A Telemedicine Follow Up Program to Improve Glycemic Outcomes For Patients With Uncontrolled Type 2 Diabetes

A Project Submitted in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF NURSING PRACTICE University of Alaska Anchorage December 2020 APPROVED: Sharyl Eve Toscano PhD, RN, Committee Chair Sarah Llewellyn PhD, RN, Committee Member Denise K. Stiltner, DNP, FNP-C, Committee Member Carla Hagen PhD, MPH, RN, Director School of Nursing Jeff Jessee, Dean College ofType 2 Diabetes is responsible for a global public health burden and affects an estimated 30 million people in the United States, many of whom have difficulty reaching glycemic targets. Approximately 15 percent of the diabetic patients in the Family Health Clinic have an A1C above 8.0. Telemedicine shows promise in improving glycemic control and enhancing access to care. Current literature supports the use of telemedicine to improve glycemic outcomes. The purpose of this project was to assess the acceptability and effectiveness of a provider implemented intense telephonic follow-up program on glycemic outcomes and self-management of patients with uncontrolled Type 2 Diabetes. This quality improvement project used a pre-test post-test design using laboratory and survey data collection methods to measure hemoglobin A1C, diabetes self-care, and a post-test provider satisfaction survey. Over a 3-month period, patients meeting criteria for the intervention were provided with telephonic provider follow-up visits at 2-3 week intervals including education on lifestyle changes, medication management and self-care. The mean change in A1C was statistically and clinically significant. The mean change in total self-care survey score was also significant. The data indicated that utilization of telemedicine follow-up improved clinical outcomes for Type 2 Diabetics.Title Page / Abstract / Table of Contents / List of Figures / List of Tables / List of Appendices / Chapter 1: Overview of the Problem / Chapter 2: Review of the Literature / Chapter 3: Organizational Framework / Chapter 4: Design and Methods / Chapter 5: Implementation / Chapter 6: Outcomes and Data Analysis / Chapter 7: Implications for Nursing Practice / Chapter 8: Summary and Conclusion / References / Appendice

Spitzer Phase Curves of KELT-1b and the Signatures of Nightside Clouds in Thermal Phase Observations

We observed two full orbital phase curves of the transiting brown dwarf KELT-1b, at 3.6um and 4.5um, using the Spitzer Space Telescope. Combined with previous eclipse data from Beatty et al. (2014), we strongly detect KELT-1b's phase variation as a single sinusoid in both bands, with amplitudes of $964\pm36$ ppm at 3.6um and $979\pm54$ ppm at 4.5um, and confirm the secondary eclipse depths measured by Beatty et al. (2014). We also measure noticeable Eastward hotspot offsets of $28.4\pm3.5$ degrees at 3.6um and $18.6\pm5.2$ degrees at 4.5um. Both the day-night temperature contrasts and the hotspot offsets we measure are in line with the trends seen in hot Jupiters (e.g., Crossfield 2015), though we disagree with the recent suggestion of an offset trend by Zhang et al. (2018). Using an ensemble analysis of Spitzer phase curves, we argue that nightside clouds are playing a noticeable role in modulating the thermal emission from these objects, based on: 1) the lack of a clear trend in phase offsets with equilibrium temperature, 2) the sharp day-night transitions required to have non-negative intensity maps, which also resolves the inversion issues raised by Keating & Cowan (2017), 3) the fact that all the nightsides of these objects appear to be at roughly the same temperature of 1000K, while the dayside temperatures increase linearly with equilibrium temperature, and 4) the trajectories of these objects on a Spitzer color-magnitude diagram, which suggest colors only explainable via nightside clouds.Comment: AJ in press. Updated to reflect the accepted versio

Spitzer and z' Secondary Eclipse Observations of the Highly Irradiated Transiting Brown Dwarf KELT-1b

We present secondary eclipse observations of the highly irradiated transiting brown dwarf KELT-1b. These observations represent the first constraints on the atmospheric dynamics of a highly irradiated brown dwarf, and the atmospheres of irradiated giant planets at high surface gravity. Using the Spitzer Space Telescope, we measure secondary eclipse depths of 0.195+/-0.010% at 3.6um and 0.200+/-0.012% at 4.5um. We also find tentative evidence for the secondary eclipse in the z' band with a depth of 0.049+/-0.023%. These measured eclipse depths are most consistent with an atmosphere model in which there is a strong substellar hotspot, implying that heat redistribution in the atmosphere of KELT-1b is low. While models with a more mild hotspot or even with dayside heat redistribution are only marginally disfavored, models with complete heat redistribution are strongly ruled out. The eclipse depths also prefer an atmosphere with no TiO inversion layer, although a model with TiO inversion is permitted in the dayside heat redistribution case, and we consider the possibility of a day-night TiO cold trap in this object. For the first time, we compare the IRAC colors of brown dwarfs and hot Jupiters as a function of effective temperature. Importantly, our measurements reveal that KELT-1b has a [3.6]-[4.5] color of 0.07+/-0.11, identical to that of isolated brown dwarfs of similarly high temperature. In contrast, hot Jupiters generally show redder [3.6]-[4.5] colors of ~0.4, with a very large range from ~0 to ~1. Evidently, despite being more similar to hot Jupiters than to isolated brown dwarfs in terms of external forcing of the atmosphere by stellar insolation, KELT-1b has an atmosphere most like that of other brown dwarfs. This suggests that surface gravity is very important in controlling the atmospheric systems of substellar mass bodies.Comment: 14 pages, 3 tables, 11 figures. Accepted by ApJ. Updated to reflect the accepted versio

The tempo of cetacean cranial evolution

The evolution of cetaceans (whales and dolphins) represents one of the most extreme adaptive transitions known, from terrestrial mammals to a highly specialized aquatic radiation that includes the largest animals alive today. Many anatomical shifts in this transition involve the feeding, respiratory, and sensory structures of the cranium, which we quantified with a high-density, three-dimensional geometric morphometric analysis of 201 living and extinct cetacean species spanning the entirety of their ∼50-million-year evolutionary history. Our analyses demonstrate that cetacean suborders occupy distinct areas of cranial morphospace, with extinct, transitional taxa bridging the gap between archaeocetes (stem whales) and modern mysticetes (baleen whales) and odontocetes (toothed whales). This diversity was obtained through three key periods of rapid evolution: first, the initial evolution of archaeocetes in the early to mid-Eocene produced the highest evolutionary rates seen in cetaceans, concentrated in the maxilla, frontal, premaxilla, and nasal; second, the late Eocene divergence of the mysticetes and odontocetes drives a second peak in rates, with high rates and disparity sustained through the Oligocene; and third, the diversification of odontocetes, particularly sperm whales, in the Miocene (∼18-10 Mya) propels a final peak in the tempo of cetacean morphological evolution. Archaeocetes show the fastest evolutionary rates but the lowest disparity. Odontocetes exhibit the highest disparity, while mysticetes evolve at the slowest pace, particularly in the Neogene. Diet and echolocation have the strongest influence on cranial morphology, with habitat, size, dentition, and feeding method also significant factors impacting shape, disparity, and the pace of cetacean cranial evolution

Proton radiotherapy for chest wall and regional lymphatic radiation; dose comparisons and treatment delivery

Purpose The delivery of post-mastectomy radiation therapy (PMRT) can be challenging for patients with left sided breast cancer that have undergone mastectomy. This study investigates the use of protons for PMRT in selected patients with unfavorable cardiac anatomy. We also report the first clinical application of protons for these patients. Methods and materials Eleven patients were planned with protons, partially wide tangent photon fields (PWTF), and photon/electron (P/E) fields. Plans were generated with the goal of achieving 95% coverage of target volumes while maximally sparing cardiac and pulmonary structures. In addition, we report on two patients with unfavorable cardiac anatomy and IMN involvement that were treated with a mix of proton and standard radiation. Results: PWTF, P/E, and proton plans were generated and compared. Reasonable target volume coverage was achieved with PWTF and P/E fields, but proton therapy achieved superior coverage with a more homogeneous plan. Substantial cardiac and pulmonary sparing was achieved with proton therapy as compared to PWTF and P/E. In the two clinical cases, the delivery of proton radiation with a 7.2 to 9 Gy photon and electron component was feasible and well tolerated. Akimbo positioning was necessary for gantry clearance for one patient; the other was treated on a breast board with standard positioning (arms above her head). LAO field arrangement was used for both patients. Erythema and fatigue were the only noted side effects. Conclusions: Proton RT enables delivery of radiation to the chest wall and regional lymphatics, including the IMN, without compromise of coverage and with improved sparing of surrounding normal structures. This treatment is feasible, however, optimal patient set up may vary and field size is limited without multiple fields/matching

Near-infrared Emission Spectrum of WASP-103b Using Hubble Space Telescope/Wide Field Camera 3

We present here our observations and analysis of the dayside emission spectrum of the hot Jupiter WASP-103b. We observed WASP-103b during secondary eclipse using two visits of the Hubble Space Telescope with the G141 grism on Wide Field Camera 3 in spatial scan mode. We generated secondary eclipse light curves of the planet in both blended white-light and spectrally binned wavechannels from 1.1-1.7 µm and corrected the light curves for flux contamination from a nearby companion star. We modeled the detector systematics and secondary eclipse spectrum using Gaussian process regression and found that the near-IR emission spectrum of WASP-103b is featureless across the observed near-IR region to down to a sensitivity of 175 ppm, and shows a shallow slope toward the red. The atmosphere has a single brightness temperature of T_B = 2890 K across this wavelength range. This region of the spectrum is indistinguishable from isothermal, but may not manifest from a physically isothermal system, i.e., pseudo-isothermal. A solar-metallicity profile with a thermal inversion layer at 10^(−2) bar fits the spectrum of WASP-103b with high confidence, as do an isothermal profile with solar metallicity and a monotonically decreasing atmosphere with C/O > 1. The data rule out a monotonically decreasing atmospheric profile with solar composition, and we rule out a low-metallicity decreasing profile as unphysical for this system. The pseudo-isothermal profile could be explained by a thermal inversion layer just above the layer probed by our observations, or by clouds or haze in the upper atmosphere. Transmission spectra at optical wavelengths would allow us to better distinguish between potential atmospheric models

Miniature exoplanet radial velocity array I: design, commissioning, and early photometric results

The MINiature Exoplanet Radial Velocity Array (MINERVA) is a US-based observational facility dedicated to the discovery and characterization of exoplanets around a nearby sample of bright stars. MINERVA employs a robotic array of four 0.7 m telescopes outfitted for both high-resolution spec- troscopy and photometry, and is designed for completely autonomous operation. The primary science program is a dedicated radial velocity survey and the secondary science objective is to obtain high precision transit light curves. The modular design of the facility and the flexibility of our hardware allows for both science programs to be pursued simultaneously, while the robotic control software provides a robust and efficient means to carry out nightly observations. In this article, we describe the design of MINERVA including major hardware components, software, and science goals. The telescopes and photometry cameras are characterized at our test facility on the Caltech campus in Pasadena, CA, and their on-sky performance is validated. New observations from our test facility demonstrate sub-mmag photometric precision of one of our radial velocity survey targets, and we present new transit observations and fits of WASP-52b—a known hot-Jupiter with an inflated radius and misaligned orbit. The process of relocating the MINERVA hardware to its final destination at the Fred Lawrence Whipple Observatory in southern Arizona has begun, and science operations are expected to commence within 2015

Transit Detection in the MEarth Survey of Nearby M Dwarfs: Bridging the Clean-First, Search-Later Divide

In the effort to characterize the masses, radii, and atmospheres of potentially habitable exoplanets, there is an urgent need to find examples of such planets transiting nearby M dwarfs. The MEarth Project is an ongoing effort to do so, as a ground-based photometric survey designed to detect exoplanets as small as 2 Earth radii transiting mid-to-late M dwarfs within 33 pc of the Sun. Unfortunately, identifying transits of such planets in photometric monitoring is complicated both by the intrinsic stellar variability that is common among these stars and by the nocturnal cadence, atmospheric variations, and instrumental systematics that often plague Earth-bound observatories. Here we summarize the properties of MEarth data gathered so far, and we present a new framework to detect shallow exoplanet transits in wiggly and irregularly-spaced light curves. In contrast to previous methods that clean trends from light curves before searching for transits, this framework assesses the significance of individual transits simultaneously while modeling variability, systematics, and the photometric quality of individual nights. Our Method for Including Starspots and Systematics in the Marginalized Probability of a Lone Eclipse (MISS MarPLE) uses a computationally efficient semi-Bayesian approach to explore the vast probability space spanned by the many parameters of this model, naturally incorporating the uncertainties in these parameters into its evaluation of candidate events. We show how to combine individual transits processed by MISS MarPLE into periodic transiting planet candidates and compare our results to the popular Box-fitting Least Squares (BLS) method with simulations. By applying MISS MarPLE to observations from the MEarth Project, we demonstrate the utility of this framework for robustly assessing the false alarm probability of transit signals in real data. [slightly abridged]Comment: accepted to the Astronomical Journal, 21 pages, 12 figure