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PREDICTING SUICIDE: UTILITY OF SOCIAL DETERMINANTS OF HEALTH AND ACCESS DATA
Get PDFBy the numbers, 45,979 people died by suicide in 2020, making suicide the twelfth leading cause of death overall in the United States and the second-leading cause of death for ages 10-34.1 Suicide remains a particularly difficult condition upon which to intervene. In this respect, it perhaps resembles another high-mortality disease, cancer. A commonly held belief about cancer is that it is a single disease, while the reality is that it is a hundred – or hundreds – of different diseases each with its distinct etiology and clinical course.4 While suicides bear a superficial resemblance in their result, they are the result of a hundred, or hundreds, different pathways. While several risk factors of death by suicide, such as a diagnosis of depression or firearm ownership, stand above the rest, it is largely a murky picture.
Suicide Prediction Models (SPM) are one way to understand and trace those pathways. These statistical models use data about the facts of a person’s life to estimate their risk of suicidal behavior. SPMs are a particularly useful tool as they can consider a broad range of potential risk factors and boil that down to a single measure of risk. A common use case for these would be to identify patients at risk for death by suicide and prompt some kind of intervention. Models like this could also be used to guide interventions to reduce the population-level risk of suicide.
Through this thesis, I attempt to illustrate the role of Social Determinants of Health (SDoH) and Access to Care play in improving the performance of SPMs. The first manuscript within the thesis explores the extant literature on this subject. The second manuscript describes the development of a SPM to test the value of SDoH data. The third manuscript details an ecological model to determine the impact of SDoH and Access data on predictive ability by SPMs
Oral History of Margaret "Peggy" P. Battin
No full textThis interview with Margaret “Peggy” P. Battin, PhD, MFA, was conducted by Suzanne Snider on July 7 and July 8, 2022 in Salt Lake City, Utah, as part of Moral Histories: Voices and Stories from the Founding Figures of Bioethics, an oral history project of the Johns Hopkins Berman Institute of Bioethics. Prof. Battin is Distinguished Professor of Philosophy and Adjunct Professor of Internal Medicine, Program in Medical Ethics and Humanities, at the University of Utah. Prof. Battin’s areas of expertise include medical aid in dying, suicide, end-of-life decision making, and contraception.On Day 1 of the interview, Prof. Battin discusses her childhood in Washington, DC, including her year in India with her family for her father’s job and her Quaker upbringing. Prof. Battin tells the story of her mother dying of cancer when Prof. Battin was 21 years old, naming that as a profound introduction to death and dying. This loss inspires Prof. Battin’s later research on end-of-life issues, the history of suicide spanning back to pre-Socratic thinkers, and physician aid in dying. She describes her choice to go to Bryn Mawr College for undergraduate education and studying philosophy there. She shares about research she conducted in the Netherlands, where medical aid in dying is legal.Prof. Battin posits that bioethics has begun to assume the role that religion used to have in dictating moral thinking and offers appreciation for how bioethics clarifies difficult questions. Prof. Battin describes her interest in using “thought experiments” as a device for thinking through a problem and speaks about a current book project that will be a compilation of different thought experiments. She also shares a description of one of her manuscripts in progress about reproductive rights and contraception, and reflects on its relevance after the US Supreme Court’s 2022 abortion decision in Dobbs v. Jackson Women’s Health Organization. Prof. Battin’s coined-phrase “least worst death” is used often during the interview; she insists that it’s not about having a “good” death, but about having as much choice as possible.On Day 2 of the interview, Prof. Battin narrates her path to University of California, Irvine as a student studying for both a philosophy PhD and an MFA in fiction writing, and the experience of this combined course of study. Prof. Battin explains how the German language has four words for different types of self-death while the English language has only one term for suicide. Prof. Battin tells the story of her husband Brooke’s cycling accident and his experience of quadriplegia, which necessitated 24/7 at-home care. Prof. Battin reflects on the difficulty and necessity of reconciling her end-of-life considerations as a philosopher with her academic understandings of consent and autonomy through the real life experience of supporting a person she loves. She describes the years that Brooke spent after the accident as a “joint project.”Prof. Battin also speaks about the concept of “diagnostic odysseys,” as originally described by bioethics scholar Ruth Macklin. She notes a core part of her teaching approach: guiding her students to think first and read the literature second, so their thought process is not shaped by the literature. Prof. Battin also speaks to how poorly our society handles Alzheimer’s disease, a long-term condition that often has a very difficult end, and shares a thought experiment about an Alzheimer’s diagnosis.This interview may be of interest to those seeking to learn more about: the field of bioethics and the early history of bioethics in the US; end-of-life care and physician aid in dying, and conversations around the legality of these issues; comparative practices related to aid in dying in the US and internationally; the history and ethics of suicide; personal experience with long-term caregiving, death, and dying; personal medical experiences of bioethicists; philosophy; Utah authors; experiences of alumni from Sidwell Friends School and Bryn Mawr College; language/linguistic practices; and regional histories of bioethics (Southwest)
PROJECTING LEADERSHIP: THE INTERPLAY OF PERSONALITY AND POLICY IN U.S. PRESIDENTIAL CAMPAIGNS
Get PDFThis study delves into the intricate nexus between personality traits in politics and their influence on electoral outcomes, specifically within the context of U.S. presidential elections from 2000 to 2020. The research utilizes a three-pronged approach: a content analysis of presidential debates to discern strategic trait-mentions, an examination of American National Election Study (ANES) data to capture voter evaluations of candidates based on specific traits, and an exploration of candidates' foreign policy emphasis, reflecting their projection of leadership. Key findings suggest Republicans consistently emphasize traits more than Democrats in debates, and there is noticeable variability in trait preference across partisan lines, particularly among Independents. A shift from domestic to foreign policy considerations was also observed over the years, indicating an electorate more cognizant of international influences on domestic policy. This change allows candidates to demonstrate their leadership skills through their stance on international matters. The culmination of these insights presents a comprehensive view, underscoring the dynamic interplay of candidate personality portrayals, voter preferences, and policy considerations in shaping electoral dynamics. The research emphasizes the imperative for political transparency and robust representation, aiming to demystify leadership roles and promote informed electoral choices for the greater societal benefit
The Black Polemical Essay: Toward a New Literary History of Early Afro-Diasporic Writing
No full textThe slave narrative has been historically privileged as the beginning of an Afro-Diasporic literary tradition. My dissertation offers a crucial corrective to this literary-historical emphasis on the autobiographical genre by highlighting what I call the Black polemical essay, a rich tradition inaugurated by Quobna Ottobah Cugoano’s 1787 Thoughts and Sentiments on the Evil of Slavery. Pointedly refusing autobiographical narration for philosophical argument, Cugoano’s text is a critical response to the racist assumptions built into the literary form of so-called “freethinking”: the modern philosophical essay pioneered by Michel de Montaigne, Francis Bacon, John Locke, David Hume, and others. Enlightenment philosophers, like Hume, seized upon the essay for the intellectual and expressive freedom it afforded—which often led to espousals of anti-Black racism. What Cugoano cultivates through his pointed adaptation of the essay form is what I punningly call “free Black thought,” a critical vantage that exposes how antiblack racism itself circumscribed the mind of European Enlightenment thinkers. The Black polemical essay became a self-conscious literary tradition when Maria Stewart, at the outset of the immediate abolition movement in the US in the 1830s, extended “free Black thought” to highlight the gendered limitations of not only of the Enlightenment philosophical essay tradition but the male-dominated Black polemical essay tradition. And in the wake of emancipation and the termination of Reconstruction, W.E.B Du Bois renewed Cugoano’s theoretical premise in his 1903 The Souls of Black Folk by choosing the essay form as an explicit comment on the epistemic limitations of ascendant social-scientific discourses on “the Negro problem.
AN ECONOMIC EVALUATION, ALONGSIDE A RANDOMIZED CONTROLLED TRIAL, TO ASSESS THE EFFECTIVENESS OF A CASE-FINDING STRATEGY FOR TUBERCULOSIS IN SOWETO, SOUTH AFRICA
Get PDFProblem statement: Novel methods of improving the identification of patients with undiagnosed TB are required. A possible approach, assessed in the ACTTIS trial in South Africa, is to identify and link to treatment household contacts of paediatric patients with confirmed TB. However, the cost-effectiveness of this approach, the costs of scaling it up, and its impact on TB transmission overall, are not known.
Methods: We used a cost-effectiveness model to compare the costs and effectiveness values of the intervention (ACTTIS arm) and the control (SOC+), using measured costs in ZAR and DALY values as a measure of effectiveness. The incremental cost-effectiveness ratio (ICER) values and various sensitivity analyses were computed. We calculated the total cost of scaling the intervention (and SOC+ control) to all paediatric index patients in South Africa and their household contacts, as well as costs averted through reduced hospitalization. We used a Susceptible Exposed Infected Recovered (SEIR) model to simulate the impact of introducing the intervention in a hypothetical South African population.
Results: The overall ICER of the ACTTIS intervention relative to the SOC+ arm was computed as -ZAR 4,954 per additional DALY averted (95% CI: -5,148; -4,760). This is highly cost-effective. One-way and probabilistic sensitivity analyses showed robustness to various input parameters. The total budget impact of scaling up ACTTIS or SOC+ to all undiagnosed paediatric patients and their immediate household contacts was estimated to be ZAR 1.219 billion for ACTTIS and ZAR 644 million for SOC+, accounting for hospitalization costs. Our simulation model showed that over a 10-year period, implementation of ACTTIS in a hypothetical cohort of 100,000 South African patients resulted in a reduction of total infections by 45% (from 6,807 to 3,611) and averted 929 deaths (95% CI: 889, 973), with an ICER of ZAR 5,760.62 per death averted (95% CI: 5,500.96;6,021.11). The net benefits of the intervention approximate ZAR 1.3 billion per 100,000 population (ZAR 1.2-1.37 billion) at a return of investment of ZAR1.96 per ZAR 1 invested in the ACTTIS program (1.86-2.08).
Conclusions: The case-finding strategy deployed in the ACTTIS trial is highly cost-effective, potentially reducing the transmission of TB
Under the Knife: Non-Medical Childhood Genital Surgeries as a Form of Sexual Assault
Get PDFNon-medical childhood genital surgeries, including cosmetic intersex surgeries, circumcisions, and female genital mutilations (FGM), have sparked ethical debates and human rights concerns for decades. This paper expands upon the existing discourse by arguing that these surgeries should be considered a form of sexual assault.
First, sexual assault and acts of a sexual nature are defined, both of which are traditionally understood to include an objective and subjective component. Subsequently, each surgery is discussed within this framework, explaining how both components are fulfilled.
The objective component is fulfilled by highlighting the violation of sexual freedom, the removal of genital tissue without consent, and the lasting damage inflicted upon healthy genitalia. As the surgeries fulfill the objective component, the child’s right to an open future is violated, along with their bodily integrity and the capacity to make autonomous decisions regarding their genital autonomy.
Next, the paper explains the subjective component, which is traditionally linked to sexual intent. Because discerning intent can be complex for a variety of factors, the paper advocates for a revision of the way we understand the subjective component. A broader interpretation, influenced by social/cultural norms and historical context, allows these surgeries to sufficiently fulfill the subjective component. History, motives, and expectations underlying these surgeries include the preservation of potential heterosexual relations, the systematic oppression of women, and conformity to heteronormative gender norms. Mentioning the potential emotional and psychological impact felt by victims of these surgeries further supports the expanded understanding of subjectivity. While overt sexual intent may not always be present, the surgeries are linked to sexualized societal expectations and heteronormative ideals.
The discussion of latent sexual implications and objective links to the violation of sexual freedom urges all to consider non-medical childhood genital surgeries as a form of sexual assault, an egregious wrong that should be tolerated by no culture or society. Considering these procedures to be sexual assault makes it apparent that society and medicine should shift priorities towards protecting bodily autonomy over heteronormative ideals
The Pollution Experts: Engineers, Biologists, and the Problem of Water Quality in Rivers of the United States, 1935 to 1972
No full textIn the 1930s, the New Deal created an opportunity for engineers in the United States to address river pollution as a national problem. Leaders in sanitary engineering, such as Abel Wolman, united the profession around the problem of river pollution, demonstrated their expertise by organizing a massive survey of the Ohio River Valley prior to the Second World War, and shaped postwar policy, such as the Water Pollution Control Act of 1948. The act began a period of supportive federalism that influenced expert decision-making and collaboration until Congress passed the Water Pollution Control Act Amendments, or Clean Water Act, of 1972. Under the patronage of the Public Health Service, a multidisciplinary field of applied science emerged that was shaped by the authority of engineers. This dissertation explores how engineers defined the problem of river pollution and affected the roles played by other experts, notably biologists.
While sanitary engineers were committed to advancing drinking water safety and waste treatment processes, their influence spanned well beyond the municipal and industrial treatment plants. I argue that engineers set expectations for the appropriate cost, time, division of technical labor, and research toolkit for managing river pollution across watersheds. They appropriated systems management techniques, prioritized quantitative definitions of water quality, and promoted physical and chemical over biological data. Together, engineers and biologists opened new possibilities for managing pollution by defining water quality criteria to protect aquatic life, developing instruments to continuously monitor rivers for pollution, and designing mathematical models to simplify policy decisions. Some biologists, notably the ecologist and diatom taxonomist Ruth Patrick, pushed the field to recognize biological data as central to measures of river pollution. This dissertation therefore suggests that our current definition of “water quality” stems from engineers’ and biologists’ tense yet productive debates over how to define, measure, and model river pollution. Their need to collaborate forced them to communicate, negotiate, and overcome conflicts and misunderstandings. Together, engineers and biologists shaped legal definitions of water pollution, as enshrined in the Clean Water Act and its goal to “restore and maintain the chemical, physical, and biological integrity of the Nation’s waters.
Some Topics in Neural Network-based System Identification
No full textNeural network-based system identification is a modeling technique that uses a neural network to learn the relationship between the input states and output states of a system. The neural network is trained on a set of input-output pairs, and once trained, it can be used to predict the system response to new inputs. Neural network-based system identification is particularly useful for modeling complex systems with nonlinear dynamics and unknown or time-varying behavior. It is commonly used in control engineering, signal processing, and robotics to model and control complex systems
Using microRNA-target chimeras to study post-transcriptional gene regulation in the mammalian brain
No full textThis thesis work involves the development of a biochemical protocol (CIMERA-seq) and bioinformatic pipeline (SCRAP) for studying the interaction of microRNAs (miRNAs) with their targets in vivo. The need for this work arose from the inability of bioinformatic prediction algorithms to accurately describe the complete miRNA-target profile due to biological complexity that causes the view of simple complementarity between the miRNA seed sequence and target binding site to be inadequate. The biochemical method described here incorporates ligation of the miRNA to its target within the RNA-induced silencing complex (RISC), including significant optimizations over similar previously-published methods, and thus eliminates the need for prediction algorithms to describe these interactions. The need for the other main component of this work, a bioinformatic pipeline for processing small chimeric RNA-seq data, arose from the lack of well-annotated, user-friendly tools for processing these data. The bioinformatic pipeline presented here is easy-to-use, cross-platform, and includes extensive annotation to allow users with minimal computational experience to use the pipeline in their research. Finally, insights gained using CIMERA-seq and SCRAP in adult mouse forebrain about the interaction of let-7 family miRNAs and mitochondrially-encoded transcripts is described