• Diet Quality and Disease Activity in Rheumatoid Arthritis

      Insel, Kathleen I.; Crane, Tracy E.; McGarrity-Yoder, Maureen Elizabeth; Pace, Thaddeus W.W. (The University of Arizona., 2020)
      Background: Rheumatoid arthritis (RA) is a common autoimmune disease that affects the health-related quality of life (HRQOL) of over 1.3 million Americans. RA significantly affects HRQOL through joint deformity, disability, and an increased risk for significant sequela, often regardless of pharmacological therapy. Diet has been considered a factor in exacerbation of RA for decades, and diet quality has been associated with RA risk, associated disability, and disease progression. Unfortunately, research is limited, and findings are unclear. Dietary recommendations continue to be excluded from clinical practice guidelines in RA treatment, and communication is often lacking between providers and patients. Up to 25% of those diagnosed with RA believe their dietary intake affects disease activity and many people change their diet in an attempt to improve their HRQOL. Purpose: The purpose of this study is to examine the association between diet quality and disease activity in adults with RA. Methods: This cross-sectional, descriptive study examined the association between diet quality and disease activity of 50 adults diagnosed with RA. Participants completed the Arizona Food Frequency Questionnaire to measure dietary intake, which was scored with the Healthy Eating Index (HEI)-2015 to determine diet quality. Disease activity was measured via the self-reported Health Assessment Questionnaire-Disability Index and Pain Scale(HAQ-DI and pain scale), hematology analyses for erythrocyte sedimentation rate (ESR) and high-sensitivity C-reactive protein (hs-CRP), and a Disease Activity Score Including 28 Joints (DAS28). The DAS28 was calculated by examining 28 joints, participant self-report, and, in this study, ESR results. Perceived stress was measured with the Perceived Stress Scale. Results: Higher diet quality was not associated with any measures of disease activity (HAQ-DI, pain, DAS28, ESR, or CRP). The mean diet quality score was 56 (SD ± 12), which is lower than the national mean of 59. Higher quality diets were more common in older individuals (p=.015) and women (p=.003). In total, 44% (n=22) participants reported they believe diet affects RA disease activity, and those who believe their diet affects RA were significantly more likely to report dietary changes (p<.0001). Participants with higher educational level (some college or more) were more likely to report the belief that diet affects disease activity (B=-1.535, p=.023). Women with lower diet quality were more likely to have higher HAQ-DI scores (B=.570, p=.001). An increased BMI was associated with decreased DAS28 scores in those with a poor-quality diet (p = .018), but with lower diet quality in those with fair-good diet quality (p =.023). A decreased BMI was significantly correlated with current tobacco use in adults with fair/good quality diet (p= .013). Perceived stress was significantly associated with HAQ-DI and pain scores (B= .445, p=.001 and B= .289, p=.042, respectively). Conclusion: Many individuals with RA should improve their diet as poor diet quality was associated with increased pain and may be related to inflammation. Keywords: Rheumatoid Arthritis, Diet Quality, Disease Activity, Biopsychosocial, Psychoneuroimmunology.
    • Geographic and Racial Disparities in Mortality of Dialysis Patients

      Calhoun, Elizabeth A.; Mohan, Prashanthinie; Roy-Chaudhury, Prabir; Barraza, Leila Fs; Gilliland, Stephen (The University of Arizona., 2020)
      BACKGROUND: The incidence rate and hospitalization rate for patients with End Stage Renal Disease (ESRD) vary across different counties in the U.S. Little information is available on how geography can impact patient mortality through county health status and gaps in supply and demand for hemodialysis services. METHODS: This is a retrospective cohort study where adult patients who initiated in-center hemodialysis between 2007 and 2016 and recorded in the United States Renal Data System (USRDS) were assessed for survival time and mortality rate. The primary exposure variable in Aim 1 was the overall county health status (Most Healthy vs Least Healthy) based on the health factor ranks published by County Health Rankings & Roadmap (CHR&R). The primary exposure variable for Aim 2 was the supply-demand gap for hemodialysis services as measured by the patient-station ratio for each county. The primary exposure variable for Aim 3 was the change in the number of dialysis stations between 2011 and 2016 for each county. Kaplan-Meier estimate used to compute the median survival time and Cox regression analysis was used to compute the hazard rate (HR) for mortality after adjusting for various confounders. RESULTS: Most Healthy counties in the U.S. are likely to be larger urban counties with predominantly white and older patients. On the contrary, Least Healthy counties are comparatively more rural and smaller counties with a higher percentage of African American population, more unemployed and Medicaid patients. Patients residing in Most Healthy counties (HR = 0.899, 95% CI 0.825,0.979) had a lower hazard rate (HR) for mortality compared to patients living in Least Healthy Counties (p value = 0.0143). In Aim 2, counties in Category 1 (counties with no hemodialysis stations), Category 2.1 (underutilized HD stations with population <50,000) and Category 2.2 (underutilized HD stations with population 50,000) had higher HR compared to the reference Category 3. However, when stratified by age and race, the HR was statistically significant for Blacks only for Category 2.2 for all age groups (HR = 1.11, 95% CI 1.06,1.16) and for Whites for Category 1 (aged 40 – 79; HR=1.1) and Category 2.2 (aged 65 – 79; HR=1.11). In Aim 3, counties with No Change had a marginally higher hazard rate (HR=1.04, 95% CI 1.02, 1.07) compared to counties with an increase in dialysis stations. Race was a significant confounder but not an effect modifier to this association (p-value 0.2942). CONCLUSION: County health status and lack of hemodialysis facilities affects survival of ESRD patients. Additionally, patients residing in some suburban counties or smaller metros had a higher hazard rate for mortality despite excess supply of dialysis stations. It is important for care providers and local health officials to understand the health factor profile and spatial distribution of dialysis stations in their county to help ESRD patients navigate barriers to care, reduce rates of dialysis withdrawal, and improve mortality outcomes.
    • The CCAP: A New Physical Unclonable Function (PUF) for Protecting Internet of Things (IoT) and Other FPGA-Based Embedded Systems

      Hariri, Salim; Josiah, Jeff G.; Akoglu, Ali; Bruyere, Donald; Li, Ming (The University of Arizona., 2020)
      The importance of cybersecurity has grown exponentially over the years due to our highly interconnected world and the evolution of computer threats. These threats – once as simple as annoying computer viruses – are now destructive malware, ransomware, and advanced persistent threats (APT) sponsored by nation states used to steal military secrets, wage industrial espionage, and weaponize the Cyberspace into the 5th domain of future military conflict right behind Land, Sea, Air, and Space. Every device that interfaces with the Internet is a potential target. For instance, the attack surface for Internet of Things (IoT) is expected to expand with an estimated 14.2 billion connected “things” projected to be in use this year alone. These “things” are diverse and include rugged-industrial sensors, personal wearables, in-home appliances, and even some of the vehicles on the road today. Many IoT devices are beginning to utilize Field Programmable Gate Arrays (FPGAs) for their processing subsystem due to design flexibility and because FPGAs, as a design element, enable product lifecycle support through aftermarket upgradability of both the computer software (CSCI) and firmware/hardware (FWCI) configuration items. This allows manufacturers to enhance product functionality through over-the-Internet (OTI) or over-the-air (OTA) upgrades. Unfortunately, the increasing use of FPGAs has also brought a major concern of intellectual property (IP) theft and product counterfeiting. To help thwart IP theft, FPGA vendors such as Xilinx and Intel PSG (formerly Altera) provide end-users with the ability to encrypt design bitstreams at rest with a cryptographic key. This encryption key is typically stored in EEPROM, Battery-Backed RAM, or within dedicated Anti-Fuses within the device; however, numerous non-invasive, semi-invasive, and invasive attacks exist that can retrieve the encryption key and compromise the design bitstream. Physical (sometimes referred to as physically) unclonable functions (PUFs) have been proposed as a countermeasure to eliminate the need for cryptographic key storage. PUFs have been widely researched for nearly two decades. An efficient implementation for FPGAs has remained elusive and is an area of much needed research focus. The goal of this research was to deliver a new, innovative PUF design targeted specifically for FPGA implementation. We propose the CCAP which is an efficient, scalable hardware security primitive supporting today’s most advanced FPGAs. It requires no hard macros or interactive design floorplanning and is portable to any UltraScale+-based FPGA. Experimental results on several Avnet Ultra96 boards have shown excellent PUF performance in terms of PUF inter-device uniqueness, acceptable performance for PUF intra-device uniqueness, and good overall PUF output stability at the targeted operating temperatures. Additionally, the randomness of several CCAP “raw” signatures at various FPGA die locations have been tested and deemed random according to the NIST Randomness Test Suite, and chi-square “Goodness of Fit” test calculations. In the un-redacted portions of this dissertation, we discuss the motivation for this work, cover several of the prior PUF architectures in open literature and their shortcomings for FPGA implementation, examine our testing methodologies, provide some test results and analyses, propose a few real-world applications for the CCAP primitive, before ending with conclusion and possible future work. NOTE: The CCAP architecture and details pertaining to it are not publicly disclosed at this time.
    • Receptivity of Hypersonic Boundary Layers to Kinetic Fluctuations

      Tumin, Anatoli; Edwards, Luke; Brio, Moysey; Lega, Joceline; Glasner, Karl (The University of Arizona., 2020)
      The receptivity of high-speed compressible boundary layers to kinetic fluctuations (KF) is considered within the framework of fluctuating hydrodynamics. The formulation is based on the idea that KF-induced dissipative fluxes can lead to the generation of unstable modes in the boundary layer. Using linear stability theory (LST) and a variety of asymptotic methods, the KF-receptivity problem is solved for a range of high-speed flat plate boundary layer configurations. Approaches for solving the KF-receptivity problem in cases where the dominant modes exhibit long scale near-neutral behavior or when two modes of the discrete spectrum coalesce are developed and explored in detail.
    • An Educational Intervention for Physical Therapists to Promote Dietary Counseling in Patients with Osteoarthritis

      Mackey, Patricia A.; Lam, Lisa S.; Prettyman, Allen; Williams, Deborah K. (The University of Arizona., 2020)
      Objective: To assess the feasibility of an educational intervention on influencing physical therapist (PT) practice behaviors to include nutrition counseling or dietician referrals for the management of patients with osteoarthritis (OA). Background: Over 30 million Americans suffer from OA, which is an insidious disease, representing one of the leading causes of physical disability. Symptoms are due to the deterioration of articular cartilage and alterations of extracellular matrix. Obesity and poor nutrition are the greatest modifiable risk factors. Obesity induces the production of pro-inflammatory cytokines, which are associated with pathological processes of OA. Special attention has been given to the Mediterranean Diet (MD) for its anti-inflammatory properties. Nutritional counseling and dietary modification can supplement PT treatments in the management of OA. PTs are in an ideal position to encourage health promoting behaviors and self-management by addressing nutritional concerns in OA patients. Methods: A one-group pre-test post-test quantitative design was employed to evaluate improvements in PTs’ knowledge and attitudes. Provider education involved a brief educational intervention utilizing “It’s Your MOVE” brochure. A convenience sample of six participants were recruited at CORE Physical Therapy in Orange County, CA. Results: Six participants completed the pre-test and post-test questionnaires. Descriptive statistics demonstrated a significant improvement in post-intervention knowledge. A 76.7% change was observed. Effectiveness of the intervention on provider knowledge was likely due to the educational seminar. Limitations in PT practice was the main barrier for lack of nutrition counseling. Likelihood for practice change demonstrated variable results ranging from unlikely to absolutely. Conclusion: There is a need to improve PT involvement in health promotion efforts for OA patients. Reducing barriers in PT practice will allow providers to integrate nutrition counseling and improve interprofessional collaborations with dietitians in OA care plans. Despite the effectiveness of the education intervention, reservations regarding state practice laws heavily influenced PTs’ practice behaviors.
    • Risk Factors for Pressure Ulcer Development in Non-Critical Aeromedical Evacuation Trauma Patients

      Brewer, Barbara; Mortimer, Darcy Lee; Gephart, Sheila; Carrington, Jane (The University of Arizona., 2020)
      Background: The military in-flight care environment is unique. Non-critical Aeromedical Evacuation (AE) trauma patients are at risk for developing pressure ulcers (PUs) in-flight. This study examines the incidence of in-flight PU development and analyzes factors that may contribute to them. Methods: This study employed a retrospective case-control cohort analysis of electronic data from January 1, 2008 through December 31, 2012 comparing non-critical AE trauma patients who did and did not develop PUs within three days post-flight. The Department of Defense Trauma Registry identified 15 PU patients. Using the Aeromedical Evacuation Registry (AER), PU patients were matched four-to-one with non-PU patients (n=60) that had been flown within plus or minus one year of the event to control for changes in practice over time. Independent variables examined included demographics, diagnoses, care requirements, flight information, and the number of AE crew. Results: The mean age for the PU patients was 26.20 (SD=8.10); non-PU patients 26.98 (SD=8.16), with a range of 15-54 years old. Age was not significantly different (t(73) = .740, p > .05) between the PU and non-PU patients. All of the PU patients were male (n=15, 100%) and 96% (n=57) of the non-PU patients were male. Fisher’s exact test was conducted for a between group comparison, which was not significant (p = 1.00). The PU incidence rate was calculated as .02 (<1%) based on 73,377 patients discharged during the time period. A binomial Firth conditional logistic regression was performed in the face of PUs as a rare event (n=15; incidence rate <1%). The regression showed statistical significance in two of the 12 variables used in the model, namely the use of intravenous (IV) therapy (p = .04) and pulse oximetry (p = .01). Conclusion: As PUs are a Nurse Sensitive Quality Indicator, a PU incidence rate of <1% illustrates the outstanding quality of care that is being conducted in the U.S. Air Force Aeromedical Evacuation System. Identification of the risk factors that lead to PUs can help mitigate future PU development on the quest to zero PUs.
    • Mindfulness Meditation for Opioid Addiction in an Outpatient Psychiatric Setting

      Love, Rene A.; Bouchard, Lindsay A.; Stensrud, Phillip Allen; Newhouse, Beth (The University of Arizona., 2020)
      Opioid dependence and addiction continues to be an evolving problem with limited known effective treatment modalities. There is a need for research into new treatments and strategies to combat this rampant problem. Mindfulness meditation has been observed in many studies to be a beneficial adjunct therapy in addition to usual addiction treatment that has resulted in a reduction of craving, improved self-control, and improved rates of substance abstinence. The purpose of this project was to increase knowledge of mental health prescribers and therapists on the practice and benefits of mindfulness meditation in the setting of opioid addiction treatment in an outpatient behavioral health clinic. An additional aim was to observe a greater utilization of mindfulness meditation in this clinic for opioid abuse treatment. An educational workshop was developed for the purpose of the project and three surveys were created to gather data before, directly after, and two weeks after the intervention. Five psychiatric prescribers and seven behavioral health therapists employed at Marana Health Center were recruited and assessed via survey for baseline perceptions and current knowledge on the benefits and utility of mindfulness meditation. The participants attended the educational workshop and were surveyed again to measure the impact of the intervention on their knowledge and perceptions on mindfulness meditation. A two-week follow-up survey was delivered and completed by nine out of the 12 participants to assess the impact of the intervention. The results from the surveys one and two were analyzed and showed a significant increase of baseline knowledge and perception on mindfulness meditation for the entire group (p = 0.0006; p = 0.041). The final survey revealed that since the educational workshop there was no significant increase to the number of clients undergoing opioid addiction treatment that were recommended mindfulness meditation as an adjunct treatment. However, mindfulness recommendations to clients in general were observed across the participant group (mean: 1-5 clients). Overall, the participants were receptive to learning about mindfulness meditation and showed increased knowledge after attending an educational workshop, subsequently agreeing that they saw its potential as an effective adjunctive treatment for opioid addiction.
    • Responses to Discharge Call Center Questions among Heart Failure Patients with 30-Day Hospital Readmission

      Wung, Shu-Fen; Thangaraju, Nalini; Rothers, Janet L.; Rosenfeld, Anne G. (The University of Arizona., 2020)
      Heart failure (HF) is one of the leading causes of hospitalization (Horwitz & Krumholz, 2018). Thirty-day hospital readmission is a problem that increases financial burden through denied reimbursements to hospitals and healthcare organizations. Society of Hospital Medicine (SHM) (SHM, 2015) recommends tracking performance measures such as documentation of left ventricular ejection fraction, patients’ compliance with discharge medications, post-discharge follow-up appointment within seven days, activity level, diet, weight monitoring, and patients’ knowledge about what to do if symptoms worsen. Discharge call center personnel at the project facility make follow-up phone calls to the HF patients on days 3, 7, 14, and 28 after hospital discharge. The purpose of this quality improvement Doctor of Nursing Practice (DNP) project was to describe the responses of HF patients to the discharge call center questions about medication compliance, following-up with the physicians, monitoring of daily weight, normal salt intake, symptoms and activities and to propose suggestions for reducing 30-day hospital readmission. Retrospective chart review was executed and data collected from 52 patients’ charts. The most important findings of this project are: (1) majority of the readmitted HF patients were men; (2) The Center for Outcomes Research and Evaluation (CORE) readmission risk was calculated in 70% of the patients; (3) nearly half of the CORE readmission risk scores were between 20 and 30%; (4) 75% of the patients age 65 or older were readmitted; (5) 96% of HF patients were readmitted for non-HF related causes; (6) Among the participants, the number of patients who were compliant with the discharge education was greater than the number of patients who were non-complaint; and (7) The reason for non-adherence with the discharge teachings were documented only for few patients. Around 35% of HF patients participated in the call center’s survey. This indicated the need to focus on ways to improve patient participation in future discharge phone calls and more effective methods to improve adherence with discharge instructions.
    • Increasing Nurses’ Knowledge of an Evidence-Based Practice Pain Management Plan in the Intensive Care Unit

      Trinidad, David; Badger, Terry; King, Samantha; Williams, Deborah (The University of Arizona., 2020)
      Purpose: The purpose of this DNP project was to increase nurses’ knowledge of the “Assess and manage pain” component in working with adult critical care patients at Mercy Gilbert Medical Center. Evidence-based care practice content was included in the educational portion, with the ultimate goal of increasing compliance with the ABCDEF bundle at Mercy Gilbert Medical Center. Background: Approximately 77% of adult ICU patients have experienced pain during an intensive care unit (ICU) stay (Barr et al., 2013). Current clinical guidelines recommend using a pain, agitation, delirium (PAD) bundle to decrease delirium in the ICU by assessing pain first and screening for pain frequently (Barr et al., 2013; Devlin et al., 2018). The ABCDE bundle significantly decreases delirium (Devlin et al., 2018). Mercy Gilbert Medical Center serves a large population of adult ICU patients; therefore, the possibility of pain-related delirium among these patients is strong. Methods: This project used a pre-test/post-test quantitative design. Participants 1) completed a pre-test survey to evaluate knowledge and beliefs surrounding pain assessment and delirium; 2) viewed an educational presentation about pain assessment, delirium, and screening guidelines; and 3) completed a post-survey to evaluate any changes in knowledge and intention to screen for pain. Results were shared with ICU unit managers to help refine the education process for future testing cycles and other hospital sites. Results: A total final sample size of 11 ICU nurses completed the entire survey for a response rate of 14%. The highest proportion of respondents were ICU nurse females at 63.6%. The typical age range was 36-50 and years of practice were >10 years. The education level was 54% had Bachelor’s degrees in Nursing, 27% Associate’s degrees in Nursing and 18% Masters in Nursing. There were significant differences pre- and post-test for knowledge of pain assessment. (The Wilcoxon signed-rank test showed that five of the participants who completed the surveys and educational video demonstrated statistically significant improvement from pre- and post-testing [p < 0.01].) Conclusions: DNP quality improvement projects like this one help develop strategies to increase best practices, leading to improved patient outcomes. Results may be used to develop strategies to increase and align provider practices with the best standards for promoting early identification and treatment of pain-induced delirium.
    • Knowledge Deficits of Caffeine amongst Adolescents in Metropolitan Phoenix

      Prettyman, Allen; Mandile, Amy Michelle; Davis, Mary P.; Williams, Deborah K. (The University of Arizona., 2020)
      Caffeine is a central nervous system stimulant found in natural and artificial products such as cocoa, tea, coffee, as well as energy drinks, energy shots, and additives with variable concentration levels consumed by roughly 73% of adolescents in the United States. Caffeine has several documented side effects such as increased alertness, improved focus, decreased fatigue, improved physical performance, insomnia, headache, anxiety, dehydration, abnormal heart rhythm, restlessness, physiological dependence, and death. Not much is known on what local Arizona adolescents comprehend on caffeine, its anticipated side effects, and caffeine-containing product identification. This DNP project’s primary purpose was to evaluate knowledge adolescents; aged 13-18 years have concerning common caffeine-containing beverage products. A pre-questionnaire (Appendix F), followed by an education session (Appendix G), and post-questionnaire (Appendix H) at a local Phoenix, Arizona healthcare clinic were utilized and evaluated. Results yielded a high percentage of adolescent awareness to purposeful caffeine consumption for the result of heightened alertness. Adolescents also displayed knowledge of common products such as coffee, energy drinks, and soda products to contain caffeine. There was a knowledge gap related to hydration products containing caffeine and misidentification on chocolate-flavored drinks to be without caffeine; however, this percentage decreased post-education information session, displaying that education on products is beneficial to heighten adolescent consumer awareness.
    • A Catalog of Chamber Music Works for Cello in Trio, Quartet, and Quintet Formats from Colombian Composers Who Lived During the Late Nineteenth, Twentieth and Twenty-First Centuries

      Buchholz, Theodore; Mejía, Juan David; Alejo, Philip H.; Kantor, Timothy A. (The University of Arizona., 2020)
      When Nobel Prize-winning author Gabriel García Márquez was asked about magical realism, he replied that surrealism, the main component of magical realism, came from the reality of Latin America. It is in this same manner that the composers in this catalog have expressed their reality - through a chorus of many different sounds and rhythms distinct to Colombia. The purpose of this study is to discover and promote Colombian chamber music from 1880 to the present. This has been accomplished by researching trio, quartets, and quintets in which the cello is included as part of the ensemble. A comprehensive catalog of fifty-three composers and 126 chamber music works found while researching in Colombia are presented. Pertinent information on composers and their works, including instrumentation, publishers, and libraries where the compositions can be found, is included in this project. Finally, this study discusses four works from the catalog that serve as examples of the diversity of styles and wealth of repertoire existing in Colombia. Appendices to this research include a list of instrument abbreviations, as well as a list of publishers and libraries with their respective contact information. As significant research of Colombian chamber music, this catalog intends to introduce and facilitate these compositions, exposing and cultivating Latin American chamber music repertoire.
    • Educating People With Diabetes About Nutritional Guidelines Utilizing The MyPlate Mobile Application

      Gregg, Renee; Condo, Megan Roelle; Pacheco, Christy L.; Brown, Angela C. (The University of Arizona., 2020)
      Purpose: The purpose of this quality improvement project was to improve participants understanding of nutrition utilizing the American Diabetes Association guidelines and MyPlate mobile application at the Scottsdale/ Paradise Valley YMCA. Background: Approximately 30.3 million individuals have been diagnosed with diabetes in the United States This disease requires glucose monitoring, medication adjustments, and dietary management. The American Diabetes Association (ADA) has developed evidence-based guidelines on nutrition for individuals that have been diagnosed with diabetes. As technology advances, health care information has become easier to access on mobile devices. MyPlate is a mobile nutrition application that is recommended by the U.S. Department of Agriculture to educate children and adults about nutrition. Methods: A quality improvement project, including an educational intervention and a 5-point Likert-style pre-post questionnaire, was conducted at the Scottsdale/Paradise Valley YMCA to educate participants with diabetes about the ADA guidelines on nutrition and the MyPlate mobile tracker application. A power point, handouts, and dinner were used to educate the participants. Responses to the questionnaires were organized into four categories focusing on participants’ health literacy, nutrition, the ADA guidelines, and the MyPlate application. Results: There were six participants in this quality improvement project. The surveys utilized the 5-point Likert rating scale: improvement was determined by comparing the mean of the pre- and post-surveys. The two areas that demonstrated the greatest improvement were the individuals’ understanding of the ADA guidelines and MyPlate. Moderate improvement was seen in the participants understanding of nutrition and health literacy. Conclusion: The results of survey comparisons showed the participants’ understanding of health literacy, nutrition, ADA guidelines, and MyPlate all improved after the education session. All of the individuals that participated in this program concluded this education session improved their overall understanding of nutrition and the American Diabetes Association guidelines.
    • Improving Transition of Care for Stroke Survivors with Hospital and Post-Acute Education

      Ritter, Leslie; Bajaj, Nina Raeleen Herrera; Morrison, Helena; Gregg, Renee (The University of Arizona., 2020)
      Background: Transitioning from the hospital to home is linked with emotional, social, and health-related problems (Reeves et al., 2017). These transitions are ultimately and importantly linked to the safety of post-acute stroke survivors A basic strategy in improving challenges related to transitional care is providing better stroke education to patients and caregivers (Sanders et al., 2014; Reeves et al., 2017). Purpose: The purpose of this project is to evaluate stroke knowledge retention among Transient Ischemic Attack (TIA), stroke survivors or caregivers when they return home (14-30 days after discharge). Specifically, this project analyzed selected demographics (age, gender, type of stroke, discharge location) and assessed 1) stroke knowledge (stroke type and risk factors) and 2) the impact of the stroke education book (did they remember receiving the book and if so did they refer to it and was it helpful) that was provided to the patient and caregivers by the Comprehensive Stroke Center. Design and Methods: A quality improvement project which performed a secondary analysis of data that has been previously collected by a Comprehensive Stroke Center Transition of Care program +/- 30 days post hospital discharge. Data that has been collected included patient demographics, stroke knowledge and usefulness of a newly developed stroke education book. Results: Reponses of patients and caregivers (N=105) were included. The sample included mostly ischemic stroke and TIA patients. Less than half of the participants said they received stroke education or the newly developed stroke education book even though, according to the stroke coordinator, there is nearly 100% compliance in providing stroke education book documented in patients’ charts. Further, more than half of the participants who said they received a stroke education book did not refer to the book for any reason. Some of the participants who read the book reported not understanding it. Conclusion: There is lack of knowledge regarding stroke diagnosis and risk factors despite having educational material provided to patients/caregivers. A stroke education book is likely necessary but is not sufficient. There is a need for developing active, individualized in-hospital education as well as a need for early discharge follow up to reinforce education in order to ensure safe transitions when patients return home after experiencing stroke.
    • A Retrospective Analysis of the Brain Injury Guidelines Applied to a Level One Trauma Center

      Ritter, Leslie S.; Whetten, Erica Leigh; Morrison, Helena W.; Baning, Karla M. (The University of Arizona., 2020)
      Background: Traumatic brain injuries (TBI) result in millions of emergency room visits annually. The brain injury guidelines (BIG) were created to provide healthcare organizations a reference for the management of TBI patients. According to the BIG, neurosurgical consults (NSC) are placed for every patient who is taking aspirin and has a TBI. For the purpose of this study, TBI is defined as having an intracranial hemorrhage (ICH) on a head computed tomography (CT). Objective: The purpose of this quality improvement project was to specifically analyze neurosurgical intervention (NSI) in those TBI patients who took aspirin (ASA) pre-injury versus NSI in those not taking ASA (or any other antiplatelet or anticoagulant). Design: This quality improvement project used a retrospective cohort analysis design. This study examined the acute management of prior TBI patients to help inform recommendations to update the BIG. Setting: Banner Desert Medical Center (BDMC), Mesa, AZ between April 25, 2017 and April 25, 2019. Participants: Inclusion criteria for this study are patients who: (a) were treated at BDMC between April 25, 2017 and April 25, 2019, (b) are 18 years of age or older, (c) have a diagnosis of diffuse or focal TBI (ICD 10 codes: S06.2 and S06.2), and (d) have an ICH identified on the initial CT scan. Results: There were 16 patients (8%) classified as BIG 3 who would have been classified as a BIG 1 if they were not taking aspirin. A total of 29 patients (14%) were classified as BIG 1, 45 (22%) were classified as BIG 2, and 117 (56.5%) were classified as BIG 3. Patients classified as BIG 1 and BIG 1 and aspirin did not undergo any NSI. Conclusion: The incidence of NSI for TBI in BIG 1 and BIG 1 and taking aspirin patients did not differ. Neither group underwent any NSI. With none of the patients in either category requiring NSI, it is recommended that further retrospective and prospective studies be performed to validate altering the BIG to the modified brain injury guidelines. Patients who are taking aspirin and meet all of the other criteria of BIG 1 are classified as BIG 1 rather than BIG 3 in the modified version.
    • Russian Musical Elements: An Analysis of Selected Piano Works by Mily Balakirev (1837-1910)

      Gibson, Tannis; Beriyeva, Yelizaveta; Woods, Rex; Rosenblatt, Jay (The University of Arizona., 2020)
      Mily Balakirev (1837-1910) was a Russian composer, piano virtuoso, teacher, conductor, and a key proponent of the nationalist spirit that distinguished much of mid-19th century Russian classical music. Balakirev is considered, among historical Russian composers, to have been the one who ushered in a new era for Russian classical music. This document examines Piano Sonata No. 2 (1905), and Mazurkas Nos. 6 (1902) and 7 (1906) within the context of Russian musical elements such as folk song elements, plagal and alternative cadences, mediant key relationships and the Russian sixth harmonic progression. The purpose of this study is twofold: first, to identify, define, and locate the appearances of these elements or devices within the selected solo piano works; second, to advance the argument that these devices represent and evoke an aesthetic that one can identify as distinctly Russian in nature. After a brief overview and statement of purpose in the introductory chapter, a discussion of Balakirev’s life, biographical information and compositional output with attention paid to his close relationship with the members of the Moguchaya Kuchka composers concludes Chapter II. Chapter III offers an historical overview of Russian musical elements, which are presented, analyzed and illustrated through annotated examples from Balakirev’s piano works selected for this document. The final chapter confirms Balakirev’s successful and influential use of Russian musical elements and provides a deeper understanding of Balakirev’s innovative style of integrating those elements into classical music of the 19th-century.
    • Using Secure Messaging to Improve Patient-to-Provider Communication Among Active Duty Service Members

      Carrington, Jane M.; Burleson, Stephanie; Edmund, Sara; Stanley, Angela (The University of Arizona., 2020)
      Problem Statement: Secure messaging has the ability to improve patient-to-provider communication and patient self-management skills; however, low usage rates among Active Duty Service Members decreases its potential to initiate self-care management behavior and increase access to timely healthcare. Little is known about the barriers of secure messaging use in this population. Purpose: Identify barriers to secure messaging adoption and use among Active Duty Service Members. Methods: In this system assessment project, ten individual interviews with Active Duty Service Members and three interviews with providers will be conducted in a primary care clinic in Sigonella, Italy to assess behavior, attitudes and perception of secure messaging. Significance: Barriers reported by Active Duty Service Members were difficulty accessing website and lack of patient knowledge of secure messaging features. It is unclear if Active Duty Service Members receive formal education on how to navigate secure messaging prior to their use at the primary clinic. Therefore, employing educational and skill-based interventions to address these barriers, prior to use at the primary care clinic, should improve secure messaging utilization among Active Duty Service Members and, ultimately, increase patient-to-provider communication.
    • Feasibility of Using the Target: HF Telephone Follow-Up Tool in a Private Practice-Based Heart Failure Transitional Care Program

      Taylor-Piliae, Ruth E.; Moor, Lydia Marie; Buchner, Brian R.; Daly, Patricia (The University of Arizona., 2020)
      Background: To reduce heart failure (HF) costs, the Centers for Medicare and Medicaid Services (CMMS) Hospital Readmissions Reduction Program (HRRP) cut reimbursements by 3% to the hospitals with high readmission rates. The American Heart Association (AHA)’s transitional care model program called Target: HF includes a structured telephone support (STS) tool, the AHA Target: HF telephone follow-up tool. It identifies barriers and breakdowns in HF self-management and encourages mechanisms to support HF patients. Methods: This retrospective quality improvement Doctorate of Nursing Practice (DNP) project evaluated the feasibility of using the Target: HF telephone follow-up tool in a private cardiology practice, Old Pueblo Cardiology in Tucson, Arizona. Eligible patients were transitioning home following recent HF hospitalization. Project aims were to 1) describe patient willingness to participate in STS with rates of consent, contact, and tool completion, 2) calculate the telephone call time, and 3) assess self-management needs. Naylor’s Transitional Care Model and the Five-Stage Model of Naturalistic Decision Making were theoretical frameworks guiding this DNP project. Results: A total of five patients participated. They averaged 84 (SD 8.245) years old, were 4.6 (SD 3.647) months post discharge, and five (100%) had normal left ventricular ejection fractions (LVEF). Patient engagement was 100% (n = 5) for consent, contact, and follow-up tool completion rates. The average call duration was 26.8 (SD 9.418) minutes. The greatest self-management needs were: none (0%) had a weight diary, one (20%) was not on fluid restrictions, weighed themselves on day 1 after discharge and knew their dry weight, three (60%) weighed themselves daily, engaged in exercise/daily physical activity, drank alcohol regularly, and knew symptom triggers to call to cardiologist. Medications were not always indicated.
    • Enhancing Interdisciplinary Communication and Collaboration in the Management of Adult ECMO Patients: A Quality Improvement Project

      Carlisle, Heather; Trinidad, David; Key, Amanda; Flamm, Kristie (The University of Arizona., 2020)
      Background: Extracorporeal membrane oxygenation (ECMO) provides temporary life support to patients with severe cardiogenic shock or refractory respiratory failure. Over the last decade, ECMO patient volume has only continued to rise especially following findings of the landmark CESAR trial wherein ECMO appeared superior to conventional ventilator support for adults with severe respiratory failure. Due to the rising volume of ECMO cases as well as the complex interaction of patient and circuit-related factors, care of the adult ECMO patient requires a skilled multidisciplinary team approach—effective communication and collaboration at the core of high-quality care. Objective: The purpose of this DNP project was to improve interprofessional communication and collaboration in the care of adult ECMO patients through implementation the ECMO Daily Goals Tool. Perceived changes in knowledge of the ECMO plan of care was assessed as a secondary outcome. Design: This quality improvement project utilized a pre- and post-implementation survey design. Setting: The 30-bed intensive care unit (ICU) at Mayo Clinic Hospital, a 268-bed academic tertiary care hospital in Phoenix, Arizona. Participants: Participants included core ECMO team members including cardiothoracic surgeons, intensivists, critical care advanced practice providers, cardiothoracic surgery advanced providers, perfusionists, and registered nurse (RN) ECMO specialists (RNES). A total of 62 ECMO team members were eligible to participate in the pre-implementation survey. Due to the unpredictability and variable volume of ECMO patients at any given time, individual ECMO staff who receive the post-implementation survey were automatically selected based on their direct involvement in an ECMO patient’s care. A total of 42 ECMO team members were eligible to participate in the post-survey. Measurements: Pre- and post-implementation surveys included one multiple choice question that sought to determine the distribution of participants’ roles within the ECMO team and fourteen Likert items categorized to assess the current state and any perceived improvements in communication, collaboration, and knowledge of the plan of care. The last question was unique to the post-survey and was an opportunity for participants to make comments and suggestions for improvement. Descriptive statistics (i.e., mean & standard deviation) were used to compare and analyze each Likert item. Results: Overall, this quality improvement project achieved its objectives and ultimately found that the implementation of the ECMO Daily Goals Tool led to an improvement in collaboration and the development and communication of ECMO-related goals, a more consistent and comprehensive approach to goal planning, a structured and individualized approach to goal creation, an improved knowledge of the plan of care. Conclusion: Due to the complexities inherent to care of the ECMO patient, there is an increased risk and impact of medical errors that can result from team communication and collaboration deficiencies that lead to failures in team decision making. Effective communication and collaboration between healthcare providers, therefore, is essential to delivering high quality collaborative care. Based results of this project, use of the ECMO Daily Goals Tool can improve communication, collaboration, and knowledge of the plan of care.
    • A Needs Assessment of Bedside Nurses for Ventilator-Associated Pneumonia Prophylaxis Education

      Ritter, Leslie; Populo, Anthony; Trinidad, David; Morrison, Helena (The University of Arizona., 2020)
      Background and Purpose: Since the 1950’s when researchers first acknowledged gram-negative bacillus pneumonia as the key pathogenic component to hospital-acquired infections there have been many studies suggesting how ventilator-associated pneumonia (VAP) continues to cause increase morbidity and mortality in mechanically ventilated patients. Initiatives to mitigate this pathology have been implemented and have ranged from increasing nursing knowledge and implementation of chlorhexidine gluconate oral care to selective oropharynx decontamination prophylactic strategies. The purpose of this study was to 1) Assess the need for continual and in-depth nursing education about VAP pathophysiology and prophylactic strategies; and 2) Assess individual perception/attitude towards the prophylactic tasks. Methods: ICU nurses at St. Luke’s Phoenix Hospital were asked to volunteer in a pre-test survey followed by an education module and post-test. The survey included four knowledge-based questions and five perception/attitude assessment questions. The education module was focused on pathophysiology of VAP and proper application process of prophylactic strategies. Results: 13 nurses completed the pre/post-test and education module. Summary data of the pre-test and post-test score percentages (± SD) assessing VAP knowledge were 78.9% ± 0.27 and 98.1% ± 0.07, respectively, implying that the education module significantly improved VAP knowledge (p < 0.05, paired t-test, n = 13). On the other hand, change in perception/attitude towards VAP prophylactic tasks was not statistically significant (p > 0.05). However, 69.23% of the participants expressed interest in alternative techniques. Significance: Data supported an increase in nursing knowledge of VAP, suggesting a need for further education (p < 0.05). Findings suggest that the education intervention increased knowledge but did not alter perceptions/attitudes.
    • iMicrobe: Tools and Data-Driven Discovery Platform for the Microbiome Sciences

      Hurwitz, Bonnie; Youens-Clark, Charles Kenneth; U'Ren, Jana; Hartman, John (The University of Arizona., 2019)
      Background: Scientists have amassed a wealth of microbiome datasets making it possible to study microbes in biotic and abiotic systems on a population- or planetary-scale; however, this potential hasn’t been fully realized given that the tools, data sets, and computation are available in diverse repositories and locations. To address this challenge, we developed iMicrobe.us, a community-driven microbiome data marketplace and tool exchange for users to integrate their own data and tools with those from the broader community. Findings: The iMicrobe platform brings together analysis tools and microbiome data sets by leveraging National Science Foundation-supported cyberinfrastructure and computing resources from CyVerse, Agave, and XSEDE. The primary purpose of iMicrobe is to provide users with a freely available, web-based platform to (1) maintain and share project data, metadata, and analysis products, (2) search for related public datasets, and (3) use and publish bioinformatics tools that run on highly-scalable computing resources. Analysis tools are implemented in containers that encapsulate complex software dependencies and run on freely available XSEDE resources via the Agave API which can retrieve datasets from the CyVerse Data Store or any web-accessible location (e.g., FTP, HTTP). Conclusions: iMicrobe promotes data integration, sharing, and community-driven tool development by making open source data and tools accessible to the research community in a web-based platform.