Class of 2021 Outstanding PA Theses Event
December 03, 2021ID7237
To CiteDCA Citation Guide
- 00:00Good afternoon everyone.
- 00:02Welcome to the class of 2021's
- 00:06outstanding thesis presentation.
- 00:07For those of you at home
- 00:09who may not know me.
- 00:16For those of you at home who may not
- 00:17know me, I'm Alexandria Guerino.
- 00:18I am the director of the Yale
- 00:21Physician associate program.
- 00:23Today's event is a kickoff to graduation,
- 00:26so we're all very excited to be here.
- 00:29One of the characteristics
- 00:30that set that sets the LPA program apart
- 00:34from other programs is our focus on research.
- 00:37Our research program is a rigorous one.
- 00:40We believe that PS need to utilize
- 00:43principles of research methodology,
- 00:47public health, and evidence based medicine.
- 00:51If they're to practice.
- 00:52To the best of their ability,
- 00:54this training is one of the reasons why
- 00:57our graduates here are or soon to be.
- 00:58Graduates are so highly
- 01:01sought after this year,
- 01:02we introduced the alternative
- 01:04thesis pilot which was developed
- 01:07by Doctor Gonzalas Colosso.
- 01:09Several student students took up the
- 01:11challenge to take the traditional thesis
- 01:13one step further and collect data,
- 01:16and they were required to them produce
- 01:20a manuscript of publishable quality.
- 01:23So far we have two publications and several
- 01:26regional and national presentations
- 01:28that have come out of this pilot,
- 01:30so I would declare it's a huge success.
- 01:33We also celebrate the traditional thesis
- 01:36today and highlight a project that was
- 01:39funded by the Wilbur Downs Fellowship.
- 01:41We have many people to thank
- 01:44for today's presentation.
- 01:45First,
- 01:45we thank the students for their dedication,
- 01:48their flexibility, and their perseverance.
- 01:51The thesis project is demanding
- 01:54in the best of years,
- 01:56but you all accomplished amazing
- 01:58things with your education being
- 02:01disrupted because of the pandemic.
- 02:05I congratulate the entire class
- 02:07on your hard work and dedication,
- 02:10so I think that deserves around.
- 02:17We thank Thesis Advisors whose
- 02:19expertise and guidance made an
- 02:21important contribution to the
- 02:23development of these future clinicians.
- 02:25We thank Tiffany Chen,
- 02:26who's with us today and Andrew Arakaki,
- 02:29our research TAS.
- 02:31We thank our readers are
- 02:33dedicated librarian Caitlin Meyer,
- 02:36who's also with us today.
- 02:44And the graduate writing tutors,
- 02:45all without whom these projects
- 02:48would not be possible. We thank Dr.
- 02:50Rosanna Gonzalas Colosso for making the
- 02:53research program really distinctive
- 02:55piece of the LPA program experience for
- 02:58our students and Miss Megan Pendergast
- 03:00for her management of the program.
- 03:03We also thank Chanel Feliciano
- 03:05and the entire administration and
- 03:07administrative staff for their
- 03:09coordination of today's event.
- 03:11For those who are in person,
- 03:13we have some.
- 03:14Refreshments after the presentation.
- 03:16So please stop there little signs directing
- 03:19you to a table with very nice sweet treats,
- 03:22so please help yourself to that and
- 03:24I thank you all for joining us today.
- 03:27I hope you enjoy the thesis presentation.
- 03:40Hello everyone for those here. Thank
- 03:43you so much coming to support
- 03:45the students that went to Extra mile
- 03:47when everything was done and prepared.
- 03:49These presentations or poster
- 03:51presentations for those at home or
- 03:54somewhere else in the university.
- 03:56Thank you for joining us and
- 03:58supporting our efforts here.
- 04:00Of course, as any already have
- 04:03given all the thanks and we want to
- 04:06start the program as soon as possible
- 04:09before I would like to give you a road map.
- 04:11Of how we are going to do that.
- 04:13There will be four presentations
- 04:15representing the three current
- 04:18paths to complete API thesis
- 04:19at Yale at the year. Physician associate
- 04:20program. So there will be representation
- 04:22from the Bounce fellowship.
- 04:24A one way to do it and representation
- 04:27from the traditional thesis
- 04:29and representation for the
- 04:31new alternative thesis.
- 04:33There were too many outstanding
- 04:34presentations this year,
- 04:36way too many and we couldn't
- 04:39stop by inviting others to share.
- 04:42Also their projects through
- 04:44electronic posters presentations.
- 04:46So first we are going to have four
- 04:48before presenters live and even
- 04:51their families are joining us,
- 04:53so I hope that you appreciate how much
- 04:55they learned and also we are going
- 04:58to then acknowledge a group of very
- 05:01important people that made all these
- 05:04possible and we will invite then,
- 05:06especially those in the classes
- 05:09of 2022 and 2023.
- 05:11To join a panel of presenters
- 05:14to discuss their posters, to
- 05:16find inspiration, there is light at
- 05:18the end of the tunnel. Believe me,
- 05:21so I'm going to call the first.
- 05:24Well, of course this is the class of 2021.
- 05:3440 outstanding people that
- 05:36he looks so eager a 27 months
- 05:40ago and even before that.
- 05:42During admissions,
- 05:44everybody wanted to do their thesis here.
- 05:48So now we are showing right
- 05:51what they have produced.
- 05:52These are the ones that are going to
- 05:54be taking care of us soon because
- 05:56many are staying in Connecticut,
- 05:58so were first presented.
- 06:00Presenter is Annabelle Wilcox who I invite.
- 06:04To the podium to take charge.
- 06:06Thank you.
- 06:14Hello everyone so I'm Annabelle I
- 06:18did the alternative thesis project
- 06:20so I was able to develop a
- 06:22project and carry it out.
- 06:23I'm with my advisors and they will be
- 06:26presenting the manuscripts today so I
- 06:28just want to thank my fellow Co authors,
- 06:29Dr Venture I'm doctor Nally and my
- 06:32advisor Dr Weinzimer without their
- 06:34support throughout the whole process.
- 06:36I definitely would not have
- 06:38made it here today.
- 06:39So I thank them for their guidance
- 06:41and constant support.
- 06:42OK, so here's the outline of the
- 06:44talk that I'll go through today.
- 06:46So starting with some background information,
- 06:49diabetes technology has advanced.
- 06:51We now have continuous glucose monitors,
- 06:54insulin pumps,
- 06:55they connect to wireless devices,
- 06:57give real time glucose data,
- 06:58and all this technological advancement
- 07:00is coming at a time where there's also
- 07:02increasing prevalence of type one diabetes,
- 07:04and minority youth.
- 07:06But despite this,
- 07:07despite knowing that diabetes
- 07:09technology results in better outcomes,
- 07:11lower anyone,
- 07:12see by better glycemic control,
- 07:14my minority youth are at higher risk
- 07:16for work shortcoming outcomes and also
- 07:19less likely to be using this technology
- 07:21to manage their glycemic control.
- 07:24So study found that type one diabetes
- 07:26exchange pressure registry found that
- 07:27the odds of a white child being an
- 07:29insulin pump or 3.6 times higher than
- 07:31that of a black child and 1.9 times
- 07:33higher than that of a Hispanic child.
- 07:35So that really just shows you
- 07:37the disparity that exists.
- 07:39There's also a significant difference in
- 07:41anyone see between the two racial groups.
- 07:43Even when we control for
- 07:44socioeconomic status.
- 07:45So it seems like there's other
- 07:47factors that are contributing to
- 07:49this outside of socioeconomic status.
- 07:51So the question that I wanted to
- 07:52answer is what could be contributing.
- 07:54To this disparity and technology
- 07:56use anyone see and that racial
- 07:58and ethnic minority adolescents?
- 08:01So, one thing that's been
- 08:02associated with decreased adherence to
- 08:04treatment recommendations and a suboptimal
- 08:07anyone see his diabetes distress?
- 08:09So this is a measure of the
- 08:11negative emotions experience for
- 08:12managing and living with diabetes.
- 08:15It's thoughts. We do.
- 08:16The lack of understand from others
- 08:17and just the daily demands of
- 08:19living with a chronic illness.
- 08:21So there's been no studies
- 08:22that have directly
- 08:23compared diabetes distress.
- 08:24Between non Hispanic youth or sorry,
- 08:27not Hispanic. White youth and racial
- 08:29and ethnic minority adolescents.
- 08:31So the aim of this study was
- 08:33to describe the differences in
- 08:34diabetes technology used, IBS,
- 08:36stress and barriers to management between
- 08:38adolescents with type one diabetes.
- 08:40Specifically, comparing between
- 08:42racial and ethnic minority youth
- 08:44and then non Hispanic white youth.
- 08:47Secondarily,
- 08:47we also wanted to compare on the same
- 08:49measures between those who are using
- 08:50technology and not using technology,
- 08:52and then also between adolescents and
- 08:55their primary caregiver or parent.
- 08:57So I hypothesize that diabetes distress
- 08:59will be negatively associated with
- 09:01diabetes technology use and will
- 09:02be higher in the racial and ethnic
- 09:04minority adolescents with type one diabetes.
- 09:08So quickly just to go through the
- 09:09methods it was a cross sectional
- 09:11study design. We used Qualtrics,
- 09:12which is a HIPAA compliant software,
- 09:14and the survey was given both
- 09:16to parents and adolescents.
- 09:17Inclusion criteria was type one diabetes.
- 09:20But sorry, type one diabetes
- 09:21of at least six months,
- 09:22and between the ages of 13 and 17.
- 09:25And we recruited through email
- 09:26and phone to patients at the
- 09:29Yale Children Diabetes Center.
- 09:30We used three scales to measure diabetes,
- 09:32distress and barriers to management.
- 09:34For the paid peed scale measures diabetes,
- 09:37distress, and adolescence.
- 09:38They paid.
- 09:39PR is the same,
- 09:40but for parents and then the
- 09:42PRISM questionnaire identify
- 09:43specific barriers to management.
- 09:45So it is split into five
- 09:47different categories,
- 09:47understanding and organizing care regimen,
- 09:49pain, and bother health care team,
- 09:51family interactions and peer interactions.
- 09:54And so each of these questionnaires
- 09:56were given and they all have an
- 09:58established cutoff point to measure
- 10:00clinically significant diabetes distress.
- 10:01Or as a barrier as a clinically
- 10:04significant burden to diabetes management.
- 10:07I'm sorry, independent variables.
- 10:08We separated the adolescents
- 10:10into two groups based off of
- 10:11their self identified race,
- 10:12race and ethnicity.
- 10:13So non Hispanic white group and then
- 10:15the racial or ethnic minority group
- 10:17adolescence identified both as white
- 10:19as that minority were placed into
- 10:21the minority group for analysis,
- 10:23and then we made the following three
- 10:25comparisons so non Hispanic white
- 10:27versus minority diabetes technology
- 10:28users versus non technology users
- 10:30and so non or technology users was
- 10:32using a CGM continuous glucose
- 10:34monitor and or an insulin pump.
- 10:36Dementia.
- 10:36The Technology user group and
- 10:39then parents versus adolescence.
- 10:41We measured diabetes,
- 10:43technology use diabetes outcome
- 10:46variable SO81C DK and then the
- 10:49diabetes distress and barrier
- 10:51scales that I just went through.
- 10:53And we used SAS for data analysis.
- 10:59So to go through the
- 11:01results of the adolescents,
- 11:02we had 45 complete, the survey,
- 11:0528 of who identified as non Hispanic,
- 11:07white and 17 as a racial or ethnic minority.
- 11:12Comparing the demographics
- 11:13between the two groups,
- 11:14there was no significant difference in age,
- 11:16income or insurance status
- 11:17between the non Hispanic,
- 11:18white and minority adolescents.
- 11:20But it is important to note that
- 11:23in our sample both groups had as
- 11:25income on average higher than 75,000
- 11:28and were most or most commonly
- 11:30to have private health insurance.
- 11:35So comparing the diabetes technologies
- 11:36between our racial ethnic groups,
- 11:38there was no significant difference
- 11:40in overall diabetes technology use.
- 11:42So looking just at whether or not they
- 11:45used any technology versus no technology.
- 11:47But when we compare it, specific
- 11:48diabetes technology combinations,
- 11:49we did find a significant difference.
- 11:52So the minority group,
- 11:53which is highlighted in yellow and then
- 11:55on spanic white, which is in green,
- 11:57they might already be for far less likely
- 11:59to be using diabetes technology for both
- 12:01aspects of their diabetes management.
- 12:02So for using both the CGI Vanderpump.
- 12:05And they're more likely to be using
- 12:06technology for only one or the other.
- 12:10We asked adolescents for reasons,
- 12:12but behind nonuser discontinuation
- 12:14of diabetes technology and in
- 12:16the non Hispanic White Group,
- 12:17it was exclusively due
- 12:18to personal preference.
- 12:18But in the minority group,
- 12:20the reasons were a little bit more complex,
- 12:22so they cited insurance coverage issues,
- 12:24provider recommendations,
- 12:25difficulty with the device,
- 12:27or difficulty with diabetes management.
- 12:31So comparing diabetes, distress and outcome
- 12:33variables between the two groups,
- 12:35there was a significant difference
- 12:36in anyone see which is consistent
- 12:38with previous literature, so or not,
- 12:40or are minor minority group had a higher A1C,
- 12:43and then on Hispanic White Group,
- 12:45but there was no significant difference
- 12:47in diabetes distress for any of the
- 12:49barriers on the PRISM questionnaire.
- 12:51However, there was a very high overall
- 12:53rate of diabetes distress in both groups,
- 12:55so 86% of the non Hispanic White Group and
- 12:5882% of the minority group met clinical
- 13:00significance for diabetes distress.
- 13:02And then similarly on the prison question,
- 13:04there was a high rate of adolescents
- 13:07that met diabetes distress for all the
- 13:09categories except for health care team
- 13:10was only one that wasn't the majority.
- 13:14Comparing between technology user
- 13:15versus non technology user groups,
- 13:17again there was a significant
- 13:19difference in A1C between the two.
- 13:21So the non technology users had a
- 13:23significantly higher A1C but no
- 13:25difference in diabetes distress and
- 13:27then looking at specific burdens.
- 13:28The only significant difference was
- 13:30understanding and organizing care.
- 13:32So the non technology user groups
- 13:34found that as a more significant
- 13:36burden to their diabetes management.
- 13:40And then finally comparing
- 13:41adolescents versus parents.
- 13:43So there was a significant difference
- 13:45here between environments distress.
- 13:46So the adolescents had a much higher
- 13:49rate of clinically significant,
- 13:51clinically significant diabetes,
- 13:52distress, then the parent group did,
- 13:55and then comparing the specific barriers,
- 13:57the adolescent scored much higher for
- 13:59family interactions as a contributing
- 14:01barrier to their diabetes management.
- 14:05This is again just shows that
- 14:06difference between adolescent in Paris,
- 14:08so adolescent and orange parent and blue.
- 14:10And then we have positive diabetes distress
- 14:11on the left hand side of the graph.
- 14:13So 82% of adolescents and only
- 14:1515% of parents met clinically
- 14:17significant diabetes distress.
- 14:21So the conclusions that we
- 14:22were able to draw from this our
- 14:23population show that there was
- 14:25a difference in technology,
- 14:26user groups or technology you
- 14:28use with the minority group less
- 14:30likely to be using technology for
- 14:32both aspects of their diabetes
- 14:33management and having a higher A1C.
- 14:36This is consistent with
- 14:37previous literature and so,
- 14:38and they also cited more complex regional
- 14:41reasons behind NONUSER discontinuation.
- 14:43So in the clinical setting it's
- 14:45important to identify this and identify
- 14:47reasons behind nonuser discontinuation
- 14:48in the minority population.
- 14:50I'm sorry, better.
- 14:51To understand what's resulting
- 14:52in that and able to help them
- 14:55implement technology into their care.
- 14:57If that will give them,
- 14:58give them improved management.
- 15:01And we also saw a very
- 15:02high frequency of diabetes distress
- 15:04across both groups of our adolescence,
- 15:06so this shows that this is a significant
- 15:09mental burden of managing diabetes,
- 15:11and it may be impacted glucose control
- 15:12and quality of life amongst all
- 15:14adolescents with type one diabetes
- 15:16and the reason behind this might be
- 15:18universal stressors that are causing
- 15:20both racial and ethnic boundaries.
- 15:23So that might be social stigma or fear
- 15:27of feeling different from their peers.
- 15:30And diarrhea stress in these
- 15:32various management are modifiable,
- 15:33so we're able to identify them
- 15:34in the clinical setting,
- 15:36there's the potential to help improve
- 15:38support for adolescents with type one
- 15:40diabetes and identify those that are
- 15:41having higher rates of diabetes distress,
- 15:43so we can help give them more support and
- 15:47improve their glycemic control and then,
- 15:49between comparing between adolescents
- 15:51and their parents,
- 15:52is another tool that can be very
- 15:54helpful in the clinical setting
- 15:55on parents are often the primary
- 15:57caregiver and support for children.
- 15:59So with this high discrepancy in diabetes.
- 16:00Stress there's the potential to improve
- 16:03understanding of that discrepancy and
- 16:05support for adolescents as they make
- 16:07that transition from childhood into
- 16:09adulthood while managing a chronic disease.
- 16:13And then finally,
- 16:13it's important to note that while
- 16:16these the advancements in technology
- 16:17are improving glycemic control
- 16:19or associated with a lower A1C,
- 16:21they're not enough to mitigate
- 16:23diabetes distress,
- 16:23and that was seen in our study here.
- 16:26So family support and
- 16:28communication remains essential,
- 16:29even as we continue to advance technology.
- 16:33So some future directions,
- 16:35just further research on both patients
- 16:37and providers to understand why there
- 16:40may be provider recommendations against
- 16:42discontinuation of technology and
- 16:44minority and other reasons that are
- 16:47resulting in the discrepancy and then
- 16:49also including a diversity and diabetes
- 16:51treatment settings and locations.
- 16:53So we only recruited from Yale,
- 16:55which is a large academic center
- 16:57in a high high use of technology,
- 16:59but comparing other areas would also
- 17:01benefit to be able to make that comparison.
- 17:04And understand where the disparities
- 17:06are occurring.
- 17:07And then also assessing diabetes
- 17:09test with a qualitative study can
- 17:10help understand what specifically
- 17:12is contributing to the high rate
- 17:14of diabetes distress.
- 17:15So here are some strengths and
- 17:16just to highlight a couple,
- 17:17it was the first study that compared
- 17:18diabetes distress between ontspanning
- 17:20white and minority adolescents.
- 17:22And then we also included both
- 17:24parents and adolescents into once
- 17:26we're able to directly compare
- 17:28their level of diabetes distress.
- 17:30Some limitations are here again
- 17:32just to highlight a couple of them.
- 17:34We only recruited patients that
- 17:35had scheduled appointments,
- 17:36so this may be missing patients
- 17:37that have high level diabetes,
- 17:39distress or not using technology
- 17:41we only recruited from Yale,
- 17:42so again that has a potentially
- 17:44has a higher rate of diabetes
- 17:46technology then it's representative
- 17:48of the minority population.
- 17:49Our survey was only in English
- 17:51so that limits anyone who is non
- 17:53English speaking and then it was
- 17:54administered during the pandemic so
- 17:56that also may be contributing to a
- 17:58high level of distress in adolescence.
- 18:01Here are my references.
- 18:03Just a big thank you to Rosanna
- 18:04and Megan for all their support
- 18:06with alternative thesis.
- 18:07I really appreciate you giving us the
- 18:10opportunity to pursue it. Thank you.
- 18:24He asked. The audience, so it's OK.
- 18:26We are going to probably get presentations.
- 18:39So it's my pleasure to introduce Jamie
- 18:42Conway to present card thesis and we
- 18:45will let her introduce the topic that
- 18:48she developed and her adviser. Thank you.
- 18:58Hi everyone, my name is Jamie.
- 19:01Thank you all for being here.
- 19:03It's so nice to see you all in person
- 19:05and thank you for everyone who's
- 19:07tuning in online and also special
- 19:09thanks to my advisor Doctor Nauert.
- 19:11So my topic is tucked in weighted
- 19:14blankets to improve sleep in
- 19:16intensive care unit patients and I
- 19:18did the traditional thesis route.
- 19:21So just a quick outline of what
- 19:23will be going through today.
- 19:25So sleep in all people,
- 19:28but especially those in the critically ill,
- 19:30is incredibly important.
- 19:31Those in the intensive care unit
- 19:34have been found to have all domains
- 19:36of sleep deficiency that would
- 19:38include abnormal sleep timing,
- 19:40poor sleep quality, or short sleep duration.
- 19:44Sleep deficiency can increase the risk
- 19:46of infectious and inflammatory diseases,
- 19:49and it has contributions to all 'cause
- 19:51mortality and it shows that there
- 19:54are implications up to 12 months.
- 19:56After both physically and
- 19:59psychologically with PTSD.
- 20:02As far as measuring sleep goes,
- 20:03there are two ways to go about it.
- 20:05There are objective measures,
- 20:07which is polysomnography or PSG,
- 20:09the gold standard.
- 20:11This is a high cost and
- 20:14uncomfortable process.
- 20:15It requires a lot of wires or leads
- 20:18EKG EG on the head it tracks eye
- 20:22movements and patients already bogged
- 20:25down with a lot of Ivs and other wires
- 20:29and it overall just doesn't bode well.
- 20:32For a good study, however,
- 20:34there's actigraphy.
- 20:35It has a significant correlation,
- 20:38shown in studies with PSG,
- 20:40it's less invasive, less cumbersome,
- 20:42more cost efficient.
- 20:43It's essentially what we like
- 20:45to say is a glorified Fitbit.
- 20:47You wear it on your wrist,
- 20:48and it can track your total sleep time.
- 20:51Another way of going about measuring
- 20:53sleep is a subjective measure.
- 20:54The Richard Campbell Sleep
- 20:57Questionnaire is the only validated
- 21:00questionnaire for ICU patients.
- 21:02It's significantly.
- 21:02Has been found to correlate
- 21:05with PSG measures.
- 21:06It requires just a simple tickmark by
- 21:08patients and that are critically ill,
- 21:11so this works well for them.
- 21:12They have low stamina,
- 21:14it just requires a simple tick
- 21:16mark on a visual analog scale.
- 21:18So many ways have been trialdb
- 21:21to enhance sleep,
- 21:23especially in the critically ill,
- 21:25but there is no evidence based
- 21:28pharmacological interventions available.
- 21:30Oftentimes,
- 21:30if we try to use pharmacological methods,
- 21:33there are adverse effects
- 21:34and there can also be drug,
- 21:36drug interactions and patients
- 21:37that are already enduring a large
- 21:40pharmacological burden norm.
- 21:42Non pharmacological interventions have
- 21:44been tried and they show some promise.
- 21:46Some things like ear plugs, eye masks, music.
- 21:49Cluster nursing care specifically,
- 21:51is when nurses tried to do their
- 21:53best to do all their tasks at once
- 21:55when entering a room instead of
- 21:57going in multiple times specifically
- 21:58at Yale and the medical ICU,
- 22:01they have the standard of care,
- 22:03which is a quiet time from midnight
- 22:06to 4:00 AM and a quiet pack which
- 22:08is given to all patients and
- 22:10includes an eye mask and ear buds.
- 22:12Despite all these interventions
- 22:13that are tried consistently,
- 22:15patients report for sleep,
- 22:16whether it's at Yale or another
- 22:18hospital and for this.
- 22:19Reason it's necessary to continue
- 22:21to evaluate more methods.
- 22:25Then comes weighted blankets,
- 22:26blankets of various sizes that are filled
- 22:29with different materials to evenly
- 22:32distribute the weight across a body.
- 22:34The theoretical framework is
- 22:36that it's deep touch pressure.
- 22:38It's almost like a hug
- 22:40or a swaddle for a baby,
- 22:44and they're ideally 10% of your
- 22:45body weight and they can be
- 22:47manufactured in such a way that
- 22:48they can be wiped down with wipes,
- 22:50which would be helpful in an
- 22:52intensive care unit setting they've
- 22:53been studied in many populations.
- 22:55They've been studied in
- 22:57adult psychiatric centers,
- 22:58children with autism neonates in the ICU,
- 23:02those with breast cancer in
- 23:05inpatient and outpatient settings.
- 23:07These studies have often been flawed
- 23:10in certain ways or have not had
- 23:13significant sample sizes show bias,
- 23:15but overall results have showed an
- 23:17increase in total sleep time and
- 23:20consistently show a high user satisfaction.
- 23:23However, weighted blankets have not
- 23:25been tried in the critically ill.
- 23:27So as far as the problem goes,
- 23:30sleep deficiency is pervasive
- 23:31in the critically ill,
- 23:33with no evidence based pharmacological
- 23:35interventions shown to be effective.
- 23:37For this reason,
- 23:38non pharmacological strategies
- 23:40must be continued to be explored.
- 23:42Weighted blankets have been shown
- 23:43to help with sleep and anxiety in a
- 23:46variety of settings and populations.
- 23:47However,
- 23:48there's a lack of literature
- 23:50in this population where sleep
- 23:52is vital and jeopardized.
- 23:54So we hypothesize that weighted
- 23:56blankets used in hospital lies patients
- 23:58over 50 years old in intensive care
- 24:00units will have different mean
- 24:02total sleep time when compared to
- 24:05baseline of those with usual care.
- 24:08This will be a randomized controlled trial.
- 24:11It will have two arms,
- 24:12weighted blankets and usual
- 24:14or standard of care.
- 24:15We will study adult critically
- 24:17ill patients over 50 years old.
- 24:19The reason we specify 50 years old
- 24:21is that they are most susceptible
- 24:23to the adverse effects of low sleep,
- 24:25including things like delirium,
- 24:27which is rampant in the ICU.
- 24:29The exclusion criteria will include
- 24:31those in respiratory failure,
- 24:32so those on, say,
- 24:33a ventilator or those with active wounds,
- 24:35whether they're pressure wounds
- 24:37or recent surgeries.
- 24:38And those expected to leave within
- 24:40the next 24 hours by staff.
- 24:42We will evaluate all patients
- 24:44admitted to the MCU daily as
- 24:47potential subjects for this study.
- 24:51The key variables the
- 24:52intervention will be the weighted
- 24:54blanket plus standard of care and
- 24:56like I mentioned earlier at Yale,
- 24:57the standard of care is that
- 24:59quiet pack in those quiet hours,
- 25:01the control will be standard of care alone.
- 25:04The primary outcome will be total sleep
- 25:06time via actigraphy that glorified Fitbit.
- 25:09On night two of the blanket use and
- 25:11the secondary outcome will be the
- 25:13Sleep Questionnaire the next morning.
- 25:14Based on that night,
- 25:16two of the study we will come.
- 25:18Get consent from all patients to videotape
- 25:21to ensure that the blanket is used
- 25:23for at least one hour on that night.
- 25:26Two of the study and only those
- 25:28that use the blanket for one
- 25:30hour will qualify for analysis.
- 25:33Blinding the intervention
- 25:34to the participants.
- 25:35We will phrase it as a non pharmacological
- 25:38sleep study and we will leave out
- 25:40the fact that the intervention of
- 25:42interest is the way to blanket because
- 25:45standard of care as well also has
- 25:48non pharmacological interventions,
- 25:49the ear buds.
- 25:50Then the eye mask.
- 25:52Finding the outcome.
- 25:53The research assistant interpreting the data
- 25:55will not have access to the allocation.
- 26:00So, yells, Mccue admits 4000 patients per
- 26:03year, and the median stays three nights,
- 26:06which allows us to determine that this would
- 26:09be a feasible study to carry out at Yale.
- 26:12We calculated the sample size based
- 26:14on data historical data in the
- 26:16Yale ICU based on Dr. Narcs lab.
- 26:19They found that the average is
- 26:2194 minutes of total sleep time,
- 26:23with variants of 61 minutes willpower.
- 26:25The study to 80% affect size of
- 26:2820% or 18 minutes.
- 26:30So given all this data historical
- 26:32data based on Doctor Notes Lab,
- 26:35we will have a calculated sample
- 26:37size of 324 and will round up to
- 26:393:30 to allow for correction.
- 26:43So this is just a graphic
- 26:46kind of outlying everything.
- 26:48I already said patients will be admitted
- 26:51to the hospital later admitted to the MCU.
- 26:54They'll be randomized either
- 26:56to control or intervention,
- 26:57and they'll wear actigraphy on night one,
- 27:00though the night of interest is night two,
- 27:02once they're accustomed to all of
- 27:03these things being on their body,
- 27:04and they've adjusted to being on the unit,
- 27:07so night two will collect
- 27:09the actigraphy data,
- 27:10and the next morning will do
- 27:13the Sleep questionnaire.
- 27:14Based on night, two of the study.
- 27:17So. The impact that this
- 27:19could have is that it could.
- 27:22Improve patient outcomes both short term
- 27:24and long term like I had mentioned earlier,
- 27:26these effects of low sleep can carry
- 27:29on up to 12 months after discharge.
- 27:32It allows us to offer another non
- 27:35pharmacological option to those
- 27:38that don't have many options and it
- 27:41can increase patient satisfaction.
- 27:43It avoids secondary harm and not
- 27:46trying to treat a pharmacologically,
- 27:48and while it is a very specific population.
- 27:52It's a population where sleep
- 27:53is most disrupted,
- 27:55and ideally we would be able to generalize
- 27:57and apply to a wider population.
- 28:02The study has some potential strengths.
- 28:04It's a significant sample size
- 28:06based on historical data where the
- 28:09actual study would be taking place.
- 28:11It's also the first of its kind in that it
- 28:13offers objective and subjective outcomes,
- 28:16and we do try to address bias through
- 28:20blinding the participants to the
- 28:23non pharmacological intervention.
- 28:25We do also have limitations.
- 28:27There is difficulty with binding
- 28:29given that a weighted blanket is
- 28:30quite heavy and you can tell it's.
- 28:32Waited up and there's also a high
- 28:36variability of sleep at baseline.
- 28:37I think I mentioned earlier the average
- 28:39and Niels McHugh is 94 minutes with a
- 28:41variance of 61 minutes, pretty high.
- 28:43However, we do try to address that by
- 28:46carrying out the study in yells McHugh.
- 28:48Additionally, there's some limitations
- 28:50with the accuracy of actigraphy,
- 28:52as it is an accelerometer,
- 28:54it's worn on your wrist,
- 28:55and if you're not moving,
- 28:56it's harder for it to track,
- 28:58so it's just one thing to keep
- 29:00in mind when we interpret data.
- 29:03So I just want to thank you
- 29:04all for listening.
- 29:05I want to thank Doctor Nauert.
- 29:06She was an amazing thesis advisor.
- 29:08Thank you.
- 29:09Rosanna and Megan and the
- 29:11Graduate writing lab and everyone
- 29:12who helped get us here to this
- 29:14point and thanks class of 2021.
- 29:27Blue Jays probably chat.
- 29:31That you have some funds listening.
- 29:34Thank you so much.
- 29:36So it's my pleasure to introduce Carina,
- 29:39Legio who is going to take us in a
- 29:41more pharmacological approach to
- 29:44intervene, so thank you, Karina.
- 29:55So hi everyone, I'm Karina.
- 29:57This is my thesis presentation
- 29:59entitled efficacy of her magic pant
- 30:01plus calcitonin gene related peptide
- 30:04monoclonal antibody for migraine and
- 30:06my advisor was Doctor Schindler.
- 30:10So just to give some
- 30:11background, migraine is estimated to
- 30:13affect about 15% of the global population,
- 30:16and it's characterized by painful,
- 30:18unilateral headache attacks often
- 30:20associated with nausea, vomiting,
- 30:22photophobia, and phonophobia.
- 30:24And it's managed with a board of
- 30:27therapy during a pain attack,
- 30:29prophylactic therapy to prevent attacks,
- 30:32and often a combination of both.
- 30:35There is calcitonin gene related peptide
- 30:37CGRP and its receptor and they have a
- 30:41role in the provocation of migraines.
- 30:43So CGRP is a neuropeptide.
- 30:45It binds to the CGRP receptor and it
- 30:48causes potent vasodilation specifically
- 30:50within the trigeminal gangland and
- 30:52its proposed that elevated levels
- 30:55of CGRP may lead to sensitization
- 30:57of those neuronal circuits so that
- 31:00the usual sensory inputs like light,
- 31:03sounds, tastes and odors.
- 31:05Are then experienced as bothersome.
- 31:08And so this peptide and its receptor
- 31:10have been targeted in the development of
- 31:12both preventive and abortive therapies.
- 31:17So one of these medications
- 31:18is called magic pants.
- 31:20It's brand name is Nartec
- 31:21oral dissolving tablet,
- 31:23and it's actually produced here in
- 31:25New Haven and its uses for the acute
- 31:28treatment of migraine as an abortive.
- 31:31And it's part of the small molecule
- 31:33CGRP receptor antagonist class,
- 31:35it has a couple of proposed mechanisms,
- 31:38one of which is that it competes with
- 31:40the initial CGRP binding event and
- 31:42blocks the activation of the receptor,
- 31:44or it potentially displaces the bound CGRP.
- 31:47And deactivates the receptor and
- 31:50this medication was just approved
- 31:52by the FDA in February of 2020.
- 31:58Then there are the monoclonal antibodies
- 32:00and these are used as a preventive
- 32:02migraine therapy and they include
- 32:03class members such as air knob,
- 32:05galcanezumab, feminism,
- 32:07ABBA Neptunism app,
- 32:09and their mechanisms for gallicanism
- 32:11gallicanism app from his Mama Neptunism
- 32:14app is that they neutralize some portion
- 32:16of the circulating CGRP ligands which
- 32:19prevent the peptide from signaling.
- 32:21Erenumab is a little different in that
- 32:23it blocks the CGRP receptor instead
- 32:25of the peptide and these are given.
- 32:28As once monthly injections or via Ivy,
- 32:32and they're actually giving quarterly
- 32:34for feminism, AB, and eptinezumab.
- 32:39So this led to my development of a
- 32:42problem which is given that Japan's
- 32:44and Mads both act on the CGRP system.
- 32:46It begs the questions.
- 32:48Would patients using both experience of
- 32:50greater benefit and is this combination safe?
- 32:52So published reports of the use of both
- 32:55oral were magicant for acute treatment
- 32:57and a map for prevention or limited.
- 32:59There is a small case series that
- 33:02demonstrated possible efficacy in
- 33:03treating refractory migraine with Roma,
- 33:05Japan and Erin AB and then following
- 33:07this there was an open label.
- 33:09Substudy of 13 migraine patients
- 33:11simultaneously using their magic
- 33:13pants with a map which showed
- 33:15no serious adverse events.
- 33:17However, efficacy was not reported.
- 33:21So therefore further study in the form
- 33:24of a randomized controlled trial to
- 33:26investigate the safety and efficacy
- 33:27of our measure pant in the setting of
- 33:30common map therapy is necessary and,
- 33:31if shown to be effective as well as safe,
- 33:34this therapeutic approach may provide the
- 33:36best opportunity to expand evidence based
- 33:38migraine management and to improve the
- 33:40quality of life and migraine patients.
- 33:45So I developed the hypothesis
- 33:46that when using her magic pant
- 33:48as an abortive intervention,
- 33:50adult subjects on antique GRP
- 33:52or anti receptor map preventive
- 33:54will have a different incidence
- 33:56proportion of freedom from pain at
- 33:58two hours compared to those who
- 34:00have never used a map preventive and
- 34:02one definition that I want to draw
- 34:04attention to is the freedom from pain.
- 34:06So for the purpose of this study it's
- 34:08defined as on a zero to three pain
- 34:11numerical rating scale where zero is no pain,
- 34:13one mild to moderate and three severe.
- 34:16It's the reduction from moderate two
- 34:18or three severe at the time of Drug
- 34:21Administration to no pain for 0.
- 34:26So for my methods, UM,
- 34:29we're looking at a population of adults,
- 34:30so ages 18 to 65 years old,
- 34:33with at least one year history of migraine.
- 34:36And this is further divided into our study,
- 34:38or monoclonal antibody population who
- 34:40were treated with a map for at least
- 34:43three months prior to the screening
- 34:45and then our control population,
- 34:47or those who have never used an
- 34:50antique P or anti CGRP receptor map.
- 34:53Our target sample size would
- 34:54be 450 subjects and.
- 34:56The study design would be a biphasic trial.
- 35:00So the primary phase would be randomized,
- 35:02double blind,
- 35:03placebo controlled single attack
- 35:05study and the secondary phase would
- 35:07be a two month open label Multi
- 35:10Attack study and I further delineate
- 35:12delineated this in the table below.
- 35:14So you can see the two groups,
- 35:15there's the control group and
- 35:17the monoclonal antibody group.
- 35:18They both undergo a running
- 35:20period of four weeks.
- 35:21The primary phase which is the blinded
- 35:24phase is when the subjects will be asked.
- 35:27To treat one migraine attack of moderate
- 35:30to severe intensity and they'll be
- 35:33allocated and blinded to being given
- 35:36either were magic pant or placebo
- 35:38to treat that one migraine attack.
- 35:41Then,
- 35:41during the secondary phase,
- 35:42which is the open label phase,
- 35:43it'll go on for eight weeks and
- 35:45patients and all of the groups will
- 35:47all treat her multiple migraine
- 35:49attacks with her magic pan.
- 35:54So we're going to collect data
- 35:57through an electronic patient.
- 35:58Reported outcomes diary.
- 35:59So at the time of a migraine attack,
- 36:02the subjects will begin to document
- 36:03in their epro diary by rating their
- 36:05pain on a scale of zero to three,
- 36:08and documenting other
- 36:09symptoms such as photophobia,
- 36:11phonophobia, or nausha,
- 36:12and if their pain is rated at two or three,
- 36:15they'll be asked to self administer
- 36:17the allocated intervention.
- 36:18So during phase one it could
- 36:20be re measure pant or placebo,
- 36:22and during the second phase it will be.
- 36:25Where magic pants.
- 36:26And then they'll re-evaluate their pain
- 36:28and symptoms at several time points.
- 36:29Most importantly,
- 36:302 hours after the intervention,
- 36:33and they'll also complete a migraine
- 36:35specific quality of Life Questionnaire,
- 36:38which will be done during
- 36:39the running period and at the
- 36:41ends of weeks four and eight,
- 36:43and the MSQ is this is a valid
- 36:46and reliable measure to assess
- 36:47the effect of migraine on daily
- 36:50functioning among migraine patients.
- 36:52Our primary outcome would be freedom
- 36:54from pain at two hours and will also
- 36:57look at several secondary outcomes,
- 36:59including but not limited to,
- 37:01pain relief at two hours,
- 37:03freedom from most bothersome
- 37:04symptom at 2 hours,
- 37:05and quality of life scores.
- 37:10So some strengths of this study.
- 37:13First is that the protocol was written
- 37:15in accordance with the guidelines of
- 37:17the International Headache Society for
- 37:19controlled trials of acute treatment
- 37:20of migraine attacks and adults.
- 37:22So some of the elements,
- 37:23such as the measurement of
- 37:24freedom from pain at two hours,
- 37:26is derived from these guidelines.
- 37:28The guidelines also limits subjects
- 37:30from having to treat multiple
- 37:32migraine attacks with placebos.
- 37:33Therefore,
- 37:34most migraine studies comparing an
- 37:36abortive to placebo consists of
- 37:38subjects only treating one migraine.
- 37:40Attack with the intervention and
- 37:43the conclusions are drawn from that,
- 37:45so I decided to come up with this
- 37:48unique biphasic design in which I'm
- 37:50maintaining a phase with blinding
- 37:52and randomization to investigate
- 37:54a single migraine attack similar
- 37:56to the traditional studies.
- 37:58However,
- 37:59with the addition of the secondary phase,
- 38:02it allows for analysis of consistency
- 38:04of response to measure pant and its
- 38:07treatment of multiple migraine attacks,
- 38:09and this is all while still
- 38:11meeting the ethical.
- 38:12Guidelines such that no subject
- 38:14is treating more than one
- 38:16migraine attack with placebo.
- 38:18And lastly,
- 38:19I believe a strength is the inclusion
- 38:22of the MSQ because it really provides
- 38:24a more comprehensive measurement of
- 38:26the medications impact on patients
- 38:28overall migraine management.
- 38:32Some limitations of mine is that there is
- 38:36variability in the types of preventives
- 38:38the control subjects are taking,
- 38:40so the control subjects are allowed to
- 38:42be on preventives that aren't maps.
- 38:44These can include tapir,
- 38:46may Botox injections or beta blockers,
- 38:49and this does present a
- 38:51potential confounding variable.
- 38:53However, in order to maintain the
- 38:54external validity of the study,
- 38:56it's necessary to include subjects on
- 38:58preventive for their migraines and better
- 39:01emulate this study population at large.
- 39:03And and another limitation is
- 39:05that there's no active comparator.
- 39:07So in this study,
- 39:08were Magic Pant is being compared to placebo,
- 39:11and it might be argued that the
- 39:12inclusion of an active comparator
- 39:14or standard of care treatment
- 39:16would strengthen the clinical
- 39:17implications of the study results.
- 39:19However,
- 39:19it's really beyond the scope of this trial,
- 39:22which is primarily focused on comparing
- 39:24the effects and safety of the drug in
- 39:27those taking versus not taking a CGRP map.
- 39:29And depending on the results from this study,
- 39:31the inclusion of an active comparator.
- 39:34In similar future studies would
- 39:35be might be warranted.
- 39:39And for clinical significance.
- 39:41So this study really addresses
- 39:43both preventive and abortive
- 39:44treatment of migraine,
- 39:45which are the two pillars of
- 39:48migraine management long term.
- 39:50And although the main objective is to
- 39:52determine the efficacy of her magic,
- 39:53and in the acute setting,
- 39:55incorporation of the migraine medication
- 39:57in combination with the maps in the
- 39:59long term is what really expands
- 40:01the impacts of this study because
- 40:03there's no known cure for migraine,
- 40:05it's only managed.
- 40:08And then in terms of quality of life
- 40:10and disability for migraine patients,
- 40:12spending less time in pain,
- 40:14having fewer disability work days
- 40:16and therefore less time spent in a
- 40:18health care setting really speaks
- 40:20to the impacts that this could have.
- 40:22If this is a more effective
- 40:25way of managing migraines.
- 40:27And also it has impacts directly on
- 40:29the health care system and that it's
- 40:31cost saving to both the patient and
- 40:33to the health system when there are
- 40:35fewer visits to the ER and fewer
- 40:37hospitalizations related to migraine care.
- 40:39Treating migraine attacks at home
- 40:41and being seen as an outpatient
- 40:43is not only more economical,
- 40:45but also less distressing for the patient.
- 40:49So I'd like to acknowledge my thesis advisor,
- 40:52Dr. Schindler.
- 40:53She was really great.
- 40:54She helped tremendously in her
- 40:56guidance throughout the development
- 40:58of my protocol and she also helped
- 41:00give me a lot of great advice about
- 41:02scientific writing throughout the
- 41:04project for to Rosanna and Megan.
- 41:06Thank you for facilitating the thesis
- 41:08process in a really organized and at
- 41:11least like a little less overwhelming,
- 41:13way that was really much appreciated.
- 41:15And for my mom, dad and my sister Adriana,
- 41:18who.
- 41:19Supporting me through PA school and
- 41:22this project. I appreciate them.
- 41:25Any references?
- 41:37So I would like to invite Robert Johnston
- 41:40to discuss his thesis.
- 41:42I would like to make one comment
- 41:45that Robert approached me about
- 41:47doing a thesis abroad with the
- 41:51Downs Fellowship. The first day
- 41:53that I met him.
- 41:56And it's not the first time that
- 41:57people do that and follow me around
- 41:59in between cocktails because we used
- 42:01to have cocktails at at
- 42:02one time and the first
- 42:03week. And so it's not that I
- 42:07dismissed him, but I thought, OK,
- 42:09another one who wants to go abroad.
- 42:11Will he go abroad?
- 42:13In fact, Robert didn't go abroad,
- 42:14but did something much better than that.
- 42:17He continued to do his work and finish his
- 42:22project in developed capacity in China, too.
- 42:26Not only complete the
- 42:28project that he completed,
- 42:29but also for our colleagues in
- 42:33China to learn from him so and
- 42:36the same I have to say Tadao,
- 42:38who also is our second downs
- 42:41fellow who went through.
- 42:44A lot of travel to complete
- 42:46his project in Uganda,
- 42:48so I I just wanted to give
- 42:51a context because this was a
- 42:53different bit different.
- 42:54It took one year longer
- 42:56to do this project,
- 42:57so thank you Robert and invited
- 43:00you to walk through.
- 43:10Good afternoon everybody
- 43:12again. I'm Robert to our audience
- 43:14online and I'd like to first thank Dr
- 43:17Kush nude and Doctor Leon who really
- 43:19helped make this project possible both
- 43:22here and planning it and then executing
- 43:24it while we were in or in China.
- 43:26The team that was there.
- 43:28The focus today is on the idea
- 43:30of healthy aging in early China,
- 43:32and I'm just going to walk you through
- 43:34kind of the big picture of what that means,
- 43:36what we did, and kind of why that matters
- 43:39and why it would matter to us here.
- 43:41So by the year 2050,
- 43:43at least 20% of the world's
- 43:45going to be over the age of 60.
- 43:46So everyone in this room will be over 60.
- 43:49By that point,
- 43:50it challenges us because there's
- 43:52logistical questions and social
- 43:54questions about what are we going
- 43:56to do when more people need support
- 43:58in different ways than in the past.
- 44:00And we talked about this idea of
- 44:02healthy aging and and what that means.
- 44:04And when you look at the literature,
- 44:05it doesn't really tell you a
- 44:07strict definition.
- 44:08There's a lot of conflicting views,
- 44:10whether that's physical.
- 44:11Social health,
- 44:13psychological health.
- 44:14Some combination of that so
- 44:16we don't have something that
- 44:18strictly says this is what it is.
- 44:19And at the same time,
- 44:21a study that was conducted through
- 44:23Yale last year looked through the
- 44:24literature and said there's this
- 44:26kind of pervasive ageism both in the
- 44:28literature and across continents that's
- 44:30affecting the health care of older adults.
- 44:32And what does that mean as
- 44:34clinicians if we know that's true,
- 44:36what can we do about it?
- 44:37How can we make things better?
- 44:39But you might ask,
- 44:40why did we decide to focus in China?
- 44:42And there were a couple of reasons.
- 44:44One,
- 44:44China still has the largest
- 44:45population in the world,
- 44:46so this problem is more present to
- 44:48them and thinking how do we support?
- 44:50Our population as they grow older and second,
- 44:53there's been this distinct
- 44:55environment of younger people moving
- 44:57from rural areas to urban areas.
- 44:59That shows us that they don't have
- 45:01the support or family networks
- 45:03that they once had,
- 45:04so they've had to create different
- 45:06forms of establishing their selves or
- 45:09sustaining themselves despite those changes.
- 45:12There have been different
- 45:13efforts by groups there.
- 45:14Things like insurance programs,
- 45:15but there have been mixed results by
- 45:18that so historically in China there
- 45:20are these things called kind of red
- 45:22envelopes or backdoor payments to
- 45:24physicians to help get better care.
- 45:26Well,
- 45:26they subsidized the health care and
- 45:27said you don't have to do that anymore.
- 45:29Well,
- 45:29it actually increased the number
- 45:31of red envelopes that went out,
- 45:32and there was a large discussion
- 45:34about why that would happen if we're
- 45:35actually helping people by saying
- 45:37that you no longer have to pay.
- 45:38So there have been different
- 45:40challenges to even the things
- 45:41that we've tried to do to help.
- 45:42This situation,
- 45:43in terms of what we might think
- 45:45of as physical health.
- 45:46And the last piece I think that's
- 45:48important to consider here is that
- 45:49across the board there's this idea of
- 45:52when you study China that everything
- 45:54is applicable to everyone in China.
- 45:56As I said, China has 1.3 billion
- 45:58people and you would think that there
- 46:00would be some diversity and experience
- 46:03there simply because of geography
- 46:05or your own experience as to what
- 46:07healthy aging might mean to you.
- 46:08So we tried to make this study very
- 46:11broad and what we tried to ask.
- 46:13So we try to answer two basic
- 46:15questions here among this population.
- 46:17That we went and visited,
- 46:17that I'll introduce you to in just a
- 46:19second one is what do older men and
- 46:22women in rural Guangdong province this is?
- 46:24Southern China.
- 46:25Think healthy aging means let them
- 46:27define it for themselves and tell us.
- 46:29And the second is what are the
- 46:31obstacles to achieving that and
- 46:33how does that intersect?
- 46:34Or how is that different from
- 46:36what individuals that are involved
- 46:38with healthcare? Think there so.
- 46:41How do you investigate these
- 46:43questions though?
- 46:43If we just go and say we're just
- 46:45going to ask these questions,
- 46:46we probably won't quite get the
- 46:48results we were hoping for.
- 46:50So our design was essentially exploratory,
- 46:53where we let every we allow our
- 46:55participants to direct us in a sense.
- 46:57We had an outline where we did interviews,
- 47:00but we also had our research
- 47:03team essentially participate.
- 47:05I had two research assistants who
- 47:07we trained before they started.
- 47:09We did about 10 training sessions
- 47:11where they did interviews where
- 47:12we sent them out into their
- 47:14communities before they went there
- 47:15and they practiced interviewing.
- 47:17They practiced drawing maps,
- 47:18they took photographs and did all
- 47:20these things and then they went
- 47:21and they lived in this village
- 47:23for about two months and it was
- 47:25very challenging for anyone.
- 47:26I think if I had been there I was.
- 47:28Anticipating culture shock,
- 47:29but I think my students who are used
- 47:31to living in a 15 million person
- 47:33city moving to a town that has
- 47:35about 3000 people was a surprise
- 47:37'cause I saw on social media.
- 47:39They would say everything is going
- 47:40great but then we would go on social
- 47:42media and I would see what was
- 47:44actually going on and I would say
- 47:45well what's happening and they would
- 47:47say there's nothing to do here at night.
- 47:49There's and then I would say and
- 47:51there's this other problem that
- 47:52you have to use a special device
- 47:54to warm up the water here to take
- 47:56a bath in the evening and things.
- 47:58That they weren't anticipating,
- 47:59but are important to understanding
- 48:01to experience what people are
- 48:03going through in their life,
- 48:04rather than just asking the
- 48:05question of what the problem is.
- 48:07And I think that last part of participant
- 48:09observation is also very important
- 48:11because what people say and what
- 48:13people do or sometimes different.
- 48:14And sometimes it's your ideal.
- 48:16What you tell someone,
- 48:17what they actually do could be
- 48:19different from that and understanding
- 48:21that and recognizing
- 48:22that is an important part of what we did.
- 48:23So you can see the breakdown of
- 48:25who we interviewed there or who
- 48:27we met with my students. Again,
- 48:28were instrumental to making that happen.
- 48:30The research assistance,
- 48:31and then as a group, the team.
- 48:34We analyzed our interviews going
- 48:35by through them line by line.
- 48:37We debated we I was told I was incorrect
- 48:39about something they I told them they
- 48:41were incorrect and then we finally
- 48:42would come to some consensus about what
- 48:44the big picture was in terms of what
- 48:46we we got out of these interviews.
- 48:49So where there were three key
- 48:51themes that we got out of this?
- 48:53Oh, and one more map for you.
- 48:54Just so if you aren't oriented to China,
- 48:56we were in southern China.
- 48:57This province is called Guandong
- 48:59and the students were from that red
- 49:01area in the middle of 15 million
- 49:03people and we went to that village.
- 49:05That's kind of circled up there.
- 49:07That general vicinity was this
- 49:08small village of about 3000 people
- 49:10and I say a Hakka village.
- 49:12This is kind of a sub category
- 49:14of the main ethnicity that most
- 49:15people identify with in China,
- 49:17so we wanted to try to find some
- 49:19diversity and perspective there.
- 49:21So with regard to what we learn.
- 49:22Some of these things will
- 49:24seem familiar to you.
- 49:25Chronic disease in discussing healthy aging
- 49:28came up again and again in some form.
- 49:31It was about mobility,
- 49:32psychological health in some form,
- 49:34and high blood pressure,
- 49:35but it was also about participating,
- 49:36which I'll explain to you
- 49:38in just a moment here.
- 49:39But you can see pictures from our
- 49:41site where on special activities
- 49:43the social workers tried to address
- 49:45this by saying we can do screenings.
- 49:47They had a canteen where we called it.
- 49:50The elder rank canteen,
- 49:51where older adults often met.
- 49:53And they had activities that went together,
- 49:55so being able to participate
- 49:57despite your chronic disease was
- 49:59very important to people.
- 50:01The second is relationships and
- 50:02I think this was unexpected,
- 50:05but in some ways for others,
- 50:06not as not too surprising where
- 50:08people didn't want to burden others,
- 50:10no matter how bad their situation was.
- 50:12People often would not ask for help
- 50:15or they didn't want to even have a
- 50:17family member because they felt that
- 50:18it was wrong to put this pressure on
- 50:20family members or community members.
- 50:22So again,
- 50:22there were these social avenues that
- 50:24they tried to address this through.
- 50:26The government had subsidized housing
- 50:27that they tried to say this is
- 50:29available to you without burdening.
- 50:31Another person,
- 50:32social workers who are delivering meals
- 50:34that was built into the community efforts.
- 50:39And the final piece here.
- 50:41The third kind of result we had was
- 50:43or theme we found with this complex
- 50:45site set of ideas about where to seek
- 50:47your health care and what it means.
- 50:49I put this garden here of someone's home
- 50:53because a lot of participants use folk
- 50:55medicine in order to manage their health
- 50:57beyond the things that we had available.
- 50:59Like blood pressure medications,
- 51:01diabetes medications, and so forth,
- 51:03this was important to them,
- 51:05but no one was really discussing
- 51:06it outside of the participants.
- 51:08The healthcare workers, for instance.
- 51:10And the other was this was the local clinic.
- 51:12There were two clinicians total in the town.
- 51:16And essentially what their role was in
- 51:18that conversation that we were having.
- 51:21So before I transitioned to kind
- 51:23of why any why this matters?
- 51:26I'd just like to point out with all of
- 51:28that what I think of the strengths and
- 51:30limitations here are really connected
- 51:32to this online collaboration we had.
- 51:33I couldn't have done this without those
- 51:35students who were there on the ground,
- 51:37and the commitment to everyone on the team,
- 51:39and it was really unexplored
- 51:40territory in a sense,
- 51:42because we weren't planning for this.
- 51:44Everything we got to do the same thing,
- 51:46but we needed to build the team very strongly
- 51:48before we could go out into the field.
- 51:50So how do you foster relationships?
- 51:52You need more time than you perhaps
- 51:54would if you were there with the team.
- 51:56The second part is we made sure that we
- 51:58had a shared understanding of how we
- 52:00do this and what the literature says.
- 52:02So we at least came in with the same
- 52:05framework in terms of what this means.
- 52:07When we move forward into the field.
- 52:10And I think the last piece here
- 52:12is the geographical boundaries.
- 52:13So we're saying we were in a
- 52:15village of 3000 people,
- 52:16which is helpful in the
- 52:18sense of it closes us off.
- 52:19It says these results are probably true
- 52:22for this village for what we had in terms
- 52:25of reaching saturation for interviews.
- 52:27However,
- 52:27can that apply to another part of China
- 52:30or even another part of the world?
- 52:32And we'll kind of answer that in terms of
- 52:36clinical significance or our conclusions.
- 52:38Here one is,
- 52:40there's a dynamic relationship between
- 52:42the biomedical model of medicine
- 52:45that we understand and those social
- 52:47expectations that were defined by
- 52:49people in the community there.
- 52:51And those three results are built
- 52:53into what I've said here.
- 52:54Community engagement was directly
- 52:56tide to chronic disease.
- 52:59You don't necessarily have to
- 53:01fix every chronic disease.
- 53:02But being able to participate in
- 53:04the community was very important to
- 53:06someone saying this is healthy aging.
- 53:08So how do you reach that point?
- 53:10And I think that really relates
- 53:12to problem number 2.
- 53:14The medicine was available,
- 53:15not everyone used it,
- 53:17and expectations of it were very different.
- 53:20There were many participants who
- 53:21talked about having had a stroke,
- 53:23having diabetes, high blood pressure,
- 53:26and not using the medications
- 53:27because they said they weren't
- 53:29cured by the medicine setting.
- 53:30Those expectations perhaps wasn't
- 53:32there and what's going to happen
- 53:34later on five years after a stroke,
- 53:36they haven't had another stroke,
- 53:37so they said I don't need to take
- 53:39any of these medicines anymore.
- 53:41And the third part is there were
- 53:43a lot of people trying to help
- 53:44this community in different ways.
- 53:45The social workers,
- 53:47government officials,
- 53:48the health care workers.
- 53:49But they were kind of working in parallel.
- 53:51There weren't.
- 53:52There wasn't a lot of communication
- 53:54between them and I think that there
- 53:56is an opportunity for a little
- 53:57more interaction to say who can
- 53:59deliver this kind of information.
- 54:01You're you're getting these resources.
- 54:03You have what you need,
- 54:04but making sure that we're meeting
- 54:06what participants want in that
- 54:08community as well as we're doing
- 54:10the best in terms of delivery
- 54:11in the news that we need to.
- 54:13And I think that question of is this
- 54:16relevant to anyone else besides
- 54:18this small community in China?
- 54:20Our argument is that.
- 54:22The individual results of.
- 54:25Not wanting to burden the community
- 54:27may not be relevant to someone here.
- 54:30However,
- 54:30if you are a clinician in any form of
- 54:32clinic where you work with the Community,
- 54:34you can repeat this study very
- 54:36easily with just a few people
- 54:38to see what people want.
- 54:39And while you do that,
- 54:40perhaps in your individual meetings,
- 54:43when you meet with your patient,
- 54:44it's the idea that we can take one
- 54:46step further and say what do we
- 54:48think the broader community here is.
- 54:50What do we think we want to achieve
- 54:52and how can we kind of direct
- 54:54our resources in that sense?
- 54:56I think we do a lot of that here,
- 54:57but I think in terms of some of
- 54:59those highlights that we have there,
- 55:01it's surprising if we never asked
- 55:02the question of our Community,
- 55:04what do they want?
- 55:06We'll never get the answer.
- 55:08Alright,
- 55:08thank you everyone,
- 55:09I appreciate it and it was a great
- 55:11joy taking part in this project
- 55:12in getting to share a little
- 55:14bit of it with you today.
- 55:26Questions now to the percentage
- 55:28question anyone have?
- 55:34Any questions for our
- 55:36presenters before we move
- 55:37into our panel?
- 55:40Sandy
- 55:49Gary. Thank you, thank
- 55:52you on behalf of
- 55:53these very hardworking students.
- 55:55I think one of the things that I would
- 55:58like to comment is that through these
- 56:00examples just four before we see the
- 56:02other nine that are in the website,
- 56:05our students explore a number of topics,
- 56:09explore different types of study designs,
- 56:12from observational studies,
- 56:14randomized control trials,
- 56:16qualitative research.
- 56:17They had topics that involve global health.
- 56:21Uh, ethics.
- 56:23When you are talking about considering
- 56:26the community and how that is going to.
- 56:29Affect our thinking clinically we
- 56:31had people talking about biologics,
- 56:34people talking about non
- 56:35pharmacological interventions.
- 56:36And
- 56:38of course one of my.
- 56:40You know, very interesting the idea that
- 56:43you went into exploring healthy parities.
- 56:47So thank you all for pursuing your
- 56:51own passion and open doors to others
- 56:54to learn more about this
- 56:57question. I think there was a fan. Before.
- 57:02I was actually curious.
- 57:06I. I'm sure she just missed it.
- 57:10It was really cool. She
- 57:11did design and
- 57:12having like one place that I was checking
- 57:15was a control group where they still
- 57:17taking her translator or they not.
- 57:21I was just wondering if there if I like.
- 57:25Yeah, so the control group and the
- 57:28monoclonal antibody group during
- 57:30that first phase there pulled
- 57:31randomized Hyderabad and during
- 57:34that security everybody everybody
- 57:36even in the control room.
- 57:37This control is the fact
- 57:39that they're not on the body,
- 57:42not that they're not taking the
- 57:43approach, which I know is a little
- 57:45bit confusing, and so
- 57:46they're all taking Medicaid.
- 57:48Second phase, which variable Windley.
- 57:51So they all know that they're all taking.
- 57:54More so comparing if you're on a map
- 57:56and you're already like benefiting
- 57:58from that now. Would you experience
- 58:01any greater benefit by having a board
- 58:04that way and then those who aren't
- 58:06on map are they experiencing?
- 58:12Thanks for clarifying.
- 58:25Yeah, thank you so much. So
- 58:27I think we would like to continue just
- 58:30to talk about the the pieces 2021 in
- 58:34numbers you used 3123 references.
- 58:38We had 51 readers and 44
- 58:43advisors more advisors than.
- 58:45One to one, because many of
- 58:47these alternative thesis invited
- 58:49collaboration across multiple advisors
- 58:51with different types of expertise.
- 58:57This is a big step for our thesis advisors.
- 59:01Really big, big thanks to all of them.
- 59:04Some of them are in our audience today,
- 59:07so we appreciate so much so much.
- 59:10All the dedication and the support
- 59:12for the research program and
- 59:14the P education in general.
- 59:16And I would like to invite Kyle to give up.
- 59:21Some thanks to someone who has helped
- 59:25us for 14 consecutive years and
- 59:29has left yell and sent us lots of
- 59:32emails saying how sorry he was that
- 59:35he was leaving because he cannot
- 59:37longer work with be a student.
- 59:39So I would like you to acknowledge
- 59:42that person.
- 59:47Yeah, so I'm Kyle. I had the privilege
- 59:50of working with Doctor Cohn. Fortunate
- 59:53to be the last person here at Yale
- 59:55who will be working with him after
- 59:5714 years of distinguished service.
- 59:59We actually reached out to all of
- 01:00:01his advisors from the past 14 years,
- 01:00:03and the plan was to take all of
- 01:00:05their words and put them on a slide.
- 01:00:07And we actually got words and
- 01:00:09video recordings and they were
- 01:00:11just too much and too big.
- 01:00:13So now you're stuck with me trying to do
- 01:00:15my best to fill in for all the 14 years.
- 01:00:17The people who he's kind of
- 01:00:20touched and I gotta say,
- 01:00:22you know Dave has this extensive
- 01:00:24knowledge and this way of being that
- 01:00:27makes you as a learner feel like you're.
- 01:00:31Doing everything and that you're
- 01:00:32amazing and Dave is just in the
- 01:00:35background like a puppet master,
- 01:00:36just kind of pulling a string every
- 01:00:38once in a while when you need one
- 01:00:40cold and you don't even know it.
- 01:00:42And I don't.
- 01:00:43I don't think I can say enough thanks to him,
- 01:00:46not only for my project but for the
- 01:00:49past 14 years and for all the lives
- 01:00:50and their careers that he's advanced.
- 01:00:52So thank you, Doctor Cohn,
- 01:00:54I hope you're here and listening to this,
- 01:00:55and if not,
- 01:00:56I'm going to send you a recording.
- 01:00:58And I expect to get pictures of
- 01:01:00a beach in Hawaii in return.
- 01:01:01So thank you.
- 01:01:07When I David Cone announced that he
- 01:01:10is retiring, he said that he was semi
- 01:01:12retiring and now living in Hawaii
- 01:01:14and working part time and going to
- 01:01:16the beach every day with his wife.
- 01:01:18So David well done.
- 01:01:21So next we are going to have the
- 01:01:25opportunity to listen a bit about
- 01:01:28the thesis of other students that
- 01:01:31have recorded their projects and they
- 01:01:34are going to be coming here to talk
- 01:01:36a little bit in a minute about what
- 01:01:39inspired them and what they learned about it.
- 01:01:42We were going to go into a room
- 01:01:44and do it by zoom,
- 01:01:46but we think that we need to
- 01:01:48hold this in person situation.
- 01:01:50So I'm going to start calling people.
- 01:01:52To join us and possibly come come
- 01:01:58here in pairs and talk a little
- 01:02:00bit about your thesis. So Alicia.
- 01:02:06It's Alicia here.
- 01:02:07No listen.
- 01:02:08It's not here,
- 01:02:09so I'm going to call Maria and Kyle
- 01:02:11to talk a little bit and then we
- 01:02:14will go through some other people.
- 01:02:17Thank you.
- 01:02:27Hello.
- 01:02:31I was just up here.
- 01:02:33Would inspire oh
- 01:02:35what inspired me.
- 01:02:36Oh man, so I mean I'm going to give
- 01:02:39Doctor Cohen more props on this one.
- 01:02:41So I actually went to him
- 01:02:43with my thesis idea.
- 01:02:44Basically just looking at P as in
- 01:02:46the pre hospital space 'cause I
- 01:02:48haven't heard of anybody doing that
- 01:02:50and he said you're exactly on time.
- 01:02:52This is fantastic.
- 01:02:53There's plenty of conversations
- 01:02:55happening about this,
- 01:02:56so we just kind of ran with it.
- 01:02:59Yep. What inspired me,
- 01:03:01I think the most inspirational
- 01:03:03thing that I can share with anybody
- 01:03:05who's looking at doing their thesis
- 01:03:07and struggling with that decision
- 01:03:09about what to do and and struggling
- 01:03:12through getting it done and the
- 01:03:14massive amount of work that it takes.
- 01:03:16There's something really magical about this
- 01:03:20cluttered clump of numbers on a spreadsheet.
- 01:03:23Entering your email and you look at it,
- 01:03:25you go.
- 01:03:26What the heck is this?
- 01:03:28And then three months later,
- 01:03:29you're looking at.
- 01:03:30Words on a piece of paper and
- 01:03:31you've explained everything that's
- 01:03:33going on in that spreadsheet and
- 01:03:35watching meaning come out of these
- 01:03:36meaningless numbers on a page.
- 01:03:38Really, really cool.
- 01:03:39And I,
- 01:03:40I hope everybody gets to experience that.
- 01:03:42So there's some more words for you.
- 01:03:50For the inspiration behind
- 01:03:52my project, as many people in this country,
- 01:03:56I've had very expensive medical bills and
- 01:03:58a lot of times I don't find out what the
- 01:04:01cost of my medical care is until I get
- 01:04:03that Bill and I was actually having Tex
- 01:04:06Mex for dinner with my husband once and
- 01:04:08we were talking about cost of medicine in
- 01:04:11this country and how ridiculous it can be.
- 01:04:14So that's that. Started this conversation.
- 01:04:15It was right about the time that we
- 01:04:18were starting to choose our thesis
- 01:04:19topic and I I knew that number.
- 01:04:21Like Kyle said,
- 01:04:23numbers mean a lot in medicine.
- 01:04:25Evidence based research is
- 01:04:26what we do here at Yale.
- 01:04:28And so I wanted to put numbers
- 01:04:31to the cost of treatment.
- 01:04:33And so I love primary care.
- 01:04:35I love preventative care and I
- 01:04:37wanted to do it in a setting where
- 01:04:38we treat a very expensive illnesses,
- 01:04:40just diabetes.
- 01:04:41So yeah, if you have the time to watch,
- 01:04:44great, if not essentially.
- 01:04:45We don't talk about cost of treatment enough,
- 01:04:48and it's something that we should.
- 01:04:50We can all incorporate into our care things.
- 01:04:58So now I will invite Brittany and Linda.
- 01:05:17I want to. So what I learned
- 01:05:21during my thesis project was how much
- 01:05:24time and effort goes into developing
- 01:05:27all this evidence based medicine
- 01:05:30that you know all of the current
- 01:05:32treatments and everything are based on.
- 01:05:34So I think I just have such a great
- 01:05:37appreciation for everything that
- 01:05:38researchers and people in in the field are
- 01:05:42doing to to develop such such innovative
- 01:05:45interventions in medicine and what?
- 01:05:49Uh, what motivated me was that you
- 01:05:52know we were home during the pandemic
- 01:05:54when we were picking our topics and
- 01:05:56I was living at home with my mom who
- 01:05:58was a teacher and she was doing remote
- 01:06:00learning and telling me all about the
- 01:06:01difficulties that her students were having.
- 01:06:03So that was really the main thing
- 01:06:06that inspired me to pick my topic.
- 01:06:10And for me personally,
- 01:06:11I've always been interested in research.
- 01:06:13I did research in undergrad and coming here.
- 01:06:15I know it's something I want to continue
- 01:06:17with, and it's also something that
- 01:06:18I'm looking forward to implement,
- 01:06:20implement into my professional career.
- 01:06:23I've always had some kind of
- 01:06:25interest in Women's Health,
- 01:06:25and I knew of my advisor
- 01:06:28before even the thesis project,
- 01:06:29so I figure maybe I can formulate it to
- 01:06:32something that's in his expertise and
- 01:06:34he just so happened to have some data
- 01:06:37lying around, so I was very thankful.
- 01:06:39For him for sharing his data that way,
- 01:06:40I was able to participate in
- 01:06:43the alternative thesis project.
- 01:06:45Uhm, yeah.
- 01:06:48So young.
- 01:06:55For those who find inspiration,
- 01:06:56know that it could be at home,
- 01:06:58so next one is Ashley and Alison.
- 01:07:03If they are here, yeah.
- 01:07:18Alright, so my inspiration
- 01:07:20for my thesis was that
- 01:07:24I've always had an interest in developmental
- 01:07:27disorders and neurologic disorders,
- 01:07:29'cause my younger brother has autism,
- 01:07:32so this is kind of always been the
- 01:07:35patient population I've been interested
- 01:07:37in serving in my career as a PA,
- 01:07:40and so I thought I would take
- 01:07:42that into this project and use
- 01:07:44this opportunity for research.
- 01:07:46In epilepsy in children?
- 01:07:48UM, so that was kind of what
- 01:07:50sparked my interest for this study,
- 01:07:52and it was such a joy and to be able to
- 01:07:56learn about nonpharmacologic treatments
- 01:07:58like exercise for these children,
- 01:08:01who often have a really heavy burden
- 01:08:03of disease and take a lot of different
- 01:08:06pharmacologic measures to treat seizures.
- 01:08:09So this was kind of my interest
- 01:08:11in why this study
- 01:08:13was so important to me.
- 01:08:17Hi everyone, so this project
- 01:08:19kind of found me along the way.
- 01:08:22I was inspired by my wonderful mother
- 01:08:25who underwent back surgery and I just
- 01:08:28really wanted to learn more about
- 01:08:30it so I didn't know where to start.
- 01:08:34I had no treatment or anything in mind
- 01:08:36and I just started reading everything I
- 01:08:38could get my hands on and along the way
- 01:08:41I just kind of found this in a paper
- 01:08:43I was reading where I noticed this.
- 01:08:45Pattern of this surgery being performed
- 01:08:48very widely with an off label,
- 01:08:51this protein that they use
- 01:08:53is used extremely commonly,
- 01:08:55even though it's off label and there
- 01:08:57were some concerns that were popping up,
- 01:08:59and so I thought I would explore
- 01:09:01that a little bit more.
- 01:09:03So I would say to just the other classes,
- 01:09:07find a topic you want to learn more about,
- 01:09:09and sometimes if you read enough about it,
- 01:09:12can just find you along the way.
- 01:09:15Thank you.
- 01:09:20Monica and Stephanie to join.
- 01:09:33OK so I'm Monica and I would
- 01:09:35say the inspiration for my
- 01:09:37thesis topic came from when I was
- 01:09:39working as a medical assistant in
- 01:09:41outpatient gastro enterology before
- 01:09:43PA School and I just found that a lot
- 01:09:45of my patients and inflammatory bowel
- 01:09:47disease were young and in experiencing
- 01:09:50more depression anxiety than others
- 01:09:53and it just inspired me to look more
- 01:09:55into treatment. Or mental health
- 01:09:57and inflammatory bowel disease.
- 01:09:59And especially with colvet.
- 01:10:01I think it's extremely important to
- 01:10:03find treatment for mental health
- 01:10:04with those and chronic diseases.
- 01:10:08And then for the other classes,
- 01:10:09something that
- 01:10:10Doctor Proctor taught me was that
- 01:10:12you should not be too hard on
- 01:10:14yourself and just to take things
- 01:10:15one day at a time. And that helped me
- 01:10:17so much throughout the thesis project.
- 01:10:19And I couldn't have done it without her.
- 01:10:23Hi, I'm Stephanie.
- 01:10:25So I actually changed my thesis topic after
- 01:10:27submitting my first one over the summer.
- 01:10:30I wasn't very inspired over the summer,
- 01:10:31just kind of picked something 'cause the
- 01:10:34time you know time was then to submit
- 01:10:36it and then on my second rotation I
- 01:10:38was in Guy knock and I went to surgery.
- 01:10:41Patient was really frail.
- 01:10:43You know the the surgeon kept
- 01:10:45commenting on her BMI?
- 01:10:46You know the complications that she was
- 01:10:49worried about and I kind of just dove
- 01:10:51into that, researched it a lot more.
- 01:10:53Kind of.
- 01:10:53Found the concept of free abilitation
- 01:10:55along the way and came up with
- 01:10:58my new thesis topic and submitted
- 01:11:01it just before Thanksgiving.
- 01:11:03And yeah, I learned, you know,
- 01:11:05just kind of overall about how
- 01:11:09your baseline status going into
- 01:11:11surgery can affect outcomes,
- 01:11:12even if it's not in guy knock.
- 01:11:14You know, I think it's it can be
- 01:11:15applied to like surgery overall.
- 01:11:17So it was a fun, fun project.
- 01:11:20Great, that's great.
- 01:11:27Are there any questions for I?
- 01:11:30I don't see any questions in the chat,
- 01:11:33so we may be celebrating with
- 01:11:35cookies sooner than we think.
- 01:11:38I just wanted to say
- 01:11:39congratulations to everyone I I
- 01:11:42really appreciate so much that
- 01:11:44you found inspiration near and far from you.
- 01:11:48I think it's great too if you if
- 01:11:50you take something with you is that.
- 01:11:53When things don't work,
- 01:11:54we are here to change them and when things
- 01:11:56work we are here to make them better.
- 01:11:59Just put forward,
- 01:12:00push forward and be prepared that
- 01:12:03in 30 years from now you will still
- 01:12:06be in practice we will hope.
- 01:12:09Some of us would be home.
- 01:12:10Hopefully we will be going to you,
- 01:12:13for you know for care and we
- 01:12:16would like that you will stay,
- 01:12:17stay fresh and interested in the things
- 01:12:20that are happening, not only to your
- 01:12:23patients near you but also to others. And
- 01:12:26there are a lot of people that are
- 01:12:28not included in research and I'm
- 01:12:30delighted that you have chosen to
- 01:12:32include the those who are not seen.
- 01:12:35Sometimes that's a great way to look.
- 01:12:38Or start a career.
- 01:12:40So thank you so much and I know
- 01:12:42that I made you work a little
- 01:12:44bit too hard and that's what
- 01:12:47it makes you extraordinary.
- 01:12:49Piats, because we ask you to go
- 01:12:52extra and what you had to do Sunday.
- 01:12:55Do you have to say?
- 01:12:59Comma. Of course.
- 01:13:08Hard working.