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Decreased time-to-treatment delay through clinical guideline implementation for image-guided image biopsies in cancer diagnosis
(Montana State University - Bozeman, College of Nursing, 2024) O'Dell, Meghan Marie; Chairperson, Graduate Committee: Molly Secor; This is a manuscript style paper that includes co-authored chapters.
Background: International guidelines have been established defining the ideal period from referral to diagnosis of malignancy as two weeks. Increased time-to-treatment initiation is associated with a one to three percent increased mortality risk for each week of delayed treatment. Image-guided biopsy has emerged as a transformative tool in cancer diagnosis, impacting the rapid identification and treatment of malignancy. Clinical Problem: A rurally based oncology institute associated with a larger non-profit healthcare system in Montana identified concerns with extended time-to-treatment initiation related to delayed image-guided biopsy. The average wait time for image-guided biopsy was sixty-seven days. Methods: Utilizing the Replicating Effective Programs (REP) Implementation framework, an evidence-based clinical practice guideline was developed to define optimal referral-to-diagnosis timeframe for diagnosis or rule-out of malignancy via image-guided biopsy using the second edition of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Interventions: A guideline advisory committee including individuals from relevant professional groups was recruited to act as expert appraisers. Four-phase appraisal of the clinical practice guideline using the AGREE II tool took place over six weeks. The guideline was rated for overall quality based on a seven-point rating scale and appraisers were asked if they would recommend the guideline for use in the target facility. Results: The guideline received an average rating of 6.2 and was recommended for use by 100% of appraisers, with 18% recommending modifications during pre-implementation. During implementation, the guideline received an average rating of 6.7 and was recommended for use by 100 % of appraisers. The final guideline and appraisal data were presented to health system leadership and the guideline was successfully adopted into facility policy. Conclusion: Quality improvement initiatives will need to be implemented to identify and address systems-based complexities that could pose barriers to meeting the goal timeframe as defined by the guideline.
Undiagnosed hypertension in rural healthcare
(Montana State University - Bozeman, College of Nursing, 2023) Charlo, April Lee; Chairperson, Graduate Committee: Sandra Benavides-Vaello
Hypertension is a disease that affects numerous people worldwide. It often goes undiagnosed, causing an increased risk of cardiovascular events. This project aimed to reduce the number of patients with undiagnosed hypertension within the observed population. This project occurred within a network of clinics associated with a 25-bed critical access hospital in rural Western Montana. Participants included clinic staff, physicians, nurse practitioners, physician assistants, registered nurses, licensed practical nurses, medical assistants, and a licensed clinical social worker. The Plan-Do-Check-Act was used as the framework for this quality improvement (QI) project. Hypertension was defined using the 2017 American College of Cardiology and American Heart Association Clinical Practice Guidelines. The Electronic Medical Record system was used to identify out-of-range blood pressures in the last 2 years and add these patients to a registry. Clinical personnel performed chart reviews to eliminate patients who did not meet the criteria defined by the stakeholders. EHR message functionality alerted providers offering to schedule patients for an office visit to rule in or out hypertension. The identified patients were contacted by a licensed clinical social worker and invited to schedule an appointment with a provider to address the possibility of undiagnosed hypertension. The final numbers were assessed 6 weeks after the undiagnosed hypertension project implementation. The multistep PDCA process resulted in a significant reduction in the overall number of potentially undiagnosed hypertensive patients. The initial data collection produced 3,617 patients between the ages of 18 and 85, and the last revealed only 1,210 patients that met the criteria. The most significant decrease in number was seen in the 56-65 age group, dropping from 700 to 188 patients. This quality improvement project aimed to identify potentially undiagnosed hypertensive patients and establish a system to assess those patients by a provider. This project accomplished that objective. This quality improvement project was structured on innovative research, a trusted conceptual framework, and current practice guidelines. If the quality improvement team were to extend this project, the next step would be implementing clinical practice guidelines and monitoring hypertension outcomes within the patient population.
Widefield micro-camera integrated into the objective lens of a reflectance confocal microscope for concurrent image registration
(Montana State University - Bozeman, College of Engineering, 2023) Aist, Joseph Nicholas; Chairperson, Graduate Committee: David L. Dickensheets
With millions of new skin disease cases reported annually, non-invasive imaging methods have been developed to diagnose skin disease accurately. Reflectance confocal microscopes (RCM) have led these new technologies with high sensitivity and specificity. However, current methods use multiple devices: a digital camera, a dermoscope, and an RCM, which are not co-registered. Therefore, locating small, microscopic RCM fields-of-view (0.5x0.5 mm) at specific suspicion sites within the larger dermoscopic field-of-view (10x10 mm) is extremely difficult. This 'blind' RCM imaging results in lower and more variable diagnostic accuracy, particularly sensitivity, where positive and negative predictive values can drop by up to 30%. Our team has designed a new objective lens with an integrated micro-camera to deliver a concurrent widefield image of the skin surface surrounding the location of microscopic RCM imaging. The widefield image can be used directly to provide context for RCM or can be registered to a previously stored high-resolution clinical image to show where RCM imaging is occurring. In this thesis, the micro-camera is characterized and tested in laboratory and clinical settings. In addition, this thesis investigates a co- and cross-polarized micro-camera and LED system. It compares them to the non-polarized system to explore whether the cross-polarized version enhances feature contrast and enables better dermoscopic imaging. Non-polarized, co-polarized, and cross-polarized mock-up probes of the objective lens with a micro-camera were designed and built for testing. Images of resolution targets, color charts, and skin were taken to obtain modulation transfer function (MTF) measurements, color analysis data, and representative skin images. The results showed improvement in the MTF for the cross- polarized probe when compared to the co- and non-polarized probes. It was also found that the polarization of the imaging system did not significantly affect the color quality of the images. When tested by scientists at Memorial Sloan Kettering Cancer Center, sub-surface features not seen with the co- and non-polarized probes were observed with the cross-polarized probe. The cross-polarized probe suppressed the surface reflections, allowing for sub-surface information to be captured.
Continuing the Debate: A Response to the Literacy Research Association’s Dyslexia Research Report
(Australian International Academic Centre, 2022-08) Green, Elizabeth A.
The Literacy Research Association (LRA) is known for releasing research reports on essential topics in the field of literacy. An Examination of Dyslexia Research and Instruction, with Policy Implications is a recent LRA report with far-reaching impact in education and policy. The report claimed to be a summary of dyslexia research and instruction, however, much recent research on dyslexia definitions, diagnosis, interventions, neuroscience, and law was left out. This paper is a response to the LRA report with the intent to examine elements of the report that are particularly important and well explained, as well as those that are problematic.
An asthma annual spirometry testing quality improvement project
(Montana State University - Bozeman, College of Nursing, 2020) Abraham, Melissa Lynn; Chairperson, Graduate Committee: Laura Larsson
Asthma is a chronic inflammatory lung disease that causes coughing, wheezing, shortness of breath and chest tightness. In the United States, 7.6% of adults are living with asthma, and the prevalence of asthma in Montana is 9.1% for adults. The aim for asthma management is to help people living with asthma maintain a better quality of life. In order to bridge the gap in care and provide access to asthma management, more providers need to be well-versed and equipped to meet these needs. Research shows spirometry testing helps a provider diagnose and understand the severity of a patient's asthma symptoms. The purpose of this project is to determine if implementation of a quality improvement (QI) project in clinical practice will improve annual spirometry testing for asthma patients. A 2.5-hour asthma diagnosis and management course was provided for staff implementing spirometry testing and a retrospective chart analysis was conducted, continued support over the course of a twelve-month project period and workflow changes were implemented to facilitate change. The outcome measure focused on was spirometry testing, with a goal of 85% of patients with asthma to receive annual spirometry testing. A survey was given to determine the staff's perspective on implementing the QI project. The QI project increased annual spirometry testing by 37% post intervention. Staff found the education informative and the workflow changes beneficial to improving patient care to meet the national asthma guidelines. Changes to workflow in clinical practice using a QI project could benefit future clinical practice.
Characterization of metabolic changes in osteoarthritis using global metabolomic profiling
(Montana State University - Bozeman, College of Agriculture, 2018) Carlson, Alyssa Kay; Chairperson, Graduate Committee: Ronald K. June II; Rachel A. Rawle, Erik Adams, Mark C. Greenwood, Brian Bothner and Ronald K. June were co-authors of the article, 'Application of global metabolomic profiling of synovial fluid for osteoarthritis biomarkers' in the journal 'Biochemical and biophysical research communications' which is contained within this thesis.; Rachel A. Rawle, Cameron W. Wallace, Erik Adams, Mark C. Greenwood, Brian Bothner and Ronald K. June were co-authors of the article, 'Global metabolomic profiling of human synovial fluid for rheumatoid arthritis biomarkers' in the journal 'Clinical and experimental rheumatology' which is contained within this thesis.; Rachel A. Rawle, Cameron Wallace, Ellen Brooks, Erik Adams, Mark C. Greenwood, Merissa Olmer, Martin K. Lotz, Brian Bothner and Ronald K. June were co-authors of the article, 'Characterization of osteoarthritis phenotypes in human synovial fluid using global metabolomic profiling' submitted to the journal 'Arthritis and rheumatology' which is contained within this thesis.; Rachel A. Rawle, Erica Barboza, Albert Batushansky, Timothy M. Griffin, Brian Bothner and Ronald K. June were co-authors of the article, 'In vivio mechanotransduction: effect of acute exercise on the metabolomic profiles of mouse synovial fluid' submitted to the journal 'Journal of biomechanics' which is contained within this thesis.; Rachel A. Rawle, Erin Hutchison, Joanna Hudson, Brian Bothner, Timothy M. Griffin and Ronald K. June were co-authors of the article, 'The effect of long-term voluntary exercise on the metabolomic profiles of synovial fluid from high-fat diet-induced obese mice' submitted to the journal 'Arthritis and rheumatology' which is contained within this thesis.; Dissertation includes one article of which Alyssa Kay Carlson is not the main author.
Osteoarthritis affects over 250 million individuals worldwide. It is a disease of the whole joint, exhibiting heterogenous pathology, and a multifactorial etiology consisting of obesity and joint trauma as important risk factors. This heterogenous nature contributes to the disparity in symptom presentation and response to treatments, presenting challenges for diagnosis and the development of targeted therapies for osteoarthritis phenotypes. Therefore, the goals of this work were to (1) enhance our understanding of osteoarthritis as a heterogenous disease for improved early diagnosis and (2) evaluate the interaction between osteoarthritis risk factors and therapeutic interventions. Because osteoarthritis and its risk factors are associated with aberrant metabolism, liquid chromatography-mass spectrometry-based global metabolomic profiling was employed to investigate changes in small molecules in response to osteoarthritis, risk factors, and therapeutic interventions. The first area of research focused on osteoarthritis diagnosis. The results show that global metabolomic profiling of human osteoarthritic synovial fluid is capable of identifying candidate biomarkers of osteoarthritis and classifying donors into subgroups representative of metabolic phenotypes. Metabolic phenotypes include structural deterioration, oxidative stress, and/or inflammation. The second area of research focused on osteoarthritis risk factors and therapeutic interventions. We investigated the effects of acute exercise in mouse synovial fluid to provide insight into exercise as a nonpharmacologic mechanobiology-based intervention prescribed for osteoarthritis. We found that acute exercise may have beneficial effects in maintaining overall joint health. We expanded on exercise as a nonpharmacologic treatment by investigating the effects of long-term exercise in an obesity-associated osteoarthritis mouse model. Long-term exercise did not exacerbate osteoarthritis in the knee joints of obese mice but did abrogate some obesity-induced metabolic perturbations in the synovial fluid. In addition, a pharmacologic intervention was investigated in posttraumatic osteoarthritis. Inhibition of early response genes by a Cdk9 inhibitor immediately after joint trauma was also capable of reversing a portion of injury-induced metabolic perturbations in whole joints of injured mice. Overall, this work demonstrates that global metabolomic profiling has potential for biomarker discovery and classifying patients into metabolic phenotypes. It also demonstrates the potential for exercise and inhibition of early response genes as therapeutic interventions for obesity-associated and post-traumatic osteoarthritis.
A pilot implementation of postpartum depression screening guidelines in the pediatric primary care setting
(Montana State University - Bozeman, College of Nursing, 2019) Popa, Ryann Christine; Chairperson, Graduate Committee: Susan Luparell
Statement of the problem. Postpartum depression (PPD) is a common postpartum complication. This condition can have a negative effect on family wellness and can impact the development of the infant. Unfortunately, it is estimated that only half of PPD cases are ever recognized and diagnosed by providers. Although evidence supports incorporating PPD screening guidelines into well-child visits, the pediatric providers at the project site do not routinely include this screening process in their practice. As a result, opportunities to identify mothers with PPD and provide them with education and resources were being missed. Methods. The project took place at an outpatient pediatric clinic in Montana. Four pediatric providers incorporated PPD screening guidelines utilizing the Edinburgh Postnatal Depression Screening tool into routine well-child checks for children ages 1 to 12 months. Using a data collection tool, providers recording data related to the screening process including the age of the child, whether or not the mother was screened, the EPDS score, and how the situation was addressed if the results of the EPDS were positive. The perspectives and beliefs of the providers were captured using a pre-implementation and post-implementation survey as well as a verbal debriefing at the end of the project. Results. Data were collected on 88 encounters where screening was indicated. Fifty-three of the 88 mothers were screened. Eight screenings were positive which suggested possible depression symptoms. Although providers were in favor of this practice change overall both before and after implementation of the PPD guidelines, some significant barriers and challenges emerged during the process. Discussion. Barriers to incorporating PPD screening guidelines into well-child visits include time constraints, cooperation and willingness of the mother to participate, remembering to administer the screening tool, and repetition of unnecessary screening in mothers who have already been diagnosed with depression. Changes could be made to the design of this project to reduce limitations and improve the implementation process. Overall, this project found that PPD screening at well-child visits has the potential to be feasible and valuable to the practice of this organization.
Sepsis bundle evaluation for quality improvement
(Montana State University - Bozeman, College of Nursing, 2019) O'Connor, Christine Elizabeth; Chairperson, Graduate Committee: Susan Luparell
Sepsis is a common diagnosis in the acute care setting. Left untreated, sepsis can result in many long-term complications including permanent organ damage and death. Sepsis has become such a common diagnosis that the Centers for Medicare & Medicaid (CMS) have implemented core measures that are meant to aid in quickly diagnosing and treating septic patients. Because sepsis requires prompt treatment, these guidelines have been divided into three- and six-hour bundles to assure prompt treatment after diagnosis. If hospitals fail to follow these core measures, the institution is not reimbursed for the cost of medical care for that patient. Implementation of the three and six-hour bundles have been shown to improve patient outcomes, decreasing mortality associated with sepsis. Compliance rates with these core measures in a rural hospital in Northwest Montana, which will be called Hospital X, have been consistently below the goal of 80% compliance. This quality-improvement project (QIP) utilized interventions to identify where non-compliance was occurring and interventions to improve overall institution compliance rates. Chart review and process flow observation were used to identify which parts of the bundle were not being implemented according to CMS guidelines. Use of a newly created sepsis handoff tool and implementing nurse education on the core measures were interventions used in an effort to increase overall institution compliance. Results: Overall compliance rates improved from 57% in May, 2018 to 87% in June, 2018 after implementation of interventions. For the months of June, 2018 - September, 2018, compliance rates remained >70%. Conclusion: The two interventions that were implemented during the course of this project seemed to improve compliance based off a significant improvement in overall compliance rates during months where the interventions were implemented. There are many recommendations for future research and interventions based off the findings from this project.
Transduction of antigens into amplifiable DNA signals using structure switching aptamers
(Montana State University - Bozeman, College of Engineering, 2019) Kayalar, Canberk; Chairperson, Graduate Committee: Stephanie McCalla
Detection of specific antigens has one vital step in common: detection of biomarkers. Diagnostic testing that is rapid and reliable is unavailable in limited resource and rural settings. The solution to this need must be simple, inexpensive, robust, rapid and not require highly trained personnel to operate. Aptamers are capable of delivering those needs when matched with a novel high gain amplification method. This thesis focuses on important aspects of a novel protein detection assay that uses aptamers. Aspects that play an important role on the assay's success were investigated; aptamer selection and design of structure switching aptamers, designing DNA templates that will transduce the signal created by the aptamers, solid phase selection, aptamer immobilization on the solid phase, protein capture, and amplification of the signal. The first step was to find aptamers that were proven to specifically target clinically relevant targets and modify them to suit the needs of the assay. It is important to validate the aptamers' performance. The second important step was finding a solid phase that is compatible with the novel nucleotide amplification reaction that will be used to amplify the signal produced by the aptamers. Paramagnetic microbeads, membranes and polyacrylamide hydrogels were potential candidates for solid phases. Non-specific interaction of the target protein with the solid phase surface will not have negative effects while running the assay due to the structure switching of the aptamers however, it prevented the accurate quantification of the protein capture by aptamers. There is a need for the development of a blocking buffer that is specific to the solid phase. Washing of the excess DNA templates that are not bound to target-bound aptamers plays an important role in the assay's accuracy. The results presented here show the preliminary work that has been done for the novel protein detection assay that uses structure switching aptamers. This assay has the potential to detect diseases at point-of-care in low resource settings.
Policy development: practice improvement, blind sweep fetal fibronectin collection
(Montana State University - Bozeman, College of Nursing, 2019) Liedtka-Holmquist, Diana Elizabeth; Chairperson, Graduate Committee: Julie Ruff
Recognizing preterm labor can help guide the management of care of the mother and fetus between the obstetrician and registered nurse. A simple test called the rapid fetal fibronectin (fFN) can detect proteins that are indicators of preterm delivery. A trained registered nurse can perform this simple test, in which a swab is placed in the posterior fornix of the vagina. The March of Dimes has created a pathway for standardized preterm labor assessment developing a Preterm Labor Assessment Tool (PLAT) for hospitals to aid in the reduction preterm labor and deliveries. A positive fFN test allows for antenatal steroids and preparation for optimal neonatal care, whereas a negative fFN test allows for less intervention, avoidance of unnecessary medical treatment and hospitalization, and the provision of reassurance to both obstetrician and patient. The purpose of this project was to develop an evidence based policy that would guide and support practice improvements for the blind sweep fFN collection method. This evidence based protocol will allow trained registered nurses to perform a blind sweep fFN test without an obstetrician or residents' supervision. By performing the fFN tests on patients who present with preterm labor signs and symptoms, obstetricians will be able to recognize preterm labor assessment and initiate early treatment.

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