Three.

Dyspnea is one of the top reasons for emergency department (ED) visits and hospital admission. Chronic obstructive pulmonary disease and congestive heart failure, are two of the most common causes of dyspnea and often coexist within patients making it difficult to differentiate which disease process is causing the symptomatology. Field paramedics have therapeutics to treat these conditions yet they do not have access to diagnostic imaging for evaluation which is a standard of practice in hospital settings. Point of care ultrasound (POCUS) has become standard practice for emergency physicians offering bedside, real time images that help to diagnose and treat patients. POCUS provides high sensitivity and specificity when differentiating between lung pathologies. Research indicates that prehospital lung POCUS led by physicians can positively influence evaluation and treatment of patients. Multiple studies have also revealed the feasibility of prehospital paramedic POCUS. However, most prehospital emergency medical services in the United States have not yet invested in POCUS for their paramedic-level providers. A gap in knowledge has been identified. Research on prehospital paramedic-operated POCUS has yet to explore the use of lung POCUS on stable and unstable patients with a substantial population size. This study aims to assess the accuracy of paramedic interpretation of lung POCUS on prehospital patients with dyspnea and to report changes in accuracy of treatment. This paper proposes a study that will specifically investigate the accuracy of prehospital lung POCUS performed by paramedics by assessing their ability to differentiate between lung POCUS image findings when compared to ultrasound (US)-fellowship trained emergency physicians. Cohen’s kappa will be computed to evaluate the reliability between the paramedics’ and expert US-fellowship trained physicians’ findings. Secondarily, it will determine if there was a difference in the accuracy of treatment in patients who received lung POCUS prehospital. The secondary aim will be analyzed using a chi-squared test. Lastly, descriptive statistics including frequencies will be demonstrated in percentage, and 95% confidence intervals. Given that shortness of breath is associated with morbidity and mortality, proper field identification and treatment would likely have a positive impact on many patients nationally. POCUS can also reduce total patient care costs in the ED which is a major cause of financial ruin in the United States. The intention of this paper is to review the current literature involving prehospital paramedic use of POCUS and to propose a study that will assess whether lung POCUS makes a positive impact on paramedic evaluation and treatment in the field.

BACKGROUND: Obstructive Sleep Apnea (OSA) is a very common disease characterized by brief episodes of airway collapse and low oxygen during sleep. Many years of research on OSA have shown that social determinants of health, such as race, income, zip code, and parental education level lead to varied levels of disease prevalence and severity among different populations. It has been shown very clearly that low-income African-American children have the highest prevalence and most severe outcomes of OSA. However, there is one very important component of health that has not been evaluated in conjunction with OSA: childhood trauma. To assess for childhood trauma, physicians often use the Adverse Childhood Experiences (ACE) QUESTIONNAIRE. This series of questions has been used in numerous medical specialties, including primary care, oncology, pulmonology, general surgery, and obstetrics/gynecology, for decades to evaluate patients for childhood trauma before the age of 18. This survey not only allows clinicians to provide trauma-informed care to their patients, but also serves as a reminder to address both the social and physical aspects of disease when treating a patient, as trauma has been shown to have detrimental effects on long-term health. Over two decades of research have shown that an increased number of ACEs before the age of 18 leads to worse outcomes in a wide variety of diseases, many of which are some of the leading causes of morbidity and mortality in the United States. However, no studies to date have used the ACE questionnaire to evaluate disease and surgical outcomes in the field of otolaryngology (ENT), one of the medical specialties in which patients with OSA are treated and followed. Given the prevalence of OSA nationwide among adults and children, it is crucial to begin examining whether childhood trauma leads to worse disease outcomes in OSA. OBJECTIVE: To conduct a comprehensive literature review of research done on both pediatric OSA and the effects of childhood trauma on disease outcomes for some of most common causes of morbidity and mortality in the United States. An additional objective is to show, using data from the Kids Inpatient Database, associations between various demographic factors and diagnosis with OSA requiring an adenotonsillectomy. METHODS: For the literature review, a PubMed search was conducted on both aforementioned topics using various keywords and MeSH terms to narrow down the search. Reference lists of relevant papers were also used to find other relevant papers. For the empirical data, the Kids’ Inpatient Database, a national database created by the Healthcare Cost and Utilization Project and Agency for Healthcare Research and Quality, was used. There have been many version of this database, but the most recent version from 2016 was used for this study. Due to the COVID-19 pandemic-related restrictions, we were not able to administer the ACE Questionnaire to patients with obstructive sleep apnea as originally planned. RESULTS: The literature review on pediatric OSA showed that the main risk factors for developing severe OSA are adenotonsillar hypertrophy, African-American race, low socioeconomic status/low income, and obesity. Other important risk factors include preterm birth, male sex, and craniofacial anomalies. The literature review on childhood trauma showed that adults over the age of 18 who endorsed more adverse experiences on the ACE questionnaire consistently had worse disease outcomes in chronic illnesses such as ischemic heart disease, chronic obstructive pulmonary disease, and some cancers. The results from the Kids Inpatient Database showed that Black children had the highest odds of developing OSA and requiring a tonsillectomy. Additionally, the Kids Inpatient Database shed light on the odds of having a tonsillectomy based on income quartile, showing that children of higher income quartiles are more likely to receive surgery. CONCLUSIONS: Many years of research have shown both that social determinants of health such as income, race, and socioeconomic status are associated with severity of obstructive sleep apnea, and that increased childhood trauma is often associated with worse disease outcomes in a wide variety of chronic illnesses. However, a very important next step in research on these topics is to combine them to assess whether increased childhood trauma also correlates with increased severity of OSA.

BACKGROUND: In early 2020 the outbreak of SARS-CoV-2 was declared a pandemic. With this came the search for ways to treat infected patients. A drug that was found was remdesivir, which is a nucleotide analog RNA polymerase inhibitor that was originally used for the treatment of Ebola. With FDA emergency approval on May 1st, 2020, remdesivir was used to treat hospitalized COVID19 patients, but at that time the question of its effectiveness was still to be answered, and studies were conducted around the world. On November 20th, 2020, however, WHO issued a recommendation against the use of remdesivir in the treatment of COVID19, causing some controversy. This paper’s objective is to review the results of the studies conducted, and to draw conclusions of remdesivir’s effectiveness in treating COVID19 caused by the SARS-CoV-2 virus. METHODS: Databases were search with terms such as COVID19 and remdesivir between May 2021 and January 2022, looking for published papers that match the requirements to be included in this study, which were randomized controlled trials of remdesivir in the treatment of hospitalized COVID19 patients compared to a control or placebo, looking at mortality rates and time to recovery. From there the data was reviewed and analyzed to draw conclusions. RESULTS: Baseline characteristics of control patients and patients treated with remdesivir were similar, with similar baseline severity of illness at the time of randomization into their trial. The results showed no difference in the chances of death between the groups but showed a decrease in length of hospital stay for patients treated with remdesivir as compared to the control and placebo groups. There was no difference in the chance of adverse effects across both groups. CONCLUSION: Through this review it was found remdesivir has no effect on the mortality rate. It does aid in the time to recovery in patients diagnosed with COVID19. The lack of effect on the mortality aligns with WHO’s recommendation against the use of remdesivir in the treatment of COVID19 disease caused by SARS-CoV-2 virus, but remdesivir’s ability to decrease time to recovery contradicts it.

The five papers in this section discuss a range of topics drawing on a variety of theoretical models including Cognitive Therapy, Psychodynamic Therapy, Family Therapy and a transtheoretical model of behaviour change. Two of the papers contain issues pertaining to individuals with specific psychological and neurological difficulties, namely Parkinson's Disease and Dementia. Two further papers contain material relevant to broader groups of clients, namely older adults and individuals with health related problems. Finally one paper is applicable to any individuals seeking psychological help. The first paper aims to critically examine whether older adults differ from younger adults in their need for psychological involvement. A brief discussion of the aging process is given in order to highlight some of the differences between older and younger people. Similarities and differences between the two client groups are then discussed in relation to presenting psychological needs and therapeutic interventions. Continuing the theme of work with older adults, the second paper examines the literature concerning the design of environments for people with Dementia. This paper highlights features in the physical, social and therapeutic environment which need to be given special consideration when working with and/or designing living accommodation for members of this particular client group. The third paper also addresses issues relating to people with a specific neurological disorder. In this essay the contributions of neuropsychology to the assessment of clients with Parkinson's Disease are discussed. This includes a discussion of both the uses and problems of neuropsychological assessment. Although this paper is related specifically to the assessment of people with Parkinson's Disease, many of the issues raised are applicable to neuropsychological assessment in general. The fourth essay also raises issues that are applicable to a wide range of clients. This paper contains a discussion of the selection criteria used to assess suitability for Cognitive Therapy and Psychodynamic Psychotherapy. An examination of the similarities and differences between the criteria outlined by the two fields is undertaken. Continuing the theme of the fourth paper, the fifth and final essay also examines a theoretical model. An outline of Prochaska and DiClemente's transtheoretical approach to behaviour change is presented and its applicability to the field of health psychology is discussed.

Physician assistant programs are relatively new academic programs that aim to train and prepare PAs as advanced medical providers. Since their inception less than 60 years ago, multiple changes have been made to the curriculum. Additionally, the introduction of technology in the classroom has allowed further variations in how students learn in PA programs. As a new and growing program, limited research has been done on these PA programs regarding motivation and attendance. This paper aims to evaluate aspects of motivation and attendance that have been previously analyzed in other healthcare programs, then propose a study which explores those variables in Boston University’s physician assistant program. Ultimately, this paper will add to data regarding PA programs that examine motivation and attendance in students. This data is important to maximize student satisfaction, learning, and efficiency in a rapidly growing profession.

Progression to end stage kidney disease (ESKD) is often sudden due to few symptoms during earlier stages of chronic kidney disease (CKD), and health care access barriers preventing recommended CKD screening. Due to nonrandom processes dictating selection into pre-ESKD nephrology care, permanent access versus catheter, and arteriovenous graft (AVG) versus arteriovenous fistula (AVF), measurement of outcomes subsequent to these processes must consider remedies to potential selection bias. In paper one, a recursive bivariate probit estimated factors associated with permanent access creation prior to hemodialysis after accounting for selection into pre-ESKD nephrology care. Nearly all patient factors had small effects, whereas pre-ESKD nephrology care increased the likelihood of improved care (permanent access) more than fourfold. Polices related to health insurance access and pre-ESKD nephrology care are therefore essential for improving rates of early permanent access creation. Paper two examines determinates of vascular access type and infection, with some factors (e.g., pre-ESKD nephrology care) relating to infection risk indirectly, through selection into an access type. An endogenous Poisson was used to model variability in hospitalization for vascular access infection after adjusting for selection into permanent access. The results suggest ESKD patients under 30, patients with a history of intravenous drug use, and residents of nursing homes should be a focus of interventions to reduce vascular access infection among ESKD patients, as adjustment for selection into an access type substantially increased estimates of these groups’ infection risks, relative to estimates from a Cox proportional hazards model that does not correct for selection bias. In paper three, rates of filled opioid prescription did not differ by access type, and a modeling approach accounting for selection into AVF versus AVG was found to be inappropriate. However, among patients filling an opioid prescription, AVG recipients had, on average, 2 additional 5 milligram hydrocodone equivalents prescribed to them relative to AVF recipients. Federal, state, and health system policymakers, as well as members of surgical societies and research scientists, may wish to use these findings to inform methodological approaches and decisions related to the identification and care of late-stage CKD and early-stage ESKD patients.

Antiretroviral therapy (ART) has played a key role in extending the longevity of individuals infected with HIV. Although life expectancy increased significantly, aging with the virus has presented a new study of interest as neurocognitive impairments begin manifestations in individuals living with HIV. These manifestations lead researchers to investigate the involvement of HIV and HIV-associated neurodegeneration (HAND). As interest in this area grows, researchers demonstrate the current pathology of neuro-HIV and the damage manifests in HAND patients. The current neuropathology of HIV neuronal damage demonstrates the initiation of CD4 and chemokine coreceptors, CCR5 and CXCR4 in the brain to activate macrophages and microglia for the release of neurotoxic substances to neurons. The use of ART has provided a decreased incidence of extreme neurological impairments in HIV patients, yet, there were no significant changes to the overall incidence of HAND with ART, producing a gap for treatment against neuro-HIV. Many researchers are currently investigating different targets in neuro-HIV pathogenesis, such as chemokines, cytokines, leukotrienes, etc., to inhibit inflammatory responses that could be used as potential treatments for neuroprotection. Montelukast is a cysteinyl-leukotriene receptor 1 antagonist, initially used as an anti-inflammatory drug for asthma. Cysteinyl leukotrienes have been shown to correlate with the inflammatory response of neuro-HIV, which is why we want to see if the drug will inhibit this response and demonstrate neuroprotection in HIV-infected brains. In this paper, we will investigate the effects of a cysteinyl leukotriene receptor 1 antagonist, Montelukast in HIV gp120 mice We will conduct a 2-month administration of Montelukast and saline to HIV-gp120 transgenic and wild-type mice and then analyze the effects of the Montelukast through immunofluorescence staining and statistical analysis. Our findings suggest the neuroprotective effects of Montelukast on MAP-2-positive neuronal dendrites, presynaptic synaptophysin-positive terminals, and Iba-1-positive microglia in the cortex. Iba-1 also demonstrated a significant decrease of microglia in the hippocampus, an indication of neuroprotection in the brain. However, no other significant changes indicating neuroprotection were observed in HIV-gp120 transgenic mice treated with Montelukast.

With the latest pandemic involving SARS COVID-19, there are still many questions about the complicated chronic conditions that patients experience after initial infection. To address this emerging patient population and unify the scientific and medical community, the NIH has adopted the term post-acute sequelae of SARS-CoV-2 infection (PASC) (Vehar et al., 2021). This thesis seeks to address Central nervous system (CNS) manifestations stemming from infection of SARS COVID-19 as it pertains to their pathologies, clinical presentations, diagnostics, and lastly hopeful preventative measures and treatments. To do so, this literature review will initially detail the underlying virus, SARS-CoV-2, and hypothesized infective mechanisms that trigger the COVID-19 infection and thus elaborating on the intricate host immune response. This background information will provide the backdrop for the subsequent clinical symptoms and pathophysiology that have been documented. With the looming problem of this patient population overburdening and confounding the medical system, this paper will then summarize the current diagnostic tools to identify the at-risk populations and current PASC patients. Lastly, the latest preventative and therapeutic measures will be detailed to support efforts in the creation of a more standardized approach in addressing this patient population. With this accumulation of literature, the intention is to create a composite of approaches to research, clinical diagnostics and care for patients affected by neurological PASC.

Introduction/Background: Hispanic subgroups are often grouped under the combined Hispanic global term, preventing us from identifying any differences or disparities within that group that might exist. As California currently has the largest collectively identified Hispanic population in the US at 39%, data maintained for California has an adequate sample for the study of subgroups within this population for differences in health and illness. This paper will examine cancer-related survival involving the eight major cancer sites: colon, rectum, stomach, liver, female breast, prostate, ovary, and cervix. This study aims to discern whether there are differences in cancer-related survival in the following Hispanic subgroups: Mexican, Puerto Rican, Cuban, Southern or Central American, and other Spanish/Hispanic origin. Methods: Data was gathered from the California Cancer Registry (CCR) using 2004-2017 to conduct a retrospective longitudinal population-based cohort study. The following patient characteristics were obtained: race/ethnicity, age at diagnosis, year of diagnosis, gender, insurance type, socioeconomic status (SES), marital status, type of hospital where treatment was received, adherence to treatment status, tumor stage, and tumor grade. Cancer types included both male and female cancers: colon, rectum, stomach, liver, prostate, female breast, ovary, and cervix. A multivariate proportional hazards model was used to perform a cancer-specific survival analysis while controlling for numerous potential confounders. Non-Hispanic white (NHW) cases were used as the comparison group for each Hispanic subgroup. There were no comparisons between Hispanic subgroups themselves. Results: Between 2004-2017, 420,671 cases of cancer were identified. Of these, 306,262 (72.8%) were NHW, 34,897 (8.3%) were Mexican, 647 (0.2%) were Puerto Rican, 698 (0.2%) were Cuban, 9,638 (2.3%) were South or Central American, and 68,528 (16.3%) were other Spanish/Hispanic origins. Compared to NHW cases, Mexican race/ethnicity was associated with better survival for colon (HR 0.89, 95% CI 0.84-0.96, p=0.0008) and liver cancer (HR 0.88, 95% CI 0.82-0.95, p=0.0006), but Mexican race/ethnicity was associated with worse survival for stomach cancer (HR 1.19, 95% CI 1.10-1.27, p

Chinese Herbal Medicine has been mainstream practice for hundreds of generations, however the merits of herbal therapeutics have been debated in the era of modern medicine. With a shift towards scientific analysis and rigorous testing of conventional pharmaceuticals in the past century, critics have questioned the proclaimed effects of herbal concoctions. Nonetheless, herbal medicines are still used frequently and have spawned clinical studies meant to determine their therapeutic efficacy. This paper aims to evaluate many aspects of Chinese Herbal Medicine applications that have already been analyzed in other papers, then propose a study which explores the effects of the herbal concoction Ban Xia Bai Zhu Tian Ma Pian in lowering blood pressure. Hypertension was chosen as the focus of the study due to its extensive presence in the population and the impact a significant outcome can provide given its prevalence. The ultimate goal is to find a balance between both eastern and western practices of medicine, thus preserving Chinese medical traditions that are concurrently buttressed by scientific research.

Attention Deficit/Hyperactivity Disorder (“ADHD”) is a complex multi-factorial disorder that was first described in the late 1800s as a defect in moral control. By the early 1900s, ADHD shifted away from being a behavioral-based to a neurobiological-based disorder. During this period, individuals with ADHD were classified as having minimal brain damage. Early studies focused on the clinical presentation of ADHD. As advances in neuroimaging and molecular marker techniques started to develop, researchers were able to focus more on the neurobiological aspects of ADHD. This shift was instrumental to both the diagnosis and treatment of ADHD. This paper surveys the existing literature on ADHD in an attempt to elucidate its etiology. While several areas of research seem promising, so far, no single major contributor to ADHD has been identified. This paper first looks at the history behind ADHD. The historical background was instrumental in directing the course of ADHD research. Next, the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) is examined with a focus on the changes made to DSM-IV and reflected in DSM-V. While DSM is a valuable diagnostic tool, its purpose in elucidating the etiology behind ADHD is questionable. Despite that, discussion of the DSM is necessary as it is impossible to study a disorder without delineating the normal from the abnormal. What follows this discussion is a brief overview of comorbidities that are often associated, and possibly share, a common etiology with ADHD. The paper then examines the theories promulgated by researchers as to the neurobiological basis of ADHD. This examination is followed by a discussion of recent findings into the pathology behind ADHD, which mainly centers around differences in brain structure and connectivity. Further analysis of these studies reveals that sex plays an instrumental role in the type of brain abnormalities found in ADHD children. In addition, delays in brain development are analyzed, and age is discussed as a factor in the presentation of ADHD. This paper goes on to examine genetics as a contributor to the etiology of ADHD. This examination proves fruitful as several genes of interest seem to indicate a hereditary component of ADHD. Finally, treatment options such as psychosocial therapy and medications that help ADHD patients maintain a quality of life, are discussed. By studying the mechanism of action underlying these medications, additional clues as to the etiology of ADHD may be discovered. There is still a long way to go before a complete picture of ADHD emerges. Already, studies are showing that race and environmental factors play a role in how ADHD presents. These two areas have rarely been studied and doing so will only serve to enhance the current understanding of ADHD. Despite an incomplete picture, the scientific community has come a long way from the 1800s where ADHD was thought to result from a defect in moral control. With early diagnosis and proper treatment, the ADHD individuals of today can live a life as close to that of their neurotypical peers as possible.

In this paper, we investigate the potential for the development of a composite score investigating population-level phenotype changes in a mouse model of traumatic brain injury. Traumatic brain injuries (TBI) are a growing concern in the United States because the number of individuals impacted by TBI and associated symptoms is increasing, leading to a growing demand for research both in the clinical and preclinical setting. However, preclinical TBI modeling is complicated by the lack of inter and intra lab consistency in the assessment of behavioral and pathologic outcomes. Indeed, it remains unclear which behavior assessments are most useful in evaluating the effects of preclinical TBI. To investigate the relative contribution of various behavior tests in the assessment of preclinical TBI, three statistical models (simple linear regression, pairwise correlation, and factor analysis) were conducted on behavioral data from the Mannix-Meehan lab at Boston Children’s Hospital in Boston, Massachusetts, U.S.A. from 2012-2018. In this paper, a composite metric was created from the computation analysis of the three statistical methods. The score revealed MWM and EPM as the most potent behavioral tests. The Open Field and Rotarod test had a small impact on the outcome, but only in one of the three statistical models assessed. Thus, to effectively analyze treatment efficiencies, injury severity and long-term impairments, MWM and EPM are the best behavioral test for a mouse model. Furthermore, this method of analysis of entire populations of mice allows for more subtle phenotypic changes resultant from injury models to be revealed, and the generalizability of this model lends to widespread use.

Internationally, human trafficking is a growing, $150 billion industry. It is estimated that 40 million people are being trafficked at any one time. Human trafficking is often referred to as modern-day slavery. Because of the hidden nature of the crime, definitions, estimates, and data about it are lacking. All human trafficking definitions include a victim being involuntarily forced into labor or sex acts through force, fraud, or coercion. At least 99% of victims have health problems, making victims one of the least healthy groups of people in the world. In addition to a host of individual health concerns and untreated chronic conditions, victims are disease vectors. They have alarmingly high rates of communicable infections (including sexually transmitted infections, tuberculosis, HIV/ AIDS, and may share needles used for drugs). They frequently live in close quarters and in unsanitary conditions, causing public health concerns among other victims and nearby communities. According to the literature, 88% of victims of human trafficking are seen by a healthcare provider. However, victims are too infrequently identified. These are missed opportunities. As the healthcare system’s first line of defense, nurses have a unique opportunity to identify victims and provide essential interventions. Education, though, is key to recognizing and assessing red flags, identifying victims, and providing interventions. Teaching large numbers of nurses is a huge undertaking, which creates challenges in developing the best approach to reach those nurses. Nursing faculty are in a position to teach huge numbers of new nurses about human trafficking and the role of the nurse in assessing, identifying, and providing victims for victims. This study examines this group of nurse educators.In this study, a modified version of the previously developed PROTECT questionnaire was used to measure nursing faculty members’ actual knowledge, perceived knowledge, and confidence about teaching human trafficking. The study’s survey also included questions about faculty viewpoints. The sample size for this study was 113. Nursing faculty from five universities in Ohio were surveyed about the inclusion of human trafficking in their nursing programs. The great majority of faculty, 92.6%, contend it is important to include human trafficking content. However, only 34.9% of faculty respondents’ programs actually include human trafficking content. These results indicate there is a gap between reality and desire to teach the topic, which indicates there is a need to educate nursing faculty about their role in educating nurses about human trafficking. A full 73.6% of those faculty surveyed felt community and mental health courses are the best fit for human trafficking content, potentially connecting the role of the nurse in identifying victims in a public health setting. This study examines nursing faculty actual knowledge, perceived knowledge, confidence, known or suspected contact with a victim, and previous education about human trafficking, related to teaching. The relationship between these variables and teaching were examined. Data analysis strategies included chi square and, if there was a relationship, logistic regression. Multivariate regression was used to explain relationships when univariate analyses indicated a relationship. Odds ratios were also calculated. Nursing faculty viewpoints about teaching human trafficking were also considered. The relationship between faculty members’ perceived knowledge of human trafficking and teaching human trafficking content was statistically significant throughout all data analyses. Faculty members who had previous education about human trafficking or had known or suspected contact with a victim were also more likely to teach nursing students about this topic and reported more perceived knowledge. Interestingly, there was not a statistically significant relationship between actual knowledge about human trafficking teaching the topic. These findings suggest improving faculty perceived knowledge about human trafficking may increase the likely hood of teaching human trafficking content. Inclusion of human trafficking on the NCLEX-RN and Accreditation of nursing programs may be another incentive to include this content. In addition, this paper recommends preparing interested nurses for advocacy efforts so that legislation requiring nurse education programs to include human trafficking is considered and adopted by policymakers.

Alzheimer’s disease (AD) is a widespread neurodegenerative disorder that affects tens of millions of patients worldwide. Throughout the last two decades an incredible amount of time and resources have been funneled into hopefully finding medications that would provide a cure. Unfortunately, no such compound has been identified and instead the only FDA approved medications for AD to date target symptomatic management and may not even be effective for longer than a couple of years. To this end, this paper sets out to identify modifiable risk factors for AD as well as provide recommendations for clinicians on how best to utilize the tools currently available to them to treat AD. Additionally this paper addresses common flaws in AD clinical trial study designs and provides future research directions to expand outside of the popular amyloid hypothesis and instead potentially focus on a multi-pathway mechanism of the disease. The following thesis will outline several potential mechanisms that can lead to the hallmark pathologies seen in AD, primarily amyloid deposition and neurofibrillary tangles as well as neuronal death. The majority of commercial and research interest into AD has been focused on the amyloid hypothesis and the notion that stopping the formation of amyloid plaques would stop the disease course. However, in recent years other mechanisms and neurotoxic pathways such as inhibition of tricarboxylic acid (TCA) cycle enzymes, neuroinflammation, and tauopathy have been shown to contribute both to the formation of amyloid plaques as well as contributing to AD pathology in their own right. The modifiable risk factors explored in this paper include the effects of triglycerides as well as intake of antioxidant vitamins and omega-3-fatty acids, both of which are beneficial for brain health. This paper will also highlight some of the extensive research on the Apolipoprotein E gene and the effects the various alleles have on AD risk. These being the putative protective effect of the APOE2 allele, “neutral” effect of the most commonly found APOE3 allele, and finally the deleterious effects of the APOE4 allele, believed to be the strongest genetic risk factor for late-onset AD.

ACL injuries are ubiquitous and the literature surrounding ACL reconstructions is complex and difficult to comprehend. In summary, this paper provides a simple yet coherent overview of ACL injuries. Etiology, prevention, and the consequences of injury are discussed. The paper examines literature surrounding the decision to reconstruct the anterior cruciate ligament. An overwhelming quantity of literature is in favor of an ACL reconstruction in order to maintain an active lifestyle. ACL surgery has advanced exponentially in recent years and there is a multitude of fixation and tunneling methods. Graft choice for an ACL reconstruction is also complicated and multifactorial. In general, three types of grafts exist: autografts, allografts, and synthetic grafts. Autografts usually include the hamstring tendon (HT) and patella tendon (BTB), however, recent studies suggest the quadricep tendon (QT) may be a suitable graft. The BTB is often considered the “gold standard” due to its strength and stability. On the other hand, the HT is often used as it is less invasive and is associated with less antero-patellar knee pain. Common allografts include the patella tendon, Achilles tendon, and tibialis muscle group. Despite a higher cost, allografts are usually used in revision surgeries and leave patients with less donor-site morbidity. Lastly, synthetic grafts are growing in popularity, especially the LARS procedure, however, more research is needed. Lastly, this paper attempts to consolidate literature surrounding the QT graft. Only one meta-analysis focusing on the QT has been published, however, the last meta-analysis is from three years ago and several new studies have been published since. The recent literature suggests the QT is a viable option in terms of stability and functional outcomes. Specifically, when comparing the QT to BTB and HT, the QT grades similarity in KT-1000 scores, a common measure of knee laxity and stability. Additionally, IKDC scores, frequently used to assess functionality, show positive results. More literature is needed to fully understand the QT; however, preliminary research indicates the QT can be an esteemed option in ACL reconstruction surgery.

BACKGROUND: Current estimates indicate approximately 6.7% of women in the US are infertile. Infertility can arise from many different conditions and can be both attributed to male and female factors. In women, measures of ovarian reserve such as AMH level or FSH level on day three of the menstrual cycle can be used to predict reproductive success. In conjunction with additional tests and lifestyle screening, these values help to guide the course of treatment, with some patients moving eventually to in vitro fertilization. In vitro fertilization therapy is cost-prohibitive if the patient does not have insurance coverage, an issue for the majority of patients across the United States. AIMS: To evaluate the correlation between cycle number, age, and AMH level with achieving a successful live birth through a statistical analysis of over 50,000 cycles of in vitro fertilization. Methods: Data was obtained from Practice Highway, a company that owns the electronic medical record (EMR) program eIVF, used by over 140 reproductive endocrinology practices across the country. The database provided a total of 88 variables and 138,526 IVF cycle observations ranging from 01/01/2005 to 09/09/2015. A thorough review of available literature was performed to determine the need for the correlations analyzed in this paper. Utilizing this information in conjunction with the scope of this paper, the number of variables was reduced to four. Linear regression and multivariate regression was performed on the four main study variables to identify possible correlations. Results: The results of our study indicate that there is not a strong correlational relationship between the variables analyzed. There was not a significant correlation between age and whether a live birth was achieved. As expected, the strongest relationship identified through our study is the decrease in AMH as age increases. Conclusions: Our study results indicate that there is no correlation between AMH and live birth, suggesting that this biomarker alone is insufficient to be used by physicians as a means of advising patients on IVF success. Additionally, measures such as number of cycles completed and age at cycle start can be useful when counseling patients on their probability of success with assisted reproductive technologies.

The lack of diversity in the physician workforce poses a complex problem for the US healthcare system. Despite numerous efforts over the last 45 years, the lack of representation in the physician workforce persists, with no significant signs of reversing course. There is therefore an urgent need to engage in research to aid in the development of innovative, systemic and sustainable methods of addressing barriers in the educational pipeline leading into medicine for URM students. Much of the previous research in this area has focused largely on examining undergraduate program outcomes and impact on physician specialty/service area choice with very few examining the undergraduate premed experience in detail. These experiences can have deleterious effects which serve as barriers to academic achievement and outcomes, thereby preventing matriculation into medical school and the physician workforce. This research seeks to fill this gap in knowledge and employs qualitative methodology to accomplish three overarching goals: 1. Better understand the experiences of URM premed students as they navigate their undergraduate premed pathway. Focusing on the multi-level factors associated with academic achievement and enrollment in post-bac programs.2. Explore the role and sustainability of post-baccalaureate premed programs in facilitating entry into medical school for URM graduates of the UC system. 3. Develop empirically based recommendations to ameliorate barriers and challenges reported by URM students in the UC system. This dissertation resulted in three papers. The first paper illuminates the barriers and challenges faced by URM premed students and outlines their relation to student achievement and outcomes. The second paper sheds light on URM student perceptions and the specific reasons they apply to post-bac programs in addition to providing data that suggests that post-bacs are not a sustainable strategy to address diversity in the physician workforce. The third paper presents a list of empirically based recommendations aimed at addressing institutional-wide barriers to student achievement such as campus climate, academic/students services and course size and curriculum.

Over the past several decades, the incidence of thyroid cancer in the United States has increased substantially surmounting to higher levels of concern for physicians around the nation. This concern led to a research investigation surrounding the increased risk thyroid cancer patients may face by delaying their surgeries. OBJECTIVE: We aim to evaluate the impact of a delay in surgical intervention on survival in patients with a diagnosis of papillary thyroid cancer. METHODS: This is an observational retrospective study focusing on disease specific survival using SEER-Medicare data as well as data from the National Cancer Database to analyze whether a delay in surgical intervention leads to a decrease in mortality in patients with papillary thyroid cancer. This study focuses on specific thyroid cancer association beyond that of another research paper that found delaying time to surgery does decrease overall survival as discovered by Dr. Scott Fligor in 2021. For the purposes of this study, data was accessed between the years 1999-2018. A survival analysis was performed using the Cox- hazard ratio as well as Kaplan-Meier curves. RESULTS: Preliminary results detail the fact that delaying surgeries past 180 days for patients led to decreased survival over a course of 5, 10, and 15 years as was determined by the use of Kaplan Meyer curves and the Cox hazard ratio. A positive coefficient for a Cox hazard ratio indicates a worse prognosis whereas a negative coefficient indicates the opposite. The results of this study show that increasing time to surgery increases risk of mortality for patients as the hazard ratios suggest for this research. The hazard ratio for 90 – 180 days delay for patients versus patients who underwent surgery within 0 – 90 days was 1.18 (95% confidence internal, 0.96 – 1.45). This hazard ratio is lower than that of the group that underwent surgery after 180+ days whose hazard ratio was 1.21 (95% confidence internal, 0.89 – 1.66). Since the hazard ratio for patients who delayed surgery after 180+ days is higher than the 0 – 90 days as well as the 90 – 180 days, this indicates a worse prognosis over time for patients with increased delays. CONCLUSION: Delaying surgery for thyroid cancer patients deceases their overall survival over a period of 5, 10, and 15 years. Elective or lower risk surgeries over the past 3 years have been delayed due to the Covid-19 pandemic, and thus this data was excluded for the purposes of this study. Further research should be done on the effects the pandemic had on the overall survival for patients who had to delay their surgeries due to the pandemic.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairment in social communication and repetitive behavior. The etiology of ASD is believed to be multifactorial, yet much about causation remains unknown. There is a growing interest in the role of the intestinal microbiome, how it may differ in the ASD population and how the intestinal microbiota may impact central nervous system (CNS) function. This process involves bidirectional communication between the gut and the CNS and is referred to as the gut-brain axis or the microbiome-gut-brain axis. The gut-brain axis comprises the autonomic and enteric nervous systems, the vagus nerve, and the hypothalamic-pituitary-adrenal axis. While the exact mechanism of this pathway is currently unknown, there is growing evidence to suggest that gut microbiota plays an essential role in the brain, behavior, and cognitive development. When comparing the microbiome in ASD to that observed in neurotypical individuals, there is a good deal of variability. Research has shown that distinct bacteria are associated with GI symptoms, Autism severity, and other systemic repercussions on the host’s health. However, because of the inconsistency in microbiome composition, there is not a signature biomarker of ASD. It is still unknown if the diagnosis of ASD causes the gut biome dysbiosis or if the disruption in the biome worsens and contributes to the ASD core symptomology. Individuals with ASD are five times more likely to exhibit atypical eating patterns and six to eight times more likely to have gastrointestinal problems, including diarrhea, constipation, bloating, and gastroesophageal reflux disease when compared with neurotypical subjects. These GI disorders have been reported to be associated with anxiety problems, somatic complaints, sleep abnormalities, and externalizing problems in many ASD individuals. The microbiome in ASD is believed to be atypical and these atypicalities may contribute to some of the brain, behavior and cognitive features associated with ASD. This paper will review what is known about the microbiome in ASD and possible implications for treatment and interventions.

Sickle cell disease is caused due to a genetic mutation that results in a hemoglobinopathy that causes a rare, chronic and often progressive disease associated with severe and life-threatening outcomes. Sickle cell disease is an underfunded, under researched, poorly and inconsistently treated, burdensome disease. In comparison to other rare diseases, there is an overwhelming need to improve sickle cell disease care. This paper aims to propose the need for a combined national registry and shared EHR system to fill a gap in lack of research, as well as improve clinical management of acute care for the disease. As this is a lofty and novel approach, measuring the understanding, influence and potential opposition of those who may be major funders and supporters of sickle cell disease care and research is the first step in implementing the system. A stakeholder analysis is, therefore, necessary prior to creation. This data will provide the foundation in strengthening the understanding of Sickle Disease and its inadequate treatment, while creating an urgency towards action in improving research, knowledge and ultimately the quality of life of those with the disease.

Globally, sepsis is one of the largest causes of death in acute care units. Even with adequate treatment, severe sepsis affects over 49 million people worldwide and is responsible for approximately 11 million deaths each year. People respond differently to infection, which is evidence that individuals have varying degrees of immune suppression. As a result of a pathogen triggering the Systemic Inflammatory Syndrome (SIRS), sepsis is an immunological condition that is diagnosed based on patterns of temperature, heart rate, respiration, and white blood cell (WBC) count. Although the pathogenesis of sepsis remains unclear, there is growing evidence that oxidants and antioxidants play a major role. Oxidative stress is defined by elevated intracellular levels of reactive oxygen species (ROS) that cause damage to lipids, proteins, and DNA. Sepsis pathophysiology includes infection by gram negative or positive bacteria, an elevated inflammatory reaction; lower blood pressure that may result in vasodilatory shock; and reduction of oxygen delivery to organs as a response to cell dysfunction. It has been demonstrated that free radicals such as nitric oxide (NO), peroxynitrite (ONOO-), and hydrogen peroxide are involved in these effects. Specifically, it has been demonstrated that hydroxyl radicals play a role. An extensive network of complicated phagocytic mechanisms is implicated in the development of sepsis. As a result, phagocytosis plays an important function in sepsis and presumably contributes to most clinical phases of the disease. Only a few research studies, however, have particularly investigated and defined the effects of immunosuppression on phagocytic activity during sepsis as a result of the infection. In this paper, I explain the immune response's phagocytic mechanisms that occurs prior to the development of sepsis and identify the features of phagocytosis that may act as a predictive marker for the outcome of the disease. To begin with, I describe some of the most important characteristics of phagocytic processes such as phagocytic main receptors and signaling characteristics. After that, I address the role of phagocytic cell functions during sepsis-induced immunosuppression, as well as some of the research that's been done on the subject recently. Finally, I discuss some of the potential immunosuppressive therapies for septic patients.

The purpose of this literature review is to discuss the mechanisms of a cardiac arrest and how it contributes to the high-risk classification of congenital heart disease patients. While assessing the diagnoses process and types of treatments applied to cardiac arrest and congenital heart disease separately, we further explain this information’s significance by combining their incidence rates and analyzing their associations as it relates to surgical operations. A narrative review of studies is conducted in pediatrics and adults to reveal distinctions in lesion characteristics and interventions, as well as limitations that permit inconsistencies in data reports on health outcomes. There is not adequate research and data collection in reference to perioperative cardiac arrest in congenital heart disease patients and the aim of this paper is to highlight the need for further studies and to present current research that has been conducted to fill the gaps of this global health issue.

Brain injuries like concussions have been a prevalent issue in contact sports like football for years. It is well documented that impacts to the head can cause concussions along with clinical manifestation such as impaired balance, memory issues, and headache. The aim of this paper is to explore the impact sub-concussive events have on neuroinflammatory markers as well as motor control. The level of nine miRNA neuroinflammatory markers were measured at preseason and at the end of the season and compared to the number of head acceleration events (HAEs) that took place during practice that year. In addition, four types of virtual reality (VR) testing were conducted in preseason and postseason to determine if there are any motor functions that are impaired by an accumulation of sub-concussive impacts.

Background: Unmet social needs (USN) are defined as a privation of basic resources or services (e.g., a lack of food or medicine) that contributes to adverse health effects. Screening for USN in healthcare settings is an increasingly common strategy to connect patients and families with social assistance services. Some studies suggest that people with USN are more likely to seek healthcare services at the emergency department (ED) than those without USN. Screening and referral for USN in the pediatric emergency department (PED) may be a useful approach to help alleviate the health burden of USN on families and children. Purpose: The primary aim of this pilot study was to evaluate feasibility and acceptability of USN self-screening (i.e., self-initiated and self-completed USN screening) and self-referral at a single academic PED in San Francisco. Secondary aims were to estimate the proportions and demographics of PED patients and caregivers with USN and to describe the types of reported USN. Design: This pilot study used a quasi-experimental, single-group, survey design. Methods: Patients and caregivers presenting to the PED were first screened by PED nurses for emergent USN (i.e., expected lack of food or housing within the following 48 hours). PED nurses then facilitated administration of a self-report digital or paper USN survey that assessed six domains of non-emergent USN: concern for lack of food, housing, utilities, medications, healthcare transportation, or interpersonal safety within the following four weeks. Demographic information was collected from survey participants. Referral information for 211, a social assistance service staffed 24/7 by resource specialists, was provide to all participants. Those with emergent USN were offered a consult with the PED social worker. A follow-up survey was sent to participants two weeks after discharge from the PED to assess the status of USN, use of resources, and perceptions about usefulness. Survey response data was analyzed using Chi-square tests of independence, Fisher’s exact tests, and descriptive statistics. Field notes were used to identify themes related to the acceptability and feasibility of the intervention. Results: The USN self-screening and self-referral intervention was impeded by several barriers to feasibility and acceptability, including inadequate integration with the PED workflow and a lack of patient or caregiver willingness to engage with USN self-screening. In addition, some nurses described being ambivalent about how USN screening fit with their role or were uncertain about discussing USN screening with patients and caregivers. Only 1.6% (n=111) of the estimated 6,771 eligible individuals seen in the PED completed the USN survey. Of the 111 participants who completed the USN survey, 13.5% (n=15) endorsed at least one USN. Emergent needs were reported by 3.6% (n=4) of respondents. The two most frequently reported USN were utilities (80.0%, n=12) and food (73.3%, n=11). Participants were more likely to endorse USN if they were single, had lower income, or had lower levels household education compared to participants who were married or partnered, had higher income, or had higher levels of household education. Respondents who identified as Black, Indigenous, People of Color, (BIPOC) or Hispanic were more likely to report USN compared to White-identifying respondents. Of the five respondents who endorsed USN during the study period and completed the follow-up survey, four used either 211 or PED-provided resources. Insufficient data precluded determination of participant acceptability. Conclusion: Additional research is needed to determine acceptability and feasibility of nurse-facilitated, multi-domain, non-emergent USN screenings and surveys in the PED. In this pilot study, screening implementation and survey enrollment barriers were major obstacles to USN identification. These barriers were related to inadequate workflow integration, discretionary screening and survey enrollment practices, and indeterminate acceptability of nurse-facilitated USN screening. There also appeared to be a lack of interest or willingness to engage with self-screening among the PED population. Given the lack of outreach and engagement associated with discretionary self-initiated USN screening in this PED, USN initiatives in the PED may want to explore universal staff-initiated screenings in order to improve the likelihood of USN identification. Self-referral was reported by some participants as effective at helping them meet their USN, but there was insufficient data to determine whether self-referral reliably decreased USN. The substantial loss to follow-up of participants with USN suggested participants might have benefitted from automated referral systems or in-person resource navigation that would have allowed for improved service and follow-up capabilities.

For much of human history, microbial infections have been a problem. The discovery of antibiotics has led to the prevention of many deaths and allowed for surgeries that would be too risky otherwise to be performed. In the post-antibiotic era antibiotic resistance has become an ever-growing crisis. Overuse and misuse of antibiotics have allowed for the development of resistance to antibiotics by many strains of bacteria. There have also been very few new antibiotics that have been developed in the past three decades. Antibiotics act on single biological pathways of bacteria and can be deactivated with relative ease, particularly when bacteria are exposed to a subinhibitory concentration. Pseudomonas aeruginosa (PA) is a gram-negative bacterium that has been able to develop resistance to many antibiotics. Nanoparticulate matter has properties that differ from their bulk counterparts. Many metallic nanoparticles have been examined as antimicrobial agents. These nanoparticles tend to harm bacterial growth by many different pathways simultaneously, making the development of resistance by bacteria much more difficult. Silver has been used as an antimicrobial agent for much of human history. Metallic silver nanoparticles have been explored as antimicrobial agents, but systematic evaluation of other forms of silver nanoparticles has been rare. Silver halides are photoreactive materials, most used in paper photography. In this work, I systematically evaluate the antimicrobial activity of silver halide nanoparticles against PA. The preliminary results indicate that silver halide nanoparticles exhibit higher antimicrobial activity and better silver resistance profiles when compared with the metal silver nanoparticles.

Glioblastoma multiforme is the most common and malignant brain tumor, accounting for more than 52% of all primary brain tumors. The molecular heterogeneity of the tumor has made it difficult to treat, and even more difficult to cure. Due to the high mortality rate associated with the current treatments used, new innovative medical techniques are being explored. Prominent treatments that are currently being investigated are immune based therapies, focused on checkpoint inhibitors and biomarkers, the use of 2-deoxy-D-glucose to initiate tumor cell apoptosis, and the induction of alterations in DNA and miRNA to inhibit glioblastoma stem cell accelerated growth and tumorigenesis. Throughout the paper, various ongoing studies are summarized and discussed to compare the outcomes of different treatments. The goal of this paper is to present the different therapies and analyze which one of them is the most effective in treating and prolonging survival for patients with glioblastoma multiforme. This thesis reviewed the large collection of publications about glioblastoma multiforme and treatments for the disease. The use of immune based therapies, such as checkpoint inhibitors and biomarkers, are increasingly delivering promising results as an immunotherapy approach, but it is necessary to complete the phase III trials in order to truly know if these products are successful as anticancer agents or if further research into the matter is required. More research must be done to find the best route of treatment. In addition, the use of 2-deoxy-D-glucose has been successful in treating other types of cancer, such as breast cancer, and now studies look promising in GBM patients. This treatment is still in its initial stages of testing, so more work will need to be done to determine how efficacious this treatment is. By comparing the results of the different therapeutic agents, it was determined that genetic alterations seemed to be the most promising avenue of treatment with current information. The data showed that the greatest increase in survival time and least recurrence was achieved by MGMT promoter methylation and gene modifications of the tumor. Though these treatments have varying results in their efficacy and there are many different combinations of medications that have yet to be assessed, research in the area is greatly advancing and increasing the lives of GBM patients. By allocating resources in the best possible treatment, researchers can change the fatal prognosis of this illness.

This paper closely investigates the natural and medical exchange of knowledge and its social and historical context between Gideon Lincecum (1793 – 1874) and his Choctaw neighbors in Mississippi between the years 1818 and 1833. In his book The Roots of Dependency (1983), Richard White suggests that the Choctaw were compelled to increasingly adopt European and Euro-American economic models at the expense of their traditional notion of reciprocal exchange. This resulted in a critical loss of their traditional means of subsistence and thus diminished political power compared to the United States. White is quite persuasive on the macroscopic level of his investigation, but this paper shows that in the interaction of Gideon Lincecum with the Choctaw, this broad view becomes more complex and problematic. Lincecum and the Choctaw elder Alikchi Chitto create a mutually satisfactory (though far from perfect) exchange of medical and natural knowledge by hybridizing Euro-American market exchange and Native American reciprocity. In addition to examining the content of this knowledge as well as the historical and social context of the exchange, this paper will investigate what knowledge was valued by each party as a function of their cultural perspective and why Lincecum marginalized and thus suppressed the mystical elements of Choctaw natural knowledge.

Mental illness continues to rise within the United States. With the recent COVID-19 pandemic, adequate access to mental health services is becoming even more important. Despite this need, children facing mental health disorders are suffering from the lack of child and adolescent psychiatrists available. This shortage has been prevalent for decades with no permanent solution proposed. In hopes of providing care during this difficult time, pediatricians have been expected to take on responsibility for mental health disorder patients. However, research shows that pediatricians are unprepared and not confident in their abilities to take on this role. Therefore, they continue to provide inadequate care for these patients because of the ever-growing wait times on referrals and obligation to provide help to patients in need. This paper will explore the shortage of child and adolescent psychiatrists and the consequences of this shortage. In a case analysis, the patient, provider and systemic levels will be evaluated through different ethical frameworks including duty ethics, care ethics and justice. Changes will be proposed at the resident, attending physician and national level, in hopes of improving mental health care for children and creating a more accessible system.

Twenty percent of American citizens reside in a rural community and are, as a result, subject to a large healthcare disadvantage (U.S. Census Bureau, 2012). This paper outlines the current research detailing distinctions of rural communities from others, adverse health outcomes associated with rural status, the current state of rural healthcare access, with an emphasis on lack of radiology care and the ethical implications these imaging services have on rural patient populations. A mixed methods survey study was conducted, demonstrating the concerns among family medicine physicians and radiologists regarding their patients’ ability to obtain necessary radiology services, including lack of insurance and ability to pay for services; lack of local access to care and subsequent travel barriers; and collaborative efforts between physician specialties. Current enacted solutions include point of care imaging, mobile diagnostic units, teleradiology, RAD-AID efforts and increasing awareness. However, access to services, as evidenced by survey results, remains a concern for many. Addressing these issues requires the need for further detailed research, delving into many of the concerns detailed by a small population of surveyed physicians, along with increasing advocacy and recruitment efforts to increase specialized medicine access for rural communities.

BACKGROUND: The gold standard treatment for colorectal cancer liver metastases (CRCLM) is surgical resection. Unfortunately, the majority of patients with colorectal hepatic metastases are not candidates for resection. In recent years, several alternatives have emerged for patients whom are not resection candidates including modern systemic chemotherapy, targeted biologic treatments, regional therapies and local tumor ablation options. Microwave ablation (MWA) therapy is one such treatment alternative, based on thermal tissue ablation. This modality in concert with the most recent published literature on its use for patients with CRCLM will be reviewed in this paper. LITERATURE REVIEW FINDINGS: A structured review of the literature on ablative technologies was performed. In recent years, there has been an evolution from radiofrequency ablation (RFA) to microwave ablation therapy for the treatment of CRCLM. RFA has several limitations to its use and MWA theoretically avoids such limitations making it the currently preferable treatment option. There are limited publications comparing the use of RFA to MWA and limited publications on the use of microwave ablation for CRCLM. This paper will focus on the most recent data on MWA for CRCLM. This data can then be compared to the already published data on RFA. PROPOSED METHODS: Given the relative novel status for MWA as a treatment option for CRCLM, a potential disadvantage for its use is the perceived lack of knowledge across the medical professional spectrum. In an effort to expand the knowledge of MWA, the proposed outcomes for this study include creating a curriculum to be offered as a CME course focused for Primary Care Providers (PCPs) to provide a basis of clinical familiarity for its use. This effort will familiarize providers who may have patients diagnosed with CRCLM and also allow them to initiate the conversation about this therapy with their patients who may be candidates for this treatment. CONCLUSIONS: MWA therapy is a safe and effective treatment modality for CRCLM. Due to this new development in treating liver lesions originating from colorectal cancer, it’s imperative for providers to become familiar with these new technologies especially considering the high incidence of CRCLM. Therefore, a curriculum for PCPs will allow for a better understanding of this new technology and foster better provider-patient relationships.

This paper outlines the progression of age-related macular degeneration in the eye and discusses the diagnostic approaches and therapies used currently to treat this disease. Age-related macular degeneration has a complicated pathophysiology involving genetic and environmental factors. This paper focuses its attention on the role of lipofuscin accumulation in this disease. Lipofuscin in the eye refers to the bisretinoid products of the visual cycle. While lipofuscin accumulation is normal in healthy eyes, the excessive accumulation causes retinal dysfunction. Lipofuscin accumulation has been linked heavily not only to age-related macular degeneration but also juvenile macular degeneration, retinitis pigmentosa, Best’s Villiform disease, and many others. New techniques in ophthalmic research have evaluated the role of lipofuscin accumulation in such retinal genetic diseases. This paper proposes an approach to apply techniques such as quantified autofluorescence imaging and high-powered liquid chromatography of bisretinoids in the eye to track the role of lipofuscin accumulation in the progression of age-related macular degeneration.

Alzheimer’s Disease is a particularly vicious illness, with currently no preventative or curative treatment available. This paper focuses on how impairments in glucose metabolism and insulin signaling contribute to the disease process and further, on potential treatment options that target these specific dysfunctional processes in hopes of finding an effective cure or prevention therapy. Glucose hypometabolism presents years prior to the clinical symptoms of Alzheimer’s Disease and promotes the accumulation of Aβ, oxidative stress, and mitochondrial dysfunction. Addition-ally, a downregulation of GLUTs, particularly GLUT1 and GLUT3 also serves to de-crease neural glucose uptake as well as to escalate glucose hypometabolism. More-over, insulin resistance promotes tau hyperphosphorylation and extracellular ag-gregation of Aβ42, contributing to the Alzheimer’s Disease pathology. Due to the central role of insulin and glucose neural dysfunction to Alzheimer’s Disease, these processes pose as strong potential targets for much-needed Alzheimer’s Disease curative and preventative therapy. Specifically, antioxidants and antidiabetics such as Metformin, thiazolidinediones, sulfonylureas, incretins, and intranasal insulin have shown some potential as future treatment options for Alzheimer’s Disease but require further investigation. Some non-pharmacological approaches, such as the ketogenic diet, have also been proposed as viable treatment options and work via their effects on glucose and insulin pathways. Dysfunctional glucose metabolism and insulin resistance are incredibly important in the progression of the Alz-heimer’s Disease stages and as such, present as viable potential targets of future drug therapies.

Acute kidney injury (AKI) is a common cause of morbidity and mortality across the world and reduction of these complications is highly dependent on how quickly patients receive corrective treatment for the AKI. The initial presentation of patients is often at the emergency department (ED), which is the first opportunity for these interventions to take place. The current KDIGO guidelines for diagnosis of AKI involve serum creatinine (sCr) and urine output, parameters that carry a number of flaws. Three biomarkers have been proposed in the literature as being alternatives to the use of serum creatinine in the standardized diagnosis of AKI: urine neutrophil gelatinase-associated lipocalin (uNGAL), urine kidney injury molecule-1 (uKIM-1), and serum cystatin C (sCysC). These biomarkers show comparable AUCs to sCr in studies that have been performed on the heterogeneous population of patient’s presenting to the ED, although the body of work is limited. The study proposed in this paper is a prospective cohort study to identify the biomarker that is most rapidly able to identify AKI. The study will enroll patients presenting to the ED at several major hospitals throughout Massachusetts over the course of 4 months. These patients will have series measurements taken of sCr, uNGAL, uKIM-1, and sCysC over 48 hours. Statistical analysis will be performed to evaluate the difference in AUC between sCr and each of its proposed alternatives in order to determine those that are best at identifying AKI and the time point at which AKI can be detected will be monitored. It is expected that this study will support the use of one biomarker over the others using data from a large sample population and a diverse set of patients. There is need for a test that provides earlier and more reliable detection of AKI than sCr in heterogeneous populations and this study aims to support a potential alternative biomarker for this purpose. If used clinically, the research provided by this study is hoped to allow for earlier intervention to prevent worsening of AKI and thus avoid the increased morbidity and mortality associated with severe AKI for hospitalized patients across the United States.

In 2015 some 29.7 million women gave birth via cesarean, the majority of whom will subsequently give birth via repeat cesareans. The steep rise in surgical births might outpace the abilities of health systems to safely conduct the surgery, potentially reversing hard fought gains in reducing maternal mortality in low- and middle-income countries. The United States too has witnessed a sharp increase in cesarean use over the last 20 years, now accounting for 1 in 3 births, or 1.2 million per year. Even in California, the state that leads the nation in reducing avoidable maternal morbidity and mortality, 40% of the rise in maternal morbidity over the last 20 years can be explained by cesarean overuse, with Black women most seriously affected. After decades of advocating for universal facility-based childbirth, the global health community must now deal with the consequences of a sometimes necessary but often overused surgery. The U.S. cesarean rate is sustained by increases in primary cesareans and decreases in the number of women attempting a Vaginal Birth After Cesarean (VBAC). Down from a peak of 28% in the late 1990s, the VBAC rate is persistently low at 13%. After a first cesarean, most women in the U.S. continue to schedule an Elective Repeat Cesarean Delivery (ERCD). In a 2010 consensus statement the NIH found that several prediction models could accurately predict VBAC using varying combinations of individual risk factors. The rationale for the development of accurate VBAC prediction tools was to support clinicians in identifying those candidates with the highest chance for a successful VBAC. The VBAC rate might increase if only those candidates assessed to have the highest chance for success went on to attempt VBACs, on the assumption that a proportion of these women currently underwent repeat cesareans. One VBAC prediction tool rose to prominence in the United States: the Maternal-Fetal Medicine Units (MFMU) VBAC Success Calculator. The VBAC calculator predicted the probability for a successful VBAC by combining the indication for the prior cesarean with a woman’s age, Body Mass Index (BMI), and her race or ethnicity, categorized as White, Black, or Hispanic. All these factors were known at the first prenatal visit, allowing clinicians and women to make an early plan for the ultimate mode of birth. On average the VBAC calculator gave scores to Black and Hispanic women that were 5-15 points lower than White women with similar risk factors. The MFMU VBAC calculator was invented and widely disseminated without seeking input from those who were thought to most benefit from the tool, namely pregnant women and birthing individuals who have had a prior cesarean. The aims of this dissertation were two-fold. First, I critically evaluated the invention of the VBAC calculator, paying attention to scientific paths not taken and to the ways in which practices that sustained the calculator silenced alternative approaches to the uncertainty of planning a VBAC. Second, I assessed the impact of the VBAC calculator on the pregnancy and birth experiences of a diverse group of women with varying birth histories and racial/ethnic identifications. The methodological approach for the study was critical and ethnographic, including an 18-month immersion in scientific papers, blog posts, podcasts, visual artifacts, interviews, audio recordings of prenatal visits, and observations. In order to obtain the full range of engagements with this technology, I purposively selected 22 key informants as users and non-users of the calculator based on their research publications or public statements. In order to understand the practical applications of the calculator, I interviewed 17 providers (perinatologists, general obstetrician-gynecologists, and Certified Nurse Midwives or CNMs) who worked across 4 different institutions. I enrolled 27 pregnant and 4 postpartum women who spoke Spanish or English, were over 18-years old, and had at least one prior cesarean. Women had diverse birth histories and racial/ethnic identifications, whose calculated likelihood of successful VBAC ranged from 12% to 95%. Ultimately, 13 women went on to have VBACs, 10 had unplanned cesareans, and 8 had ERCDs. Qualitative data were analyzed thematically on multiple levels, using modified grounded theory. In Chapter 1, I argue that the VBAC calculator marginalized the diverse ways in which VBAC candidates approached risk and uncertainty. I present evidence from VBAC candidates whose experiences run counter to the calculator, including women who saw their pregnancies as an embodied and unfolding process rather than as a pre-ordained statistical fact. In Chapter 2, I directly address the racial dimensions and consequences of the calculator. I argue that the VBAC calculator automated the reproduction of racism by foreclosing the possibility that racism, not race, explained the differences in successful VBAC rates between White, Black, and Hispanic women. In Chapter 3, I examine how non-numeric elements influence the decision to attempt a VBAC or a repeat cesarean. That VBAC prediction models appear to be a globally ascendant approach to counseling should concern Global Health scholars. Under conditions of cesarean overuse, which is rapidly becoming most of the world, VBAC prediction models turn more prior cesareans into recurring indications, thus challenging Global Health efforts to safely reduce cesarean use. To date, the Global Health discussions around mistreatment of women in birth facilities has largely focused on measuring and describing experiences of mistreatment, violence, and abuse. In the mistreatment research literature, violations of autonomy are among the most common, and many recommend that women worldwide transition into the decision making role in order to fulfill their fundamental right to self-determination in childbirth. However, due to the ways that the VBAC calculator both engaged women as decision makers and reproduced racism in the process, the VBAC calculator complicates the notion that mistreatment, violence, and abuse during childbirth is adequately addressed through the concept of choice.

IntroductionFree text forms of clinical documentation stored in Electronic Health Record Systems (EHRs)contain a trove of data for researchers and clinicians alike. However, often this data is noteasily accessible for a number of reasons. Many tools have been developed to help users in the task of searching through free text notes in clinical documentation. One such tool is the Electronic MEdical REcord Search Engine (EMERSE), a clinical documentation search tool developed by the University of Michigan. The purpose of this study is to evaluate the usability and user experience of the EMERSE system for a variety of users. Methods The study was conducted in 3 phases. In Phase 1, interviews with site administrators investigated factors that facilitate or hinder the implementation and adoption of a system suchas EMERSE. Phase 2 employed semi-structured interviews to understand the uses, benefits, and limitations of the system from the perspective of experienced “power users”. In Phase 3, system-naive users performed a set of basic workflow tasks, paired with post-activity questions and surveys, to evaluate the intuitiveness and usability of the system. Results Users rated the system exceptionally high on usability, user interface satisfaction, and perceived usefulness. Feedback also indicated that improvements could be made in visual contrast, affordances, and scope of notes indexed. Conclusions These results indicate that tools such as EMERSE should be highly intuitive, attractive, and moderately customizable. This paper discusses some aspects of what may contribute to a system having such characteristics.

The portfolio has three parts.Part One is a systematic literature review concerning the nature and severity of the psychological distress experienced by carers (primarily parents) of people with Muscular Dystrophy. Quantitative and qualitative studies investigating distress in these carers have been reviewed and critically evaluated to draw conclusions and implications for clinical practice. Part Two is an empirical paper aimed at creating a cognitive profile for people suffering from Duchenne Muscular Dystrophy in the advanced stages of the illness. The focus of this cross-sectional study is placed on the investigation of whether hypoventilation, inevitably seen to develop in this population, is related to permanent cognitive deficits in memory and/or executive functioning. The participants who have been identified to suffer from hypoventilation (N=17) are compared on measures of memory and executive functioning to a group of DMD participants of similar age (N=16) who have not yet developed hypoventilation. Other measures are also taken in the form of questionnaires to compare the groups on, including demographics, mood (depression and anxiety), health-related quality of life, sleepiness, and beliefs about sleep. Part Three comprises the Appendices.