Doctor of Philosophy

dissertationThis study explored the characteristics of adolescents and young adults referred for testing to rule out Autism Spectrum Disorder (ASD) while admitted to a psychiatric hospital for inpatient or day treatment between 2012 and 2017. Data regarding social-developmental, psychiatric, and ASD-symptom variables were collected from an archival database. Seventy-five files belonging to individuals between the ages of 13 and 25 at the time of admission were included. Forty-six participants (61%) were male, and 29 participants (39%) were female. Forty-two patients (56%) were diagnosed with ASD at time of discharge, and 33 patients (44%) were not. Regression analyses were conducted to compare the ASD and non-ASD groups. Participants in the non-ASD group were more likely to be the first-born child in their family and had a greater number of symptoms related to obsessive-compulsiveness and psychosis. Individuals in the ASD group were more likely to use stereotyped or idiosyncratic language, display poor social response, use few emphatic and/or emotional gestures, and demonstrate limited acceptance of responsibility for their own behavior. Participants diagnosed with ASD were shown to be more impaired in terms parent-reported social awareness and self-reported social motivation compared to those in the non-ASD group. Qualitatively, a discharge diagnosis of ADHD was common for the ASD group, while substance use disorders were prevalent in the non-ASD group. For the total sample, the most common reason for hospital admission was risk of self-harm. Individuals in both groups had extensive psychiatric histories and had previously accessed various treatments. Most participants had been tried on four or more psychotropic medications, and nearly half received three or more diagnoses at discharge. The most common diagnoses both prior to admission and at discharge were depressive and anxiety disorders. These patients were typically referred for ASD evaluation due to social interaction difficulties and rigidity. The retrospective design of this study presents multiple limitations. The data collected were limited to the information available in patients' charts, and the researchers were unable to address inconsistencies in these files. Future studies using prospective designs would allow researchers to obtain more detailed information and clarification on study variables

Verbal Abuse of Pediatric Nurses by Patients and Families

Objective: The purpose of this study was to determine the extent to which nurses practicing in a pediatric hospital encounter verbal abuse by patients and families and their reactions to this abuse. Background: Verbal abuse, the most common type of workplace violence against nurses results in declining morale and job satisfaction, and can negatively impact nurse turnover and quality of patient care. Methods: The study employed a concurrent triangulation strategy using mixed methods. The 162 nurses who volunteered completed a 3-part questionnaire, and a subgroup participated in one of three focus groups. Results: Eighty-two percent of subjects reported verbal abuse an average of 4 times per month. The majority of these continued to think about the incident for a few hours (25%), a few days (36%), or a week or more (12%). Nearly half reported feeling angry or powerless and 14% said they thought of leaving their position. Conclusions: The findings of this study described the nature and scope of the problem, and prompted improvement in processes and education to support nurses. This study was motivated by nurses employed at an urban children\u27s hospital reporting increased incidences of verbal abuse by patients and families. These nurses told of negative encounters which produced feelings of frustration. They perceived that the hospital\u27s increased emphasis on patient and family satisfaction prevented them from setting limits on verbal abuse perpetrated by patients and families. Nursing administration, concerned about staff morale, proposed a study that would describe the extent to which nurses practicing in a pédiatrie hospital encounter verbal abuse by patients and families and their reactions to this abuse

The Competitive Performance of Life Insurance Firms in the Retirement Asset Market

This paper summarizes the findings of the joint Wharton Financial Institutions Center and KPMG study of the retirement assets market and the role of life insurance companies within it. The study began with the following goals: Investigate how people save for retirement and whether this is adequate. Determine the primary products and institutions of the retirement asset market and observe how these have changed through time. Key findings: For most, asset accumulation is less than adequate for a comfortable retirement. The average worker exhibits little of the needed financial understanding to adequately plan for retirement. Upon retirement, households do not spend down their assets optimally. The retirement asset market is rapidly expanding. Products in retirement portfolios have shifted with time. The market share of mutual funds has exploded, mostly at the expense of depository institutions. Life insurance companies maintain a large, but slipping share.

Proposed research criteria for prodromal behavioural variant frontotemporal dementia

At present, no research criteria exist for the diagnosis of prodromal behavioural variant frontotemporal dementia (bvFTD), though early detection is of high research importance. Thus, we sought to develop and validate a proposed set of research criteria for prodromal bvFTD, termed \u27mild behavioural and/or cognitive impairment in bvFTD\u27 (MBCI-FTD). Participants included 72 participants deemed to have prodromal bvFTD; this comprised 55 carriers of a pathogenic mutation known to cause frontotemporal lobar degeneration, and 17 individuals with autopsy-confirmed frontotemporal lobar degeneration. All had mild behavioural and/or cognitive changes, as judged by an evaluating clinician. Based on extensive clinical workup, the prodromal bvFTD group was divided into a Development Group (n = 22) and a Validation Group (n = 50). The Development Group was selected to be the subset of the prodromal bvFTD group for whom we had the strongest longitudinal evidence of conversion to bvFTD, and was used to develop the MBCI-FTD criteria. The Validation Group was the remainder of the prodromal bvFTD group and was used as a separate sample on which to validate the criteria. Familial non-carriers were included as healthy controls (n = 165). The frequencies of behavioural and neuropsychiatric features, neuropsychological deficits, and social cognitive dysfunction in the prodromal bvFTD Development Group and healthy controls were assessed. Based on sensitivity and specificity analyses, seven core features were identified: apathy without moderate-severe dysphoria, behavioural disinhibition, irritability/agitation, reduced empathy/sympathy, repetitive behaviours (simple and/or complex), joviality/gregariousness, and appetite changes/hyperorality. Supportive features include a neuropsychological profile of impaired executive function or naming with intact orientation and visuospatial skills, reduced insight for cognitive or behavioural changes, and poor social cognition. Three core features or two core features plus one supportive feature are required for the diagnosis of possible MBCI-FTD; probable MBCI-FTD requires imaging or biomarker evidence, or a pathogenic genetic mutation. The proposed MBCI-FTD criteria correctly classified 95% of the prodromal bvFTD Development Group, and 74% of the prodromal bvFTD Validation Group, with a false positive rate of \u3c10% in healthy controls. Finally, the MBCI-FTD criteria were tested on a cohort of individuals with prodromal Alzheimer\u27s disease, and the false positive rate of diagnosis was 11-16%. Future research will need to refine the sensitivity and specificity of these criteria, and incorporate emerging biomarker evidence

Further Expansion of Nested E-Modules to Address Anatomical Knowledge Retention in Medical Students entering the Obstetrics and Gynecology Clinical Rotation

Previous work has shown that a curriculum that included computer-based teaching modules (“e-modules”) improved retention of preclinical concepts of gross anatomy, as medical students transitioned to the third-year OBGYN clerkship. However, data showed that deficiencies still remained in areas not addressed by the curriculum. Two of these areas were microscopic anatomy and embryology, where retention scores were 4% and 38%, respectively (Jurjus et al., unpublished). Based on this research, an expanded series of e-modules will be created to target these anatomical topics that still require improvement, specifically in microscopic anatomy and embryology: 1) Ultrasound in Pregnancy using Embryological Knowledge 2) Pregnancy Timeline and the Embryo and 3) The Cervix in Health and Disease. The learning objectives correlate clinical medicine and anatomical categories. Once finalized, these e-modules will be live on the Himmelfarb Library website. By further expanding the number of e-modules available to students, we hope to improve retention of clinically relevant anatomical knowledge in adult learners. Funding: GW Office of the Vice Provost for Teaching and Learning, Spring 2013 Grants for High Impact Teaching and Learning Practices

Improving Anatomical Knowledge Through Interactive Modules on the OB/GYN Clinical Clerkship

The goal of this study is to evaluate the impact of a newly designed interactive method of teaching clinically relevant anatomy to medical students on the OB/GYN clerkship. A 20-question multiple-choice exam was administered to 143 consenting third-year medical students at the beginning and end of each OB/GYN rotation. Students participated in a skills lab with preparatory e-modules that linked anatomy to clinical applications during each rotation. Topics included perineal muscle anatomy (laceration), anterior abdominal wall anatomy (cesarean section), vulvovaginal and uterine anatomy (IUD), and pelvic organ, vasculature, and neural anatomy (hysterectomy). Mean scores improved significantly after the nesting of interactive modules, increasing from 55.1% to 67.4% (p\u3c0.001). In comparing mean scores from questions that were covered in the e-modules (intervention) and questions that were not covered in the e-modules (non-intervention), students improved significantly after receiving an intervention (9.4% difference; p\u3c0.001). Therefore, completing the clerkship without an intervention did not yield significant improvement in relevant anatomical knowledge, compared to intervention. Thus, nesting anatomical science into the clinical curriculum through preparatory e-modules and hands-on anatomy lab sessions may improve clinically-significant anatomy knowledge. This data may be used to increase longitudinal integration of the various disciplines across the undergraduate medical curriculum

Electronic health records to facilitate clinical research

Electronic health records (EHRs) provide opportunities to enhance patient care, embed performance measures in clinical practice, and facilitate clinical research. Concerns have been raised about the increasing recruitment challenges in trials, burdensome and obtrusive data collection, and uncertain generalizability of the results. Leveraging electronic health records to counterbalance these trends is an area of intense interest. The initial applications of electronic health records, as the primary data source is envisioned for observational studies, embedded pragmatic or post-marketing registry-based randomized studies, or comparative effectiveness studies. Advancing this approach to randomized clinical trials, electronic health records may potentially be used to assess study feasibility, to facilitate patient recruitment, and streamline data collection at baseline and follow-up. Ensuring data security and privacy, overcoming the challenges associated with linking diverse systems and maintaining infrastructure for repeat use of high quality data, are some of the challenges associated with using electronic health records in clinical research. Collaboration between academia, industry, regulatory bodies, policy makers, patients, and electronic health record vendors is critical for the greater use of electronic health records in clinical research. This manuscript identifies the key steps required to advance the role of electronic health records in cardiovascular clinical research

Screening for C9ORF72 repeat expansion in FTLD

In the present study we aimed to determine the prevalence of {C9ORF72} {GGGGCC} hexanucleotide expansion in our cohort of 53 frontotemporal lobar degeneration (FTLD) patients and 174 neurologically normal controls. We identified the hexanucleotide repeat, in the pathogenic range, in 4 (2 bv-frontotemporal dementia (FTD) and 2 FTD-amyotrophic lateral sclerosis ALS) out of 53 patients and 1 neurologically normal control. Interestingly, 2 of the \{C9ORF72\} expansion carriers also carried 2 novel missense mutations in \{GRN\} (Y294C) and in PSEN-2(I146V). Further, 1 of the \{C9ORF72\} expansion carriers, for whom pathology was available, showed amyloid plaques and tangles in addition to \{TAR\} (trans-activation response) DNA-binding protein (TDP)-43 pathology. In summary, our findings suggest that the hexanucleotide expansion is probably associated with ALS, FTD, or FTD-ALS and occasional comorbid conditions such as Alzheimer's disease. These findings are novel and need to be cautiously interpreted and most importantly replicated in larger numbers of samples

Cervical Spine Osteomyelitis after Esophageal Dilation in Patients with a History of Laryngectomy or Pharyngectomy and Pharyngeal Irradiation

Dysphagia is a common sequela of the treatment of head and neck cancer and is frequently managed with esophageal dilation in patients with dysphagia secondary to hypopharyngeal stenosis. Reported complications of esophageal dilation include bleeding, esophageal perforation, and mediastinitis. We examine four cases of cervical spine osteomyelitis presenting as a delayed complication of esophageal dilation for hypopharyngeal stenosis in patients with a history of laryngectomy or pharyngectomy and radiation with or without chemotherapy. The history of head and neck surgery and radiation in these patients further complicates the management of the cervical spine osteomyelitis