• Alveolar Lung Recruitment Maneuver Utilization among Transplant Clinicians in Arizona

      Piotrowski, Kathleen; Bergstrom, Benjamin Scott; Herring, Christopher; Pace, Thaddeus (The University of Arizona., 2019)
      The reservation of lung transplant procedures as a final treatment measure for patients with acquired end-stage pulmonary disease is partly due to the lack of supply, which mostly comes from brain dead donors. Separate from the other life-saving transplantable organs that have progressively increased in transplant rates over the last decade, the national ratio of lung transplantation has remained stagnant (Bergstrom, 2018). Transplant clinicians medically manage authorized brain dead organ donors in Arizona (AZ) according to their clinical judgment that is supplemented by the Organ Procurement Organizations (OPO) Clinical Practice Guidelines (CPG). The goal is to maximize the gift of donation by increasing the number of organs transplanted per donor (OTPD). The United Network for Organ Sharing (UNOS) sets the benchmark for the Expected (E) OTPD, and in AZ the Observed (O) OTPD ratio (i.e., O: E) has been below that benchmark. Meeting the organ-specific diagnostic endpoints of the Donor Management Goals (DMG) demonstrate organ system recovery and suitability for transplant. Alveolar recruitment maneuvers were at the forefront of the pulmonary management regimes of potential lung donors, and there were three in the CPGs at Donor Network of Arizona (DNAZ), the federally designated OPO of AZ. Each of the three methods have been tested at DNAZ in the past years and each has shown some ability to improve lung transplant rates but, clear superiority of one method has not been definitively established. Despite the prior utilization of these measures, according to an analysis of CPGs utilized and DMGs met, the use of the techniques has waned in the last year. Underutilization of alveolar recruitment maneuvers was the suspected reasoning behind the O: E gap. This project used theoretical foundations that aimed to improve utilization of the DNAZ CPGs by; (1) exploring the reasoning behind why they are avoided, (2) creating and presenting a learning lesson based on that assessment (3) evaluating the learning lesson and (4) closing the O: E gap by improving transplant metrics.
    • Locating and Supporting the Developing Pedagogical Language Knowledge of College Writing Instructors

      Tardy, Christine M.; Miller-Cochran, Susan; Pawlowski, Madelyn Tucker; Staples, Shelley; Lancaster, Zak (The University of Arizona., 2019)
      The role of language in the study and teaching of writing has long been a subject of controversy and debate for scholars and teachers. Despite a history of language “erasure” in composition studies (Connors, 2000; MacDonald, 2007), however, composition scholars now find themselves traversing a “new linguistic frontier” (Matsuda, 2013). Scholars are, for example, (re)considering the role of language-related “standards” in writing assessment practices, designing innovative approaches to help students develop their linguistic repertoires, and demonstrating heightened awareness of the presence and needs of multilingual writers. Missing from these conversations, however, is a consideration of what writing instructors are expected to know about language, possibilities for transforming this knowledge, and how they are supposed to develop this knowledge. Scholars in related disciplines such as general education, language education, and second language writing have explored the complexity of teacher cognition and its impact on teaching effectiveness, but teacher knowledge development has been largely unexplored in the context of mainstream college writing instruction. This dissertation uses qualitative and quantitative methods to explore the developing language-related knowledge, beliefs, and teaching practices of novice college writing instructors at a large research institution in the U.S. Using insights from these instructors as well as published scholarship, I develop a model of “pedagogical language knowledge” that elucidates the multitude of ways writing instructors transform various sources of knowledge to navigate a broad range of language-related issues in the college writing classroom. This model helps draw attention to the complexity of teachers’ knowledge and could also be used to help designers of writing teacher education find ways to better support teachers’ developing language-related knowledge. This dissertation follows the interdisciplinary work of Aull (2015), Lancaster (2016), Hyland (2007), Matsuda (2013) and others invested in ensuring that teachers of writing are also confident teachers of language; it envisions a new generation of linguistically aware teachers ready to support students “who are now coming to us from all corners of the world” in navigating a broad range of language-related situations (MacDonald, 2007, p. 619).
    • Defining Ancient Maya Communities: The Social, Spatial, and Ritual Organization of Outlying Temple Groups at Ceibal, Guatemala

      Triadan, Daniela; Inomata, Takeshi; Burham, Melissa; Fogelin, Lars (The University of Arizona., 2019)
      What was the spatial and social organization of ancient Maya cities, and how were diverse populations socially and politically integrated? This dissertation explores these questions by investigating the formation of local communities around minor temples in outlying areas of Ceibal, Guatemala. Many researchers have suggested that minor temples were important integrative hubs in lowland Maya settlements. I further propose that they were the physical and ideological centers of different local communities, akin to neighborhoods, throughout Ceibal. I define a local community as a supra-household social group comprised of members who share common histories and ties to particular places. Communities may be constituted through co-residence, similar modes of living, and common beliefs and practices, which foster shared identities and differentiate one group from others. At the same time, many communities can arise within—and in turn reinforce—a greater vision of cohesion across a larger society. To assess the relationships between minor temples and the socio-spatial formation of local communities, I investigate: 1) whether different segments of the population settled around each temple, creating discrete residential zones around the city; 2) whether there was a communal source of water within each zone, which would have been an important location for daily interactions and a crucial source of potable water; and 3) if there were variations in material culture across different residential zones, which could relate to social differences. A diachronic evaluation of multiple lines of evidence enables me to explore how these groups formed and changed through time. Data for this study was collected through systematic excavations of five minor temples, nearby residents, and potential aguadas (manmade reservoirs) associated with temples across Ceibal. The results of my analysis suggest that different groups of people constructed their own temple as they moved into outlying areas of the site throughout the Late and Terminal Preclassic periods (ca. 350 BC-AD 175). I found evidence that people routinely gathered at the temples for ceremonies, which may have helped foster group identities. The geospatial analyses of settlement data I performed in ArcGIS and my comparisons of pottery assemblages from different temple groups strongly suggest that local communities formed as discrete socio-spatial units around specific temples. Analysis of pollen in soils collected from the aguadas revealed that these features held water seasonally, and that maize was cultivated nearby. Together, my research suggests that local communities were established through ritual practices carried out at the temples, co-residence, management of communal sources of water, and potentially collective participation in agricultural production. Community patterns may have changed in later times, however, after many of the temples were ritually terminated around sometime between AD 175 and AD 300. In summary, local communities at Ceibal were somewhat autonomous: they controlled their own local resources, carried out their own building programs, and performed many of their own religious ceremonies. Nevertheless, the social relations undertaken at this intermediate level of society were integral to shaping, maintaining and changing the larger sociopolitical order through time.
    • The Making of a Sacred Place: The Rise of Mt. Jiuhua in the Late Imperial and Republican Eras (1368–1949)

      Wu, Jiang; Ouyang, Nan; Welter, Albert; Miura, Takashi; Tong, Daoqin (The University of Arizona., 2019)
      This dissertation focuses on the historical transformation of Mt. Jiuhua from a local mountain to a national pilgrimage destination and the ways in which Mt. Jiuhua became the seat of Dizang Bodhisattva (Skt. Kṣitigarbha), a savior of the underworld beings in Chinese Buddhism, in the late imperial and Republican eras (1368–1949). This study explains the making of the sacred mountain by analyzing four salient features of local Buddhism. First, it deals with the cult of mummified bodies by looking into local mortuary practices. Jiuhua Buddhists, choosing not to follow the monastic rules concerning cremation, opted to create a successful tradition of mummy-making for the deceased Buddhists. The continuing emergence of new mummies shaped the perceived sacred atmosphere of Mt. Jiuhua. Second, by analyzing relevant precious scrolls (baojuan) and local dramas, it reveals how vernacular literature functioned as a medium for the localization of Dizang. The performance based on such literature that was carried out at Buddhist events was the key to the further dissemination of the image of Mt. Jiuhua as a sacred mountain. Third, it argues that the sacredness of the mountain was constructed and negotiated through pilgrimage practices, evidenced by diverse material objects used in pilgrimage. Fourth, it explores the accrued layers of local history, represented by three predominant discourses pertaining to Mt. Jiuhua (i.e., Jin Dizang’s ascetic practice, Li Bai’s visits, and Wang Yangming’s sojourn), which promoted the fame of Mt. Jiuhua in concert. In summary, in explicating the uniqueness of Jiuhua Buddhism, this dissertation adopts an interdisciplinary approach that bridges religion and geography and contributes to the study of sacred space in Chinese religion. By challenging the artificial dichotomy between “institutional” and “popular” religion and using understudied local materials, it provides an alternative evaluation of the vitality of Ming-Qing Buddhism by focusing on religious practices.
    • Direct Numerical Simulations of Hypersonic Boundary-Layer Transition for a Flared Cone

      Fasel, Hermann F.; Hader, Christoph; Kerschen, Edward J.; Craig, Stuart A. (The University of Arizona., 2019)
      Direct Numerical Simulations (DNS) were carried out to investigate the laminar-turbulent transition for a flared cone at Mach 6 and zero angle of attack. The flared cone geometry of the experiments in the Boeing/AFOSR Mach 6 Quiet Tunnel (BAM6QT) at Purdue University was chosen for the simulations. This study explored the linear and secondary instability regimes as well as the nonlinear breakdown to turbulence using a controlled disturbance input (“controlled” breakdown) and “natural” transition models. Low amplitude, axisymmetric, short-duration pulse calculations were performed in order to map out the linear stability regime for the flow conditions of the BAM6QT facility. A parametric study of the secondary instability regime was carried out in order to identify the azimuthal wavenumber that led to the strongest fundamental and subharmonic resonance. For the BAM6QT conditions, the fundamental resonance was found to be much stronger compared to the subharmonic resonance and was therefore considered to be the relevant breakdown scenario. For the case which led to the strongest fundamental resonance onset, detailed investigations were carried out using high-resolution DNS. The simulation results exhibit streamwise streaks of very high skin friction and of high heat transfer at the cone surface. Streamwise “hot” streaks on the flared cone surface were also observed in the experiments carried out at the BAM6QT facility using temperature sensitive paint (TSP). Two different “natural” transition models were employed to assess the differences between “controlled” and “natural” breakdown. Both “natural” transition models resulted in a streak pattern similar to that obtained with the “controlled” break- down DNS and in the experiments. A detailed flow analysis revealed that the streamwise streaks are generated by steady longitudinal modes that are nonlinearly generated by the primary and secondary disturbance waves. The presented findings provide strong evidence that the fundamental breakdown is the most likely nonlinear transition mechanism in the BAM6QT flared cone experiments.
    • Essays in Experimental Methodology

      Romero, Julian; Candreva, Christopher James Waldron; Noussair, Charles; Dufwenberg, Martin (The University of Arizona., 2019)
      This thesis focuses on questions about experimental methodology, examining novel treatments and subjects’ understanding of experimental environments. The first chapter examines differences between the traditional discounted model of repeated Prisoner’s Dilemmas used in the theory, and the random termination model used in the laboratory. Under relatively general assumptions, the threshold δ ∗ -value, above which cooperation can be supported as a subgame perfect equilibrium, varies based on subject’s specific utility function under random termination, but not under discounting. To test this, a new experimental design was created that captures features of the infinite horizon discounting model absent in random termination Using a between-subject, subjects played six repeated Prisoner’s Dilemmas at δ = 0.98, and either the new treatment or random termination. Cooperation rates were higher in the random termination treatment. Maximum likelihood estimation was used to determine what repeated games strategies subjects used during this experiment. Subjects in the discounted treatment tended to use more defective, yet forgiving strategies, while subjects in the random termination treatment used more cooperative yet less forgiving strategies. This finding suggests that more work needs to be done to understand the differences between random termination and discounting The second chapter further examines the differences between these two treatments. One specific channel that could created a difference in behavior between random termination and discounting is subject’s risk attitude. Using the theory model from chapter one, the threshold δ ∗ -value, above which cooperation can be supported as a subgame perfect equilibrium, varies based on subject’s risk attitude in random termination, but is independent of subject’s risk attitude under discounting. Using a within-subject design, subjects played 32 unique supergames. Each supergame featured either this new treatment or random termination, one of eight distinct δ-values, and one of two different game matrices. This experiment was used to determine if risk attitude caused subjects’ decision making to differ between the two settings. First period cooperation rates did not differ between the two treatments, even though differences were predicted by the risk attitudes elicited. Subjects’ behavior did vary in more complex ways, though risk attitude did not explain these differences. The final chapter examines the influence of pre-experiment tasks on subject understanding. This experiment used a 2x2 design varying the type of instructions and whether or not the pre-experiment quiz was incentivized. One set of instructions was based on instructions used in prior studies. The other was written using techniques from the Multi-Media Learning literature, which aims to find ways to maximize subject understanding from instruction. After the pre-experiment procedures, subjects participated in ten modified BDM selling markets with induced values. High ability subjects in this experiment showed higher understanding of the BDM mechanism after receiving Multi- Media Learning instructions compared to Standard instructions. This was true in both the first market, and across all markets. Incentivizing the quiz had a negligible impact on subject understanding.
    • Second-Person Thought

      Horgan, Terence; Nichols, Shaun; Chambliss, Bryan Christopher; Weinberg, Jonathan (The University of Arizona., 2019)
      Imagine that as you are sitting down to eat a sandwich, you hear someone issue a command: “Stop that this instant!” Perplexed, you look up to see a stranger glaring at you, and come to believe that they told you to stop eating. But in the midst of your ongoing interaction with this person, your thought about the stranger doesn’t seem to represent them as either a mere object or agent. Instead, it seems natural to think of them in a second-person way, as a “you” or an agent with whom I am interacting. I argue that during face-to-face interactions with other agents, some of our thoughts represent these agents in an irreducibly second-person way. My dissertation defends an account of these irreducibly second-person thoughts. Chapter 2 introduces second-person thought. I argue that irreducibly second-person thought employs an irreducibly second-person mode of presentation, and that this mode of presentation should itself be understood in terms of its function: recognizing its object as an agent with whom I am engaged in interaction. This recognition-based account is superior to competing accounts that model the second-person mode of presentation in terms of paradigmatic interactions, like communicative interactions (e.g., linguistic exchanges which employ the second-person pronoun ‘you’), or cooperative interactions. Chapters 3 and 4 defend a basic argument for the irreducibility of second-person thought. Among others, John Perry and David Lewis argue that irreducibly first-person thought—variously called essentially indexical thought or de se thought—plays an essential role in the explanation of action and yields a distinctive form of self-knowledge. While prominent defenses of the irreducibility of such thought extend only to self-directed thought, chapter 3 develops an analogous argument for thought about other agents, contending that irreducibly second-person thought plays an analogous role in the explanation of interaction and yields a distinctive form of knowledge of others. Thus, the same kinds of reasons that have driven many philosophers to accept irreducibly first-person thought can be expanded to give structurally identical arguments for irreducibly second-person thought. Chapter 4 then defends a basic argument for irreducibly second-person thought. Perry and Lewis have taught us that irreducibly first-person thought exists. But the arguments for irreducibly first and second-person thought stand and fall together, so if irreducibly first-person though exists, then irreducibly second-person thought exists too. Thus, irreducibly second-person thought exists. Having established that irreducibly second-person thought exists, Chapter 5 develops an account of it. Extending the account of Francois Recanati, my account of second-person thought captures the cognitive significance of the second-person mode of presentation as a “mental file” containing distinctively second-person information. The mental files linked to second-person thoughts are populated with information by what Recanati calls “epistemically-rewarding relations” that hold between the thought’s thinker and the thought’s object. Perceptual acquaintance is the paradigmatic epistemically-rewarding relation, but, in irreducibly second-person thought, the distinctively second-person information results from the thinker’s being directly engaged with the agent with whom they are interacting. Finally, the referent of a second-person thought is determined not by satisfying the information in the mental file (which could be inaccurate), but by bearing the epistemically rewarding relation to the thought’s thinker. This dissertation argues that while philosophers have rightly recognized irreducibly first-person thought as a distinctive form of thought, they have incorrectly restricted this irreducibility to the first-person perspective. Instead, analogous considerations show that both first- and second-person thought are irreducible. The result is that thought about other agents is different when interacting with them, as opposed to merely observing them. This capacity to recognize an agent as a partner in interaction is characteristic of a distinctively social form of thought, which lies at the root of interpersonal morality.
    • Developing a System to Investigate Age-Related Differences in the Real-Time Utilization of Dynamically Changing External Cues during Navigation

      Barnes, Carol A.; Lester, Adam Ward; Zinsmaier, Konrad E.; Nadel, Lynn; Cowen, Stephen L.; Redish, A. David (The University of Arizona., 2019)
      Successful navigation depends critically upon two broad categories of sensory information, environmental (allothetic) and self-motion (idiothetic). Both the hippocampus and the medial portion of the entorhinal cortex (MEC) are critical for spatial navigation and contain functionally distinct sub-networks of spatially-modulated cells. These cells are characterized by their tuning to different spatial sensory-perceptual features of the environment and all utilize both allothetic and idiothetic cues to anchor and update their spatial firing to generate a comprehensive and dynamic representation of space. As with older adults, aged rats show pronounced impairments on a number of different spatial navigation tasks and these impairments are accompanied by a bias toward relying on egocentric over allocentric navigation strategies. Similarly, the hippocampus and MEC are also highly susceptible to age-associated changes. The influence visual allothetic cues exert on hippocampal place cell spatial tuning is diminished and delayed in aged animals. Two plausible and non-exclusive explanations that could account for these age-related alterations in allothetic processing are 1) circuit disruptions caused by known age-related functional and anatomical changes in the entorhinal-hippocampal processing pathway or 2) degraded sensory-perceptual information resulting from well-established age-related deficits across multiple sensory domains. Either of these possibilities could have the effect of either slowing allothetic cue processing or weakening the ability of these cues to influence firing field alignment. Within this context, this thesis was conceived with the aim of investigating the degree and timing with which young and aged animals utilize allothetic and idiothetic feedback to update their internal representation of space and calibrate their behavioral output. A large focus of this thesis is given to the incremental design and piloting of a number of novel technologies. Foremost among the methodological contributions of this study is the development of an augmented reality behavioral apparatus, termed the Instantaneous Cue Rotation (ICR) arena, which utilizes projected visual cues to allow for rapid remote control of all symmetry breaking visual features in the environment as rats actively engage in a visual-cue based goal navigation task. The results of extensive behavioral piloting of old and young rats validate both the ICR rotation manipulation as well as the mobile reward delivery system. This system traverses the track in tandem with the rat, enabling food based spatial reinforcement while preventing food-related olfactory cues from becoming associated with any specific location. In parallel with this work, microdrive technology was developed to enable simultaneous recording from both MEC and CA1 which is discussed along with results from single-region hippocampal and MEC implanted rats assessed in the context of a cue rotation manipulation conceptually similar to the that of the ICR. Finally, the results of the behavioral study suggest that in young rats the cue rotation exerts reliable but incomplete control over running behavior. In aged rats, by comparison, the cues exert an overall less pronounced influence on running behavior, consistent with known age-related deficits in allothetic processing. When assessed on a lap-by-lap basis, it was found that the behavior of both young and aged rats became progressively more aligned with the cues over the first few laps following cue rotation. These findings suggest a progressive realignment of behavior from an egocentric to an allocentric reference frame which is reminiscent of the reported progressive realignment of place field firing in response to conflicting spatial feedback.
    • Task-Based Information-Theoretic Design of X-Ray Computed Tomography Systems: Detection and Estimation Tasks

      Ashok, Amit; Masoudi, Ahmad; Vasic, Bane; Tandon, Ravi; Thamvichai, Ratchaneekorn (The University of Arizona., 2019)
      X-ray Computed Tomography (CT) is an established imaging and anomaly detection modality that is employed widely across multiple applications such as medical imaging, security screening and non-destructive testing. In security screening applications, traditional X-ray threat detection systems employ image reconstruction and segmentation as pre-processing steps before making threat/non-threat decision. In this work, we consider image reconstruction and threat detection as separate tasks. For the threat detection task, we consider detection directly on the raw CT sinogram data without any post-measurement data processing steps like image reconstruction and segmentation. We also explore methods that improve the X-ray CT threat detection and image reconstruction performance using non-traditional measurement designs. In the first part of this work, we consider multiplexed measurement design by optimizing a metric on the threat detection error rate (Bhattacharyya Bound), given a fixed photon budget. We also consider an adaptive measurement design for X-ray threat detection, where the next measurement design is based on the information retrieved from previous measurements. We observe that while multiplexed and conventional systems have comparable threat detection performance, the adaptive system outperforms both systems in terms of detection error rate. We also study the effect of material variation on the threat detection performance of X-ray CT systems. Traditionally, X-ray measurements are modeled by Poisson distribution (shot-noise) based on a fixed photon-absorption model. The fixed photon absorption model ignores the inherent material variations due to environmental and manufacturing factors that are encountered in applications. Here we incorporate material variability in the X-ray measurement by employing a Negative Binomial (NB) distribution. Based on this measurement model, we derive an information-theoretic metric (Cauchy-Schwarz Mutual Information) as a measure of threat detection performance. We observe that material variation in high Signal to Noise Ratio (SNR) region becomes a limiting factor for threat detection performance of X-ray systems. However, in low SNR region the measurement is dominated by shot-noise and the effect of material variation on threat detection performance is negligible. In the second part of this work, we consider multiplexed measurement design for the image reconstruction task using the Bayesian Cramer-Rao Lower Bound (BCRLB) on Mean Squared Error (MSE) metric subject to a fixed photon budget. We observed that the multiplexed system with 5 exposures outperforms the conventional system in terms of MSE.
    • Literarische Identitätskonstruktionen und das Verhältnis zu Deutschland in Ausgesuchten Werken Zeitgenössischer Jüdischer Schriftstellerinnen Deutscher Sprache

      Jacobs, Joela; Kovach, Thomas; Heiss, Lydia Helene; Gramling, David; von Ammon, Frieder (The University of Arizona., 2019)
      A declaration of her love for Germany by the Jewish author Lena Gorelik in her semi-autobiographical text Lieber Mischa (Dear Mischa 2011) has led me to ask whether the Holocaust is still the point of reference and central characteristic of the self-conception of the contemporary or third generation of Jewish writers in Germany after 1945. In addition to Gorelik's text, this study analyzes Katja Petrowskaja's Maybe Esther (2014) and Olga Grjasnowa's All Russians Love Birch Trees (2012). The three Jewish women writers immigrated from Eastern Europe, live in Germany, and write in German. I show that their texts belong to the genre of autofiction. The third generation of authors, publishing after 2010, is part of the ‘new’ German Jewry, which is composed mainly of immigrants from the former Soviet Union and their children – a fact that significantly influences contemporary Jewish identity in Germany. I argue that the authors voice their desire for ‘normalization’ in the German-Jewish relationship in these autofictional books: The texts show that, generally speaking, the Holocaust is no longer the central characteristic of Jewish identity in Germany, but rather a request for a peaceful, undisturbed, ‘normal’ life in Germany. My analysis of the literary identities the authors constructed for their protagonists sheds light on current trends in contemporary Jewish life in Germany and demonstrates that they reject the special status assigned to them as ‘victims of the Holocaust’ or as ‘exotic,’ both in the sense that they are seen as representatives of the Jewish minority and as ‘immigrants’ from the former USSR. This ascription of ‘otherness’ nourishes both philo- and anti-Semitic discrimination. Although the novels mark the Holocaust as an event that should never be forgotten, it is not history but rather the experience of ‘otherness’ that keeps Jewish life in Germany from being ‘normal.’ Only if German society viewed Jews living in Germany as unspectacular, i.e. ‘normal,’ would a state of ‘normalcy’ be achieved, which in itself would be a “triumph,” as Gorelik's protagonist puts it, over the attempted extermination of Jews during National Socialism.
    • Assessment of Barriers to Using Depth of Anesthesia Monitoring

      Davis, Mary; Zakula, Sarah Ashley; Piotrowski, Kathleen; Hoch, Kristie (The University of Arizona., 2019)
      Background: Depth of Anesthesia monitoring is an available technology used to determine the depth of a patient’s anesthetic by analyzing the electroencephalogram readings of the anesthetized patient. This technology has been available since the 1990s, yet it is not commonly used during the average anesthetic plan. Objective: To determine what barriers prevent anesthesia providers from choosing to use a depth of anesthesia monitor as a regular part of their practice, to assess the needs of the providers involved, and encourage and increase the use of depth of anesthesia monitoring when appropriate. Design: Using descriptive methodology, providers were administered a pretest, self-paced educational module, and posttest that examined their current practice regarding the use of depth of anesthesia monitoring and their willingness to change. Setting: A 487-bed Level I trauma center in Southern Arizona. Participants: Seven Certified Registered Nurse Anesthetists (CRNAs) Measurements: Responses to pretest and posttest questions, and comparisons between the two surveys based on provider. Results: Most providers have never used a depth of anesthesia monitor at this facility, though they would be willing to try using them. Providers had a strong knowledge of when depth of anesthesia monitoring is recommended, but reported they prefer a different approach to monitoring anesthetic depth. Conclusion: Providers reported that an in-service on the monitors would enhance their ability to use the monitors and give them confidence in interpretation of the monitor’s values.
    • The Development and Validation of a Novel Task to Quantify Functional Language Proficiency in Spanish-English Learning School-Age Children

      Alt, Mary; Arizmendi, Genesis D.; Plante, Elena; Fabiano-Smith, Leah (The University of Arizona., 2019)
      Clinicians, educators, and researchers alike continue to struggle without adequate and functional tools to measure language proficiency in bilingual populations. Language proficiency refers to the ability of an individual to use a language. However, the ways in which proficiency is classified are inconsistent and potentially invalid. Proficiency in young bilingual children is often determined through indirect measures (e.g., parent report) with unknown or inconsistent validity, impacting the field in both clinical and research arenas. The purpose of this study was to develop and validate a novel task that will allow us to quantify a child’s functional language proficiency, while also identifying areas of language strengths and weakness across languages in Spanish-English 1st, 2nd, and 3rd grade children. The task capitalizes on the theory of natural translation (Harris & Sherwood, 1978), which refers to translation done in everyday circumstances by those who have had no special training. We evaluated task components and total task reliability and validity using test theory procedures. This work will set the foundation for quantifying and characterizing language proficiency in typically-developing Spanish-English speaking children.
    • Evaluation of a Daily Activity Program for Early School-Age Children in a Rural Setting

      Peek, Gloanna J.; Lyders, Stacee; Edmund, Sara J.; Bencs, Nicole (The University of Arizona., 2019)
      Background: Obesity is greatly impacting people, adults and children, in the United States (U.S.). Approximately 17% of children ages six to 11 years old in the U.S. are obese. Obesity puts children at increased risks of physiological and psychological conditions in childhood and into adulthood. Montana youth are more overweight or obese than the national average of 17%. Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to determine if a structured activity program (i.e., The Daily Mile program) could be implemented in the first thru third grade classrooms of two Montana schools. Methods: The Daily Mile program was introduced to two schools via PowerPoint presentations. Six classrooms implemented the program for a minimum of eight weeks. Teachers kept a daily log and participated in two surveys: initial and follow-up. School administrators were sent an additional survey. Results: Six teachers and two school administrators at two schools participated in this DNP project. The majority (83.3%) of the teachers agreed with the program evaluation statements during the initial teacher survey. Per the daily logs, teachers reported completing The Daily Mile 49% of the school days during the implementation period. All the teachers expressed an intent to continue to The Daily Mile program in their classrooms. Four teachers participated in the follow-up survey reporting they continued to utilize the program zero to three days per week. Three themes were identified during this project: program support, teachers’ feedback on students’ participation, and barriers. Administrators agreed that schools can participate in the obesity prevention. Additionally, both reported the resources needed for this program were reasonable and a wish to see the program continue in their schools. Discussion: The projects’ results were similar to what has been found in the literature about school-based obesity prevention programs. Stakeholders support these types of programs in schools. However, barriers (i.e., time constraints) exist making it difficult to implement in an educational setting. More research is needed to evaluate The Daily Mile program’s impact on the rate of childhood obesity.
    • Assessing Policy Innovation: Climate Action Planning in the U.S. Southwest

      Garfin, Gregg M.; Keith, Ladd; Austin, Diane E.; Bakkensen, Laura A.; Ferguson, Daniel B.; Livingston, Margaret (The University of Arizona., 2019)
      Cities are on the front lines of climate change, and local climate action planning has the potential to both reduce greenhouse gas emissions through mitigation and reduce vulnerability to climate risk through climate adaptation. A growing body of planning research has explored climate action planning but has primarily focused on dedicated climate action plans and generally relied upon a narrow sample of coastal and larger cities that do not represent the diversity of cities that planners serve within the United States. This dissertation focuses on climate action planning in arid lands with an overarching research question: How are cities in the U.S. Southwest planning for climate change? The original research I present in this dissertation addresses this question through three interrelated papers that assess the state of planning literature on climate action planning research (Appendix A), document the concerns, approaches, and catalyst and barriers planners report facing when addressing climate risk (Appendix B), and evaluate how climate action planning is being mainstreamed into comprehensive plans (Appendix C). This dissertation advances planning scholarship and practice by expanding the understanding of climate action planning in cities in the arid lands of the U.S. Southwest.
    • Advanced Design and Development of Novel Microparticulate/Nanoparticulate Dry Powder Inhalers for Targeted Treatment of Pulmonary Hypertension

      Mansour, Heidi M.; Acosta, Maria Fernanda; Mayersohn, Michael; Cherrington, Nathan; Raghavan, Srini (The University of Arizona., 2019)
      Pulmonary drug delivery is rapidly becoming one of the most important routes for targeting drugs to treat respiratory diseases. Pulmonary hypertension (PH) is a life-threatening disease characterized by an increase in pulmonary artery pressure. PH is complex and multifactorial making a challenge to researchers for the understanding of molecular mechanisms that are involved in the pathogenesis and the developing of novel pharmacological strategies to treat this disease. The objective of this study was to design targeted dry powder inhalers (DPIs) for the treatment of this fatal disease using new active pharmaceutical ingredients (APIs) which trigger novel molecular and cellular mechanisms of the disease. Dry powder inhalable microparticles/nanoparticles of Simvastatin (Sim), L-Carnitine (L-Car), L-Carnitine (HCl), Metformin (Met) and a combination of Sim and L-Car HCl were developed using the advanced spray drying (SD) technique in closed mode. This particle engineering technique offers many advantages such as the ability to tailor particle properties and characteristics for the appropriate deposition of the DPIs into the lungs. Many analytical techniques were utilized in this dissertation to perform the physicochemical characterization of the achieved powders. The Next Generation Impactor (NGI™) and different human FDA approved DPI devices were employed to evaluate the in vitro aerosol dispersion performance of the DPIs. The results were statistically analyzed and correlated with the microscopic and macroscopic properties of the powders. Different in vitro cell models such as 2-D vs. 3-D in liquid covered conditions vs. air-liquid interface conditions were employed to test the drug-response and safety of the powder formulations. Different in vivo models in healthy and diseased animals were used to test our DPIs. After this extensive study, it was concluded that the formulated DPIs showed promising results to treat PH.
    • Educating Mental Health Clinic Providers on the Benefits of Yoga for Older Adults

      Love, Rene A.; Okorie, Kalu; Kahn-John, Michelle; Gallagher, Shawn (The University of Arizona., 2019)
      Background: Depression is a grave mental health condition in the United States, and 3.4% of the older adult population experiences depression (Centers for Disease Control and Prevention, 2011). Older adults with depression may not engage in mental health treatment because of the cost of co-pay, treatment duration, the stigma of having depression and seeking mental health services and intolerance to medication side effects. Traditional care for treatment of depression, including antidepressant medicines, cognitive behavioral therapy, and supportive treatment, continue to be utilized. However, there is also an increase in the use of naturalistic and more holistic treatment options which include exercise therapies such as yoga (Prathilkanti et al., 2017). Evidence suggests that yoga reduces symptoms of depression (Cahoon, 2012). Objective: The purpose of this project was to educate mental health providers in an Arizona clinic on the benefits of yoga for older adults with depression. Setting: A private solo-practitioner psychiatry practice serving adults in the suburban Phoenix, AZ area Findings: Post yoga education questionnaire was completed by the mental health providers in an Arizona clinic to determine the participants knowledge on yoga as a therapeutic treatment option for older adults with depression. Results revealed positive findings that mental health providers in an Arizona clinic agreed to the facts that yoga would be beneficial as a treatment modality for depressive conditions among older adults. Discussion: Participants indicated they were open to recommending yoga as an adjunct therapy to older adults with depression and identified additional education on yoga education would be helpful. The ability of the mental health providers to participate in yoga education session indicates willingness to recommending yoga as a treatment option to older adults with depression. Further study is indicated to identify the efficacy of educating mental health providers on the benefits of yoga for older adults with depression.
    • Adolescent Depression Screening in Primary Care Practice

      Davis, Mary P.; Davis, Meagan Chase; Edmund, Sara J.; Peek, Gloanna J. (The University of Arizona., 2019)
      Purpose: The purpose of this DNP quality improvement project was to increase primary care provider knowledge about indications for adolescent depression screening. Background: Approximately 13.3% of adolescents experienced depression in the past year. In Oklahoma alone, rates are increasing, with depression totaling 60% of all mental health illness among adolescents. Primary care providers see approximately 75% of adolescents; however, mental health conditions are missed 84% of the time. Current clinical guidelines recommend screening for adolescent depression during wellness visits or when risk factors are present. Methods: The providers of interest were nurse practitioners, physicians, and physician assistants providing primary care to children between the ages of 12 and 17 in a private pediatric practice group consisting of three clinics. The Model for Improvement guided the process of developing, implementing, and evaluating an educational intervention through use of a pre-test/post-test quantitative design. An email invited participants to complete an anonymous pre-test survey to evaluate knowledge and beliefs surrounding adolescent depression, then view an educational presentation on adolescent depression and screening guidelines, then complete a post-survey to evaluate any changes in knowledge and intention to screen. Results were shared with clinic representatives to help refine the education for future testing cycles and other clinic sites. Results: Data collection took place over one week. Five providers completed both the pre-test and post-test surveys. Provider knowledge scores significantly increased 29% after participating in the education and self-reported knowledge on screening increased. Conclusions: DNP quality improvement projects like this help develop strategies to increase best practices, leading to improved patient outcomes. Nurse-led improvement programs like this contribute to healthcare literature and the advancement of the nursing profession by developing patient-centered interventions applicable to a wide variety of providers. Results may be used to develop strategies to increase and align provider practices with best standards to help promote early identification and treatment of adolescents with depression.
    • The Evaluation of a Diabetes Self-Management Program Delivered in a Community Health Clinic

      Badger, Terry; Sumler, Tamara Neshae; Brown, Angela; Gordon, Judith (The University of Arizona., 2019)
      Background: The prevalence and incidence of type 2 diabetes are steadily increasing in the United States. Diabetes self-management education (DSME) programs seek to improve delivery of diabetes care and education. The end result of diabetes self-management education is behavior change towards successful self-management of diabetes and improved outcomes. Aims: Aims of project are to assess whether project site’s existing DSME program meets evidence based standards for diabetes self-management education, to explore potential variables that reflect existing diabetes self-management program, and to obtain perceptions about existing program, barriers and facilitators to class attendance, and ideas for program improvement from self-management class participants and class facilitators. Methods: The project was implemented in a large Federally Qualified Health Care (FQHC) clinic using a descriptive study design. A sample of 20 adult diabetic patients who attended at least one diabetes self-management class between months of July, August, and September, 2018 was obtained. Additionally, I attended two diabetes self-management classes to distribute surveys to both self-management class participants and class facilitators. Results: Among the sample of adult diabetic patients, 75% were women. Mean age was 60.7 years old. Mean number of classes attended among sample was 7.35, the mean A1C was 8.7%. The project site’s diabetes self-management education program met six out of 10 of National Standards for Diabetes Self-Management Education and Services (evidenced-based tools for health care providers and health care organizations who provide diabetes education). Eleven class participant surveys were returned and demonstrated that the majority of class participants were satisfied with existing self-management program, including current method of education (face-to-face group education). Barriers for self-management classes were transportation, distance between home and clinic where classes are held, time that classes are held, and conflicting appointments during time classes are held. Facilitators to attending class were vouchers for fresh fruits and vegetables given as incentive for attending classes, being provided with transportation to classes, and social interaction that occurs from attending classes. Class facilitators most enjoyed opportunities class participants had to ask more questions pertaining to diabetes self- management. Limited class offerings in English language and time restraints were identified among class participants as least enjoyed aspect of existing self-management program. Both class participants and facilitators suggested addition of an exercise segment and cooking demonstration to existing diabetes self-management program. Conclusion: Project findings suggest while the sample utilized diabetes self-management education classes conducted at the clinic, they demonstrated poor glycemic control and thus poor self-management of diabetes. Continuous quality improvement measures should be initiated to ensure the existing program is meeting evidence-based standards, while delivering diabetes self-management education and services that are patient centered, effective in meeting and sustaining glycemic control, and improve outcomes subsequently. A significant project limitation was low class attendance among diabetes self-management class participants during time of data collection. Lack of medical provider stakeholder input regarding project site’s existing diabetes self-management program was an additional limitation in this project. These conclusions must be reviewed cautiously in light of identified project limitations.
    • Practice Improvement by Implementing Cerebral Oximetry during Shoulder Surgery in the Beach Chair Position

      Torabi, Sarah; Crosley, Michael William; Hoch, Kristie; Ritter, Leslie (The University of Arizona., 2019)
      The beach chair position (BCP) is a reclined or sitting position at varying angles from 30-90° implemented for orthopedic shoulder arthroscopy and neurosurgical procedures. This position can lead to severe hemodynamic changes in the anesthetized patient due to marked decreases in cerebral blood flow (CBF) which increases the risk of cerebral tissue ischemia (Dippmann, Winge, & Nielsen, 2010). The use of cerebral oximetry during general anesthesia in the BCP allows the anesthesia provider to monitor brain tissue perfusion during all stages of anesthesia. Research indicates cerebral oximetry has the possibility of reducing postoperative complications, hospital length of stay, and allowing patients to quickly resume their activities of daily living (Abraham, 2014). The purpose of this Doctor of Nursing Practice (DNP) project was to identify barriers and evaluate the change in perceived benefit and implementation of cerebral oximetry for shoulder surgery in the BCP at a hospital in the Phoenix area. A pre and post-survey following an educational presentation identified barriers of implementing cerebral oximetry. Results from the post-survey revealed that 55.6% of providers (n=10) were not using cerebral oximetry even after the educational presentation on the benefits of this technology. On the post-survey, 89% of respondents (n=16) reported that they thought cerebral oximetry was potentially beneficial. Barriers to using cerebral oximetry were that cerebral oximetry was not available, 42% (n=18) or the provider did not have enough time to apply the monitor, 26% (n=11). Respondents also reported that surgeon interference, 14% (n=6) was a major barrier that prevented them from using cerebral oximetry. Results from this project show that anesthesia providers believe that cerebral oximetry may be beneficial to their patients but were limited in its implementation by several barriers.
    • Improving the Use of Mobile Medical Alert Devices in the Elderly

      Shea, Kimberly D.; Conway, John L.; Trinidad, David R.; Carrington, Jane M. (The University of Arizona., 2019)
      Background In relation to falls, 30% of elders experience the danger of an inability to return to get back up (Taylor et al., 2016). This critical period is called a “long-lie,” and can result in catastrophic medical complications such as dehydration, internal bleeding, pressure sores, rhabdomyolysis, or death (Taylor et al., 2016; Lipsitz, Tchall, & Klickstein, 2016). Fall detection devices (FDD) send an alert to summon the assistance of a telephone responder; who notifies family and emergency services to prevent fall from becoming a catastrophe (Feldwiser, 2016). Purpose The purpose of this DNP quality improvement (QI) project is to increase the knowledge, attitude, and willingness of residents of an assisted living facility to utilize FDDs. Design Eligible participants were given two surveys, one prior to viewing the informational video, and another after viewing the video. The surveys consisted of eight (six point) Likert scale questions ranging from ‘strongly disagree’ to ‘strongly agree.’ The process allowed a descriptive analysis between the survey answers for comparisons of knowledge, attitude and willingness towards wearing FDDs. Setting The survey was conducted at a 150 unit assisted living apartment style community called Madison Meadows in Phoenix, Arizona (Appendix B). The residents range from wheelchair dependent to fully functional, but all share similar risks for poor outcomes related to an undetected fall. Methods The (QI) project utilizes the power of CAPTology (computes as persuasive technology) to deliver an informational video to change the participants’ perceptions from negative to positive regarding FDD use. This may occur without realization; a behavioral modification has occurred. Limitations The sample size was limited, allowing bias and decreased generalizability. Some participants were able to discuss survey questions prior to participation. This was a onetime look at one facility. The questionnaires may have been to arduous as some participants needed help to complete the forms. Results The greatest common factor surrounding the use of FDD at Madison Meadows is a lack of resident communication. After presenting the informational video, most resident responses reflect positive changes in knowledge attitude and willingness to use the fall detection device. Conclusion The greatest common factor surrounding the use of fall detection devices at Madison Meadows is lack of communication, and most specifically resident education. The suggestions of this quality improvement project are to provide education of FDD use at every opportunity.