• A Narrow Therapeutic Range: Public Health Role of Micronutrient Dietary Supplementation – Chronic Disease Prevention to Consumer Safety Risk

      Barraza, Leila; Degnan, William John, III; Jacobs, Elizabeth T.; Farland, Leslie V.; Klimentidis, Yann (The University of Arizona., 2021)
      BACKGROUND: Micronutrients are essential chemical compounds required in small quantities by humans and other living organisms for tissue growth and development, immune function, disease prevention, and optimal health. Dietary supplements have recognized benefits for certain populations, such as folic acid and iodine for pregnant or lactating women, vitamin D for the elderly and persons who lack adequate sun exposure, and vitamin B12 for vegans. However, there is insufficient scientific evidence to justify their use for reasons other than pregnancy, lactation, or deficiency. There are also safety risks associated with micronutrient supplementation ranging from potential interaction with prescription drugs to toxicity from excessive use. This benefit-risk trade-off is further complicated by the economic value generated by dietary supplement manufacturing and sales in the United States, which exceeded $46 Billion in 2020. OBJECTIVE: This dissertation examines the Janus-like quality of micronutrient dietary supplement use in three study manuscripts listed in the Appendix. They investigated three key research questions. Study 1: In the modified Sel/Cel Clinical Trial (“Modified Sel Trial”) conducted between 2001 and 2013, is the risk of colorectal adenoma recurrence in patients treated with selenium versus placebo meaningfully different when calculated on a per-protocol versus intention-to-treat basis? Study 2: For the Nurses’ Health Study II (NHSII) prospective cohort, was chromium, selenium, or zinc supplement intake associated with risk of incident endometriosis? Study 3: In the Quincy Biosciences v. Federal Trade Commission class action lawsuit settled in 2020, were Quincy Bioscience’s unplanned post hoc subgroup results for Prevagen®, a dietary supplement hereafter referred to as “Prevagen”, statistically significant versus placebo in a randomized clinical trial?
    • A Nearest-Neighbor Nonparametric Multiple Imputation Approach for Incomplete Categorical Data under Missing at Random

      Hsu, Chiu-Hsieh; Zhou, Muhan; Bell, Melanie L.; Guerra, Stefano; Hu, Chengcheng (The University of Arizona., 2019)
      Incomplete categorical data is a common problem in medical research. If researchers simply use complete cases for data analysis, the estimation might be biased and/or inefficient due to ignoring the missing values. Under the assumption of missing at random (MAR), i.e. missing values depend only on the observed data but not on the unobserved data, an increasing number of approaches have been proposed to handle missing data. However, most of the existing missing-data methods for incomplete categorical data are either not robust or sensitive to extreme missingness probabilities. In my dissertation, I study a nearest-neighbor nonparametric multiple imputation approach (NNMI) using two working models to impute values for a missing at random categorical variable, and to estimate marginal mean as well as conditional mean under three different study designs. In the first paper, I adopt the NNMI for dealing with a categorical outcome with missing values and estimating the proportion of each category. Specifically, multinomial logistic regression/cumulative logistic regression is performed to construct a working model for predicting the incomplete categorical outcome. Logistic regression is performed to fit a working model for predicting the missingness probabilities. The predicted values from the two working models are used as scores for calculating distances between each missing value with other non-missing values. A weighting scheme is used to accommodate contributions from two working models when generating predictive scores. A missing value is imputed by randomly selecting one of the non-missing values with the smallest distances (donors) from each of the missing observations. I conduct a simulation study to evaluate the performance of the NNMI method and compare it with several alternative methods. A real-data application is presented using a dataset from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) survey. In the second paper, I use the NNMI method to handle missing covariate in logistic regression. Similarly, two working models are used to predict the incomplete covariate and the missingness probabilities. First, I perform a computation to assess the potential factors related to selecting an optimal size of donors. Second, the performance of the proposed method is compared with several alternative methods. Finally, the NNMI is applied on the 2013 BRFSS survey data to impute an incomplete categorical covariate and estimate the regression coefficients from a logistic regression model. In the third paper, the NNMI is extended to handle missing covariate under a matched case-control study. The estimation is conducted using a conditional logistic regression model. The performance of the NNMI is compared with complete cases and six parametric multiple imputation methods. The objective is to assess whether the NNMI demonstrates a doubly robust property compared with parametric methods. Then the NNMI is applied to impute an incomplete categorical covariate under a nested case-control cohort using the 2013 BRFSS survey data. To summarize the three papers, the proposed NNMI is a reasonable approach to dealing with an incomplete categorical outcome with more than two levels for assessing the distribution of the outcome. In terms of the choices for the working models, we suggest a multinomial logistic regression model to predict the missing outcome and a logistic regression model to predict the missingness probability. For imputing an incomplete covariate and estimating logistic regression coefficients, the NNMI demonstrates a doubly robust property and works stably when missingness probabilities are close to 0 or 1. When missing values occur in the covariates under a matched case-control design, the NNMI can be used on multiple incomplete covariates as long as the misspecification is moderate.
    • 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.
    • A Needs Assessment Regarding a Fire Risk Assessment Checklist In the Operating Room

      Piotrowski, Kathleen A.; Aram, Margie Huna; Torabi, Sarah; Henker, Richard (The University of Arizona., 2018)
      Background: A surgical fire in the operating room (OR) is a devastating hazard that carries the weight of high morbidity and mortality. Through acknowledgment of fire risks among all OR team members, proper education, and training, as well as effective communication, a surgical fire in the OR is a preventable medical error. The addition of a fire risk assessment (FRA) checklist has been proven to increase awareness of potential fire risks and improve the quality and safety of patient care. Purpose: The purpose of this project was to perform a needs assessment regarding surgical team members’ knowledge, awareness, and utilization rate of FRA checklist as a precautionary measure to prevent surgical fires. Moreover, this project attempted to gather data concerning potential barriers towards the implementation and adoption of the FRA checklist to the already established surgical timeout prior to every procedure being performed. Setting: This project took place at a Level 1 trauma hospital in the greater Phoenix, Arizona metro area. The study included (N=16) participants, who were the members of the surgical team at this organization. Method: An online survey was disseminated to participants. The survey consisted of two sections which examine 1) sociodemographic information, and 2) assessment of knowledge, practice, and attitudes related to FRA checklist during the surgical timeout. Results: Majority of the respondents acknowledged that FRA is an appropriate tool and is necessary during the surgical timeout. Only 25% (N=16) of respondents acknowledged reviewing this current practice guideline on FRA checklist. The most important finding from this study is that half of the respondents (N=8) supported on the usefulness of the FRA checklist during the surgical timeout in their current clinical practice setting. Furthermore, 69% (N=11) of the participants agreed this gap exists in their current practice related to FRA checklist during the surgical timeout. Conclusion: By surveying the surgical team members’ knowledge, attitudes, and perceptions, the researcher identified gaps in current practice. These findings were then used to determine the need for the FRA checklist during the surgical timeout at this healthcare organization. This Facility implemented a protocol for the FRA checklist effective February 7, 2018.
    • A New Edition of Anlun Huang's A Requiem in Chinese with an English Translation and International Phonetic Alphabet Transliteration

      Chamberlain, Bruce; Brobeck, John; Luo, Yujia; Schauer, Elizabeth (The University of Arizona., 2020)
      Anlun Huang’s (b. 1949) A Requiem in Chinese is the only large, unaccompanied,mixed-voice choral requiem in Chinese history. It was completed in May 2004 and the premiere was conducted by the composer on September 12, 2004. Despite the fact that a large unaccompanied requiem in traditional Western style with Chinese liturgical text is unique in both Western and Eastern music of the twenty-first century, the work has received little international attention and only a small number of performances. It is my belief that the difficulty of Mandarin pronunciation and the understanding of the Chinese text are the main obstacles to learning and performing this piece for non-Mandarin-speaking choirs. I have provided an English translation of the text and a new edition of the work featuring an International Phonetic Alphabet (IPA) transliteration of the text, making the work more accessible and allowing it to be widely studied and performed.
    • A Nonparametric Multiple Imputation Approach for Survival Data Subject to Informative Censoring

      Hsu, Chiu-Hsieh; O'Connor, Patrick Anthony; Roe, Densie; Hu, Chencheng; Pogreba-Brown, Kristen (The University of Arizona., 2020)
      Most existing survival analysis methods work under the assumption that censoring times are independent of failure times. When censoring is informative of failure times, those methods will produce biased survival estimates. We have developed a nonparametric multiple imputation approach that uses the estimated correlation between failure and censoring times to impute missing failure times for every censored observation. A sensitivity analysis shows the efficacy of the imputation approach by comparing survival estimates of the imputed data sets to estimates from data where all failure times are known. Dependence between the failure and censoring data is then induced using a shared frailty model. Parametric assumptions of failure and censoring times are applied allowing for the dependence parameter to be estimated using the EM algorithm. The dependence parameter is used to create an imputing risk set for each censored observation. A Kaplan-Meier survival curve is then fit to the imputing risk set to impute a failure time from this set for the censored observation. Traditional Kaplan-Meier estimation is performed on the imputed data sets to estimate survival. The method is then extended using a Cox proportional hazards model to include auxiliary variables in the dependence parameter estimation. Simulations along with results using the ACTG-175 clinic trial HIV data set are presented for each approach.
    • A Parametric Exploration of the Paired-Stimulus Suppression Paradigm

      Cone, Barbara K.; Mongelli, Janette Marie; Fabiano-Smith, Leah; Velenovsky, David S.; Musiek, Frank E. (The University of Arizona., 2019)
      The paired-stimulus suppression paradigm has been used to evaluate sensory gating in the auditory nervous system. Previous work in the AHEAD Lab has employed the paired-stimulus paradigm to investigate the perception of noise level or interference during speech perception tasks. In the present study, the effects of stimulus frequency and inter-stimulus interval were investigated as two previous experiments suggested that these could influence the amount of suppression observed. The aims of this study were to evaluate the effects of stimulus frequency and inter-stimulus interval on the latencies and amplitudes of the CAEP components evoked by each stimulus. Eleven normal hearing adults were tested using paired-stimulus paradigms in which both stimuli were 500 Hz or 4000 Hz tone bursts, and the interstimulus intervals were varied in 100 ms steps between 100 and 500 ms. The results indicated that stimulus frequency had an effect on the CAEP onset response latencies and amplitudes, whereas interstimulus interval did not. Conversely, interstimulus interval had an effect on the CAEP response amplitude to the second stimulus (the suppressed response) whereas the effect of stimulus frequency was not significant. The results of these findings will be discussed with respect to the physiological mechanisms proposed to explain these differences and the possible translation of a two-stimulus suppression paradigm into a clinical test of acceptable noise level for those who use hearing aids.
    • A Patient-Focused Educational Intervention on Skin Cancer Prevention

      Prettyman, Allen; DaLessio, Samantha; Godfrey, Timian; Locke, Sarah (The University of Arizona., 2021)
      Purpose: This quality improvement project aims to increase patient knowledge on skin cancer prevention and lesion detection strategies to minimize their risk of this disease. This project took place in a concierge clinic in Surprise, AZ. Background: The significance of prevention efforts on skin cancer is demonstrated in the Surgeon General’s Call to Action, emphasizing the importance of patient education efforts regarding skin cancer preventive behaviors as a high priority to our nation and an imperative intervention in public health. UV protection strategies, dangers of indoor tanning, and lesion detection strategies such as the ABCDE rule and skin self-examinations were focused on in this project. Methods: This quality improvement project took place over three days and involved an in-person educational intervention utilizing pre-survey and post-survey questionnaires. The educational intervention utilized an educational brochure that focused on skin cancer prevention and lesion detection strategies. All patients 18 years or older during implementation were invited to participate in the project. Data collection and descriptive statistics were done utilizing Qualtrics. Results: Participant knowledge before and after the educational intervention was evaluated in a 5-point Likert format. After the educational intervention, 80% of participants rated their level of knowledge on skin cancer prevention as "good" or "excellent," and 100% of participants rated their level of expertise on lesion detection strategies after the educational intervention as "good" or "excellent." Through the satisfaction assessment, 100% of participants were "somewhat satisfied" or "very satisfied" with the educational intervention. In assessing the likelihood of carrying out teachings to their health, 90% of patients felt they were likely to utilize the education. Discussion/Conclusion: Overall, this quality improvement project successfully illustrated an increased level of knowledge of skin cancer prevention and lesion detection strategies among participants of the concierge clinic. Participants also had a high satisfaction rate with the educational intervention and demonstrated high likelihood of utilizing the education presented.
    • A Phonetic Description of the Kawaiisu Language

      Warner, Natasha; Thomas, Patrick Neal; Archangeli, Diana; Zepeda, Ofelia; Fountain, Amy (The University of Arizona., 2018)
      This dissertation represents the first acoustic phonetic description of Kawaiisu, an endangered language of the Uto-Aztecan family spoken in the area near Tehachapi, California. The Kawaiisu language is understudied and underdocumented. Although an impressive grammar (with a lexicon and texts) has been published (Zigmond et al. 1990), discussion of the sound system is relegated to only a few pages. The present dissertation expands on the description of Kawaiisu phonetics and phonology contained in Zigmond et al. (1990), finding support for many of the claims made in their grammar. In addition, I show that the phonetic system of Kawaiisu is characterized by rich variation, examining acoustic evidence to illustrate the different ways that Kawaiisu sounds can be articulated. The analyses presented in this dissertation come from recordings made by Sheldon Klein in the 1950s and 1980s (Klein 1958, 1981-1983). Digital versions of these recordings are hosted online at the California Language Archive, and numerous types of data are represented therein: wordlist elicitation, sentence elicitation, traditional narratives, monologues, and conversations in Kawaiisu are all included in the archival data. In this dissertation, I examine words produced in isolation during elicitation sessions exclusively. These data come from four speakers: one male speaker recorded in the 1950s, and three female speakers recorded in the 1980s. From these data, I examine both the consonant and vowel systems of Kawaiisu. Considering vowels, evidence is presented which supports Zigmond et al.’s (1990) claim of a six-vowel system with phonemic vowel length contrast. I also find that an increase in pitch is the most robust acoustic cue to Kawaiisu stress, and that unstressed vowels often lie more toward the periphery of the vowel space than stressed vowels. Additionally, the pervasive phenomenon of word-final vowel deletion in Kawaiisu is examined, claimed by Zigmond et al. (1990) to target verbs specifically. Although word-final vowel deletion is found to be a common process in Kawaiisu, no evidence is found in the available data linking this process to a specific lexical category, and some suggestions are offered for why Zigmond et al. (1990) may have arrived at this conclusion. Concerning consonants, this dissertation provides support for some of the phonological alternations mentioned by Zigmond et al. (1990), including the palatalization of coronal sibilants preceded by front vowels. I also show that many consonants have differing articulations in apparent free variation: the rhotic phoneme of Kawaiisu is variously realized as a flap or trill, while the consonant commonly labeled as /g/ (especially by Zigmond et al. (1990), and Klein (2002)) may often be produced with fricative or approximant articulations, rather than as a stop. Additionally, I show that the glottal stop (both intervocalically and in some cases pre-consonantally) is associated with the presence of creaky voice. Finally, I discuss voice onset time of voiceless stops, finding that VOT is often greater when the following vowel is phonemically long. This research can be useful to both the community of linguists and to the Kawaiisu community. For linguists, this work presents a phonetic description of a language whose sound system was previously not adequately described. Variation in articulation has been noted where acoustic evidence for such variability was found, and several cross-linguistically rare patterns and structures have been indicated (for example, peripherality of unstressed over stressed vowels, the relationship between phonemic vowel length and VOT of stops, etc.). For community members, the information presented in this document can be used to help create pedagogical materials for purposes of language revitalization. Finally, this research highlights the importance of working with existing archival data. Archival language data is available through a number of sources, and in many cases, it may be all that remains of a once widely spoken language. This dissertation shows that important descriptive and documentary work can still be done, both to the benefit of the academic community, and to indigenous speech communities.
    • A Post-Pancreaticoduodenectomy Clinical Pathway to Improve Interdisciplinary Collaboration

      Wung, Shu-Fen; Kim, Juliet; Baldwin, Caroline; Gephart, Sheila (The University of Arizona., 2018)
      Background: Pancreatic cancer is one of the leading causes of cancer-related deaths in men and women. Due to its resistance to chemotherapy and radiation, pancreaticoduodenectomy, also known as the Whipple surgery, remains as the last resort option. Due to the complexity of the surgery, postoperative care is crucial in providing the patients with necessary interventions without omission. Objective: The objective of this project was to assemble an organization-specific postoperative care clinical pathway for patients undergoing the Whipple surgery and to assess the attending surgeons’ views on the new pathway. Design: This project was a descriptive qualitative study to determine the views of the attending surgeons regarding the clinical pathway and its influence on interdisciplinary collaboration and patient care planning. Setting: This project took place at an academic medical center in Southern Arizona. Participants: The participants were two of the three attending surgeons who perform the Whipple surgery, from two different surgery departments. Measurements: Attending surgeons were interviewed one-on-one. The assembled pathway was presented during the interview, and a set of interview questions were asked to solicit the surgeons’ views. Results: The two attending surgeons agreed with the components of the clinical pathway. They thought the pathway can improve interdisciplinary collaboration and postoperative patient care planning. Each attending voiced willingness for an inter-departmental pathway for their patients undergoing Whipple surgery. They viewed the pathway feasible for future implementation but were concerned about potential organizational barriers for implementation. Conclusion: The interviewed attending surgeons support the idea of a pathway for consistent postoperative care among Whipple patients. Although this study was limited due to a small sample size, the findings are promising for a potential implementation of a clinical pathway for the post-Whipple patient care.
    • A Program Evaluation of the Sertoma Arizona Hearing Aid Bank: Resource Availability and Community Needs

      Marrone, Nicole; Penkoff, Jessie-Anne; DeRuiter, Mark; Hartley, Michael; Muller, Thomas (The University of Arizona., 2019)
      The University of Arizona Hearing Clinic is responsible for receiving all Sertoma Arizona Hearing Aid Bank donations and fitting qualified individuals with one hearing aid at reduced cost. These donations come from a variety of community partners within the greater Tucson area. However, it is not known where the partners receive their donations from, how many donations are brought in per month, or whether the program receives enough donations per month to meet the needs of new applicants. This study aimed to create a clinical process to systematically track hearing aid donations, including donation sources and device characteristics, and determine device resources relative to the number of monthly program applications received. Data collection of all the hearing aid donations and new program applications was conducted between February 1st to March 31st, 2018. During this period, 121 hearing aids were donated and 23 Hearing Aid Bank applications were received, with 12 applicants being referred to the program for services. Only 4% of donated devices were immediately useable for program fittings. An additional 23% of donated devices would be useable if funding were available to recondition them. The other 73% of donated devices could previously have been exchanged for salvage credit through a repair lab. However, the present market for salvageable hearing aid parts is saturated. Therefore, the Hearing Aid Bank cannot rely on salvage credit alone to recondition hearing aids. Additionally, through interviews with the community partners, several program challenges and possible solutions were identified. Recommendations were made for finding new volunteers to help identify and reach out to new donation sources, changing current program practices from unilateral to bilateral fittings, and updating eligibility criteria to serve more individuals. Yet, the data collected here suggests that the current rate of donations and funding would need to be increased to sustain the program.
    • A Proposal for a Computational Model of Phonemic Acquisition

      Wedel, Andrew B.; Parchment, Jaime; Hammond, Michael T.; Ohala, Diane K. (The University of Arizona., 2018)
      In the field of computational linguistics, computational modeling of linguistic behavior has been motivated not only by the creation of practical language-related tools such as machine translation, automatic speech recognition, speaker identification, and natural language search, but also by a desire to deepen our understanding of how language works, either in an abstract mathematical sense or in the more literal sense of describing human behavior at various levels of analysis. These models take various forms, some derived from mathematical models of electronic transmission of information (Shannon, 1948), others from abstract models of neural behavior (McCulloch and Pitts, 1943; Rosenblatt, 1958). In computational neuroscience, computer models are developed to mimic the behavior of brains, with a greater degree of biological realism. These models focus on neural behavior ranging from single neurons to large-scale networks of neurons. Typically, the behavior of interest is the relative activation of groups of neurons, the emergence of synchronized or otherwise patterned activation, and the propagation of signals across networks. The elaboration of relatively high-level cognitive behavior is, at best, secondary to the exploration of low-level physical and electrical interaction (Zednik, 2018). The growing field of computational cognitive neuroscience has as a goal the development of computational models that are biologically plausible and that exhibit cognitive behavior of interest (Ashby, 2011). Linguistic models of this type are intended to exhibit the kind of linguistic behavior that is observed in humans, but with an underlying structure and behavior that closely parallels the human brain. Marr (1982) offers a three-level framework for analyzing models of the brain that has become a standard in neuroscience (Bechtel, 2014). Applying this method of analysis to broad classes of computational models yields insights into the strengths and weaknesses of each. While the ideas in this dissertation may ultimately find broader relevance, it is presently concerned primarily with the modeling of phonemic acquisition in infants. Application of Marr’s analysis to the actual system being modeled – the human infant – suggests an approach to the development of acquisition models that departs significantly from traditional computational linguistics models and computational cognitive neuroscience models.
    • A Qualitative Descriptive Approach Exploring the Perceptions, Attitudes and Experiences of HIV Testing Uptake Among Sub-Saharan African Born Immigrants in the United States

      Silva Torres, Graciela Emilia; Nyambi, Marcelline; McEwen, Marylyn; Loescher, Lois (The University of Arizona., 2021)
      Human immunodeficiency virus (HIV) testing is essential when implementing HIV prevention and treatment services because it can lead to positive behavioral change and increased access to HIV care services. The high incidence of HIV rates among sub-Saharan African born immigrants (SSAIs) living in the United States (US) mirrors the rate of infection burden in the sub-Saharan Africa region. SSAIs data is often aggregated among the data of Blacks or African Americans masking the important distinctions between these populations. There is a paucity of knowledge about HIV testing perceptions, attitudes, and experiences of SSAIs, many of whom have emigrated to the US from high HIV prevalence countries in sub-Saharan Africa. The purpose of this study was to describe the perceptions, attitudes, and experiences of HIV testing uptake among SSAIs living in the US. Identifying barriers and facilitating factors for HIV testing encountered by this specific subgroup within the US black community, who are vulnerable to HIV infection, was paramount. The framework that guided this study was the Health Belief Model (HBM). Purposive and snowball sampling was used to recruit participants. The researcher conducted virtual face-to-face semi-structured in-depth interviews via Zoom with eight sub-Saharan African born immigrant men and women and used an inductive and deductive thematic qualitative analysis to analyze the data. Domains were selected apriori to respond to each research question and, the categories and subcategories were identified through immersion and crystallization of thematic units. Four overarching domains describe perceptions, attitudes, and experiences of SSAIs living in the US towards HIV testing uptake: 1) Barriers to HIV testing among SSAIs; 2) Facilitators to HIV testing among SSAIs; 3) SSAIs cultural influences on HIV testing decisions; and, 4) SSAIs self-confidence to take or adhere to HIV testing. Understanding the HIV testing perceptions, attitudes, and experiences of SSAIs will help healthcare professionals better understand the facilitators and the barriers that SSAIs face regarding HIV testing. This study adds to the science by supporting previous findings that create facilitators and barriers to HIV testing for SSAIs in the US and new knowledge of the significance of cultural barriers. These findings will inform the design of future research, practice, and policy in the US aimed at integrating the unique needs of SSAIs to increase HIV testing uptake.
    • A Quality Improvement Project to Increase Medicare Annual Wellness Visits in a Primary Care Clinic

      Ruel, Jennifer; Pinder, Clare Hedrick; Davis, Mary; Shurson, Lauren (The University of Arizona., 2019)
      INTRODUCTION: This Doctor of Nursing Practice Project is a quality improvement project for a single-site primary care clinic in Tucson, Arizona. It was noticed that Medicare beneficiaries were not consistently participating in Medicare annual wellness visits. The causes were multifactorial, but for the purpose of this project, the focus for a solution became the knowledge level of providers at the clinic. The term providers includes physicians and nurse practitioners. A literature review was conducted to determine the benefits of annual wellness visits, how they may be implemented, and how to best educate providers. Using recent findings in the literature, a web-based module was developed with the intention of educating providers about Medicare annual wellness visits. METHODS: Along with an informed disclosure, pretest, and posttest, the education module was implemented using Qualtrics over a two-week period in August. The education module was emailed from the office manager to all seven providers at the primary care clinic. Three providers chose to participate in the project (N=3). RESULTS: The results comparing the responses on the pretest and posttest show that providers gained knowledge by reading the web-based education module. Providers also self-reported and increased intent in encouraging patients to schedule wellness visits. Limitations include the small sample size. CONCLUSIONS: Participants demonstrated an increase in knowledge gained about Medicare annual wellness visits as evidence by aggregated data. Participants also reported an increase intent to encourage patients to schedule wellness visits, which will potentially lead to a larger source of revenue for the clinical site of implementation.
    • A Quantum Stochastic Approach to Poisson Master Equation Unravellings and Ghirardi-Rimini-Weber Theory

      Wehr, Jan; Keys, Dustin Michael; Kennedy, Tom; Sethuraman, Sunder (The University of Arizona., 2022)
      The theory of quantum stochastic calculus is used to expand the traditional Ghirardi-Rimini-Weber theory to a fully quantum theory, where the noise can be then be interpreted as a new field interacting with quantum systems. A derivation of a stochastic unravellling of the GKSL master equation is first presented from the standpoint of a purely quantum theory, which is then specialized to the case of the GRW master equation. Reverse engineering this procedure gives rise to a new nonlinear quantum stochastic wave equation which preserves a generalized system norm and is an unravelling of the GKSL master equation. Comments on how this particular interpretation can be tested are given.
    • A Question of Being Seen: Xito and Decolonizing in White Colonial Spaces

      Lopez, Francesca; Gonzalez, José Alberto; Koyama, Jill; Henry Jr., Kevin Lawrence (The University of Arizona., 2021)
      Purpose: The purpose of this qualitative multi-case study presented as counter-narratives is to examine how Xicanx Institute for Teaching and Organizing (XITO) former participants understand and implement the decolonizing professional development indigenous and critical theory precepts in their respective communities which humanizes self and others. Background: Given the demographic reality of urban public schools as majority-minority districts, there exists a sparse yet developing body of literature that underscores indigenous ways of knowing, coupled with critical theory that serves to rehumanize, thus decolonize in-service participants in professional development opportunities. This study aims to address this gap. Methods: The participants having established exemplar Huitzilopochtli Humanizing Project (HHP), were purposefully (purposeful sampling) selected to answer the research questions. Specifically, through a series of two platicas, or friendly interviews, data was collected and analyzed. Emergent themes were identified through descriptive and concept codes that addressed the phenomenon being studied. Findings: The findings presented indicate former XITO participants DPD utilized Indigenous epistemologies to humanize themselves and their communities. Additionally, XITO participants, through critical theory, were politicized by embodying an agentic positioning (praxis) to transform their professional and community spaces. Conclusions: Professional development, which centers humanity while advancing indigenous and critical theory formations, the time has come. Teachers are seeking professional development opportunities that will support rehumanization of self in order to create humanizing spaces for their students.
    • A Randomized Controlled Pilot Trial of a Mindfulness Intervention for Grief in Widows and Widowers

      O'Connor, Mary-Frances; Knowles, Lindsey M.; Sbarra, David A.; Lawrence, Erika E.; Kaszniak, Alfred W. (The University of Arizona., 2019)
      Background: Following bereavement, prolonged and intense yearning and grief rumination are repetitive cognitive processes that can promote a complicated course of grief. Mindfulness training (MT) has been shown to reduce maladaptive repetitive thought in healthy and clinical populations. However, empirical investigation of MT in bereaved populations is limited. The current randomized controlled pilot trial implemented a MT intervention for widow(er)s to examine the feasibility, acceptability, and preliminary efficacy of MT for improving grief outcomes and to test the mediating effects of yearning and grief rumination on grief severity. Method: Ninety five people who experienced the death of a spouse or romantic partner between six months to four years prior were randomly assigned to a 6 week MT intervention or a Progressive Muscle Relaxation (PMR) intervention, or were quasi randomized to a wait list condition. Self reported psychosocial outcomes were assessed at baseline, post intervention, and 1 month post intervention. In addition, yearning, grief rumination, decentering, and grief severity were assessed at two additional time points at weeks two and four of the intervention/wait list period to preserve a temporal connection between mediators and outcomes. Results: Controlling for relevant covariates, the MT and PMR groups showed significant declines in grief severity and yearning from baseline to the 1 month follow up, though only the PMR group showed a significant difference in rates of change compared to the wait list control group. Multi level mediation analyses revealed that reductions in yearning mediated the declines in grief severity. The MT, PMR, and wait list groups showed significant decreases in grief rumination across intervention time points for all but one grief rumination subscale, which was rumination about injustice of the death. Last, the PMR and wait list groups showed significant increases in decentering across study time points whereas the MT group did not experience significant change. Conclusion: The results of this first pilot RCT of a MT intervention in widows and widowers support the feasibility, acceptability, and preliminary efficacy of MT and PMR for improving grief outcomes in widows and widowers, and they suggest that PMR is most effective compared to the wait list control. With replication, PMR and MT could be standalone interventions for normative grief or components added to treatments for disordered grief.
    • A Responsible Softmax Layer in Deep Learning

      Rychlik, Marek; Coatney, Ryan Dean; Maier, Robert S.; Glickenstein, David A.; Morrison, Clayton T. (The University of Arizona., 2020)
      Clustering algorithms are an important part of modern data analysis. The K-means and EM clustering algorithm both use an iterative process to find latent (or hidden) variables in a mixture distribution. These hidden variables may be interpreted as class label for the data points of a sample. In connection with these algorithms, I consider a family of nonlinear mappings called responsibility maps. The responsibility map is obtained as a gradient of the log likelihood of N independent samples, drawn from a mixture of K distributions. I look at the discrete dynamics of this family of maps and give a proof that iteration of responsibility converges to an estimate of the mixing coefficients. I also show that the convergence is consistent in the sense that the fixed point acts as a maximizer of the log likelihood. I call the process of determining class weight by iteration dynamic responsibility and show that it converges to a unique set of weights under mild assumptions. Dynamic responsibility (DR) is inspired by the expectation step of the expectation maximization (EM) algorithm and has a useful association with Bayesian methods. Like EM, dynamic responsibility is an iterative algorithm, but DR will converge to a unique maximum under reasonable conditions. The weights determined by DR can also be found using gradient descent but DR guarantees non-negative weights and gradient descent does not. I present a new algorithm which I call responsible softmax for doing classification with neural networks. This algorithm is intended to handle imbalanced training sets and is accomplished via multiplication by per class weights. These weights may be interpreted as class probabilities for a generalized mixture model, and are determined through DR rather than by empirical observation of the training set and heuristically selecting the underlying probability distributions. I compare the performance of responsible softmax with other standard techniques, including standard softmax, and weighted softmax using empirical class probabilities. I use generated Gaussian mixture model data and the MNIST data set for proof of concept. I show that in general, responsible softmax produces more useful classifiers than softmax when presented with imbalanced training data. It will also be seen that responsible softmax approximates the performance of empirically weighted softmax, and in some cases may do better.
    • 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.
    • A Retrospective Review: Impact of Mesa Fire and Medical Departments Advanced Practice Prehospital Program on ED Overcrowding and Healthcare Fiscal Bearing

      Ruel, Jennifer; Green, Darcia Lynn; Prettyman, Allan; Carlisle, Heather (The University of Arizona., 2018)
      Background: As the cost of healthcare in the United States (US) continues to increase, it becomes imperative to find solutions that permit safe, quality care with a lower financial investment. Utilization of the emergency department for non-emergent care is considered to be one of the costliest, and most preventable methods of healthcare. Advanced practice (AP), pre-hospital programs provide a solution to decreasing the cost of healthcare without sacrificing quality or safety. Purpose: This doctor of nursing project provides a summative evaluation of an advanced practice, pre-hospital program in Mesa, Arizona. In 2014, Mesa Fire and Medical Department (MFMD) received a grant for $12.5 million to design and implement an advanced practice program to divert non-emergent patients away from the local emergency departments while cutting the cost of healthcare. This program utilizes nurse practitioners and physician assistants to respond to non-emergent calls made within the 911 system. Results: A total of 1079 charts were selected for evaluation between October 1, 2015 to March 31, 2016. Of the 1079 charts evaluated, 694 patients (64.3%) were successfully diverted away from local emergency departments. A cost comparison between pre-hospital and hospital care was completed using evaluation and management (E/M) codes provided by MFMD. Relative value units (RVUs) were obtained for each level of care and used for estimation of emergency provider care. Based on these estimates, the costs savings provided by the MFMD advanced practice program was determined to be $718,865.09 for the six-month analysis period. Conclusions: Advanced practice providers in a pre-hospital setting are a cost-effective method of providing safe, high quality care at a significantly lower cost than hospital care.