Master of Science, The Ohio State University, 2008, Graduate School

Committee: Not Provided (Other) Subjects:

Doctor of Philosophy, The Ohio State University, 2024, Public Health

Introduction: Human milk is the recommended infant food for the first six months of life. Despite recommendations and known health benefits for infants and lactating parents, only a quarter of the infants in the United States meet the recommended human milk feeding goals. While human milk feeding is often a personal decision, engaging in this health behavior may be shaped by neighborhood- and systemic-level factors. Aims: This dissertation aimed to evaluate the association between human milk feeding behaviors and three factors: (1) neighborhood-level social determinants of health, (2) caregiver-reported social needs, and (3) neighborhood-level food access. Methods: I performed secondary analyses of electronic health record data from infants born from April 2019 through July 2022 who attended a well-child visit at Nationwide Children's Hospital (NCH) primary care clinics during the neonatal period. Infant records were linked to Ohio birth certificate data to obtain maternal demographic information and hospital breastfeeding data. During well-child visits at NCH, caregivers are asked about infant food intake. At each visit where feeding data was recorded in the first two years of life, I categorized an infant's human milk consumption as exclusive, mixed, or none. In Aim 1, neighborhood-level social determinants of health were measured using the Child Opportunity Index (COI) 2.0 and the Area Deprivation Index (ADI). In Aim 2, caregiver-reported social needs were assessed using data from routinely administered social needs screenings performed at NCH. In Aim 3, neighborhood-level food access was assessed using the Food Access Research Atlas. Multivariable interval-censored accelerated failure time modeling was used to evaluate the time to cessation of (1) exclusive human milk feeding and (2) any human milk feeding. In secondary analyses, multivariable logistic regression modeling was used to evaluate the odds of (1) breastfeeding initiation and (2) exclusive b (open full item for complete abstract)

Committee: Maria Gallo (Committee Chair); Fernanda Schumacher (Committee Member); Sarah Keim (Committee Member); Deena Chisolm (Advisor) Subjects: Epidemiology; Public Health

Master of Arts, The Ohio State University, 2024, Educational Studies

INTRODUCTION: Emotional intelligence (EQ) and good leadership are two crucial characteristics of an effective physician. Most leadership experiences during residency training are as a senior resident overseeing interns or during mock code simulations. As a modifiable skill, it is important to assess a trainee's leadership skills and their perspective to help them gain insight to their strengths and weaknesses. As fundamental feature of effective leadership, emotional intelligence is essential for physician practice especially in highly charged situations. Simulation has been proposed as an effective setting to perform EQ evaluation but not yet trialed. Thus, the purpose of this study was to discover the relationship between leadership skills during simulated scenarios and emotional intelligence. METHODS: Pediatric trainees performed a simulated resuscitation scenario. Crisis Resource Management (CRM) skills were scored by the instructor and trainees performed a self-evaluation both using the Resuscitation Team Leader Evaluation (RTLE). A performance gap analysis was performed, comparing the self-assessment to the instructor's. Next trainees completed the Trait Emotional Intelligence Questionnaire (TEIQue) which was then compared to their CRM and performance gap analysis with a canonical correlation analysis. RESULTS: Trainees who led simulations included 58 residents and 20 fellows and 26 of those trainees completed the TEIQue. Trainees inaccurately assessed CRM skills with average gap of 3 points. Resident trainees overestimated their CRM skills while fellows underestimated theirs with mean gaps +4 and -3.5 respectively, with larger gaps in the areas of communication and future needs anticipation. In addition thee were a mix of positive and negative correlations between EQ and the CRM skills & gap analysis. CONCLUSION: Pediatric trainees inaccurately assessed their team leadership skills. Certain areas of trait EQ do correlate with CRM skills. Further stu (open full item for complete abstract)

Committee: John Mahan (Committee Member); David Stein (Advisor) Subjects: Adult Education; Educational Evaluation; Health Care; Higher Education; Medicine

DNP, Otterbein University, 2025, Nursing

In the United States, around 40,000 surgeries are conducted on pediatric patients yearly to address congenital heart disease. These surgeries involve a variety of complications beyond cardiovascular problems, including pain management. Traditional pain management involving intravenous opioids has drawbacks such as sedation, respiratory depression, and prolonged recovery times. As the healthcare industry moves away from opioid-centric pain management, the use of multimodal analgesia, including ultrasound-guided regional anesthesia, is being utilized. Regional anesthesia techniques, such as the transversus thoracis muscle plane block and the thoracic erector spinae block, are being considered for the ability to provide adequate pain relief while reducing opioid usage. The goal of using ultrasound blocks for congenital heart patients is to decrease postoperative opioid consumption and decrease the time to extubation in pediatric cardiac surgical patients in the first 24 hours postoperatively. A 12-month timeline outlines the development of guidelines, staff training, and clinical practice change integration. The project follows the Iowa Model for Evidence-Based Practice to guide its implementation, focusing on reducing opioid use, improving postoperative outcomes, and enhancing patient safety.

Committee: Dr. Brian Garret, DNP, CRNA (Committee Chair); Dr. Amy Bishop, DNP, AGCNS (Committee Member); Dr. Danielle Winch, DNP, CRNA (Committee Member); Dr. Ruth Chavez, DNP, NP (Committee Co-Chair) Subjects: Anatomy and Physiology; Health Care; Medical Imaging; Surgery

Master of Science, The Ohio State University, 2024, Vision Science

Purpose: This project was designed to measure the repeatability of the Ohio Contrast Cards (OCCs) in a pediatric population across examiners, and before and after cycloplegia. Methods: We measured contrast sensitivity (CS) using the OCCs on 44 children (ages 3-11) who attended their routine, dilated eye exams. There were 38 normally sighted children and seven amblyopes. CS was measured twice, by different examiners, before and after dilation with cycloplegic agents (1% Tropicamide, 1% Cyclopentolate, or both). The pre-dilation tests were performed monocularly through any habitual refractive correction. One of the post-dilation tests was performed monocularly without any refractive correction to evaluate the effect of blur on measured CS. Results: CS measured with the OCCs was similar across examiners before dilation (95% Bland-Altman Limits of Agreement (LoA) +/-0.211). An Analysis of Variance (ANOVA) showed no significant effect of the examiner performing the test (p=0.561) or the order in which the tests were performed (p=0.924). CS was also similar within examiners before and after dilation (r=0.573, p<0.001; LoA +/-0.244). A second ANOVA showed that the post-dilation CS values did not depend significantly on eye color (p=0.429), dilating agent (p=0.562), or dilation time (p=0.216). There was also no association between CS and total blur due to uncorrected cycloplegic refractive error (r=-0.099, p=0.518). Conclusion: The OCCs show good inter-examiner repeatability in this population. The OCCs are robust to moderate amounts of blur, so they may be used after dilation as a time-saving examination measure.

Committee: Angela Brown (Advisor) Subjects: Ophthalmology; Optics

Doctor of Philosophy, The Ohio State University, 2024, Biomedical Sciences

Respiratory syncytial virus (RSV) is a highly prevalent virus, and a major cause of morbidity and mortality amongst both infants and elderly individuals. The virus infects through the nasal mucosa, and then can progress in susceptible individuals to the lower respiratory tract and cause severe symptoms and inflammation, leading to hospitalization, mechanical ventilation, and even death. While there are several conditions that predispose infants to severe disease, most infants who required hospitalization for RSV were previously completely healthy with no known risk factors. Early attempts at a pediatric vaccine led to enhanced RSV disease and multiple deaths. This tragedy ultimately set research and development of therapeutics and vaccines back several decades. Despite the immense burden of RSV on global pediatric health, there is still much to investigate about the role the immune system plays in pathogenesis. Further, much of the research into immune correlates of protection has taken place in the systemic compartment, despite the infection occurring in the respiratory tract. We seek to elucidate the immune response to RSV in the nasal mucosa, and how this immune response differs based on viral load, host age, and disease severity. We achieved this using four overall methodologies: transcriptomic and immune cell profiling from the nasal mucosa of children hospitalized with RSV, daily nasal mucosal cytokine concentration data from children hospitalized with RSV, and a primary nasal epithelial cell culture to disentangle the roles of the epithelial cells and immune cells in the respiratory tract. Overall, RSV infection induces robust innate immune and cytokine responses in the nasal mucosa and leads to suppression of adaptive immune response genes. Unexpectedly, we have previously observed that children with mild disease only requiring outpatient care had higher RSV viral loads than patients with severe disease requiring hospitalization. On examination of mucosal (open full item for complete abstract)

Committee: Mark Peeples (Committee Chair); Asuncion Mejias (Advisor); Zhaohui Xu (Other); Katherine Bline (Committee Member); Emily Hemann (Committee Member); Octavio Ramilo (Advisor) Subjects: Biomedical Research; Immunology; Medicine

MS, University of Cincinnati, 2024, Medicine: Clinical and Translational Research

Bacteremia is a significant cause of morbidity and mortality in children and young adults with sickle cell disease (SCD), but among those presenting to the Emergency Department (ED) with fever, the absolute risk of, risk factors for, and outcomes of bacteremia are poorly defined. Objective: We sought to obtain contemporary data on the absolute risk of, risk factors for, and outcomes associated with bacteremia in children and young adults with SCD presenting to the Emergency Department (ED) with fever. Design/Setting/Participants: We performed a multi-center retrospective cohort study of individuals with SCD under 22 years of age presenting to EDs within the Pediatric Health Information Systems (PHIS) database from January 2016 to December 2021 with fever (identified by diagnostic codes for fever or the collection of blood cultures and intravenous antibiotic administration). Main Outcomes and Measures: We determined the risk of bacteremia (defined by diagnostic coding) in these children and young adults and used univariate analyses and multivariable regression to determine associations between patient level factors and bacteremia. Results: We analyzed 35,548 encounters from 36 hospitals. The median age of the cohort was 6.2 years and 52.9% were male. Bacteremia was present in 405 encounters (1.1%, 95% CI 1.05%-1.27%). A history of bacteremia, osteomyelitis, stroke, central line associated blood stream infection (CLABSI), central venous catheter, or apheresis were statistically significant in univariate analysis with the diagnosis of bacteremia, while age, gender, HbSC genotype, and race were not. In multivariable analysis, a history of bacteremia (odds ratio [OR] 1.36, 1.01-1.83), CLABSI (OR 6.39, 3.02-13.52) and apheresis (OR 1.77, 1.22-2.55) had higher odds of bacteremia. Conclusions and Relevance: In this large observational cohort, bacteremia in children and young adults with SCD presenting with fever was rare. History of previous (open full item for complete abstract)

Committee: Patrick Ryan Ph.D. (Committee Chair); Luke Smart M.D. (Committee Member); Matthew Lipshaw M.D. (Committee Member); David Schnadower (Committee Member) Subjects: Medicine

MS, University of Cincinnati, 2024, Medicine: Genetic Counseling

Congenital heart disease (CHD) is the most common birth defect, with approximately 25% having a primary genetic etiology. Expert consensus guidelines recommended genetic testing for apparently isolated CHD (iCHD) in infants. Prenatal CHD detection (8% diagnosed prior to birth) allows for earlier genetic counseling. Timing of genetic counseling can affect parental decision-making and genetic testing uptake (prenatal vs postnatal). The primary aim of this study was to examine postnatal genetic testing uptake among families of infants with apparently isolated CHD who received prenatal versus postnatal cardiac genetic counseling. We hypothesized that families of infants who received prenatal genetic counseling would have a higher uptake of postnatal genetic testing than those who received postnatal genetic counseling. A retrospective chart review was completed for infants admitted to the Cincinnati Children's Hospital Medical Center (CCHMC) Cardiac Intensive Care Unit (CICU) between January 1, 2019 and April 30, 2023 for an apparently isolated CHD. Eligible patients were seen by cardiovascular genetic counselors (CVGC) either prenatally or postnatally for discussion of postnatal genetic testing. A total of 228 infants were eligible for inclusion in the retrospective chart review. Of these, 76 families received prenatal genetic counseling from a CVGC and 152 were counseled postnatally. Patients receiving prenatal genetic counseling were four times more likely to consent for postnatal genetic testing (OR=4.4, p=0.03) than those seen in the postnatal period. Yield of diagnostic genetic testing was 14%, of which 60% were copy number variants and 40% were single nucleotide variants. Families of infants with CHD who met with a CVGC prenatally were significantly more likely to consent for postnatal genetic testing. Although expert consensus statements often recommend chromosomal microarray as a first line of genetic testing for iCHD, the yield reported i (open full item for complete abstract)

Committee: Erin Miller M.S. L. (Committee Chair); Amy Shikany MS (Committee Member); Cara Barnett M.S. (Committee Member); Nicole Weaver M.D. (Committee Member); Hua He M.S. (Committee Member); Nadine Kasparian Ph.D. (Committee Member); James Cnota M.D. (Committee Member) Subjects: Genetics

MS, University of Cincinnati, 2024, Medicine: Clinical and Translational Research

Purpose: Acute kidney injury (AKI) is common in pediatric septic shock and confers increased risk for poor outcomes. Early identification of high-risk patients can facilitate targeted intervention to improve outcomes. We previously derived the PERSEVERE-II AKI Model, which had excellent predictive performance for severe AKI at Day 3 of pediatric septic shock (D3 severe AKI). We sought to externally validate the PERSEVERE-II AKI Model for prediction of D3 severe AKI in a separate cohort of children. Methods: We performed a secondary analysis of a multicenter, prospective, observational study of children with septic shock aged 1 week to 18 years admitted to the pediatric intensive care unit from 1/2019-12/2022. The primary outcome was D3 severe AKI (=KDIGO Stage 2). Patients were assigned a probability of D3 severe AKI based on our previously derived model using the PERSEVERE biomarkers, PERSEVERE-II mortality probability, and Day 1 (D1) KDIGO AKI stage. Model performance was assessed and compared to D1 context-free serum creatinine (SCr) elevation. Results: Seventy-nine of 363 patients (22%) had D3 severe AKI. The PERSEVERE-II AKI Model predicted D3 severe AKI with AUC 0.89 (95%CI 0.85-0.93), sensitivity 77% (95%CI 66-86), specificity 88% (95%CI 84-92), PPV 65% (95%CI 54-74), and NPV 93% (89-96); model performance was superior to D1 SCr elevation above baseline (AUC 0.82, 95%CI 076-0.88, p=0.004). On multivariable regression, PERSEVERE-II model prediction was the strongest independent predictor of D3 severe AKI (aOR 11.2, 95%CI 4.9-25.3, p<0.001). Conclusion: The PERSEVERE-II AKI Model demonstrates excellent performance for prediction of D3 severe AKI in children with septic shock, outperforming D1 context-free SCr elevation alone. Timely biomarker availability is necessary to translate this tool to the bedside.

Committee: Patrick Ryan Ph.D. (Committee Chair); Bin Zhang Ph.D. (Committee Member); Stuart Goldstein M.D. (Committee Member) Subjects: Surgery

PHD, Kent State University, 2024, College of Public Health

Background: Infant mortality is a significant problem in the United States (U.S.). In 2018, the infant mortality rate (IMR) was 5.7 deaths per 1,000 live births. Approximately 3,600 infants die annually from Sudden Unexpected Infant Death (SUID) and other sleep-related infant deaths. The infant's sleep environment plays a critical role, as some deaths are linked to unsafe sleep-related practices. Physicians and nurses influence the sleeping practices of parents and caregivers as they provide advice based on the infant safe sleep recommendations of the American Academy of Pediatrics (AAP). To address other health issues, community health workers (CHWs) act as a bridge between the health care providers and their communities and can become advocates for safe sleep. Research on the CHWs' role relative to safe sleep is lacking. Thus, this study aimed to assess CHWs' awareness of AAP recommendations on safe sleep by pursuing the following specific aims: 1) determine the knowledge, attitude, and practice (KAP) of CHWs toward safe sleep practices, 2) understand the methods currently used by CHWs to communicate to parents and caregivers about safe sleep practices, and 3) determine the relationship between KAP and sociodemographic characteristics (age, race, education, years of experience) of CHWs. Methods: A cross-sectional study design approach was employed. A 64-item questionnaire was developed based on AAP infant safe-sleep recommendations. Outcome measures included knowledge of infant safe sleep (12 items), attitude (9 items), and practice (14 items). The questionnaire was distributed to CHWs in partnership with the American Public Health Association (APHA) through their national CHW listserv. Descriptive, One-way ANOVA and regression analyses were used for analysis. Results: Overall, respondents had fair to good levels of knowledge (M =10.14, SD =2.19), attitude (M =.642, S.D. = .491), and practices (M =1.11, SD = 1.07) related to infant safe sleep. CHW (open full item for complete abstract)

Committee: Sonia Alemagno (Committee Chair); Jeffrey Hallam (Committee Member); Bethany Lanese (Committee Member) Subjects: Public Health; Public Policy

MS, University of Cincinnati, 2023, Medicine: Clinical and Translational Research

Background: Ambulatory blood pressure monitoring (ABPM) is the gold standard for diagnosis and monitoring of hypertension (HTN) in children and young adults with chronic kidney disease (CKD). Data on longitudinal ambulatory blood pressure (ABP) trends in this population are limited. Methods: Retrospective review of the children and young adults who received CKD care at Cincinnati Children's Hospital Medical Center (CCHMC) from 1/2014 to 12/2021 to evaluate longitudinal trends in use of and assessment of blood pressure control by ABPM. Univariate analysis was performed to describe the population at time of each ABPM procedure and to identify interval change in pertinent patient and clinical characteristics. Generalized linear mixed modeling (GLMM) assuming binomial distribution and logit link was performed to identify factors associated with worsening ABP control. Results: Over the study period, 302 ABPM studies were completed among 122 unique CKD patients (59% male; mean age 12.7 years at first ABPM; 85.2% non-black; 17% glomerular disease, 54% non-glomerular disease, 29% secondary/other cause of CKD; mean CKID U25 eGFR 69.2mL/min/1.73m2). Half of the population was prescribed antihypertensive medications at the time of the first ABPM. Median time between studies was 23.9 months. More CKD patients had normal blood pressure classification by ABPM over time (46.7%, 61.5%, and 61.7% at first, second, and third ABP study, respectively; p = 0.043). A univariate analysis revealed a significant increase in the number of patients prescribed an antihypertensive agent (50.8%, 66.4, and 78.7% at the time of the first, second, and third ABP study, respectively; p = 0.001), with more patients being prescribed ACEi/ARB therapy (41%, 54.9%, and 63.8% at the time of the first, second, and third ABP study; p = 0.013) and beta blockers (4.1%, 7.3%, and 17% prescribed beta blockers at the first, second, and third ABP study; p = 0.017). GLMM identified increasing number (open full item for complete abstract)

Committee: Patrick Ryan Ph.D. (Committee Chair); Wei-Wen Hsu Ph.D. (Committee Member); Donna Claes (Committee Member) Subjects: Medicine

Doctor of Nursing Practice , Case Western Reserve University, 2023, School of Nursing

Problem: Evidence-based practice (EBP) attributes are significantly associated with EBP implementation science, which improve patient care outcomes. Nurses influence EBP, yet little is known of the specific EBP attributes of pediatric nurses in their clinical sub-specialties. Aim: To investigate the relationship between nursing academic degree, years of experience, and clinical specialty, with mean survey scores on EBP belief, organizational culture, and implementation scales, across all levels of nursing in a Children's Hospital. Methods: A convenience sample of nurses (n=185), participated in a descriptive, cross-sectional, correlational study in May 2023. The electronic surveys comprised 11 demographic questions and nine survey items from the short-version EBP Beliefs Scale (Cronbach α = 0.81), Organizational Culture and Readiness Scale for System-wide Integration Scale (Cronbach α = 0.87); and EBP Implementation Scale (Cronbach α = 0.89). Findings: EBP belief scores were notably higher in nurses working in neonatology (m=4.33); critical care (m=4.47), and among nurse leaders (m=4.50). There was a statistically significant difference in EBP organizational culture among nurse leaders (m = 3.95, p=0.039), compared to clinical nurses (m = 3.34), and advanced practice nurses (m = 3.34). EBP implementation was favorable in neonatology (m=4.20), acute care (m=4.05), and nurse leaders (m=4.33). No significant difference or correlation was found in EBP belief, organizational culture, or implementation mean scores related to nurses' age, academic nursing degree, or years of experience in our cohort (EBP beliefs (r = -.06, p = .400), organizational readiness (r = .02, p = .770), and implementation scales (r = .01, p = .867). Conclusions: This study identified nurse's EBP attributes in a Children's Hospital using key variables studied with EBP social cognitive and learning theory. Magnet status, shared governance structure, specialty certification, and nurse l (open full item for complete abstract)

Committee: Joyce Fitzpatrick (Advisor); Schreiner Nathaniel (Committee Member); Reynaldo Rivera (Committee Member) Subjects: Health Care; Management; Nursing

MS, University of Cincinnati, 2023, Medicine: Clinical and Translational Research

Objectives: We sought to evaluate associations between Magnetic Resonance Imaging (MRI) findings, exocrine pancreatic insufficiency (EPI) and endocrine insufficiency (prediabetes or diabetes) in children. Methods: This was a retrospective study that included patients<21 years of age who underwent MRI and endoscopic pancreatic function testing (ePFT; reference standard for pancreatic exocrine function) within 3 months. MRI variables included pancreas parenchymal volume, secreted fluid volume in response to secretin, and T1 relaxation time. Data were analyzed for the full sample as well as the subset without acute pancreatitis (AP) at the time of imaging. Results: Of 72 patients, 56% (40/72) were female with median age 11.4 years. A 5 mL decrease in pancreas parenchymal volume was associated with increased odds of exocrine pancreatic dysfunction by both ePFT (OR= 1.16, p=0.02 full sample; OR=1.29, p=0.01 no-AP subset), and fecal elastase (OR=1.16, p=0.04 full sample; OR=1.23, p=0.02 no-AP subset). Pancreas parenchymal volume had an AUC 0.71 (95% CI: 0.59, 0.83) for predicting exocrine pancreatic dysfunction by ePFT and when combined with sex and presence of AP had an AUC of 0.82 (95% CI: 0.72, 0.92). Regarding endocrine function, decreased pancreas parenchymal volume was associated with increased odds of diabetes (OR=1.16, p=0.03), and T1 relaxation time predicted glycemic outcomes with an AUC 0.78 (95% CI: 0.55-1), 91% specificity and 73% sensitivity. Conclusions: Pancreas parenchymal volume is an MRI marker of exocrine and endocrine pancreatic dysfunction in children. A model including sex, AP, and pancreas volume best predicted exocrine status. T1 relaxation time is also an MRI marker of endocrine insufficiency.

Committee: Patrick Ryan Ph.D. (Committee Chair); Bin Zhang Ph.D. (Committee Member); Andrew Trout (Committee Member); Maisam Abu-El-Haija (Committee Member) Subjects: Medical Imaging

MS, University of Cincinnati, 2023, Medicine: Clinical and Translational Research

Objective: To assess the validity of Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) mortality probability across all body mass indices (BMI) and association of BMI and outcomes in pediatric septic shock. Design: We performed a secondary analysis of a prospective observational study of primarily children with septic shock in whom a PERSEVERE-II baseline mortality risk was assigned. Setting: The PERSEVERE study enrolled patients with septic shock admitted to 14 pediatric intensive care units (PICUs) across the United States from January 2015 to December 2018. Patients (for clinical investigations): Patients from the original study were excluded from these analyses if they were missing height, weight, age, and sex or if calculated BMI was a significant outlier and could not be verified. Interventions: None Measurements and Main Results: This secondary analysis included 434 patients of the original 461 patients, of which 47 (11%) were underweight, 217 (50%) were normal weight, 61 (14%) were overweight, and 109 (25%) were obese. PERSEVERE-II accurately predicted mortality across all BMI: area under receiver operating curve (AUROC) for underweight = 0.78, 95% confidence interval (CI): 0.41-1.00; AUROC for normal weight = 0.79, 95% CI: 0.68-0.89; AUROC for overweight = 0.88, 95% CI: 0.77-0.98; and AUROC for obese = 0.87, 95% CI: 0.80-0.95. Compared to patients with normal weight, patients with obesity were more likely to have multi-organ failure within 7 days of admission (86% vs 74%, P =0.01) and to have a complicated course defined as persistent organ failure at 7 days after sepsis or death within 28 days of sepsis (52 patients [24%]) vs 39 patients [36%], P =0.02). However, on multivariable analysis, BMI was not associated with complicated course. There was no difference in 28-day mortality across BMI. Conclusions: PERSEVERE-II accurately predicted mortality across all BMI classifications. Patients with obesity were more likely to have multi-or (open full item for complete abstract)

Committee: Scott Langevin Ph.D. (Committee Chair); Jennifer Kaplan MD MS (Committee Member); Lin Fei Ph.D. (Committee Member); Matthew Alder (Committee Member) Subjects: Medicine

Master of Arts in Medical Ethics and Humanities, Northeast Ohio Medical University, 2023, College of Graduate Studies

Narrative medicine is a quickly growing field that is founded in the value obtained from understanding the importance of the incorporation of patient's unique life story into their medical care. While there is an abundance of evidence supporting the use of narrative medicine in clinical practice, there is no literature detailing how narrative medicine may be applied to individuals with communication barriers, including children who are developmentally non-verbal. Through a consideration of fundamental aspects of narrative medicine, pediatric narrative medicine, and disability studies, this paper details the value and feasibility of utilizing narrative medicine among children who are non-verbal. Given the importance of further research on the utility of narrative medicine in the pediatric non-verbal population, this paper concludes with an example research study proposal, detailing how one may conduct research within this discipline. Ultimately, advocating for the utilization of narrative medicine among children who are non-verbal will best ensure that pediatric non-verbal patients' needs and values are incorporated into their medical care.

Committee: Julie Aultman (Advisor); Nicole Robinson (Committee Member); Daniel Grossoehme (Committee Member) Subjects: Ethics; Health Care; Medical Ethics; Medicine

Doctor of Philosophy in Engineering, Cleveland State University, 2022, Washkewicz College of Engineering

Several genetic, developmental and neurological disorders can cause various levels of gait impairment in the pediatric population. Powered lower limb orthoses, or exoskeletons, have recently been used to address gait impairment and afford therapists alternative solutions and strategies for gait therapy. Most exoskeleton research has focused on the adult population while the pediatric population remains underserved. The limitations of current pediatric exoskeletons make them impractical for use in both community and clinical settings. Furthermore, exoskeleton controllers suitable for these environments should promote human volitional control while guiding the subject towards a dynamically stable healthy gait pattern. This dissertation presents the design of a pediatric lower limb exoskeleton and the application of a virtual constraint-based controller on the device. First, a small and lightweight exoskeleton joint actuator capable of delivering the torque and power requirements needed to assist and guide the hip and knee joints was developed. Testing and in-air gait tracking of a model leg in a provisional orthosis demonstrated that the joint actuators were suitable for use in a pediatric exoskeleton. Second, an adjustable exoskeleton frame was designed and fabricated, and a human factors assessment of the fully assembled pediatric lower limb exoskeleton demonstrated that the device was lightweight, comfortable, easily adjustable and suitable for children. Third, a virtual constraint-based controller was applied on an underactuated adult exoskeleton. This initial investigation demonstrated that virtual constraint-based control guided the subject towards a dynamically stable gait in a time-invariant manner, provided greater volitional control to the subject and promoted active participation in the walking exercise. Finally, this dissertation research concluded with the application of a virtual constraint-based controller on the pediatric lower limb exoskeleton in (open full item for complete abstract)

Committee: Jerzy T. Sawicki Dr. (Advisor); Ryan J. Farris Dr. (Committee Member); Douglas A. Wajda Dr. (Committee Member); Antonie J. van den Bogert Dr. (Committee Member); Lili Dong Dr. (Committee Member) Subjects: Mechanical Engineering; Rehabilitation; Robotics

Doctor of Philosophy, Case Western Reserve University, 2023, Clinical Translational Science

Despite growing priority for social risk screening and intervention in pediatric care settings, little attention has been paid to the challenges of these processes in practice. Recent guidance from professional organizations and funders encourages the implementation of Social Determinants of Health (SDoH) intervention in healthcare settings, despite limited evidence regarding which patients are most likely to make use of SDoH intervention services or how engagement with SDoH intervention services influences subsequent healthcare utilization, health outcomes, and experience of care. To address these open questions, this program of research aimed to determine whether greater engagement by families with SDoH intervention services related to stronger connections with the medical home, focusing on an embedded SDoH program's interactions from April 2020 through October 2022 with children obtaining care in an academic pediatric practice serving a population of predominantly urban-dwelling, Black children with public insurance. First, SDoH program data were interrogated to characterize the factors influencing program reach at each stage (screening, intake, and follow up). Second, program data were connected to medical records data to assess the effectiveness of social needs screening and intervention in promoting subsequent adherence to other aspects of preventive care. Finally, longitudinal parent-reported survey data explored how social needs intervention services influenced their relationship with the practice. Review of SDoH program data found that family-reported urgency of needs and activation for social care assistance most strongly predicted subsequent engagement with the SDoH navigation team. Evidence for beneficial impact of that engagement on health care use and health outcomes was mixed, with increased health services use (both preventive and acute) observed among children with positive screens, but gaps in routine immunizations persisted. There was no evi (open full item for complete abstract)

Committee: Mary Dolansky (Committee Chair); Kurt Stange (Advisor); James Spilsbury (Committee Member); Marlene Miller (Committee Member) Subjects: Health Care

MS, University of Cincinnati, 2022, Medicine: Clinical and Translational Research

Objective: To assess the frequency of celiac disease (CD) in youth with type 1 diabetes and to describe their individual-level characteristics, co-existing autoimmune diseases, and the potential added cardiovascular risk and diabetes-associated complications associated with CD. Research Design and Methods: 2,444 youth with type 1 diabetes, enrolled in the SEARCH for Diabetes in Youth Study, completed a CD questionnaire and underwent IgA tissue transglutaminase autoantibody (tTGA) testing. Integrating the CD questionnaire and tTGA results, participants were categorized as: 1) CD (reported); 2) seropositive for CD (no reported CD, elevated tTGA); and 3) no CD (no reported CD, normal tTGA). Participant characteristics and coexisting autoimmune diseases were compared between reported CD and seropositive for CD to participants with no CD (comparison group). The relationship of cardiovascular risk factors and diabetes-associated complications with CD status and tTGA levels was assessed utilizing a Poisson model with robust error variance to estimate relative risk. Results: The prevalence of reported CD in youth with type 1 diabetes was 7%; seropositive for CD in youth with no reported CD was 4%. Individuals with reported CD were more likely to be female (61.3% vs. 48.8%, p=0.002), younger at age of diabetes diagnosis (8.3±4.0 years vs. 9.8±4.3 years, p=1.0x10-4) and differed in regard to race and ethnicity (p=2.3x10-4), with a higher percentage of Non-Hispanic White, compared to those with no CD. Additionally, individuals with reported CD were more likely to have co-existing autoimmunity, including hyperthyroidism (8.3% vs. 2.3%, p=1.0x10-5), hypothyroidism (14.3% vs. 6.4%, p=1.0x10-4) and Addison's disease (3.0% vs. 0.3%, p=1.0x10-5) compared to those with no CD. Individuals who were seropositive for CD were more likely to be female (52.5% vs. 48.8%, p=0.02) and younger at age of diabetes diagnosis (8.2±4.4 years vs. 9.8±4.3 years, p=3.0x10-4) compared to (open full item for complete abstract)

Committee: Scott Langevin Ph.D. (Committee Member); Amy Shah (Committee Member); Jane Khoury Ph.D. (Committee Member); Lawrence Dolan M.D. (Committee Member) Subjects: Surgery

MS, University of Cincinnati, 2022, Medicine: Clinical and Translational Research

Background: Improving the clinical utility of end-tidal capnometry (ETCO2) in the emergency department (ED) requires an understanding of the association between ETCO2 and venous carbon dioxide (vpCO2). Identifying features associated with discordance of ETCO2 and vpCO2 would allow emergency clinicians to better interpret ETCO2 values during initial clinical evaluation. Methods: We conducted a cross-sectional study utilizing video review. We studied pediatric patients (=18 years) evaluated in the ED resuscitation area who had both ETCO2 and vpCO2 measurements within 5 minutes of each other. We excluded patients receiving CPR. Our main outcomes were the association between ETCO2 and pvCO2 and the difference between pvCO2 and ETCO2 (?CO2). We defined a ?CO2 of >10mmHg as our threshold for discordance. Linear regression was conducted controlling for covariates including: 1) capnometry interface (nasal cannula, tracheostomy, endotracheal tube, bag-valve-mask), 2) respiratory rate, 3) mean arterial blood pressure (MAP) and 4) age. Results: Our sample consisted of 200 patients with paired values of ETCO2 and pvCO2 observed from December 2020 to August 2021. ETCO2 and vpCO2 were highly correlated (r = 0.76, p-value <0.0001). In our sample, 53% of ?CO2 values were > 10mmHg, a clinically relevant threshold. ETCO2 and ?CO2 were not correlated (r=0.07, p-value=0.3086). VpCO2 and ?CO2 were highly correlated (r=0.7. p-value<0.0001)), with greater variance at higher vpCO2 and ETCO2 values. Capnometry interface, specifically nasal and bag-valve mask, of the variables included in our multivariate model was the only independent predictor of vpCO2 (b=18.1, p<0.0001). Patients who had their ETCO2 values obtained by nasal interface, had lower ETCO2 and pvCO2 values (36.1+/-11.9 mmHg) (46.7 +/-14.9mmHg) respectively, compared to bag valve mask (53.3 +/-17.2mmHg) and (79.5+/-22.3mmHg) respectively. Conclusion: ETCO2 and vpCO2 in critically ill pediatric patients at presentati (open full item for complete abstract)

Committee: Patrick Ryan Ph.D. (Committee Member); Yin Zhang M.S. (Committee Member); Richard Ruddy (Committee Member); Kevin Overmann (Committee Member) Subjects: Medicine

PhD, University of Cincinnati, 2022, Medicine: Epidemiology (Environmental Health)

Objective: Data from electronic health records (EHRs) was used to determine individual characteristic association with aggressive incidents in children and adolescents during psychiatric hospitalization. Predictive probability of risk factors for aggression was examined to provide an evidence-based methodology for early detection of unsafe behavior among adolescent psychiatric inpatients and reducing harmful incidents. Methods: This retrospective study involved 10,054 unique patient admissions to inpatient psychiatry at Cincinnati Children's Hospital Medical Center (CCHMC) from April 1, 2010 until June 30, 2021. Children and adolescents aged 4-18 years old were admitted through the emergency department (ED). All admissions were unique and no patient had more than one inpatient admission at CCHMC during the study period. Factors obtained in the ED assessment prior to admission were analyzed. Aggressive incidents were documented by the psychiatric nursing staff using the Overt Aggression Scale (OAS). Pearson's chi-squared tests were conducted to determine associations between aggressive incidents and categorical variables. Wilcoxon's rank sum exact tests were used to compare the continuous characteristics in aggressive and nonaggressive groups. The Brief Rating of Aggression by Children and Adolescents (BRACHA) alone was compared to an expanded model for risk prediction. For the expanded model, the optimal predictors were identified using random forest. The expanded model cut point was chosen based on similar sensitivity to the BRACHA score cut point. Predictive power of the expanded model was compared to that of the BRACHA alone using the Delong's test. The expanded model was evaluated comparing logistic regression and recursive partitioning. The optimal model was chosen based on improvements to sensitivity, specificity and the area under the curve (AUC) of the receiver operating characteristics (ROC). Results: Age, sex, health insurance, living arr (open full item for complete abstract)

Committee: Scott Langevin Ph.D. (Committee Member); Richard Brokamp Ph.D. (Committee Member); Marepalli Rao Ph.D. (Committee Member); Lisa Martin Ph.D. (Committee Member); Ranjan Deka Ph.D. (Committee Member) Subjects: Epidemiology