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... 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Cricothyrotomy: The Life-saving Airway Procedure Merandah Tokarz and Hannah Harris Marian University Leighton School of Nursing 2 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Cricothyrotomy: The Life-saving Airway Procedure Merandah Tokarz and Hannah Harris Chair: Derrianne Monteiro, DNP, CRNA Derrianne Monteiro, DNP, CRNA _______________________ Derrianne Monteiro, DNP, CRNA (Nov 30, 2023 14:53 EST) Project Team Members: Merandah Tokarz, SRNA Merandah Tokarz, SRNA _______________________ Merandah Tokarz, SRNA (Dec 4, 2023 08:58 EST) Hannah Harris, SRNA _______________________ Committee Members: Mary Nguyen Reynolds, CRNA _______________________ Mary Nguyen Reynolds (Dec 4, 2023 10:25 EST) Bradley Stelflug, DrAP, CRNA _______________________ Bradley Stelflug (Dec 4, 2023 06:51 PST) Date of Submission: 3 Table of Contents ABSTRACT ...................................................................................................................................................6 CRICOTHYROTOMY: THE LIFE-SAVING AIRWAY PROCEDURE ............................................... 7 BACKGROUND ............................................................................................................................................. 8 PROBLEM STATEMENT ................................................................................................................................9 NEEDS ASSESSMENT AND GAP ANALYSIS ................................................................................................. 10 REVIEW OF THE LITERATURE ........................................................................................................... 10 DIFFICULT AIRWAY ALGORITHM IN SIMULATION ..................................................................................... 11 CONFIDENCE IN PROCEDURAL SKILL AND KNOWLEDGE ........................................................................... 12 NURSING EDUCATION IN SIMULATION ...................................................................................................... 13 LITERATURE REVIEW CONCLUSION .......................................................................................................... 14 THEORETICAL FRAMEWORK............................................................................................................. 14 PROJECT AIMS AND OBJECTIVES ..................................................................................................... 16 SWOT ANALYSIS ...................................................................................................................................... 17 DESIGN AND METHODS......................................................................................................................... 18 PROJECT SITE AND SAMPLE ....................................................................................................................... 18 METHODS .................................................................................................................................................. 19 MEASUREMENT INSTRUMENT.................................................................................................................... 20 SATISFACTION AND CONFIDENCE INTERVAL ............................................................................................. 21 KNOWLEDGE ASSESSMENT ....................................................................................................................... 21 DATA COLLECTION ................................................................................................................................... 22 ETHICAL CONSIDERATIONS ....................................................................................................................... 22 ANALYSIS.................................................................................................................................................. 23 RESULTS..................................................................................................................................................... 24 SATISFACTION AND SELF CONFIDENCE WITH CURRENT LEARNING .......................................................... 24 4 OVERALL SATISFACTION WITH CURRENT LEARNING (PRE- AND POST-TEST) ........................................... 25 OVERALL SELF CONFIDENCE WITH CURRENT LEARNING (PRE- AND POST-TEST) ..................................... 25 KNOWLEDGE ASSESSMENT ....................................................................................................................... 26 PROCEDURAL CHECKOFF SCORES ............................................................................................................. 27 PROCEDURAL TIME TO COMPLETION ........................................................................................................ 27 SUMMARY ................................................................................................................................................. 28 DISCUSSION .............................................................................................................................................. 28 RECOMMENDATIONS.....29 STRENGTHS AND LIMITATIONS .................................................................................................................. 29 CONCLUSION ............................................................................................................................................ 30 REFERENCES ............................................................................................................................................ 31 APPENDIX A: ASA DIFFICULT AIRWAY ALGORITHM ................................................................. 37 APPENDIX B: LITERATURE REVIEW MATRIX ............................................................................... 38 APPENDIX C: PRISMA DIAGRAM........................................................................................................ 45 APPENDIX D: JEFFERIES SIMULATION THEORY MODEL ......................................................... 46 APPENDIX E: SWOT ANALYSIS INFOGRAPHICS ........................................................................... 47 APPENDIX F: IRB APPROVAL LETTER ............................................................................................. 48 APPENDIX G: STUDENT SATISFACTION AND SELF-CONFIDENCE IN LEARNING .............. 49 APPENDIX H: PRE-TEST AND POST-TEST ........................................................................................ 50 APPENDIX I: SELDINGER PROCEDURE INSTRUCTIONS ............................................................. 52 APPENDIX J: TABLES ............................................................................................................................. 53 TABLE 6 .................................................................................................................................................... 53 TABLE 7 .................................................................................................................................................... 54 TABLE 8 .................................................................................................................................................... 55 5 TABLE 9 .................................................................................................................................................... 56 TABLE 10 .................................................................................................................................................. 57 TABLE 11 .................................................................................................................................................. 58 TABLE 12 .................................................................................................................................................. 59 TABLE 13 .................................................................................................................................................. 60 TABLE 14 .................................................................................................................................................. 61 TABLE 15 .................................................................................................................................................. 62 TABLE 16 .................................................................................................................................................. 63 TABLE 17 .................................................................................................................................................. 64 TABLE 18 .................................................................................................................................................. 65 TABLE 19 .................................................................................................................................................. 66 TABLE 20 .................................................................................................................................................. 67 TABLE 21 .................................................................................................................................................. 68 6 Abstract Background: Anesthesia providers are trained to adapt and rapidly respond to cannot intubate cannot ventilate situations based on a difficult airway algorithm. In anesthesia education, simulated events allow for effective learning in a safe environment. Currently, at Marian University, there is no simulated education on the cricothyrotomy procedure. Purpose: This DNP project was developed to assess the effectiveness of a cricothyrotomy simulation on student confidence level, knowledge base, procedural accuracy, and satisfaction in learning compared to the current didactic curriculum. Methods: This project collected quantitative data through electronic pre- and post-simulation surveys. Information for the simulation was published through a Canvas page. The questions were derived from the curriculum textbooks and the Student Satisfaction and Self-Confidence in Learning instrument. Implementation: A total of 12 SRNAs participated in this project. Students were given access to the Canvas course before the simulation date, which contained access to the pre-test. All students underwent the same simulation set-up and were asked to perform the procedure based on the information provided on Canvas. After completion of the simulation, students were asked to complete the post-test survey. Conclusion: Simulation education increased the students knowledge and self-confidence regarding the cricothyrotomy procedure (p<0.05; p<0.05). Overall, students revealed that they had increased satisfaction in learning with simulated events versus didactic learning (p<0.05). Similarly, the knowledge base of the students increased because of this simulation (p=0.01). Keywords: Anesthesia, SRNA, Simulation, Cricothyrotomy, CICV, INACSL, Education 7 Cricothyrotomy: The Life-saving Airway Procedure This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Anesthesia track. Anesthesia providers are taught throughout their education how to manage an airway and the corresponding side effects of administering anesthetics. A prominent component of anesthesia education focuses on the assessment and management of airway complications. A student registered nurse anesthetist (SRNA) is expected to be able to respond to an emergency airway event through the guidance of a prefabricated airway algorithm. In the United States, the most common flowsheet is distributed by the American Society of Anesthesiologists (ASA) (Apfelbaum et al., 2022). This algorithm details how an anesthesia provider should differentially perform interventions in order to secure the airway. In the rare occurrence of a cannot intubate cannot ventilate (CICV) event, the algorithm requires the provider to insert an invasive airway after other interventions have been attempted (Appendix A). Simulation incorporation within healthcare education is increasing in demand and popularity as it provides a safer route of hands-on demonstration for both the patient and the provider (Council of Accreditation, 2020). As such, the International Nursing Association for Clinical Simulation and Learning (INACS) has published guidelines that outline the best practice for simulations with references to standards, design, facilitation, and operations which should be included within an educational platform (Watts et al., 2021). Due to the invasive nature of cricothyrotomies, it is plausible that SRNA education may not fully meet the criteria outlined by the INACS guidelines. If simulation education improves knowledge, skill, and retention; then it 8 is imperative that curriculum models follow this practice structure to acquire the best results for the students (Council of Accreditation, 2020). Background The cricothyrotomy procedure can be the intervention that determines life or death for critically injured and ill patients. A study completed by Kwon and colleagues (2019) concluded that 0.23% of tracheal intubations result in cricothyrotomy. Of these, the procedure success rate was 73.9% and the patient survival rate was 47.8% (Kwon et al., 2019). Based on these statistics, it can be assumed that the survival rate would have increased to 60.2% had the procedure been performed correctly every time. In a patient population of 1,000, this adjustment would have saved the life of an additional 124 patients. Interestingly, Kwon and colleagues (2019) found that residents had a higher success rate (100%) than practicing physicians (68.4%) in performing a cricothyrotomy. This could suggest that recent education and practice can increase the success rate of the procedure. Fortunately, the cricothyrotomy procedure is not a frequently required procedure due to the advancements in the Difficult Airway Algorithm (Apfelbaum et al., 2022) However, this has left little opportunity to practice the skill during training (Chang et al., 1998; Cho et al., 2016). In fact, it is estimated that anesthesiologists and intensivists will experience a CICV situation an average of 2.6 times in their entire career (Cho et al., 2016). With cricothyrotomy being the final step in the difficult airway algorithm, this leaves little room for clinical experience and a high reliance on simulation training. Hands-on simulation strategies have been used to teach a number of different medical skills, resulting in increased confidence in the provider, such as vascular access (Okano, 2021; 9 Blanie, 2022), airway management (Hansen, 2020), TEE performance and interpretation (Yang, 2021), regional techniques (Koh, 2021), and advanced life support (Massoth, 2019). Due to the technological advancements in simulation-based education, this method of teaching has become a staple in most medical-related professions. Current literature states that anesthesia providers retain procedural skills for up to one year following a single session of a high-fidelity simulation (Boet et al., 2011). Providers who have less than 10 years of anesthesia experience are, at a minimum, 50% less likely to not know how to perform an emergency airway procedure (Fayed et al., 2022). Of those who are currently in practice, 87% of providers have never had hands-on experience in the cricothyrotomy procedure (Fayed et al., 2022). These statistics are alarming and demonstrate the education inadequacy surrounding the cricothyrotomy procedure. Problem Statement Anesthesia providers must be prepared to identify, a difficult airway, proceed to secure it, and provide the patient with ventilation. If initial attempts to secure an airway are futile, providers are taught to initiate a clinical algorithm to help guide the decision-making process. In the event of a CICV situation, the final step includes implementing a surgical airway (Apfelbaum et al., 2022). Students should enter the profession having firm confidence in their skills to perform this life-saving measure. This Doctor of Nursing Practice project focused on how SRNAs rank their confidence level in performing cricothyrotomies and their knowledge base founded on current educational practices in comparison to a hands-on simulation education curriculum. 10 Needs Assessment and Gap Analysis Within the state of Indiana, there are currently two graduate programs that have a nurse anesthesia tract; both of which with varying degrees of incorporation and complete simulation of the ASAs difficult airway algorithm. Within Marian University, an Indianapolis-based campus, SRNAs are taught didactically the purpose, implications, and use of a cricothyrotomy. Simulation of the ASA difficult airway algorithm incorporates the hands-on experience of a CICV scenario, but students are requested only to act out the scenario until the decision point to place an invasive airway. A cricothyrotomy procedure is not physically performed in the simulation lab. The Council of Accreditation of Nurse Anesthesia Educational Programs states that simulation-based education produces higher learning outcomes, competency attainment, and skill retention (Council of Accreditation, 2020). By performing a needs assessment and literature review on how simulation improves cricothyrotomy skill confidence, this study hoped to prove that simulation could enhance student preparedness, performance, and retention of the cricothyrotomy procedure among Marian SRNAs. Review of the Literature A review of the literature was conducted to investigate the PICO question of what is the effect of participation in a hands-on simulation experience in comparison to current curriculum methods on SRNA confidence level and knowledge basis concerning the performance of a cricothyrotomy? The following electronic databases were utilized: PubMed, Academic Search Complete, Alt Health Watch, Biomedical Reference, CINAHL, ERIC, Health Business, Health Source: Nursing/Academic Edition, MEDLINE, and Professional Development. The search was conducted with the following combination of keywords: CICV; simulat*; difficult airway algorithm; skill; anesthes*; cricothyrotom*; FONA; and nursing education. Any articles that 11 were not scholarly peer-reviewed, published within the last five years (2018-2022), and written in English were immediately disqualified (n= 15,382). For a journal article to be included within this literature review, the content must relate to the knowledge, confidence, and performance surrounding emergency surgical airway placement for anesthesia providers and/or the impact of simulation on nursing education. All articles that did not pertain to either of these categories were excluded from the review (n= 2,575). These search criteria resulted in 4,174 articles populating, however, after a screening of inclusion and exclusion criteria, only 2, 598 were assessed. Based on those articles, 23 pertinent articles were included in the literature matrix found in Appendix B. The articles found in this literature review can be distributed within the following categories: difficult airway algorithm in simulation (n=11), confidence in procedural skill and knowledge (n=7), and nursing education in simulation (n=12). Reference the Prisma diagram in Appendix C. Difficult Airway Algorithm in Simulation Eleven articles pertained to the assessment of anesthesia providers ability to work through the ASAs difficult airway algorithm and perform a surgical airway procedure (Alamrani, et al., 2018; Aez Simn et al., 2019; Clark et al., 2022; George et al., 2022; Issa et al., 2021; Johnson et al., 2022; Liu et al., 2022; Ott et al., 2018; Rajwani, Mauer & Clapper, 2019; Scott Hering et al., 2020; Zhang et al., 2022). The use of simulation has been shown to be effective in analyzing the knowledge base of providers for the cricothyrotomy procedure (Alamrani, et al., 2018; Aez Simn et al., 2019; Clark et al., 2022; Issa et al., 2021; Johnson et al., 2022; Scott Hering et al., 2020). Pre-education skill results show that providers range from successful completion of a cricothyrotomy by 2-86% (Aez Simn et al., 2019; Clark et al., 12 2022; Issa et al., 2021). However, when researchers placed a time restriction on the successful completion of a cricothyrotomy during testing, less than 10% could achieve this benchmark preeducation (Clark et al., 2022; Issa et al., 2021; Scott Hering et al., 2020). The articles varied on the equipment that providers could use to perform the procedure, but it was noted that the scalpel/bougie/endotracheal tube technique produced the fastest times (Clark et al., 2022; George et al., 2022; Scott Hering et al., 2020). The project design for these articles incorporated demonstrations, traditional lectures, visual aids, and feedback as part of the educational component between pre-testing and posttesting (Alamrani, et al., 2018; Aez Simn et al., 2019; Clark et al., 2022; George et al., 2022; Issa et al., 2021; Johnson et al., 2022; Liu et al., 2022; Ott et al., 2018; Rajwani, Mauer & Clapper, 2019; Scott Hering et al., 2020; Zhang et al., 2022). Every study showed significant improvement in the first attempt post-education to perform a surgical cricothyrotomy regarding completion time and/or the number of safety breaches (p<0.05) (Alamrani, et al., 2018; Aez Simn et al., 2019; Clark et al., 2022; George et al., 2022; Issa et al., 2021; Johnson et al., 2022; Liu et al., 2022; Ott et al., 2018; Rajwani, Mauer & Clapper, 2019; Scott Hering et al., 2020; Zhang et al., 2022). In one study, it was noted that although results improved after educational interventions, some participants needed additional attempts to successfully complete the procedure (Issa et al., 2021). Confidence in Procedural Skill and Knowledge Seven articles pertained to students evaluation of their self-reported confidence level regarding both their knowledge and ability to perform a surgical cricothyrotomy (Alamrani et al., 2018; Aez Simn et al., 2019; Bessman et al., 2020; Fayed et al., 2022; Issa et al., 2021; 13 Johnson et al., 2022; Rajwani, Mauer & Clapper, 2019). The most common tool utilized for the assessment of self-reported confidence was a Likert-type questionnaire (Alamrani et al., 2018; Aez Simn et al., 2019; Bessman et al., 2020; Fayed et al., 2022; Issa et al., 2021; Johnson et al., 2022; Rajwani, Mauer & Clapper, 2019). Knowledge assessments were generated with researcher-designed surveys that included multiple-choice questions and fill-in-the-blanks (Aez Simn et al., 2019; Bessman et al., 2020; Fayed et al., 2022; Issa et al., 2021; Johnson et al., 2022; Rajwani, Mauer & Clapper, 2019). In general, the majority of participants rated their self-confidence in procedural confidence and technique low (Bessman et al., 2020). Furthermore, results disseminate that students struggle with preoperative planning of a difficult airway, optimization of basic airway techniques, and optimization of advanced airway techniques (p<0.001; p=0.02; p<0.001) (Bessman et al., 2020). For practicing providers, two studies reveal that actual clinical performance of the skill and years of practicing have a significant impact on knowledge and skill confidence (p<0.05) (Fayed et al., 2022). After educational intervention, 89% of participants ranked their confidence level as greatly improved (Issa et al., 2021). Nursing Education in Simulation Twelve articles focused on the impact that simulation had on nursing education, specifically with changes in confidence, communication, and critical thinking (Alamrani et al., 2018; Boostel et al., 2018; Chang et al., 2021; Fayed et al., 2022; Kim & Yoo, 2018; LaCerra et al., 2019; Leguox et al., 2020; Lei et al., 2022; Mulyadi et al., 2021; Oliveira Silva et al., 2022; Rajwani, Mauer & Clapper, 2019; Zasso et al., 2021). These studies focused on comparing hands-on simulation experience to traditional lecture-style education (Boostel et al., 2018; Chang 14 et al., 2021; Lei et al., 2022; Mulyadi et al., 2021). Overall, the simulation shows improvement in the following categories: effective communication skills, problem-solving, confidence, feeling prepared, critical thinking, clinical judgment ability, and novel learning experience (p<0.05) (Change et al., 2021; Kim & Yoo, 2018; Lei et al., 2022; Oliveira Silva et al., 2022; Rajwani, Mauer & Clapper, 2019). Three of the twelve articles showed a significant improvement in participants knowledge base in comparison to pre and post-test evaluation scores (p<0.05) (Fayed et al., 2022; Lei et al., 2022; Mulyadi et al., 2021). Regarding satisfaction with the educational intervention, participants preferred simulation-style learning over traditional lectures and suggested that simulation be introduced as part of annual competencies (Chang et al., 2021; Fayed et al., 2022; LaCerra et al., 2019; Mulyadi et al., 2021). Literature Review Conclusion Simulation training for anesthesia providers is effective and recommended. This style of education allows for content review, safe practicing, feedback, and self-evaluation while improving the speed of performance and confidence levels. For these reasons, simulation regarding the ASA difficult airway algorithm should be encouraged within SRNA curriculum in conjunction with the requirements set forth by the Council of Accreditation (Council of Accreditation, 2020). Theoretical Framework The foundational framework for this DNP project was based on the National League for Nursing (NLN) Jeffries Simulation Theory. This theory was originally developed in 2005 but has since been revamped three times. Appendix D represents the current conceptual illustration and 15 representation of this theory. The basis of the NLN Jeffries Simulation Theory focuses on the interaction of six specific concepts that fit within an overarching theme of context. The six components that correspond to the context are background, design, simulation experience, facilitator and educational strategies, participant, and outcomes (Jeffries et al., 2015). Context is described as the circumstance or environment in which the learning will occur and can include the purpose for why this education must be implemented (Jeffries et al., 2015). The background and design aspects of this theory filter into the simulation experience. The background takes into consideration the objectives and expectations of the educational intervention (Jeffries et al., 2015). This must build upon an existing curriculum and current resources in order to correspond to the educational benchmarks that are assigned to the students (Jeffries et al., 2015). This is fulfilled with the use of current clinical textbooks as references for the educational information and knowledge-based questions. The design of the simulation must further incorporate the educational objectives with a focus on developing a scenario that engages in curriculum content and the development of problem-solving (Jeffries et al., 2015). During this step, the participants roles, the progression of the simulation, and the discussion must be established (Jeffries et al., 2015). This is pertinent to the SRNA education because it reinforces concepts and expectations set forth by the accreditation board (Council of Accreditation, 2020). The simulation portion of this project was structured as the same format students are accustomed to with their skill test-outs. The simulation experience incorporates the facilitator, educational strategies, and the participant before converging into the simulation outcome (Jeffries et al., 2015). The simulation experience is meant to be a place of judge-free learning and collaboration where mistakes can be 16 made. Educational strategies directly apply to the facilitator and can be tailored to the facilitators preference. The facilitator brings their expertise, skill set, engagement, and preparation into the simulation (Jeffries et al., 2015). The relationship between the facilitator and the participant must be dynamic, with each one responding to the other (Jeffries et al., 2015). Participants bring forth various attributes to the simulation, such as preparation, confidence, anxiety, and personal experience (Jeffries et al., 2015). The outcomes of the simulation can be categorized as participant, patient, and system outcomes (Jeffries et al., 2015). This project incorporated an analysis of both participant and system outcomes. A review of participant reactions and learning experiences has been reflected in the dissemination of the post-test information. Project Aims and Objectives The three aims of this project were to improve the knowledge foundation of the difficult airway algorithm regarding the purpose and utilization of cricothyrotomies, to teach the process of how to perform a cricothyrotomy, and to improve the participants confidence level in performing a cricothyrotomy. The main objective of this DNP project was to give Marian SRNAs a hands-on cricothyrotomy simulation, which enhanced their knowledge and confidence level, in comparison to their pre-experience assessment, by the end of the workshop. The goal was that students would demonstrate a two-point increase in their post-workshop knowledge of anatomy and the cricothyrotomy procedure as well as perceived confidence levels based on the Student Satisfaction and Self-Confidence in Learning assessment tool. 17 SWOT Analysis Before the initiation of the workshop, a thorough assessment was completed to identify the positive and negative characteristics of the project. Positive contributions are sectioned as strengths and opportunities, while the negative aspects are labeled as weaknesses and threats, as demonstrated in Appendix E. The strengths of this project lie within having access to Marian Universitys simulation and cadaver lab as the physical environment to conduct the workshop, having numerous interested stakeholders (specifically the Marian SRNAs and faculty), and enlisting the help and resources of a community partner that is heavily connected within the Indiana CRNA community. This project has the potential to expand into something more including leg. This project has been set up in a way that it can be used as a legacy project for Marian DNP projects, be included in the future SRNA curriculum through yearly simulations, and can be replicated and offered to members of the CRNA community rather than students alone. However, as important as it is to acknowledge the benefits of a project, it is equally important to identify and recognize the barriers that also are involved. Key weaknesses of this project included resource availability for both cricothyrotomy kits and organic tissue, potential discrepancies between student users as they will be asked to perform the procedure on artificial tissue that is not identical to human tissue, the need for volunteers to help during the workshop, and accuracy in timing the procedure length. Threats to this project included the weakness of insufficient resources for participants to utilize single-use items as intended. Secondly, the data collection for this project was dependent on the participant's effort in completing the questionnaires fully and being accurate in their responses. 18 Design and Methods This DNP project utilized a quality improvement design in hopes to update the current cricothyrotomy teaching method at Marian University to a hands-on simulation experience. This quality improvement project collected quantitative data utilizing a variety of evaluation tools, such as a confidence scale, pre-test, post-test, and a skill observation and technique evaluation. The project was deemed as an experimental quantitative study using a within-subjects and pretest/post-test design with the independent variable being the education method and the dependent variable being the participants knowledge and confidence performing the skill. This design allowed for evaluation of pre-simulation compared to post-simulation knowledge basis, skill performance, and confidence levels. The goal of this project was to remodel the education at Marian University surrounding the cricothyrotomy procedure, and this quality improvement project design has adequately and numerically demonstrated the difference and the effectiveness in the current teaching and the purposed teaching method. Project Site and Sample This cricothyrotomy lab was held within the skills lab of the Marian University Anesthesia simulation lab. This location was ideal because, if implicated, the cricothyrotomy simulation mannequin would likely be housed in the anesthesia skills room. The Marian University Anesthesia Simulation Lab has recently been revamped to include two operating rooms, a skills lab, and a debriefing conference room. This revitalized simulation lab with high fidelity equipment has the chance to make Marian a front runner to prospective students. The program director and the simulation lab director are stakeholders in this project and have a vast interest in its results. In a broader since, this project could directly impact prospective students to 19 Marian Universitys medical programs and the patients that will come into their care. Ultimately, the company that creates the cricothyrotomy simulation mannequins, Design and Business LLC, are potential stakeholders because this project could provide efficacy of their product. A sign-up sheet was presented to all CRNA students currently enrolled at Marian University. A total of 12 participants were included. Despite being a smaller population, this sample population will adequately represent the students within Marian Universitys Anesthesia program because of the comparably small class sizes. Inclusion criteria must have been met to be involved, this included being actively enrolled in the Marian Anesthesia program, ability to speak English, and a willingness to come to in-person training. Students that did not sign up before the deadline or were unable to be on campus for the cricothyrotomy simulation lab were excluded from the data collection. Additionally, students that have not completed the first two semesters of the program have yet to receive difficult airway algorithm training and therefore, were excluded from the study. Methods Before developing this project, an exemption was obtained from Marian Universitys Institutional Review Board (IRB) (Appendix F). Afterwards, the curriculum for this simulation was created based upon resources that are readily available to students who are enrolled in Marian Universitys nurse anesthesia program. Specifically, the resources included the textbooks, Nurse Anesthesia, 6th edition (Nagelhout & Elisha, 2018), and Clinical Anesthesia, 6th edition (Barash et al., 2017); as well as online material found on prominent organizations and equipment manufacturers webpages, such as the American Society of Anesthesiologists, Cook Medical, and the Center for Disease Control and Prevention. Upon reviewing these resources, the 20 authors developed a Canvas course that outlined this information in document, PowerPoint, and video format. Students who enrolled into the project were given access to the Canvas course via email invitation. Before the students were able to view the media files within the course, they were asked to complete the measurement instrument pre-test, which was available and secured through Qualtrics. After completion of the pretest, the students were asked to view the media files found within the Canvas course before their requested time slot. Students were notified that they would have 30 minutes to conduct the cricothyrotomy procedure on the mannequin, with the possibility of a question-and-answer session, as well as personalized feedback after their performance. During the procedure, the authors would assess student performance based on the accuracy of the completion of the cricothyrotomy steps, as listed in the Cook Medical document, given to students within the Canvas course. After the completion of the simulation, students were asked to complete the measurement instrument post-test which was available and secured through Qualtrics. Measurement Instrument The measurement instruments, the pre- and post-test, were created based on the integration of a Student Satisfaction and Self-Confidence in Learning assessment tool (Appendix G) and knowledge found within the required readings for Marian University curriculum in regards to current difficult airway simulation. During the pre-test, the authors included demographic based questions, such as years working as a registered nurse, learning preferences, and current experience with cricothyrotomies. Please review Appendix H for the questions contained within the pre- and post-test. The pre- and post-test questionnaires were 21 administered through a Qualtrics link that was available through the Canvas course, as well as the students Marian University email address. For the skill performance, the authors created a check-off that included the exact steps listed in the Cook Medical document, with each step being given a one point, for a total of seven points possible. While the Cook Medical has eight steps, the Melker Emergency Kit that was provided in the simulation does not have an inflatable cuff, therefore that step and subsequent point was deleted from the check off. Satisfaction and Confidence Interval The Student Satisfaction and Self-Confidence in Learning assessment tool was developed by the National League for Nursing in 2005 (Appendix G). Since its publication, it has been validated for academic use, with a Cronbach alpha value range of 0.77-0.85 (Unver et al., 2017). It is a 13-question test that uses a Likert-like scale to gauge participants self-reported satisfaction and confidence regarding the learning outcomes. The participants were asked to rank their answers on a one to five scale, with one equating to strongly disagree and five equating to strongly agree. An analysis of the tool indicates that five of the questions relate to student satisfaction, while the other eight pertain to their perceived confidence level in the learning outcomes. As such, scores were tallied into two categories; the satisfaction questions contained a point range of 5-25, while the confidence questions contained a point range of 8-40. Knowledge Assessment In the pre- and post- test, there were seven questions that pertain to the clinical application of the cricothyrotomy procedure. Five questions were written with a multiple-choice structure, while one was a select all that apply, and the final question was order ranking format. 22 The order ranking question asked the participants to order the steps of the Seldinger technique (Appendix I). The topics included in the knowledge assessment focused on anatomy, contraindications, duration of use, proper cuff inflation, and procedural technique. The questions were derived from information found within the Nurse Anesthesia, 6th edition (Nagelhout & Elisha, 2018). The validity of the knowledge-based questions was confirmed by Marian Universitys simulation instructor, who is a Doctorly Prepared Nurse Anesthetist, and serves as a content expert on this project. Data Collection The authors utilized Qualtrics to collect data regarding the pre- and post-test. Students were given a one-week timeframe to complete the pre-test before the date of the simulation. The authors reminded the students of the post-test at the end of their timeslot and asked that it be completed within five days. The authors also sent a follow-up email after the simulation with a reminder message and a link to the Qualtrics survey. All responses were kept confidential. Ethical Considerations This project commenced after approval was granted from Marian Universitys IRB Committee on March 03, 2023 (Appendix F). Questionnaire results remained confidential and anonymous throughout the project as Qualtrics distributed the surveys to participants academic email accounts. Qualtrics also acted as the secured storage location for survey results. Each participant chose a four-digit code and they placed it on each of their assessment tools. This allowed for correlation of the pre-evaluation assessments to the post-evaluation assessments with anonymity. No identifying information was required on the evaluation tools. The researchers had 23 access to the list of 12 students who participated in the project. This access was required so that the appropriate students could be contacted regarding education material and lab sign up. However, no other stakeholders had access to which students participated in the study. An educational video demonstrating the cricothyrotomy technique on a deceased donor was available for participants to see. Participants only had access to the video during the education portion of this project. Great care was taken to maintain the safety of the demonstrators and to uphold respect for the donors. Demonstrators received safety training and educational modules from the cadaver lab supervisor. After taping, the video was uploaded to a USB drive and securely stored at Marian University within the CRNA program directors locked office. It will stay there until the completion and dissemination of this project. After dissemination, it will be destroyed. University regulations pertaining to the use of deceased tissue for educational purpose were upheld throughout the entirety of this project. The researchers would like to acknowledge the generous people who donated their bodies to science as key contributors to this project. Analysis The data analysis for this project utilized descriptive and inferential statistics. Descriptive data was processed via central tendency, frequency, and variability measures. The calculations for central tendency including mean, median, and mode, along with frequency were performed on Microsoft Excel. Variability in the data was accounted for through standard deviations. Based on the knowledge survey and the demonstration of skills, the data fell into either ordinal or interval scales. After performing a Jarque-Bera test for normality, the resulting p value was 0.569, meaning that the null hypothesis is rejected, and the data is normally distributed. Since the 24 data shows equal distribution, an independent samples t-test with equal variance was used to compare the pre- and post-tests. The quantitative data was analyzed using the program IBM SPSS Statistics v.27, a software provided by Marian University. Results A total of twelve Marian SRNAs were eligible and participated within this study. All students completed the pre-test prior to the simulation and completed the post-test immediately after the simulation. The participants were distributed between those in the junior and senior classes. The majority of participants were female (67%), healthcare providers who had 2-5 years of experience (42%) and never have had to perform a cricothyrotomy before either in simulation or life (83%; 92%). Table 1: Demographics and Characteristics of Study Participants Gender Females Males Years of Experience 2-5 5-10 10+ Previous Demonstration Simulated Actual n= % 8 4 66.7 33.3 3 5 4 25 41.7 33.3 2 1 16.7 8.3 Satisfaction and Self Confidence with Current Learning Based on the separation of questions found within the Student Satisfaction and SelfConfidence in Learning assessment tool, the questions were analyzed in relation to their category. The first five questions targeted overall satisfaction with current learning, and the other 25 eight questions related to the students self confidence in skill performance. Students were made aware that in the pre-test, they should answer based on the previous didactic learning they have experienced through Marian University, and the post-test is based on the education from the Canvas course and simulation. Please refer to Tables 6-18 for a complete representation. Overall Satisfaction with Current Learning (Pre- and Post-test) The students were asked to answer five questions based on a Likert-like scale, ranking their responses from 1-5. An independent samples t-test with equal variance indicated that students were statistically more satisfied with their learning after completion of the simulation than with didactic only (p< 0.05). Furthermore, individual question analyzed showed that all five questions were statistically significant in improvement of learning outcomes (p< 0.05). Table 2: Results of 5-Items to Measure Satisfaction with Current Learning Item Pre-test Mean Satisfaction 1 Satisfaction 2 Satisfaction 3 Satisfaction 4 Satisfaction 5 Summed Satisfaction 2.75 2.75 2.83 2.83 2.75 2.78 Post-test Mean 4.67 4.75 4.58 4.67 4.67 4.67 Mean Difference +1.92 +2.0 +1.75 +1.84 +1.92 +1.79 p-value 4.91 x 10 2.25 x 10 1.39 x 10 6.81 x 10 5.31 x 10 7.58 x 10 *Note: statistically significant change at p<0.05 Overall Self Confidence with Current Learning (Pre- and Post-test) The students were asked to answer eight questions based on a Likert-like scale, ranking their responses from 1-5. An independent samples t-test with equal variance indicated that students were statistically more confident with their ability to perform the skill after completion of the simulation than with didactic only (p< 0.05). Individual question analysis showed 26 statistically significant increases in self-confidence in seven out of the eight questions. The question It is the instructors responsibility to tell me what I need to learn of the simulation activity content during class time did not have a significant change (p= 0.21). Table 3: Results of 8-Items to Measure Self-Confidence with Current Learning Item Pre-test Mean Self-Confidence 6 Self-Confidence 7 Self-Confidence 8 Self-Confidence 9 Self-Confidence 10 Self-Confidence 11 Self-Confidence 12 Self-Confidence 13 Summed Confidence 2.67 2.75 2.75 2.92 3.83 4.00 3.83 3.33 3.26 Post-test Mean 4.50 4.58 4.58 4.58 4.58 4.67 4.58 3.67 4.47 Mean Difference +1.83 +1.83 +1.83 +1.66 +0.75 +0.67 +0.75 +0.34 +1.21 p-value 4.96 x 10 2.15 x 10 9.85 x 10 6.76 x 10 1.42 x 10 9.07 x 10 3.78 x 10 0.21 7.58 x 10 *Note: statistically significant change at p<0.05 Knowledge Assessment Students were given a series of seven knowledge base questions as part of the pre- and post-test. These questions included the format of select one, select all that apply, and list in order. For the select all that apply and list in order questions, the scoring was all-or-nothing. Overall, the mean score for pre-test was 3 (range 1-7), while post-test was 5 (range 2-7). As a whole, this result is statistically significant (p=0.01). Between both pre- and post-test, the question concerning absolute contraindications was missed the most (8.3%; 33.3%). For the pre-test, the question concerning anatomy was answered correctly the most (91.7%), while for the post-test, the question of needle direction was answered correctly the most times (91.7%). The full 27 breakdown of answer selection for the increased difficulty of placement and the order of the procedural steps can be found in Tables 19-21. Procedural Checkoff Scores The authors used the Cook Medical document that was provided to the students in the Canvas course to create a scoring basis for procedural step completion (Appendix I). Students were asked to perform seven steps, with each step earning a single point. The mean score from this simulation was 6, within a range of 0 to 7. The authors made notes as to why points were taken away. The results can be found in Table 4. Table 4: Results of Missed Points in the Performance of a Cricothyrotomy Deviations to Procedure Did not stabilize the cricothyroid membrane Did not insert needle/catheter into the cricothyroid membrane Inserted the needle in the cephalad direction Inserted the assembled airway in the cephalad direction Did not attach syringe to needle/catheter for aspiration Did not use the guidewire Did not combine the dilator and tracheostomy device together Did not take needle/catheter off guidewire before attempting to place airway device Did not attach tracheostomy ties Occurrences 1 1 1 1 1 2 5 1 2 Procedural Time to Completion Before the start of the procedural demonstration, students were made aware that their efforts would be timed, but that the time would not be disclosed to them. The authors began the time after they said, you may begin, and ended the time after the student verbalized the final step. The mean time to completion was 288 seconds. The timed results may be found in Table 5. 28 Table 5: Timed Results of Procedural Completion Time (seconds) 273 349 474 243 265 493 126 131 159 212 194 535 Summary A total of 12 Marian University SRNAs fully completed the components of this simulation project. Overall, there was a significant increase in satisfaction with learning, selfconfidence in procedural skill, and knowledge base between pre- and post- simulation (p<0.05; p<0.05; p=0.01). During the simulation, participants averaged a check-off score of six out of seven, with the most missed step being putting the airway device and dilator together to make a single unit. The average time of completion during the simulation was 288 seconds. Discussion Although an anesthesia provider will only encounter a CICV scenario a few times in their career, having adequate knowledge and comfortability in invasive airway procedures are critical for patient survival (Cho et al., 2016). Creating a productive learning environment through simulation allows for students to learn new skills in a manner that promotes safety and selfconfidence. The aim of this project was to determine the effect simulation had on students 29 knowledge base, self-confidence, and satisfaction in learning. The results indicate that simulation has a positive and significant effect on students. This further supports COAs recommendation that anesthesia education incorporates simulations. Recommendations The basis of this project is one that can create various other questions, aims, and goals. There are multiple techniques for how to perform a cricothyrotomy, however, we chose one for consistency. Studies have shown that when focusing on successful time of completion, certain techniques are faster than others (Clark et al., 2021; Geroge et al., 2022; Zang et al., 2022). Another aspect to consider would be to look at the retention rate for knowledge and procedural skill level for students after a specific timeframe has lapsed. Finally, we promote the use of larger sample sizes in order to create a more representative picture. Strengths and Limitations The study had five specific limitations. Primarily, single use Melker Emergency Cricothyrotomy kits were used multiple times due to the lack of equipment. The participants were able to complete the workshop prior to watching the educational material despite being prompted to do it firsthand. There should have been a definitive criterion that required full review of the required educational material prior to completion of the workshop. Although the mannequin and additional equipment simulated the procedure, it could not identically replicate human tissue. Additionally, the study was concluded at one location on one day, which limited participants to those who did not have other obligations such as class, clinical, or personal 30 responsibilities. Also, the data retrieved could be disproportionate due to the smaller sample size. Participant variability was noted regarding their previous cricothyrotomy training prior to Marian University. For instance, some participants had work-related education in various techniques with their previous healthcare occupations, such as respiratory therapists and EMTs. There was also variability in the amount of required educational material that the participants completed prior to the workshop and in what timeframe it was completed. For instance, some students arrived to the workshop after only completing the pretest while others had completed the pretest and the entire educational module. Conclusion This project provided insight into the benefits of a simulated cricothyrotomy workshop on student learning. Specifically, students showed an improvement in knowledge, satisfaction, and self-confidence with the simulation in comparison to didactic teaching alone. As simulation is a recommended resource for anesthesia learning, the hope is that an incorporation of simulated invasive airway procedures within anesthesia curriculum will produce SRNAs that are safe and competent care providers. Recommendations for future studies include focusing on different cricothyrotomy techniques and retention rate of knowledge and procedural skills. 31 References Alamrani, M. H., Alammar, K. A., Alqahtani, S. S., & Salem, O. A. (2018). 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G., Reeves, S. T., & Schaefer, J. J. (2022). Emergency subglottic airway training and assessment of skills retention of attending anesthesiologists with simulation mastery-based learning. Anesthesia & Analgesia, 135(1), 143151. https://doi.org/10.1213/ane.0000000000005928 33 Council on Accreditation. (2020). The value of simulation in nurse anesthesia education. https://www.coacrna.org/wp-content/uploads/2020/01/COA-ResponseRegarding-theUse-of-Simulation.pdf Fayed, M., Nowak, K., Angappan, S., Patel, N., Abdulkarim, F., Penning, D. H., & Chhina, A. (2022). Emergent surgical airway skills: Time to re-evaluate the competencies. Cureus, 14(3). https://doi.org/10.7759/cureus.23260 George, N., Consunji, G., Storkersen, J., Dong, F., Archambeau, B., Vara, R., Serrano, J., Hajjafar, R., Tran, L., & Neeki, M. M. (2022). Comparison of emergency airway management techniques in the performance of emergent cricothyrotomy. International Journal of Emergency Medicine, 15(1), 24. https://doi.org/10.1186/s12245-022-00427-3 Issa, N., Liddy, W. E., Samant, S., Conley, D. B., Kern, R. C., Hungness, E. S., Cohen, E. R., & Barsuk, J. H. (2021). Effectiveness of a simulation-based mastery learning to train clinicians on a novel cricothyrotomy procedure at an academic medical centre during a pandemic: A quasi-experimental cohort study. BMJ Open, 11. https://doi.org/10.1136/bmjopen-2021-054746 Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives, 36(5), 292293. https://doi.org/10.5480/1536-5026-36.5.292 Johnson, S., Rice, A., Martin, G., & Simmons, V. (2022). Mobile cricothyrotomy simulation cart improves anesthesia providers' confidence, technical skills, and procedure time. AANA Journal, 3(90), 206214. 34 Kim, Y. J., & Yoo, J. H. (2022). Effects of manikin fidelity on simulation-based nursing education: A systematic review and meta-analysis. The Journal of Nursing Education, 61(2), 6772. https://doi.org/10.3928/01484834-20211213-03 La Cerra, C., Dante, A., Caponnetto, V., Franconi, I., Gaxhja, E., Petrucci, C., Alfes, C. M., & Lancia, L. (2019). Effects of high-fidelity simulation ased on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: A systematic review and meta-analysis. BMJ open, 9(2), e025306. https://doi.org/10.1136/bmjopen-2018-025306 Legoux, C., Gerein, R., Boutis, K., Barrowman, N., & Plint, A. (2020). Retention of critical procedural skills after simulation training: A systematic review. AEM Education and Training, 5(3), e10536. https://doi.org/10.1002/aet2.10536 Lei, Y.-Y., Zhu, L., Sa, Y. T., & Cui, X.-S. (2022). Effects of high-fidelity simulation teaching on nursing students' knowledge, professional skills and clinical ability: A meta-analysis and systematic review. Nurse Education in Practice, 60. https://doi.org/10.1016/j.nepr.2022.103306 Liu, H.-H., Wang, Y., Zhong, M., Li, Y.-H., Gao, H., Zhang, J.-F., & Ma, W.-H. (2021). Managing the difficult airway. Medicine, 100(38). https://doi.org/10.1097/md.0000000000027181 Mulyadi, M., Tonapa, S. I., Rompas, S. S., Wang, R. H., & Lee, B. O. (2021). Effects of simulation technology-based learning on nursing students' learning outcomes: A systematic review and meta-analysis of experimental studies. Nurse Education Today, 107. https://doi.org/10.1016/j.nedt.2021.105127 Nagelhout, J., & Elisha, S. (Eds.). (2018). Nurse anesthesia (6th ed.). Elsevier 35 Oliveira Silva, G., Oliveira, F. S. E., Coelho, A. S. G., Cavalcante, A. M. R. Z., Vieira, F. V. M., Fonseca, L. M. M., Campbell, S. H., & Aredes, N. D. A. (2022). Effect of simulation on stress, anxiety, and self-confidence in nursing students: Systematic review with metaanalysis and meta-regression. International Journal of Nursing Studies, 133, 104282. https://doi.org/10.1016/j.ijnurstu.2022.104282 Ott, T., Truschinski, K., Kriege, M., Na, M., Herrmann, S., Ott, V., & Sellin, S. (2018). Algorithm for securing the unexpected difficult airway. Der Anaesthesist, 67(1), 1826. https://doi.org/10.1007/s00101-017-0385-2 Rajwani, K., Mauer, E., & Clapper, T. (2019). Improving the competence and confidence of pulmonary and critical care medicine fellows in performing a cricothyrotomy. Canadian Medical Education Journal, 10(3), e107e109. Scott-Herring, M., Morosanu, I., Bates, J., & Batoon, B. (2020). Cut to air. AANA Journal, 2(88), 116120. Unver, V., Basak, T., Watts, P., Gaioso, V., Moss, J., Tastan, S., Iyigun, E., & Tosun, N. (2017). The reliability and validity of three questionnaires: The student satisfaction and selfconfidence in learning scale, simulation design scale, and Educational Practices Questionnaire. Contemporary Nurse, 53(1), 6074. https://doi.org/10.1080/10376178.2017.1282319 Watts, P., Rossler, K., Bowler, F., Miller, C., Charnetski, M., Decker, S., Molloy, M., Persico, L., McMahon, E., McDermott, D., & Hallmark, B. (2021). Onward and upward: Introducing the healthcare simulation standards of bets practice. Clinical Simulation in Nursing, 58, 14. https://doi.org/10.1016/j.ecns.2021.08.006 36 Zasso, F. B., Perelman, V. S., Ye, X. Y., Melvin, M., Wild, E., Tavares, W., & You-Ten, K. E. (2021). Effects of prior exposure to a visual airway cognitive aid on decision-making in a simulated airway emergency: A randomized controlled study. European Journal of Anaesthesiology, 38(8), 831838. https://doi.org/10.1097/EJA.0000000000001510 Zhang, J., Ong, S., Toh, H., Chew, M., Ang, H., & Goh, S. (2022). Success and time to oxygen delivery for scalpel-finger-cannula and scalpel-finger-bougie front-of-neck access: A randomized crossover study with a simulated "Can't intubate, can't oxygenate" scenario in a manikin model with impalpable neck anatomy. Anesthesia and Analgesia, 135(2), 376 384. https://doi.org/10.1213/ANE.0000000000005969 37 Appendix A: ASA Difficult Airway Algorithm Apfelbaum, J. L., Hagberg, C. A., Connis, R. T., Abdelmalak, B. B., Agarkar, M., Dutton, R. P., Fiadjoe, J. E., Greif, R., Klock, P. A., Mercier, D., Myatra, S. N., OSullivan, E. P., Rosenblatt, W. H., Sorbello, M., & Tung, A. (2021). 2022 American Society of Anesthesiologists Practice Guidelines for management of the difficult airway. Anesthesiology, 136(1), 3181. https://doi.org/10.1097/aln.0000000000004002 38 Appendix B: Literature Review Matrix Citation Research Design & Level of Evidence Population / Sample size n=x Major Variables Instruments / Data collection Results Alamrani et al., 2018 Randomized controlled trial; Level 1 n= 30 Participants were undergraduate nursing students enrolled within a specific program Years of nursing education, previous exposure to simulation training, scenario the participant was assigned to, baseline mastery of nursing knowledge, Data collection as based on a survey that incorporated components of Cscale. Data analysis No significant differences in outcomes were identified between the simulator-based and traditional teaching methods, indicating that well-implemented educational programs that use either teaching method effectively promote critical thinking and selfconfidence in nursing students. includes paired samples t test, Wilcoxon signedrank test, and MannWhitney U test on SPSS v. 22. Ambardekar et al., 2019 Randomized controlled trial; Level 1 n=67 Participants were anesthesia focused medical students at the University of Texas Southwestern Medical Center Years of experience, previous exposure to the difficult airway algorithm, previous airway management experience The pre- and posttests included assessments from the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index. Data statistics were measured with the Fishers exact test and descriptive statistics. Medical students perform better in a simulated airway crisis after training in the Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load. There was no difference in anxiety scores. Aez Simn et al., 2019 Nonrandomized control trial; Level 3 n=91 Participants were students enrolled into anesthesiology specialty at an academic center Years of education, previous exposure to cricothyrotomy education, time to perform the skill, number of attempts, pre- and post-test knowledge scores, self-reported performance confidence Timing was based on stopwatches, and the pre- and postknowledge tests were surveys. Data analysis was preformed via Wilcoxon signed rank test in IBM SPSS Statistics. Bessmann et al., 2020 Descriptive study; Level 6 n=191 Participants were anesthesiologists who have performed an airway management Location of anesthesia services, years of experience, self-reported confidence scores, pre and post module test scores The e-learning course and quizzes were given through Area9 Lyceum ApS coding. Data analysis was completed via frequency analysis At first attempt, 86% of students performed a surgical cricothyrotomy with successful ventilation, and 92% at the sixth attempt (P<.0001). Time taken was 163 seconds at first attempt, and 70 seconds at the sixth (P<.0001). At the end of workshop, students had improved their theoretical knowledge (P<.0001) and perception of the ease of the technique. For preoperative planning, participants stated low confidence regarding predictors of difficult airway management. Subjective and objective assessments correlated, and lower confidence was associated with lower test 39 procedure in the past 60 days and Spearman's rho through IBM SPSS Statistics. Boostel et al., 2018 Randomized controlled trial; Level 1 n=52 Participants were undergraduate nursing students in one program Year in the program, previous experience in patient interaction, previous experience with simulation The survey for data collection was based on the KEZKAK questionnaire. Data analysis was conducted through Bioestat and included descriptive statistics, Mann-Whitney and Wilcoxon test. Chang et al., 2021 Randomized controlled trial; Level 1 n=107 Participants were students enrolled in a Fundamentals of Nursing class, found within the second year of a nursing program Assignment and examination performance, number of times participants interacted with the animation simulation, score on the Confidence in Communication assessment Clark et al., 2021 Nonrandomized control trial; Level 3 n=60 Participants included board certified anesthesiologists Performance without a safety breach, number of skill attempts, performance time, years away from residency Simulation instructors created the knowledge-based questionnaires. Surveys used in this project include the Confidence in Communication selfassessment and another validated survey with 11 questions. Data was analyzed with paired or independent t-tests via IBM SPSS 22. Data collection was gathered by the instructor and simulation engineer. Data analysis was run through a pairwise Wilcoxon signedrank tests of medians and post-hoc power analysis. Fayed et al., 2022 Descriptive study; Level 6 n=119 Collaboration of various anesthesia providers, including attendings, residents, and CRNAs. Years of occupation, extent of prior training, self-reported competency, previous exposure to a CICV event Data collection was gathered via surveys sent to providers work email addresses with Microsoft Forms. The results of scores: preoperative planning [P < .001], optimization of basic techniques [ P = .002], and advanced techniques [ P < .001]. There was a significant increase in the perception of factors related to lack of competence, not controlling the relationship with the patient, emotional involvement, and contact with suffering as stressors for the students after the simulation (p< 0.05). Simulation promotes the students awareness of their responsibility in patient care. Both groups showed statistically significant improvement in Confidence in Communication; however, the experimental group performed better on the skillset (p < .001; p< 0.001). The experimental group demonstrated a positive response to the simulation. The following themes emerged: effective communication skills, problem solving, confidence, feeling prepared and novel learning experience. Initial testing showed a success rate of less than 25% for each technique. After master-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved in speed with zero safety breaches. BC was the fastest technique. 15 months later, retesting showed that 80% and 82.6% performed successful airway securement for TTJV and BC. ment for TTJV and BC. 87% of participants had not performed the surgical airway procedure before. The vast majority (96.7%) recommended simulation training compared to online 40 the survey were analyzed through chi square and Fishers exact test. Statistical analysis was gathered through SAS 9.4 programming. George et al., 2022 Case control studyretrospective; Level 3 n=51 Charts included in this review occurred in a single hospital over a decade timeframe. Issa et al., 2018 Nonrandomized control trial; Level 3 n=37 Participants were doctoral students in years 2-5 of their medical education in the specialty of ENT or general surgery Pre-procedural Glasgow Coma Scale (GCS), Injury Severity Score (ISS), past medical history, vital signs, chief complaint, other injuries/symptoms, hospital course, hospital length of stay, disposition, clinical outcome, indication for cricothyrotomy, technique used, performing physician by subspecialty, location performed, and complications Participation practice time with the simulation manikin, procedure performance time, participant base knowledge, and previous experience of performing a cricothyrotomy, Data collection occurred from the electronic health records. Data analysis included an independent t-test, descriptive statistics, Wilcoxon rank sums test and chi-square test on the SAS software. Pre and posttests, as well as the procedure checklist, were created in conjunction with the Mastery Angoff standard setting method and Likert scale. Data analysis includes paired Wilcoxon signed rank test, and unpaired t-tests on SPSS v26. training or lecture series, and just over 50% recommended annual training frequency. When looking at the differences in responses based on years of experience as an anesthesia provider, the longer the work experience, the more familiar with the procedure participants were. Two techniques of cricothyrotomy were identified as preferred techniques (SFB and surgical). Both procedures were successful in securing an emergency airway. There was no significance difference in patient mortality rates (p=0.217). 24% of participants indicated they were never trained on performing a cricothyrotomy and 32% had never done a cricothyrotomy. Only one participant reached the set goals at pretest. All 37 participants were able to reach the goals at posttest. 76% of learners passed the posttest on the first attempt. 14% required a second posttest, 3% required a third posttest, while 8% required a fourth posttest. The mean time of completing the procedure was 4:25 min for the pretest compared with 3:10 min for the posttest (p<0.001). Thirty-one participants (89%) indicated they felt more confident in their ability to perform cricothyrotomy on patients after the training. 41 Johnson et al., 2022 Nonrandomized control trial; Level 3 n=66 Participants were anesthesiologists and CRNAs who worked at a level 1 medical center Years of experience, previous simulation exposure, previous experience with a task trainer, number of simulated cricothyrotomies, number of actual cricothyrotomies Participants skills were judged based on the Global Rating Scale (GRS) for Cricothyrotomies and a checklist. Time was measured via cell phone stopwatches. Data analysis was preformed via Wilcoxon signedranks test and IBM SPSS. Kim & Yoo, 2022 Systematic review and meta-analysis; Level 1 n=12 Articles included in this study were found on the following databases: CINAHL, Medline, Scopus, Embase, PsycINFO, ProQuest, KMbase, and RISS. Previous clinical practice, variables of nursing students that were measured, mastery of nursing knowledge, publication bias Data analysis included funnel plot, Eggers regression test, and the Begg and Mazumdar rank correlation test on the Comprehensive Meta-Analysis Software v.3. La Cerra et al., 2019 Systematic review and meta-analysis; Level 1 Previous clinical practice, variables of nursing students that were measured, mastery of nursing knowledge, publication bias Data was synthesized using meta-analytic procedures based on random-effect model and computing effect sizes by Cohen's d with a 95% CI, on ProMeta v.3 and IBM SPSS v.19. Legoux et al., 2020 Systematic review and meta-analysis; Level 1 n=33 Articles included in this study were found on the following databases: PubMed, Scopus, CINAHL with Full Text, Wiley Online Library and Web of Science n=10 Articles included in this study were found on the following databases: MEDLINE, Embase, and Central Trials Previous simulation experience, previous difficult airway exposure, time elapsed after simulation training, skill measurements Data analysis included qualitative and quantitative measures; however, the author only mentions standard deviation and Only 3 participants (4.5%) reported performing a real-life cricothyrotomy. Thirty-seven (56.1%) had not performed a simulated cricothyrotomy in the previous 10 years. There was a significant increase in median total confidence scores from presimulation to post-simulation (P < .001). The median total GRS scores significantly improved from pre-education to posteducation (P < .001). There was also a significant increase in overall checklist scores from preeducation to post-education (P < .001). The median procedure time in seconds decreased significantly from 151 in the preeducation assessment to 119 in the post-education assessment (P = .007). Higher-fidelity manikins were more effective than lower-fidelity manikins in improving skill performance/clinical competence and perception of nursing students and nurses. In terms of learners' knowledge, satisfaction, and selfconfidence, both higher- and lower-fidelity manikins were similarly effective for nursing students. Compared with other teaching methods, high-fidelity patient simulation revealed higher effects sizes on nursing students' knowledge and performance. While there was some evidence of skill retention after simulation, overall, most studies demonstrated skill decline over time. 42 Lei et al., 2022 Systematic review and meta-analysis; Level 1 Liu et al., 2021 Descriptive study; Level 6 Mulyadi, et al., 2020 Oliveira Silva et al., 2022 Registry of the Cochrane Collaboration n=15 Articles included in this study were found on the following databases: PubMed, Embase, Cochrane library, Web of Science, CNKI (China National Knowledge Infrastructure) and Wangfang I test. Previous clinical practice, variable of nursing students that were measured, measurement tools used, Cronbachs reliability score, risk of bias, baseline mastery of nursing knowledge Data analysis program used RevMan 5 to run chi square tests and I tests. n= 1935 Participants were anesthesia providers who were currently working in China Working years in anesthesia, evaluation methods for difficult airway, approaches to difficult airways, participation in an airway training course A questionnaire was submitted via survey. Data analysis includes Fishers exact test, descriptive statistics, and IBM SSPS v. 20. Systematic review and meta-analysis; Level 1 n= 17 Studies were found from the following sources: CINAHL, Embase, MEDLINE, PubMed, and Web of Science Varying risk of bias, type of study design, study location, education platform (e-learning vs manikin vs traditional lectures), learning outcomes, data collection scales/ questionnaires/ assessments Systematic review and meta-analysis; Level 1 n= 62 Studies were found on the following databases: Previous clinical practice, variable of nursing students that were measured, The methodological quality of included studies was evaluated by the Cochrane riskof-bias tool. Comprehensive Meta-Analysis Version 3.0 was used to conduct a metaanalysis using the random-effects model. Begg's and Egger's tests were performed to assess publication bias, and sensitivity analysis performed using a remove one study method. The methodological quality of included studies was evaluated by the Cochrane risk- High-fidelity simulation significantly increased nursing students knowledge acquisition (P 0. 0001), and enhanced nursing students professional skills (P = 0. 0001). In terms of clinical practice ability outcomes, high-fidelity simulation significantly improved the levels of critical thinking ability (P 0. 00001), clinical judgement ability (P0. 006) and communication skills (P 0. 001). When suffering from unanticipated difficult airway 63% less than 10 years anesthesiologists (LA) and 65% more than 10 years anesthesiologists (MA) would ask for help after trying 1 to 2 times (P = .000). More than 70% of LA and MA respondents reported preferring cannula cricothyrotomy to deal with emergency airway, Simulated technologybased learning significantly increased nursing student knowledge acquisition (p = 0.043), and increased student's satisfaction in learning (p < 0.001). Subgroup analyses showed that receiving simulation by manikins simulator had a greater effect on knowledge acquisition. When comparing simulation with other teaching strategies, simulation showed small effect size for anxiety (p = 0.051) and 43 CENTRAL, CINAHL, Embase, ERIC, LILACS, MEDLINE, PsycINFO, SCOPUS, Web of Science, PQDT Open (ProQuest), BDTD, and Google Scholar measurement tools used, Cronbachs reliability score, risk of bias, baseline mastery of nursing knowledge, previous experience to simulation, selfassessment, simulation scenario, nursing program (ASN vs BSN) of-bias tool. Critical appraisal of the studies was managed by means of the risk of bias tools RoB 2 and ROBINS-I, and quality of evidence by means of the GRADE tool. Data summarization was performed by qualitative synthesis with descriptive analysis and quantitative synthesis by meta-analytic methods and metaregression. Data was collected via pre- and post-test questionnaires, observational time, central tendency, and the Wilcoxon rank test. Ott et al., 2018 Nonrandomized control trial; Level 3 n= 50 Participants were students enrolled in the simulation center Previous experience with intubations, time spent in the simulation center, time to identify a CICV scenario, time spent on decisionmaking Rajwani, Mauer, & Clapper, 2019 Nonrandomized control trial; Level 3 n=11 Participants were pulmonary critical care fellows within the first 3 years of their medical education Years in medical school, previous exposure to cricothyrotomy, practice time on the models Data was collected via pre- and post-test questionnaires, checklist provided by Cook Medical, and the Wilcoxon signed rank test. Scott-Herring et al., 2020 Cohort study; Level 4 n=43 Participants were CRNAs Number of attempts, placement time, years of experience as a CRNA, previous airway course, performed live cricothyrotomy previously, preference in skill equipment A professional development survey was distributed to participants work emails. Cell phone timers were used for timing. Data analysis was preformed via Wilcoxon signed medium effect size for selfconfidence (p < 0.001); there was no difference in the effect-size for stress (p = 0.90). A positive relationship between selfconfidence and learning was identified by meta-regression (p = 0.018). In the CICV situation, 91% of the participants complied with the algorithm. A median of 63 s was required to perform the cricothyrotomy, with no difference being made between specialists and residents (p = 0.46). The cricothyrotomy could be performed surgically faster than the puncture cricothyrotomy using the Seldinger technique. Survey results demonstrated an improvement in perceived confidence (p<0.005) and competence (p<0.002) following this educational intervention. Fellows also achieved significant improvement in knowledge (p<0.003) and performance in two cricothyrotomy techniques (Seldinger and MacIntyre) (p<0.004). All but 1 CRNA completed the cricothyrotomy in under 2 minutes. The scalpel/bougie/endotracheal tube combination was the fastest, with an average completion time of 86.6 seconds. The confidence of CRNAs in performing a successful cricothyrotomy in less than 2 minutes was significantly 44 rank test in IBM SPSS Statistics. Zasso et al., 2021 Randomized controlled trial; Level 1 n= 40 Participants were divided into teams and employed at a tertiary hospital. Teams included an anesthesia resident, nurse, and respiratory therapist. Job, years of experience, previous exposure to airway emergencies, previous education on difficult airway algorithm Zhang et al., 2022 Randomized controlled trial; Level 1 n= 65 Participants were anesthesiologists and senior residents working in a hospital Years of experience, previous exposures to difficult airways, self-assessment, technique preference Data was collected based on a checklist and assessment from the Mayo HighPerformance Teamwork Scale. Cell phone timers were used for simulation timing. Data analysis includes two-sided two-sample equalvariance t-test, Shapiro-Wilk normality test and Wilcoxon rank sum test with SAS 9.4. Data collection included pre- and post-test survey and timing with cell phone timers. Data analysis included descriptive statistics, numerical equations (proportions), and Cox proportional hazards model with shared frailty on a STATA v.16.1 program. increased (P .001). Simulating airway skills improved performance, speed, and confidence. Prior exposure and teaching of a visual airway cognitive aid improved decision-making time to perform a FONA during a simulated airway emergency. SFC was associated with a shorter time to oxygen delivery (p<0.01). Higher first-attempt success was reported with SFC than SFB (p<0.01). Successful delivery of oxygen after the "can't intubate, can't oxygenate" declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (p=0.06) Footnotes: TTJV= transtracheal jet ventilation; BC= bougie cricothyrotomy; MC= Melker cricothyrotomy kit; SFC= scalpel-finger-cannula; SFB= scalpelfinger-bougie 45 Appendix C: Prisma Diagram Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.113 46 Appendix D: Jefferies Simulation Theory Model Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries Simulation Theory: Brief Narrative Description. Nursing Education Perspectives, 36(5), 292293. https://doi.org/10.5480/1536-502636.5.292 47 Appendix E: SWOT Analysis Infographics 48 Appendix F: IRB Approval Letter 49 Appendix G: Student Satisfaction and Self-Confidence in Learning Student Satisfaction and Self-Confidence in Learning Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some of the statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement Satisfaction with Current Learning SD D UN A SA 1. The teaching methods used in this simulation were helpful and effective. 1 2 3 4 5 2. The simulation provided me with a variety of learning materials and activities to promote my learning the medical surgical curriculum. 1 2 3 4 5 3. I enjoyed how my instructor taught the simulation. 1 2 3 4 5 4. The teaching materials used in this simulation were motivating and helped me to learn. 1 2 3 4 5 5. The way my instructor(s) taught the simulation was suitable to the way I learn. 1 2 3 4 5 UN A SA Self-confidence in Learning SD D 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me. 1 2 3 4 5 7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum. 1 2 3 4 5 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting 1 2 3 4 5 9. My instructors used helpful resources to teach the simulation. 1 2 3 4 5 10. It is my responsibility as the student to learn what I need to know from this simulation activity. 1 2 3 4 5 11. I know how to get help when I do not understand the concepts covered in the simulation. 1 2 3 4 5 12. I know how to use simulation activities to learn critical aspects of these skills. 1 2 3 4 5 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time.. 1 2 3 4 5 Copyright, National League for Nursing, 2005 Revised December 22, 2004 50 Appendix H: Pre-test and Post-test Post-test Survey Pre-test Survey What is your 4-digit identification code? Which category best fits your time as a licensed medical professional? o <2 years o 2-5 years o 5-10 years o >10 years What choice best fits your preferred education method when learning a new procedural skill? o I prefer to read about the procedure from a textbook. o I prefer to watch a video of the procedure. o I prefer to stimulate the procedure with hands-on experience. o I prefer to discuss the procedure and its steps with the instructor. Have you ever preformed a cricothyrotomy in clinical practice? o Yes o No Have you ever performed a simulated cricothyrotomy on a mannequin or other simulation tool? o Yes o No How do you rate your satisfaction regarding previous cricothyrotomy procedural education through Marian University's simulation lab? o Extremely dissatisfied o Somewhat dissatisfied o Neither satisfied nor dissatisfied o Somewhat satisfied o Extremely satisfied What structure is punctured during a needle cricothyrotomy? o Cricoid o Cricothyroid membrane o Cricothyroid ligament Regarding the cricothyrotomy procedure, what are the absolute contraindications? o Tracheal transection o Pre-existing coagulopathy condition o Child less than 10 years old o All of the above o None of the above What anatomical structures or conditions make a cricothyrotomy more difficult but are NOT relative contraindications to performing the procedure? SATA What is your 4-digit identification code? What structure is punctured during a needle cricothyrotomy? o Cricoid o Cricothyroid membrane o Cricothyroid ligament Regarding the cricothyrotomy procedure, what are the absolute contraindications? o Tracheal transection o Pre-existing coagulopathy condition o Child less than 10 years old o All of the above o None of the above What anatomical structures or conditions make a cricothyrotomy more difficult but are NOT relative contraindications to performing the procedure? Select all that apply. o Obesity o Tracheal transection o Child less than 10 years old o Geriatric patient greater than 60 years old o Hematoma on the neck o Radiation to the neck o Squamous cell carcinoma of the trachea How long should a cricothyrotomy tube be in place? o < 6 hours o Until medically unnecessary o 7- 10 days o < 24 hours Once the tube is placed, how many milliliters of air should be placed in the cuff? o 2-3 ml o 5-6 ml o 8-10 ml o 10-15 ml You are placing the needle through the cricothyroid membrane. Which technique is most accurate? o Insert the needle directly into the trachea at a 90-degree angle o Insert the needle caudally at a 45degree angle o Insert the needle rostrally at a 45degree angle o The direction of the needle does not matter as long as the needle tip punctures the cricothyroid membrane 51 Obesity Tracheal transection Child less than 10 years old Geriatric patient greater than 60 years old o Hematoma on the neck o Radiation to the neck o Squamous cell carcinoma of the trachea How long should a cricothyrotomy tube be in place? o < 6 hours o Until medically unnecessary o 7- 10 days o < 24 hours Once the tube is placed, how many milliliters of air should be placed in the cuff? o 2-3 ml o 5-6 ml o 8-10 ml o 10-15 ml You are placing the needle through the cricothyroid membrane. Which technique is most accurate? o Insert the needle directly into the trachea at a 90-degree angle o Insert the needle caudally at a 45degree angle o Insert the needle rostrally at a 45degree angle o The direction of the needle does not matter as long as the needle tip punctures the cricothyroid membrane List the steps of the Seldinger technique for cricothyrotomy in order. o Advance the needle through the cricothyroid membrane o Palpate the cricothyroid membrane o Make a vertical midline incision o Place tracheostomy tape around the patients neck o Tread a guide wire through the needle (or catheter if utilized) o Remove the dilator o Stabilize the cartilage o Inflate the cuff o Connect a ventilation device to the emergency airway catheter o Use the guide wire to advance the airway catheter assembly into the trachea o o o o List the steps of the Seldinger technique for cricothyrotomy in order. o Advance the needle through the cricothyroid membrane o Palpate the cricothyroid membrane o Make a vertical midline incision o Place tracheostomy tape around the patients neck o Tread a guide wire through the needle (or catheter if utilized) o Remove the dilator o Stabilize the cartilage o Inflate the cuff o Connect a ventilation device to the emergency airway catheter o Use the guide wire to advance the airway catheter assembly into the trachea 52 Appendix I: Seldinger Procedure Instructions 53 Appendix J: Tables Table 6 Helpfulness of Teaching Methods Used in Simulation Helpfulness of Teaching Methods n % Strongly Disagree 2 16.7 Disagree 2 16.7 Undecided 5 41.7 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 4 33.3 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 54 Table 7 Promotion of Learning within the CRNA Curriculum through the Learning Materials and Activities Provided by the Curriculum versus the Simulation Promotion of Learning n % Strongly Disagree 2 16.7 Disagree 2 16.7 Undecided 5 41.7 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 3 25.0 Strongly Agree 9 75.0 Pre-test Post-test Note: n=12 55 Table 8 Enjoyment of Teaching Methods Enjoyment of Teaching Methods n % Strongly Disagree 1 8.3 Disagree 3 25.0 Undecided 5 41.7 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 1 8.3 Agree 3 25.0 Strongly Agree 8 66.7 Pre-test Post-test Note: n=12 56 Table 9 Teaching Materials Were Motivating and Helped Students Learn Motivation and Helpfulness n % Strongly Disagree 2 16.7 Disagree 1 8.3 Undecided 6 50.0 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 4 33.3 Strongly Agree 8 66.7 Pre-test Post-test Note: n=12 57 Table 10 Teaching Methods Suitable to Learning Style Teaching Methods Suitable n % Strongly Disagree 1 8.3 Disagree 3 25.0 Undecided 6 50.0 Agree 2 16.7 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 4 33.3 Strongly Agree 8 66.7 Pre-test Post-test Note: n=12 58 Table 11 Confidence in Mastering the Content of the Simulation Activity Confidence in Mastery of Content n % Strongly Disagree 2 16.7 Disagree 2 16.7 Undecided 6 50.0 Agree 2 16.7 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 6 50.0 Strongly Agree 6 50.0 Pre-test Post-test Note: n=12 59 Table 12 Confidence that the Simulation Covered Critical Content Confidence in Content Coverage n % Strongly Disagree 2 16.7 Disagree 3 25.0 Undecided 3 25.0 Agree 4 33.3 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 5 41.7 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 60 Table 13 Confidence in Developing the Skills and Obtaining the Knowledge from the Simulation to Perform Necessary Tasks in a Clinical Setting Confidence in Skill and Knowledge n % Strongly Disagree 2 16.7 Disagree 2 16.7 Undecided 5 41.7 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 5 41.7 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 61 Table 14 Helpfulness of Resources Instructors Used to Teach Simulation Helpfulness of Resources n % Strongly Disagree 1 8.3 Disagree 2 16.7 Undecided 6 50.0 Agree 3 25.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 5 41.7 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 62 Table 15 Student Responsibility to Learn from the Simulation Activity Student Responsibility n % Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 3 25.0 Agree 8 66.7 Strongly Agree 1 8.3 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 5 41.7 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 63 Table 16 Knowing How to Get Help with Confusing Concepts How to Get Help n % Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 1 8.3 Agree 10 83.3 Strongly Agree 1 8.3 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 4 33.3 Strongly Agree 8 66.7 Pre-test Post-test Note: n=12 64 Table 17 Using Simulation Activities to Learn Critical Aspects of Skills Using Activities to Learn Critical Aspects of Skills n % Strongly Disagree 0 0.0 Disagree 1 8.3 Undecided 1 8.3 Agree 9 75.0 Strongly Agree 1 8.3 Strongly Disagree 0 0.0 Disagree 0 0.0 Undecided 0 0.0 Agree 5 41.7 Strongly Agree 7 58.3 Pre-test Post-test Note: n=12 65 Table 18 Responsibility of Instructors to Educate on Simulation during Class Responsibility of Instructors n % Strongly Disagree 0 0.0 Disagree 2 16.7 Undecided 4 33.3 Agree 6 50.0 Strongly Agree 0 0.0 Strongly Disagree 0 0.0 Disagree 3 25.0 Undecided 1 8.3 Agree 4 33.3 Strongly Agree 4 33.3 Pre-test Post-test Note: n=12 66 Table 19 Correct Identification of Factors that Increase the Difficulty of a Cricothyrotomy Correct Factors for Increased Difficulty n % Pre-test 12 100 Post-test 12 100 Pre-test 9 75 Post-test 12 100 Pre-test 11 91.7 Post-test 12 100 Obesity Hematoma Radiation Note: n=12 67 Table 20 Incorrect Identification of Factors that Increase the Difficulty of a Cricothyrotomy Incorrect Factors for Increased Difficulty n % Pre-test 8 66.7 Post-test 3 25.0 Pre-test 9 75.0 Post-test 6 50.0 Pre-test 4 33.3 Post-test 4 33.3 Pre-test 10 83.3 Post-test 7 58.3 Tracheal Transection Child less than 10 years old Geriatrics Squamous Cell Cancer Note: n= 12 68 Table 21 Correct Placement Order of the Steps of the Cricothyrotomy Procedure Correct Order of Steps Palpate the cricothyroid membrane Pre-test Post-test Stabilize the cartilage Pre-test Post-test Make a vertical midline incision Pre-test Post-test Advance the needle through the membrane Pre-test Post-test Tread the guidewire through the needle/catheter Pre-test Post-test Use the guidewire to advance the airway assembly Pre-test Post-test Remove the dilator Pre-test Post-test Inflate the cuff Pre-test Post-test Place tracheostomy tape around the neck Pre-test Post-test Connect the ventilation device Pre-test Post-test Note: n=12 n % 11 11 91.7 91.7 10 11 83.3 91.7 5 11 41.7 91.7 4 11 33.3 91.7 4 10 33.3 83.3 8 10 66.7 83.3 5 11 41.7 91.7 9 10 75.0 83.3 5 8 41.7 66.7 3 9 25.0 75.0  ...

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PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 1 1 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 2 Table of Contents Abstract ................................................................................................................................3 Introduction .........................................................................................................................4 Background ....................................................................................................................4 Problem Statement ........................................................................................................7 Organizational Gap Analysis of Project Site .............................................................7 Review of the Literature ......................................................................................................8 Conceptual Model...............................................................................................................19 Project Design/Methods .21 Project Site and Population ..........................................................................................21 Measurement Instruments.........................................................................................22 Data Collection Procedures ..........................................................................................23 Ethical Considerations/Protection of Human Subjects ....25 Data Analysis and Results...25 Discussion ......................................................................................................................... 31 Conclusion .........................................................................................................................33 References .........................................................................................................................35 Appendices Appendix A .................................................................................................................46 Appendix B .................................................................................................................47 Appendix C .................................................................................................................48 Appendix D .................................................................................................................53 Appendix E .................................................................................................................55 Appendix F .................................................................................................................56 2 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 3 Abstract Semaglutide is a prescription medication for weight loss and combating obesity. Current evidence indicates patients are regaining weight after discontinuing the medication unless diet and exercise regimens are sustained. Additionally, there is a lack of evidence regarding specific dietary recommendations for patients taking once-weekly subcutaneous semaglutide injections for weight loss. The purpose of this DNP project was to assess the effectiveness of an educational intervention focused on improving patient knowledge and receptiveness of making diet and exercise changes during their semaglutide treatment plan. The study included adult patients who were overweight or obese and currently taking semaglutide for weight loss at a specified outpatient medical practice in Indianapolis. The study spanned 21 days and included two data collection periods. Data was collected via surveys to assess knowledge, diet and lifestyle habits, and readiness to change utilizing the Readiness Ruler tool. The educational intervention included a video and written information focused on evidencebased diet and exercise recommendations while taking semaglutide. The projects results indicated the educational intervention was beneficial and positively impacted participant knowledge and perspectives regarding diet, exercise, daily caloric intake, and water intake as recommended while taking semaglutide for weight loss. Recommendations for practice include incorporation of the educational intervention as part of the plan of care for patients prescribed semaglutide at the outpatient practice. Keywords: obesity, semaglutide, weight loss, weight management, glucagon-like peptide, Mediterranean diet, patient education 3 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 4 Assessing Perspective of Diet and Exercise in Patients Taking Semaglutide: An Educational Intervention This project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Family Nurse Practitioner Track. Semaglutide, a subcutaneous injectable glucagon-like-peptide (GLP-1), is currently being utilized by many Americans to combat obesity. The popularity of semaglutide is leading society toward a misconception that the prescription medication is solely responsible for weight loss without little-to-no regard for making lifestyle modifications such as diet and exercise (Ghusn et al., 2022). Emphasizing the importance of lifestyle changes while taking semaglutide for longterm weight loss is critical. Without adopting and continuing lifestyle modifications such as diet and physical activity, weight can be regained when weight loss medications are discontinued due to metabolic adaptation (Garvey et al., 2016; Rubino et al., 2021; Updike et al., 2021: Wharton et al., 2020). Background Obesity is an ongoing public health crisis posing a global health challenge as a multifactorial, complex, and progressive chronic disease with a substantial burden on individuals, society, and the economy (Amaro et al., 2022; Rubino et al., 2021). Obesity is defined as a body mass index (BMI) of 30 kg/m2 in adults (WHO, 2020). Individuals with obesity, compared to those with a healthy weight, are at an increased risk of numerous health conditions and diseases including hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and breathing problems, cancer, 4 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 5 low quality of life, mental illness, body pain, and a decreased life expectancy (CDC, 2022; Garvey et al., 2016; Wilding et al., 2021). The prevalence of obesity in the United States (U.S.) in 2020 was 41.9% and increased 11.4% from 2000 to 2017 (CDC, 2023). The estimated annual medical costs of obesity in the U.S were $173 billion dollars in 2019, and estimates are that the global health expenditure on obesity-related complications will be 1.2 trillion U.S. dollars by 2025 (CDC, 2023; Updike et al., 2021). The global burden of obesity demonstrates that emphasizing a healthy lifestyle alone has proven insufficient, and efforts to combat the obesity epidemic require a more concerted effort to educate all populations on what constitutes a healthy lifestyle (Updike et al., 2021). Current recommendations for adults with obesity include being active three to five days each week to reach the goal of least 150 min/week of moderate exercise (U.S Department of Health and Human Services, 2018; WHO, 2020). Resistance training should be prescribed for patients who are overweight or obese and undergoing weight-loss therapy to help promote fat loss while preserving fat-free mass; resistance training should be two to three times per week consisting of single-set exercises that use the major muscle groups (Wharton et al., 2020). Additionally, adults 65 years and older need at least 150 minutes each week of moderate intensity activity (such as brisk walking), at least two days per week of activities that strengthen muscles, and activities to improve balance (U.S Department of Health and Human Services, 2018; WHO, 2020). Losing at least 5% of body weight is recommended for people with obesity to prevent or improve weight-related health complications (Wharton et al., 2020). However, lifestyle modifications foundational to obesity management, such physical activity and healthy eating habits, may not be enough to achieve long-term health benefits. Up to 90% of individuals with 5 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 6 obesity are unable to keep weight off long term (Bray et al., 2017; Garvey et al., 2016; Kaplan et al., 2018). Regaining weight is impartially due to difficulties adhering to lifestyle interventions and compensatory changes in appetite-regulating hormones, which act to maintain normal weight homeostasis (also known as metabolic adaptation) (Garvey et al., 2016; Rubino et al., 2021; Updike et al., 2021; Wharton et al. 2020). The United States Food and Drug Administration (FDA) has approved five medications to utilize as adjuncts to a reduced-calorie and increased physical activity regimen for chronic weight management. These include orlistat, phentermine/topiramate, naltrexone/ bupropion, liraglutide, and semaglutide (Amaro et al., 2022). This DNP project was limited to semaglutide. Semaglutide was introduced into the U.S. market in 2017 in response to the obesity and diabetes epidemics. The role of GLP-1 is to prompt the body to produce more insulin, which reduces blood sugar (glucose). GLP-1 in higher amounts interacts with parts of the brain that suppress the appetite and cause one to feel full (satiety). Common side effects of semaglutide include nausea, diarrhea, vomiting, constipation, abdominal pain, fatigue, dizziness, bloating, belching, gas, symptoms of stomach flu, heartburn, runny nose, or sore throat (Novo Nordisk, 2023a). Current recommendations to help reduce side effects include eating bland, low-fat foods such as crackers, toast, and rice; eating foods that contain water, eating more slowly; and avoiding lying down after eating (Novo Nordisk, 2023a). Semaglutide manufacturer instructions also direct patients to contact their health care provider to help manage side effects. When semaglutide is used in conjunction with diet and exercise, it can enhance weight loss results and reduce side effects, lead to sustained long-term weight loss, and significantly decrease the risk of developing the common health conditions and diseases associated with obesity (Amaro et al., 2022; Muller et al., 2019; Rubino et al., 2021). Unfortunately, when 6 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 7 semaglutide is discontinued, multiple pathophysiologic mechanisms act to restore weight to its elevated baseline (Garvey et al., 2016). These metabolic adaptations in addition to reduced physical activity; decreased resting energy expenditure; lowered efficiency of muscle metabolism; and changes in leptin, ghrelin, and other gut hormones that augment the appetite and counteract weight loss contribute to weight regain (Garvey et al., 2016; Sumithran et al., 2011). Efforts to sustain lifestyle changes over an extended time should be maintained to counterbalance these mechanisms that drive weight regain as part of the natural pathophysiology of obesity (Garvey et al., 2016). Problem Statement The project focused on implementing an educational intervention for improving patient knowledge and receptiveness to making the necessary lifestyle changes during their semaglutide treatment plan. By increasing their knowledge regarding the recommended diet and exercise interventions for patients taking semaglutide, they also improve their understanding of the pharmacological agents role in weight loss. Additionally, patients may also minimize the medications side effects, achieve their weight loss goals, and maintain their weight loss results long-term while combating the unavoidable metabolic adaptation. This project aimed to respond to the inquiry, For patients 18 years and older who have received at least one semaglutide injection for weight loss, will an educational video and written resource enhance patient understanding and perspective of lifestyle modifications necessary during and after treatment with semaglutide? Organizational Gap Analysis of Project Site The project site took place at an outpatient medical practice located in Indianapolis, IN that prescribed semaglutide for patients seeking weight loss. The site had been relying on verbal 7 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 8 education regarding diet and exercise recommendations for patients on semaglutide. No educational handout had been made available to patients during the verbal education nor for them to take home for future reference. The site was supportive of the project and its educational intervention for their patients throughout its planning and implementation phases. Review of the Literature A comprehensive literature search and review was conducted to gather pertinent evidence applicable to the project. A scoping review methodology was used to identify and analyze the current literature related to semaglutide, weight loss, diet and exercise, and methods recommended for patient education. The databases searched for the literature were PubMed, MEDLINE, CINAHL, and the Cochrane Library. This search was conducted from May 2023 to July 2023. The keywords utilized included semaglutide, glucagon-like peptide 1, GLP-1, weight loss, obesity, anti-obesity, pharmacology, weight management, patient education, healthy behavior, Mediterranean Diet. Additionally, BOOLEAN phrases were used to combine keywords such as semaglutide AND weight loss, semaglutide AND weight loss, semaglutide AND diet, semaglutide AND exercise, semaglutide AND side effects, semaglutide AND lifestyle intervention, semaglutide AND obesity, education AND diet AND exercise. In total, the database searches resulted in 903 articles regarding semaglutide associated with weight loss, obesity, diet, exercise, and side effects. The inclusion criteria established was to consider clinical trials, comparative studies, meta-analysis, observational studies, random control trials (RCTs), and systematic reviews conducted or published between 2018 and 2023. Other inclusion criteria specified patients 18 years of age or older taking semaglutide for weight loss and published in English. Particular 8 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 9 attention was given to published studies focused on semaglutide for weight loss in patients with obesity. Exclusion criteria included studies on patients taking semaglutide for diabetes management or taking other forms of weight loss drugs; studies comparing outcomes with another drug (such as liraglutide), cardiovascular research, or focused on GI intolerability; lower levels of evidence; articles published in other languages; and studies with participants under 18 years of age. After applying the inclusion and exclusion criteria, 882 of the articles discovered in the database searches were deemed impertinent for the proposed project and eliminated. The remaining 21 articles were contributed to this review of literature. The diagram in Appendix A outlines the literature search process. In addition to the database searches, information regarding the MyPlate diet was sought out to utilize as an educational resource to study participants. The review of literature is organized into three categories: studies focused on semaglutide, obesity and weight loss diet recommendations (the MyPlate diet, the Mediterranean diet), and methods to educate about diet and exercise. Studies Focused on Semaglutide Semaglutide Dosing Protocols In the RCTs reviewed, semaglutide was initiated per manufacturer protocol until the maximum dose was achieved and then maintained for the duration of the trial period. Per manufacturer guidelines, semaglutide should be initiated at 0.25 mg once weekly for 4 weeks (Novo Nordisk, 2021). In 4-week intervals, the dose should be increased until a dose of 2.4 mg is reached (Novo Nordisk, 2021). The maintenance dose is 2.4 mg once weekly. 9 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 10 Semaglutide and Weight Loss Twelve RCTs reviewed were related to semaglutide and weight loss and without mention of which lifestyle interventions in the study. Weight loss of 5% - 10% or more of baseline weight is desired as it produces greater improvements in several obesity-related risk factors and diseases (Friedrichsen et al., 2021; Wadden et al., 2021). Six of the 12 studies also found improvements in cardiometabolic risk factors, including body weight and waist circumference, decreased A1C levels, fasting blood glucose levels, blood pressure (systolic and diastolic), lipids, urine albuminto-creatinine ratio, C-reactive protein, and liver parameters with the addition of semaglutide (Arastu et al., 2022; Davies et al., 2021; Kosiborod et al., 2023; Lingvay et al., 2018; Wharton et al., 2023; Wilding et al., 2021). Kosiborod et al. (2023) found greater improvements in the cardiometabolic risk factors compared to placebo when lifestyle interventions were implemented with administration of 2.4 mg semaglutide once-weekly subcutaneous injections. Four RCTs included adults who did not have diabetes with a BMI 30 kg/m2 or a BMI 27 kg/m2 with one or more weight-related coexisting conditions (n = 2,810 participants). These RCTs concluded patients treated with semaglutide experienced reduced mean body weight, decreased waist circumference, and a lower BMI (Arastu et al., 2022; Friedrichsen et al., 2021; ONeil et al., 2018; Wadden et al., 2021; Wilding et al., 2021). The systematic review conducted by Arastu et al. (2022) found patients treated with semaglutide experienced a clinically significant reduction in mean body weight of 11.62 kg (95% confidence interval: -13.03 to -10.21, p < 0.00001). Two double-blind studies including weekly 2.4 mg semaglutide injections determined semaglutide reduced hunger and prospective food consumption, while increasing fullness and satiety compared to placebo: Blundell et al. (2016) in their 12-week study with 30 participants 10 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 11 (P = .0023) and Friedrichsen et al. (2021) in their 20-week study with 72 participants (P <0.02). Of note, Blundell et al. (2016) also found participants indicated a lower explicit liking for highfat and non-sweet foods with semaglutide compared to placebo (P=.0016). Rubino et al. (2021) conducted a 68-week study with 803 participants who each received a one-weekly 2.4 mg subcutaneous injection of semaglutide coupled with lifestyle interventions. Their findings included a mean weight loss of 10.6% at week 20 and an estimated 17.4% loss from weeks 60 to 68. An interesting discovery from this study revealed participants who switched to placebo at week 20 gradually regained weight, signifying the potential withdrawal effects of obesity medications and the importance of a sustained diet and lifestyle to maintain and maximize weight loss. There was no mention of which lifestyle interventions were used, how they were disseminated to patients, or follow up therapies. Semaglutide with Specified Diet and Exercise Interventions Some of the studies reviewed included weekly injections of semaglutide with specific diet and exercise interventions. These specified considerations for liquid shakes, low-calorie diets, food intake tracking, and physical exercise. According to Friedrichsen et al. (2021), intensive lifestyle intervention and pharmacotherapy are the most effective noninvasive weight loss approaches. Three of the studies suggested a reduced-calorie (500 kcal/d deficit) diet with 150 minutes of physical activity per week for patients taking semaglutide (Davies et al., 2021; Rubino et al., 2021; Wharton et al., 2023). However, two of the three RCTs indicated the addition of health counseling provided by a qualified healthcare professional or dietician (Davies et al., 2021; Rubino et al., 2021). These two also suggested instructing patients how to measure their physical activity and food intake, while encouraging them to keep a food and activity diary daily. 11 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 12 The study by Wadden et al. (2021) included 611 participants without diabetes who were either obese (BMI 30 kg/m2) or overweight (BMI to 27 kg/m2) plus at least one comorbidity. They found the greatest weight reduction (16%) with semaglutide, diet, and exercise over a 68week period compared to placebo (5.7%). This was achieved utilizing a low-calorie diet (1,0001,200 kcal/day) consisting of meal replacements such as liquid shakes, meal bars, and portioncontrolled meals over the first eight weeks, followed by a hypocaloric diet (1,200 1,800 kcal/day) of conventional food over the remaining 60 weeks. Physical activity consisted of 100 minutes of physical activity/week (spread across 4-5 days), which increased by 25 minutes every 4 weeks, to reach 200 min/week at week 68. Behavioral counseling was also provided over the 68-week trial period. Such evidence supports the need for coaching in addition to diet and exercise during semaglutide treatment timeframe. Wharton et al. (2023) also noted a preference for connecting with a dietician or healthcare professional during a 30-day follow-up. Adverse Effects and Side Effects The most common reported adverse effects of semaglutide were nausea and lack of appetite, followed by alternative gastrointestinal (GI) complaints such as diarrhea, constipation, dyspepsia, and abdominal pain (Friedrichsen et al., 2021; ONeil et al., 2018; Wadden et al., 2021; Wilding et al., 2021). The RCT trial by Rubino et al. (2021) reported GI events in 49.1% of their 803 participants with continued subcutaneous semaglutide compared to 26.1% with placebo. Wilding et al. (2021) mentioned the reported side effects were transient, mild-tomoderate in severity, and subsided with time. Lingvay et al. (2018) mentioned patients reporting adverse events with semaglutide were dose dependent. Notably, none of the articles referred to the importance of diet to help minimize GI events while taking semaglutide. 12 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 13 Obesity and Weight Loss Diet Recommendations Evidence indicates semaglutide results in weight loss even without diet and exercise interventions; however, weight regain around week twenty can be expected due to the bodys natural compensatory mechanisms (metabolic adaptation). This confirms the importance of diet and exercise lifestyle interventions to sustain long-term weight loss over time. Due to the inconclusive diet recommendations for patients taking semaglutide, two diets recommended by one semaglutide manufacturer, the CDC, UpToDate, and clinical practice guidelines were explored for the projects educational intervention. These two diets include MyPlate and the Mediterranean diet. These diets are recommended to aid in weight loss and help reduce the most recurrent GI side effects of semaglutide. MyPlate Diet According to Novo Nordisk (2023b), a semaglutide manufacturer, the Plate Method is a recommended diet to assist individuals with type 2 diabetes. It supports portioning out meals while designating how much of each food group is recommended. Figure 1 features the MyPlate diet, a version of the Plate Method. 13 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 14 Figure 1 MyPlate Diet (U.S. Department of Agriculture, 2018) This method encourages the modeling of meals as follows: (a) half of the plate is filled with non-starchy vegetables such as lettuce, broccoli, asparagus, peppers, or yellow squash; (b) one-quarter includes protein such as chicken, fish, lean meat or eggs; (c) one-quarter has foods such as brown rice, lavash, peas, or corn; (d) one piece of low-glycemic index fruit and a few teaspoons of a healthy fat such as avocado, nuts, or olives are included with each meal; (e) water, tea, or coffee should have little to no sugar; milk/dairy is limited to one or two servings/day; and 14 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 15 juice is limited to one small glass/day; and (f) sugary drinks and alcohol are avoided (Novo Nordisk, 2023b). Additionally, greasy or fatty foods should be limited with the use of semaglutide as they can increase nausea, one of the most common medication side effects (Blundell et al., 2017; Novo Nordisk, 2023b). Of note, despite providing information about the Plate Method, the manufacturer defers consumers to talk to your doctor about what nutrition plan is right for you (Novo Nordisk, 2023b). Mediterranean Diet The systematic review conducted by Mancini et al. (2016) determined the Mediterranean diet was superior to low-fat diets for long-term weight loss. The first step to weight loss is evidence-based lifestyle modification through diet, behavioral therapy, and physical activity. Combining diet with physical activity has been found to increase weight loss compared to either of these interventions used alone; specifically, physical activities are unlikely to yield clinically significant weight loss unless it is of a high level or aerobic exercise or is in conjunction with a calorie-restricted diet (Curioni & Lourenco, 2005; Swift et al. 2014; Wu et al. 2009). The Mediterranean Diet is a scientifically supported diet for weight loss, improving cognitive health, and risk reduction of cardiovascular disease, vascular diseases, diabetes, and cancer (Davis et al., 2015; Fart et al., 2009; Mancini et al., 2016; Psaltopoulou et al., 2013; Willett et al., 1995). This diet reflects the dietary pattern of the people living on the Mediterranean Sea coast, particularly Greece, southern Italy, and southern Europe (Corella et al., 2018; Finicelli et al., 2019). Although the Mediterranean countries have some eating habit differences, the common features characterizing the Mediterranean Diet are defined as: (a) daily consumption of nonrefined cereals and other products (e.g., whole grain bread, whole grain pasta, and brown rice), 15 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 16 fresh fruits, vegetables, nuts, and low-fat dairy products; (b) olive oil as the principal source of lipids; (c) moderate intake of alcohol, preferably red wine, with meals; (d) moderate consumption of fish, poultry, potatoes, eggs, and sweets; (e) monthly consumption of red meat; and (f) regular physical activity (Finicelli et al., 2019; Gouveri and Diamantopoulos, 2015; Schwingshackl et al., 2020). The beneficial impact of the bioactive molecules found within these food sources is an essential component of the diet. See Figure 2 for an illustration of the components of a Mediterranean diet. Figure 2 Schematic representation of the nutritional and bioactive characteristics of Mediterranean food components (Finicelli et al., 2022) Marine omega-3 fatty acids are the most important bioactive molecules in fish and seafood consumed in the diet (e.g., sardines, mackerel, mussels, octopus, salmon, squid, and tuna). Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the major n-3 fatty acids recognized for their cardioprotective effects and beneficial effects on HDL cholesterol and 16 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 17 triglycerides levels (Schwingshackl et al., 2018; Wang et al. 2022). Olive oil, especially extra virgin olive oil, is the primary source of fat in the Mediterranean Diet, attributed to reducing DNA oxidation and inflammatory markers and decreasing the risk of stroke, chronic heart disease, and diabetes. (Sanchez-Rodriguez et al., 2019; Schwingshackl & Hoffmann, 2014; Schwingshackl et al., 2015; Schwingshackl, Schewedhelm, Galbete et al., 2017). Fruit and vegetable consumption is also emphasized in the diet. Fruits, such as oranges, pomegranates, berries, figs, and grapes, are a source of fiber, potassium, vitamin C, polyphenols (mostly flavones), and terpenes (Finicelli et al., 2019). Vegetables, such as field greens, tomatoes, eggplants, cabbages, radishes, garlic, onions, spinach, and lettuce, are an excellent source of nutrients (e.g., dietary fiber, potassium copper, magnesium, folate, vitamin A, B6, C, E, and K) (Finicelli et al., 2019). High consumption of vegetables or fruit is thought to lower risk for all-cause mortality, chronic heart disease, stroke, type 2 diabetes, colon rectal cancer, and adiposity (Bechthold et al., 2019; Schwingshackl, Schewedhelm, Galbete et al., 2017; Schwingshackl et al., 2018). Legumes, grains, and nuts are regularly consumed in the Mediterranean Diet. Grains appear both as a single food (e.g., rice and oatmeal) and as ingredients of processed foods (e.g., bread, pasta, cereal, crackers). Common nuts include almonds, hazelnuts, walnuts, and pistachios. Legumes represent lentils, beans, and chickpeas. These foods are a valuable source of fiber, folate, vitamin B6, magnesium, potassium, and copper (Delgado et al., 2017; Schlesinger et al., 2019). The beneficial effect of nut consumption primarily impacts the incidence of cardiovascular disease, diabetes, and metabolic syndrome (Jiang et al., 2006; Kelly & Sabate, 2006; Schwingshackl, Schwedhlem, Hoffman et al., 2017; Zec & Glibetic, 2018). The beneficial effects of legumes and grains on cardiovascular disease, body weight, and cholesterol (total and 17 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 18 LDL-C) have also been noted. Lastly, red wine is a source of resveratrol, the most abundant polyphenol. The molecule polyphenol has a beneficial effect on several chronic diseases such as cancer, myocardial infarction, and brain disorders (Finicelli et al., 2019; Opie & Lecour, 2007). This diet also limits red meats, refined grains, trans fats, processed meats, added sugar, and other highly processed foods (Willet et al., 1995). Overall, the five most important influences induced by adherence to the Mediterranean diet can be summarized by the following: (a) its lipid-lowering effect, (b) anti-oxidative and antiinflammatory actions, (c) modification of key molecules (hormones and growth factors) involved in the pathogenesis of cancer, (d) inhibition of nutrient-sensing pathways, and (e) gut microbiotamediated production of metabolites influencing metabolic health (Tosti et al., 2018). Diet and Exercise Educational Methods Literature was reviewed to determine effective strategies and methods of delivering patient education. Ardoin et al. (2022) concluded that using multiple modalities including a patient-centered video and handouts to educate patients about diet is effective in teaching, motivating change, and encouraging communication between patients and healthcare professionals. Schoeppe et al. (2016) completed a systematic review that included 27 studies (70% of which were randomized controlled trials) comparing the efficacy of interventions that used apps to improve diet, physical activity, and weight loss. They found that multiple interventions such physical education, printed materials, motivational emails, pedometer use, and a website along with use of an application were more effective than use of an app alone. Three systematic reviews or meta-analyses evaluated the effect of verbal information on outcomes related to patient education (Johnson & Sandford, 2005; Theis & Johnson, 1995; Trevena et al., 2006). Johnson and Sandford (2005) found that the combination of written and 18 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 19 verbal information was significantly better than verbal information alone with respect to knowledge. Regarding recall, three of five studies found higher recall with illustrated text compared to text alone in both the young and older participants (Houts et al., 1998; Houts et al., 2001; Winograd et al., 1982). Research indicated that new patient information packages are useful for patients, and all written information should be prepared at a reading level appropriate for the general population. When considering the review of the literature, the evidence consistently indicates increased weight loss with semaglutide injections when coupled with lifestyle interventions such as diet and exercise. However, the research is lacking regarding specific dietary recommendations for patients taking once weekly subcutaneous semaglutide injections for weight loss. Patients experience decreased appetite and increased satiety while taking semaglutide; however, once patients stop taking the medication, patients can regain weight unless they have sustained diet and exercise regimens. This supports the need for a concerted effort for patient education regarding evidence-based diet and exercise recommendations for patients taking semaglutide. This intervention in the form of an educational video and written resource can help improve perspective, increase knowledge, and sustain long-term weight loss. Conceptual Model The ADDIE model for online education was selected to guide the project. The educational intervention included an online educational video and an educational resource for athome reference. The ADDIE model served to guide both components. The ADDIE model has five distinct steps: Analyze, Design, Develop, Implement, and Evaluate (Patel et al., 2018). During the Analyze stage, the target audience, learning environment, goals and objectives are identified. The target audience for this project was distinguished as adult patients over the 19 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 20 age of 18 who were either overweight (BMI of 27 kg/m2) with one comorbidity or obese (BMI 30 kg/m2). Additionally, eligible participants were to have taken at least one semaglutide injection for weight loss at the designated outpatient medical practice in Indianapolis, IN. After completion of the educational intervention, the goal was that participants would have an increased perspective and knowledge of the lifestyle modifications necessary during and after their semaglutide treatment plan for weight loss. Design is the second step in the ADDIE model. While planning the educational video and handout, it was helpful to create an outline of what information to include. This step also included thoughtful preparation of the pre- and post-assessment survey questions. It was critical that the survey items reflect the best measures of patient perspective and knowledge. This allowed for further refinement of the questions, ensured the educational intervention was meaningful, and the data collected would accurately reflect what was intended to be measured. It was also important to develop the timeline for data collection during this stage. The third step in the ADDIE model is Develop. During this stage, the surveys were finalized into the Qualtrics online application platform. This is also the stage when the educational resources (video and handout) were finalized. As the final part of this step, the educational intervention and surveys were previewed and tested on Qualtrics to ensure accessibility and functionality for participants. The fourth step of the ADDIE model is Implement. This project included two data collection periods. Participants were sent an email via Demandforce at the start of the first data collection period with a link to Qualtrics where they accessed the pre- and post-surveys, educational video, and educational handout. The second data collection period included a final post-survey and was sent to participants using the same method. 20 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 21 The final step in the ADDIE model is Evaluate. This is when data collected from the two data collection periods were analyzed and evaluated through Qualtrics. It also starts the process for discerning any changes that should be made if the project is repeated in the future. Project Design/Methods The DNP project was a quality improvement project implementing an educational intervention to assess changes in patient knowledge and perspective of lifestyle modifications necessary while taking semaglutide. Project Site and Population The project site was an outpatient medical practice in Indianapolis, IN. It is considered an integrative practice specializing in primary care, functional medicine, weight loss, hormone replacement therapy, peptide therapy, and chiropractic care. For the project's purpose, there were two key investigators: a Doctor of Nursing Practice- Family Nurse Practitioner (DNP-FNP), referred to as Investigator One, and a registered nurse (RN), referred to as Investigator Two. These two investigators were actively engaged in the project to recruit participants and send project communications to participants via a HIPAA-protected software platform (Demandforce). Prior to this project, Investigator One assessed and prescribed qualified patients semaglutide prior to their initial injection. Once the semaglutide order was received, Investigator Two provided verbal education to patients regarding semaglutide, side effects, recommended lifestyle interventions while taking semaglutide, and demonstrated how to properly administer injections. Investigator Two then administered the semaglutide injection. Investigator One reassessed patients at their 30-day follow-up appointment. No educational video or take-home educational handout was being utilized at the practice. 21 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 22 Participant inclusion criteria for the project included: (a) adults 18 years or older without diabetes; (b) must be either overweight (BMI to 27 kg/m2) plus at least one comorbidity or obese (BMI 30 kg/m2); (c) be an established patient of the practice and already received an initial evaluation from the DNP-FNP for clearance; (d) has already received at least one semaglutide injection; and (e) has computer or mobile access capable of displaying survey and images. Participants were excluded from the project if they did not meet these requirements. Stakeholders in the project included participating patients and the practices healthcare team consisting of Investigator One and Investigator Two at the medical facility. The practice was supportive of the project and the educational intervention as no prior educational video or take-home handout existed for their patients. No barriers were experienced during the DNP project. Measurement Instruments The Readiness Ruler tool was used during data collection one to measure motivation to change prior to and after the educational intervention, and again, two weeks later at data collection two. This widely recognized tool added validity and rigor to the project (Appendix B). To facilitate the data collection and analysis process, surveys were created in Qualtrics, a web-based software platform in which researchers can create and administer surveys as well as collect and analyze data. The surveys created for data collection one and two are shown in Appendix C and Appendix D, respectively. The pre- and post-survey for participants during data collection one assessed current knowledge, diet and lifestyle habits, and readiness to change prior to and direct after the educational intervention. The post-survey on data collection two reassessed knowledge, exercise and diet habits, and readiness to change lifestyle behaviors one 22 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 23 week after the educational intervention. Survey data was analyzed and measured via Qualtrics and Excel after the 21-day data collection period. In addition to this measurement instruments, additional resources were utilized for the project including PowerPoint and YouTube for the video component of the educational intervention, Canva for designing the educational handout, and Demandforce to send HIPAAcompliant communications to participants. Appendix C includes a visual of the introductory screen of the educational video. Appendix E includes the educational handout provided to participants. Data Collection Procedures The timeline for the project was established as 21 days in length with two data collection periods. Investigator One and Investigator Two identified qualified patients in accordance with the established inclusion and exclusion criteria provided by the researcher. After organizing the evidence-based diet and lifestyle information to be included in the educational intervention, the researcher developed the pre- and post-surveys, educational video, and educational handout. The educational video was created in PowerPoint, converted to an mp3 file, and then uploaded to YouTube. The six-minute video included information about semaglutide, recommendations for diet and exercise while on semaglutide, tips on fitting exercise into a busy lifestyle, common side effects, foods to avoid, recommended diets, and 10 tips to get the best results. The educational handout served as a summarized version of the content from the educational video for participants to utilize as a reference. Participant surveys, the educational video, and handout were uploaded into Qualtrics so participants could access them through a link on the study invitation email. 23 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 24 Data collection one surveys consisted of a pre-test with ten items (seven multiple choice, two select all that apply, and one open-ended) to measure current knowledge and perspective of lifestyle interventions recommended while taking semaglutide for weight loss; an educational presentation; and a seven-item post-test (with one select all that apply and six multiple choice questions) to measure perspectives of likeliness to implement the recommendations and immediate knowledge gained from the educational presentation (see Appendix C). One of the multiple-choice questions helped measure participant knowledge of foods to avoid and how many minutes/week of physical activity is recommended while taking semaglutide for weight loss. Data collection two surveys consisted of nine items: one open-ended question, one select all that apply, and six multiple choice questions (see Appendix D). The initial question asked participants if they participated in the previous survey with the educational presentation. Subsequent questions measured current level of readiness for change, retention of knowledge gained in the educational intervention, and whether or not participant had begun implementing the recommended lifestyle changes while taking semaglutide for weight loss. The researcher composed the participant invitation email that Investigator Two sent qualified candidates via Demandforce on the project implementation start date. The educational video, handout, surveys, and emails were reviewed and validated by Investigator One and Investigator Two prior to project implementation. The initial email to qualified candidates described the purpose of the study, what to expect during participation, assured candidates that participation was voluntary, explained responses would be anonymous, and included the survey deadline. An embedded link was used to redirect participants to Qualtrics for accessing the pre-survey, educational intervention, post- 24 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 25 survey, and educational handout. Project days 1-14 were dedicated to the first email invitations to participate and the initial data collection period. Project days 15- 21 were dedicated to the second round of invitations and the final data collection period. Similar to the first part of the project, the final data collection period included a link embedded in the email redirecting participants to Qualtrics for the post-survey, which reassessed knowledge, exercise and diet habits, and readiness to change lifestyle behaviors. Ethical Considerations/Protection of Human Subjects Approval from the Marian University Institutional Review Board (IRB) was sought prior to project implementation. The IRB determined the project was exempt from further review under the federal regulation. See Appendix F for the IRB approval form. Participating in the project posed no additional risk compared to the risks of receiving standard medical care. Participation was voluntary, and no participant identifiers were used. Data Analysis and Results Qualtrics was utilized to collect and analyze the data collected. Both quantitative and qualitative data were collected, and sample size was indicative of participant participation. The levels of measurement for the quantitative data were nominal and ordinal. Qualitative data gained from open-ended pre- and post-test questions were categorized by topic to quantify data. Paired samples t-test was conducted to determine the standard deviations, p-values, and to discern differences between the two data collections periods. Participants (n = 30) who met the inclusion criteria were invited to participate in the project. At data collection one, which included the pre-test, educational intervention, and posttest, 18 participants (n = 18) responded. At data collection two, 6 participants (n = 6) responded. However, three of the six participants for data collection two indicated they did not participate in 25 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 26 data collection one. The results of the data analysis are discussed below, including demographics, missing data, key findings, and a summary of findings related to each measurable outcome. Demographics Participant Age Participant age ranges were collected at data collection one. Seven participants were 3145 years of age, ten were 46-60 years of age, and one individual was 61+ years old (Table 1). Table 1 Participant Age Missing Data There was no missing data for data collection point one. All participants who completed the pre- test also completed the post- test. As previously mentioned, three participants in data collection two indicated on the survey that they did not complete data collection one, and thus, were excluded from the data analysis. There was no other missing data. 26 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 27 Key Findings Regarding Preparation to Make Diet and Exercise Changes The Readiness Ruler tool utilizes a 0 10 scale and was used to assess preparation to make the recommended diet and exercise changes while on semaglutide with 0 indicating not prepared to change, and 10 indicating already changing. The average rating of these three items in the surveys were 8 at pre-intervention (data collection one), 8.16 post-educational intervention (data collection one), and 8 at the second post-survey (data collection two). Descriptive statistics Paired t-test Paired-samples t-test was conducted to evaluate the pre- and post-intervention means for determining change in perspective after viewing the educational presentation for participant likelihood of drinking half of their body weight (lbs.) in ounces (oz.) of water/day and reduction of caloric intake by 500 kcal/day. When analyzing participant likelihood of drinking half of their body weight (lbs.) in oz. of water/day, there was a significant difference between the pre(M = 0.44, SD = 0.51) and post- (M = 0.77, SD = 0.43) educational intervention (Table 2); t (17) = 2.91, p = 0.01. When analyzing participant likelihood of reducing caloric intake by 500 kcal/day, there was also a significant difference between the pre (M = 0.60, SD = 0.51) and post (M = 0.90, SD = 0.32) educational intervention (Table 3); t (17) = 2.38, p = 0.03. These results suggest the educational intervention improved participant perspective of making lifestyle and dietary changes directly after the educational intervention (Table 4, Table 5). Table 2 Paired Samples Statistics for Drinking Half of Body Weight in Ounces of Water Pre- Intervention Post- Intervention Mean 0.44 0.77 N 18 18 Std. Deviation 0.51 0.43 Std. Error Mean 0.13 0.1 27 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 28 Table 3 Paired Samples Statistics for Reducing Caloric Intake by 500 kcal Pre- Intervention Post- Intervention Mean 0.60 0.90 N 18 18 Std. Deviation 0.51 0.32 Std. Error Mean 0.12 0.08 Table 4 Paired Samples Test (Paired Differences) for Table 2 Data Mean PreIntervention PostIntervention -0.34 Std. Deviation 0.08 Std. Error Mean 0.02 95% Confidence Interval of the Difference Lower Upper -0.38 -0.29 t df p 2.91 17 0.01 t df p 2.38 17 0.03 Table 5 Paired Samples Test (Paired Differences) for Table 3 Data Mean PreIntervention PostIntervention -0.33 Std. Deviation 0.59 Std. Error Mean 0.14 95% Confidence Interval of the Difference Lower Upper -0.63 -0.03 Short Answer Question: Type of Diet One question on the pre-intervention survey at data collection one and post-intervention survey at data collection two asked participants to describe their current type of diet. Most participants indicated they were not on any particular diet, fasted intermittently, or were on a low 28 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 29 carb diet. Other participants stated they eat according to the mediterranean diet, gluten free, or eat less in general. At data collection one, post-intervention, participants were asked how likely they were to change their current diet plan after viewing the educational presentation. Twelve participants (67%) selected yes, five stated their current diet plan is effective for them (28%), and only one participant (5%) selected no (Table 6). Table 6 Participant Change of Perspective Regarding Diet After Viewing Educational Intervention Select All That Apply Question: Foods to Avoid One of the select all that apply questions measured participant knowledge of foods to avoid while taking semaglutide for weight loss. At data collection one, 50% of participants answered the question correctly pre-educational intervention, and 95% of participants answered 29 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 30 the question correctly post-educational intervention. At data collection two, 100% of participants answered the question correctly, indicating the knowledge gained was retained. Multiple Choice Questions Regarding Physical Activity One of the multiple-choice questions measured participant knowledge of how many minutes per week of physical activity is recommended while taking semaglutide for weight loss. At data collection one, 22% of participants answered the question correctly pre-educational intervention, and 67% of participants answered the question correctly post-educational intervention. At data collection two, 33% of participants answered the question correctly These values indicate participants gained knowledge immediately following the educational intervention but may not have retained the knowledge at data collection two. When asked how many minutes of physical activity participants exercised per week, 11% of participants were already participating in the 150 minutes of recommended exercise per week. At data collection two, no participants indicated they were participating in the recommended 150 minutes of exercise per week. However, two of the three indicated they were exercising 121- 129 minutes/week, and the remaining participant was exercising 61-120 minutes/week (Table 7). 30 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 31 Table 7 Number of Minutes per Week of Participant Physical Activity While on Semaglutide Discussion Limitations The project had several notable limitations. The sample size for the project was a small convenience sample recruited from a specific population, and thus, may not be representative of other populations. Second, due to the small number of survey questions and project timeframe of 21 days, limited information was collected. However, some information can still be useful to determine outcomes after viewing the educational presentation. Data collection two only had six respondents, of which, three of the six were excluded since they did not participate in the first data collection. Data collection two was also conducted during the week of Thanksgiving, a national holiday, which may have limited the number of respondents. Also, during this time, participants could have easily been impacted by the holiday 31 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 32 and distracted from reducing their daily caloric intake, drinking half of their body weight (lbs.) in oz. water, and exercising 150 minutes/week. The project had a limited timeframe for implementation and evaluation, which could have impacted the results. Data collection two was conducted two weeks after the educational intervention and may not have allowed participants enough time to plan for, implement, or sustain lifestyle changes. This makes it difficult to definitively conclude that the educational intervention was effective or led to a change in patient perspective and knowledge. Lastly, the timing of data collection two being the week of Thanksgiving may have impacted the response rate as well as the participants answers to questions regarding hydration, eating habits, and physical activity. Strengths The project's strengths include the ability to utilize evidence-based guidelines to implement and provide educational resources to patients, further assisting with current and longterm weight loss efforts. Such at-home resources can aid in patient receptiveness of making lifestyle changes recommended for sustained weight loss. The educational video and handout can also continue to be used as a resource provided to patients engaged in weight loss at the project site, serving as an educational tool. The project also provided the opportunity to measure patient perspective and knowledge utilizing a small sample size. Implications for Practice and Future Research Findings from the project support use of the educational intervention to increase education and awareness regarding recommended lifestyle changes for weight loss while taking semaglutide and after discontinuation of the medication. Findings also suggest implementing the educational intervention into practice can promote continued utilization of recommended 32 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 33 guidelines in practice. Such recommendations could be incorporated in healthcare facilities for patients taking semaglutide for weight loss. Opportunities for further research include repeating this study with a larger group of patients taking semaglutide for weight loss and measuring data at two, four, and six weeks after the educational intervention. Implementing the project amongst a larger group of patients will also allow for greater generalizability of the results and greater understanding of how the project impacts patient perspective and knowledge of the recommended lifestyle changes during and after treatment with semaglutide. Further research should also be done to measure how educational material can be used to enhance patient outcomes. Lasty, ongoing education for patients and providers regarding the lifestyle changes necessary while taking semaglutide can be important to improve weight loss outcomes in the long term. Future studies are recommended. Conclusion The purpose of the evidence-based project was to assess the effectiveness of an educational intervention focused on improving patient knowledge and receptiveness of making necessary diet and exercise changes during patients semaglutide treatment plan. The clinical question prompting the project asked if an educational intervention would enhance patient understanding and perspective of lifestyle modifications necessary during and after treatment with semaglutide. The findings of the project indicate the educational intervention was beneficial and positively impacted participant knowledge and perspectives regarding diet, exercise, daily caloric intake, and daily water intake as recommended while taking semaglutide for weight loss. By increasing the knowledge of recommended lifestyle interventions for patients taking semaglutide, they may have enhanced their understanding of the pharmacological agent for 33 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 34 weight loss. 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Elsevier. https://doi.org/10.1016/B978-0-08-100596-5.22511-0 45 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 46 Appendix A Screening Identification Identification of studies via databases Records identified from*: Databases (n = 903) Records screened (n = 778) Records excluded** (n =200) Reports sought for retrieval (n = 578) Reports not retrieved (n = 98) Reports assessed for eligibility (n = 480) Included Records removed before screening: Duplicate records removed (n = 75) Records marked as ineligible by automation tools (n = 50) Studies included in review (n = 21) Reports excluded: Semaglutide and diabetes (n = 123) Patients taking other forms of weight loss drugs (n= 42) Comparable outcomes to another weight loss drug (n = 60) Cardiovascular research (n = 14) GI intolerability (n = 23) Adolescents 13-18 yrs. Old (n = 13) Lower level of evidence (n = 78) Published prior to 2018 (n = 81) Other languages (n = 25) Reference: Page et al. (2021) 46 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 47 Appendix B The Readiness Ruler Tool Reference: Weissbein, C. (2015) 47 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 48 Appendix C Data Collection One Surveys 48 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 49 49 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 50 50 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 51 51 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 52 52 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 53 Appendix D Data Collection Two Survey 53 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 54 54 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 55 Appendix E Educational Handout 55 PERSPECTIVE OF DIET AND EXERCISE WITH SEMAGLUTIDE 56 Appendix F 56  ...

... Analysis of Sunscreen UV Protection Utilizing UV-Visible Spectrophotometry Kailynn Berger College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 ABSTRACT Sunscreen is a staple in any household and with a variety of varying brands and SPF values it can be difficult to decipher which is the best choice. UV-visible spectrophotometry is one useful analytic method to compare the effectiveness of differing sunscreen samples. Absorbance of UVB and UVA radiation can be compared between the sunscreens by looking in the wavelength ranges of 290 to 320 nm (UVB) and 320 to 400 nm (UVA). Between the four varying sunscreens (Up & Up SPF 30 and 50 and Banana Boat SPF 30 and 50), the Up & Up SPF 50 showed greatest absorbance at all wavelength values. INTRODUCTION When exposed to UV rays for excessive time health complications can arise including change in pigment, wrinkled skin, atrophy, or malignancy as well as common types of cancer including basal cell carcinoma, squamous carcinoma and malignant melanoma[1]. Daily sunscreen use can help prevent keratinocyte cancers and death due to melanoma [2]. Determining just how much protection sunscreen is truly providing gives consumers an accurate representation of the investment they are making to protect their skin and overall health. Figure 1. Diagram of light rays and wavelength from the National Eye Institute[3]; Light rays of interest include UVA, UVB, and UVC all which are released from the sun. UVB and UVA are of most interest as they reach earths surface and are the light rays sunscreen attempts to protect against. Of the four sunscreen varieties being tested it can by expected to see the name brand (Banana Boat) SPF 50 would show the greatest absorbance values specifically for the UVB wavelength range. MATERIALS AND METHODS The sunscreens used were the Up & Up sport sunscreen spray SPF 30 and SPF 50 as well as the Banana Boat sport ultra clear sunscreen spray broad spectrum SPF 30 and 50+. For each sample 0.1200 grams of sunscreen was mixed with 20 mL of 70% isopropyl alcohol. After the first round of UV-vis data collection resulted in excessively high peaks before 400 nm, the samples were diluted. These samples were then diluted with a factor of 100 to 1 to create 5mL samples. To gather the absorbance measurements a double beam UV-vis Spectrophotometer was used with 1 cm cuvettes with a 70% isopropanol blank to calibrate. FINDING 1: ABSORBANCE BY SPF VALUE Both Up & Up sunscreens showed similar peak patterns with peaks from 290 to 315 nm and from 315 to 380 nm Both Banana Boat sunscreens showed a similar peak pattern with an obvious peak in the range of 260 to 325 nm and a less obvious shallower less obvious peak Up & Up SPF 50 showed significant higher absorbance values to SPF 30 Banana Boat sunscreens were nearly identical in values For the Up & Up sunscreens absorbance values were approximately 1 value higher for lower wavelength and double for higher wavelengths For the Banana Boat sunscreens the absorbance differences were 0.1 to 0.2 higher for low wavelengths and 0.01 to 0.02 higher for high wavelengths Figure 2. Graph of absorbance levels for four different samples Blue Up & Up SPF 50 Red Up & Up SPF 30 Green Banana Boat SPF 30 Orange - Banana Boat SPF 50 FINDING 2: ABSORBANCE BY BRAND For both SPF 30 and SPF 50 sunscreens the store brand, Up & Up, showed greater absorbance values for both the UVA and UVB radiation wavelength ranges. All sunscreens showed a scattered pattern for absorbance of some UVC radiation. Table 1: Absorbance values for specific wavelengths in both UVA & UVB ranges Up & Up SPF 30 Banana Boat SPF 30 Up & Up SPF 50 Banana Boat SPF 50+ 300.0003 nm 2.674675 1.240579 3.676106 0.973779 319.9911 nm 2.246514 1.074813 3.146533 0.81567 340.0098 nm 1.85499 0.854556 2.688409 0.631637 360.0137 nm 2.163869 0.843229 3.016202 0.648056 For SPF 30 sunscreens the Up & Up sunscreen showed absorbance values 1 that of the Banana Boat values. For the SPF 50 sunscreens the Up & Up sunscreen showed absorbance values 2 that of the Banana Boat SPF 50+ sunscreens. Both of the Up & Up SPF 30 and 50 showed more obvious and greater peaks in the UVA radiation wavelength range, where the Banana Boat sunscreens showed small bumps with no clear maximum absorbance values. a b c d Figure 3. a shows absorbance for store brand SPF 30; b shows name brand SPF 30; c shows graph for store brand SPF 50, d shoes graph for name brand SPF 50 SUNSCREEN ACTIVE INGREDIENTS Figure 4. Chemical structures of active ingredients from left to right Avobenzone, Homosalate, Octocrylene, and Octisalate all redrawn from PubChem [4] Up & Up SPF 30 Avobenzone(3.0%), Homosalate(10.0%), Octisalate(5.0%), Octocrylene(2.0%) Up & Up SPF 50 Avobenzone(3.0%), Homosalate(10.0%), Octisalate(5.0%), Octocrylene(4.0%) Banana Boat SPF 30 Avobenzone(2.0%), Homosalate(6.0%), Octocrylene(6.0%) Banana Boat SPF 50 Avobenzone(2.7%), Homosalate(9.0%), Octisalate(4.5%), Octocrylene(6.0%) CONCLUSIONS Considering the idea that high price tag means better product as well as the thought that in theory a higher SPF value would provide more protection, it would be a fair assumption to make that the name brand, Banana Boat SPF 50 plus sport spray sunscreen would perform the best. Therefore, it could be expected that this sunscreen would have the highest absorbance values; however, the complete opposite occurred as this sunscreen had the lowest absorbance values. In fact, the Banana Boat brand all together showed lower absorbance values for both UVB and UVA radiation than the store brand, Up & Up sunscreens. Comparing the two Banana Boat sunscreens there was little difference in the performance of the two when analyzed by UV-vis with the higher SPF showing ever so slightly lower values. Both Banana Boat sunscreens also showed slightly higher absorbance of UVB radiation compared to UVA radiation. When comparing the two Up & Up sunscreens there was a significant difference in the performance of the two with SPF 50 showing, as expected, higher absorbance values. Both Up & Up sunscreens did show a similar pattern with having higher absorbance of UVB radiation in comparison to UVA radiation. In the end all of the data points to one clear winner, when searching for the sunscreen that will provide the most protection against the suns harmful rays, the Up & Up sport spray SPF 50. LITERATURE CITED 1D'Orazio J, Jarrett S, Amaro-Ortiz A, Scott T. UV radiation and the skin. Int J Mol Sci. 2013 Jun 7;14(6):12222-48. doi: 10.3390/ijms140612222. PMID: 23749111; PMCID: PMC3709783. 2Testing and Evaluating Aerosol Sunscreens. ARPANSA. (n.d.). https://www.arpansa.gov.au/understanding-radiation/radiation-sources/more-radiation-sources/sunprotection-sunscreen 3U.S. Department of Health and Human Services. (n.d.). Protecting your eyes from the Suns UV light. National Eye Institute. https://www.nei.nih.gov/about/news-and-events/news/protecting-your-eyes-sunsuv-light 4U.S. National Library of Medicine. (n.d.-b). Homosalate. National Center for Biotechnology Information. PubChem Compound Database. https://pubchem.ncbi.nlm.nih.gov/compound/Homosalate#section=Drug-and-Medication-Information ACKNOWLEDGMENTS Thank you Dr. McVey!  ...

... Phytoremediation Design for Community Garden Phytoremediation Design for Community Garden Phytoremediation Design for Community Garden Jackie Picazo, Dr. Kamila Devers College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 ABSTRACT INTRODUCTION The soil samples were collected from various areas within the community garden to investigate contamination plumes. The analysis was performed with compliance of EPA 3050a - Acid digestion of Soil Samples. AAS (Atomic Absorption Spectrometry) was utilized for digested sample analysis. Knowing the lead concentration would help us to determine the plant species that are suitable for lead phytoremediation. The urban garden has already raised beds in certain areas and utilizes sunflower sunflowers as phytoremediators. The vegetables accumulate lead, especially root vegetables. To prevent the accumulation the rotation of vegetable crops and hyperaccumulators was suggested. Hyperaccumulators are plants that accumulates high amount of lead in their biomass such as decorative cabbage, alfalfa, sunflowers Mand ATERIALS AND [1]. METHODS Sampling: Soil was sampled at Flanner House community garden, Indianapolis. Soil pH: Use a pH meter or testing kit with calibrated solutions. Analyze the recorded pH values to discern acidity variations, aiding in soil quality assessment and targeted gardening interventions. Digestion of soil samples for AAS: EPA 3050a, Acid digestion. This digestion process enhances the accessibility of elements for AAS, ensuring accurate measurement of metal concentrations in the soil. Calibration and Analyzing Standards for AAS: The calibration curve with 0ppm, 1ppm, 3ppm, 5ppm, 7ppm, 10ppm, 12ppm was prepared and the absorbance was measured. The lead concentration was calculated utilizing the best fit trend line from standards. Sa Absorbance ppm [mg/L] ppm soil [mg/kg dry weight) Tomatoes (1) Tomatoes (2) Tomatoes (3) Tomatoes (4) Sunflower (5) Sunflower (6) Sunflower (7) Kale (8) Kale (9) 0.005 1.18 127.27 0.012 3.30 355.70 0.017 2.70 382.44 0.008 2.09 225.17 0.006 1.48 159.90 mple 0.006 1.48 159.90 0.007 1.79 192.53 0.004 0.008 0.88 2.09 94.64 225.17 Corn (10) 0.004 0.88 94.64 Corn (11) 0.005 1.18 127.27 Callard (12) 0.013 3.61 388.33 Callard (13) 0.009 2.39 257.80 The essential for tracking of contamination plume and phytoremediation design. The lead concentration is increasing toward the kale, and collard garden area. The concentration of lead is moving with underground water flow. The ornamental cabbage will be set up in the area in line rotating with collard and kale to start removing the lead from the soil. The trees will be used to mitigate lead as a barrier between low and high concentrations. FUTURE DIRECTIONS We advance our understanding of lead distribution in the soil through meticulous sample collection and precise analytical techniques. To investigate the long-term effects of lead in soil on plant health and exploring sustainable remediation strategies will be crucial for mitigating environmental risks and promoting ecosystem resilience. To applythe phytoremediation method in spring In addition, the workshops for citizens to understand lead poisoning and how to prevent it from their gardens. LITERATURE CITED [1]Yan A, Wang Y, Tan SN, Mohd Yusof ML, Ghosh S, Chen Z. Phytoremediation: A Promising Approach for Revegetation of Heavy Metal-Polluted Land. Front Plant Sci. 2020 Apr 30;11:359. doi: 10.3389/ fpls.2020.00359. PMID: 32425957; PMCID: PMC7203417. ACCLPP. 2012. Low level lead exposure harms children: A renewed call for primary prevention. Report of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention. CDC, Washington, DC. Carey, A.E., Gowen, J.A., Forehand, T.J., Tai, H., and Wiersma, G.B.. 1980. Heavy metal concentrations in soils of five United States cities, 1972 urban soils monitoring program. Pestic. Monit. J 13: 150154. Codling, E.E., Chaney, R., and Green, C.E.. Lead and arsenic uptake by carrots grown on five orchard soils with history of lead-arsenate application. 2007. Paper presented at: Trace elements, heavy, metals, Absorption vs Lead concentration [ppm] 0.045 y = 0.0033x + 0.0011 R = 0.9965 0.04 0.035 0.03 Absorbance This research project investigates lead exposure in urban areas, focusing on community gardens with lead-contaminated soils. Lead exposure causes brain damage, IQ decrease, and behavioral problems. Lead is one of the health risks that can be prevented in children. The study measured concentrations in the vegetable community garden to minimize lead exposure to citizens for whom the vegetables are provided to encourage heart-healthy options for their diets. Phytoremediation has been designed to gate lead and prevent the accumulation in vegetables. CONCLUSIONS 0.025 ACKNOWLEDGMENTS 0.02 0.015 0.01 0.005 0 0 2 4 6 8 Lead [ppm] 10 12 14 Thank you to Dr. Devers for allowing me to be a part of the research. Another thing thank you so much for the Flanner House.  ...

... Genetic Insight into Store-Bought Shrimp: A DNA Barcoding Exploration Jones McNamar, Etiniabasi Inyang and Alexis Hockett ABSTRACT DNA EXTRACTION WHAT WENT WRONG? In the DNA barcoding project, an investigation was conducted on commercially acquired shrimp from grocery stores with the aim of determining their origin, identifying the species, and detecting potential mislabeling. A prior research explored the mislabeling phenomenon within seafood, encompassing varieties like grouper, pike perch, yellowfin tuna, and bluefin tuna. This study revealed a correlation between mislabeling occurrences and the affordability of certain fish species (Pardo, Miguel, et al., 2018). The primary objective of DNA extraction is the isolation of target material through a systematic process. In this extraction procedure, fragments of two different shrimp specimens (0.625 g of shrimp 1 and 0.630 g of shrimp 2) were broken down to achieve a pasty consistency. Subsequently, the paste was transferred to a small collection tube and subjected to heat for an extended duration. Following this, the collection tube underwent processing in a flow tube, incorporating specific buffers to facilitate tissue breakdown. Utilizing a vortex spinner iteratively, the resulting mixture was refined until only DNA remained in the collection tube. Upon calculating the DNA content in each tube, the concentrations were determined to be 9.2 nanograms per microliter for shrimp 1 and 1.74 nanograms per microliter for shrimp 2. In the intricate process of DNA extraction or PCR creation and barcoding, the likelihood of errors occurring in the PCR creation is notably minimal. Potential errors, such as using incorrect primers or incorrectly mixing the PCRs, were ruled out, as the primers were verified for accuracy. The most likely source of the issue points toward the DNA extraction phase, where there is a considerable chance that an insufficient amount of shrimp tissue was utilized or that the tissue was inadequately broken down. Additionally, the introduction of human error during the buffering and vortexing steps of the extraction process could have contributed to the challenge. INTRODUCTION Determining the species of shrimp being sold in grocery stores is important due to that fact that several shrimp species are at risk of endangerment (Bilgin, R., et al, 2015). Studying their DNA can help determine if the shrimp sold in stores is endangered or not, as well as if there are any health risks in consuming that type of shrimp. DNA barcoding is a source that is useful in identifying species (Grave, S. De, et al, 1970). DNA barcoding will help answer our questions because we can gather the shrimps DNA and compare it to the DNA of shrimp species already logged on the internet, or potentially even discover new species. Figure 1. Photo via Bon appetite, Delany, A. (2019, May 21). How to thaw frozen shrimp and win weeknight dinner. Bon Apptit. https://www.bonappetit.com/story/how-to-thawfrozen-shrimp MATERIALS AND METHODS DNA Extraction: Frozen shrimp samples were obtained for the study. DNA extraction was done using the sample and InstaGene Matrix according to protocol. This method was used to ensure a high-yield of DNA extraction from shrimp samples. PCR Amplification: To amplify a large quantity of DNA, COI (Cytochrome Oxidase I) is used. The primers utilized were HC02198 and LCO1490 which are used to amplify invertebrate. Gel Electrophoresis: Following PCR amplification, the DNA results were analyzed using gel electrophoresis. Agarose gel (1.5%) was prepared, and the PCR products were loaded along with a DNA ladder. Figure 2. What the shrimp DNA looked like after the buffer and vortex process (left photo is shrimp 1, right photo is shrimp 2) PCR AND DNA BARCODING After determing remaining DNA post-extraction, insights from Oskar Rennstam Rubbmark, Daniela Sint, Nina Horngacher, and Michael Traugott guided the selection of the necessary primersHCO2198 and LCO1490. The preparation of the polymerase chain reaction (PCR) for both shrimp specimens involved a blending of ingredients in a microtube, destined for utilization in the subsequent barcoding process. The concoction comprised 1 microliter of each primer, a specific quantity of DNA (2 microliters for shrimp 1, 6 microliters for shrimp 2), 12.5 micrometers of biomix, and water (10.5 microliters for shrimp 1, 66.5 microliters for shrimp 2), culminating in a total volume of 25 microliters for the PCR. Upon completion, the PCR products underwent gel insertion, which was subjected to gel electrophoresis to detect any discernible DNA strands. Regrettably, the analysis revealed an absence of observable DNA strands after running the gel through the machine. CONCLUSIONS In conclusion, our DNA barcoding project, aimed at determing the origin, species identification, and potential mislabeling of store-bought shrimp, which encountered a setback during gel electrophoresis. While the error likely originated from the DNA extraction phase, where insufficient tissue or human errors might have occurred, the detailed PCR creation process minimized the chances of mistakes. The selection of primers, guided by the research of Oskar Rennstam Rubbmark, Daniela Sint, Nina Horngacher, and Michael Traugott, ensured accuracy in the barcoding proccess. Despite facing a challenge in gel electrophoresis with no observable DNA strands, this provides valuable insights for conducting future experiments and spotlights the complexity of the genetic processes. Figure 4. Photo via Fisher Scientific: Eppendorf pipette pick-a-pack sets - pipette products, pipettes. Eppendorf Pipette Pick-a-Pack Sets:Pipette Products:Pipettes | Fisher Scientific. (n.d.). https://www.fishersci.com/shop/products/eppendorf-pipette-pick-a-packsets-5/p-4344412 SOURCES Bilgin, R., et al. DNA Barcoding of Twelve Shrimp Species (Crustacea: Decapoda) from Turkish Seas Reveals Cryptic Diversity. Mediterranean Marine Science, ejournals.epublishing.ekt.gr/index.php/hcmr-med-mar-sc/article/view/12494. Accessed 11 Oct. 2023. Pardo, Miguel, et al. DNA Barcoding Revealing Mislabeling of Seafood in European Mass Caterings. Food Control, Elsevier, 23 Apr. 2018, www.sciencedirect.com/science/article/pii/S095671351830207X. Rennstam Rubbmark, Oskar, et al. A Broadly Applicable COI Primer Pair and an Efficient Single-Tube Amplicon Library Preparation Protocol for Metabarcoding. Ecology and Evolution, U.S. National Library of Medicine, 11 Dec. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6308894/#:~:text=It%20combines%20DNA%E2%80%90based%20identification,et%20al.%2C%202012). ACKNOWLEDGMENTS Figure 3. From right to left, two images of the gels after the gel electrophoresis process, the two PRC that were made and placed into the gel. Thanks to Pardo, Miguel, Bilgin for the great articles, as well as Dr. Rob Denton for the help and support throughout the whole research process!  ...

... The Case of the Mystery Frogs Investigators: Molly Kelly, Keara Eder, and Kiley Breeden Intro/Background: Biologists in Arizona are working to relocate the endangered Chiricahua Leopard frogs due to heavy droughts and immense livestock grazing. The Chiricahua Leopard frogs have a similar appearance to other species of leopard frogs. This makes it difficult to determine which frogs need to be relocated. Our hope is to genetically identify these frogs to help biologists relocate the correct species. First Gel Sequence Second Gel Sequence Summary: We obtained samples of an unknown frog from a project in Sequencing results: Arizona. Our group extracted the DNA, prepared our samples for PCR reactions, then started the process of gel electrophoresis. Once we had a ladder and good band readings we prepared and sent our samples off to be sequenced by a company called GENEWIZ. All of this was done to discover what type of frog these samples were from and determine if this species was endangered. Conclusion: Materials/Methods: Our DNA sequences that we sent to GENEWIZ were Dissection and DNA extraction successful! With these results, we discovered - Primers: ControlP-H, CytbA-L, R012s 460 Reverse, R012s that our frog samples were most similar to a few 216 Forward. PCR and gel electrophoresis- to separate the DNA products species of lowland leopard frogs (Lithobates yavapainesis and Rana yavapaiensis). With this and analyze them. information, we can send our findings back to PCR conditions: Bio mix red and approximately 8 the Arizona Game and Fish Department. Biologists hours in a PCR machine. there can then use our results to compare them Gel materials: Agarose and Tris-acetate-EDTA (TAE with those of other Chiricahua Leopard frogs in buffer). the area. This will help them keep track of the DNA sequencing number of frogs they have in the area and - PCR samples with R012s 216 Forward and CytbA-L primers. determine which frogs in the area are endangered Cited Sources: Rana chiricahuensis. AmphibiaWeb. (n.d.). https://amphibiaweb.org/cgi/amphib_query?where-genus=Rana&wherespecies. species=chiricahuensis&account=lannoo Acknowledgments: Chiricahua leopard frog. (n.d.). https://www.biologicaldiversity.org/species/amphibians/Chiricahua_leopard_frog/index.html Alam, A. (2021, March 24). Threatened Chiricahua leopard frogs face habitat challenges. Cronkite News. https://cronkitenews.azpbs.org/2021/03/23/chiricahua-leopard-frogs-habitat-challenges/ Goldberg, Caren S., et al. Mitochondrial DNA Sequences Do Not Support Species Status of the Ramsey Canyon Leopard Frog (Rana Subaquavocalis). Journal of Herpetology, vol. 38, no. 3, 2004, pp. 313319, www.jstor.org/stable/1565770. Accessed 18 Oct. 2023 Dr Robert Denton Audrey Owens Arizona Game and Fish Department Ian Latella Arizona Game and Fish Department Cat Crawford US Fish and Wildlife Service  ...

... Sodium Chlorides Impact on Enzyme Activity Delainey Smith, Lizzie Piercy and Sarah Travis College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCTION FINDINGS GLUCOSE LEVELS CONCLUSIONS The enzyme lactase reacts with lactose, creating glucose as a product. For some members of the human population, their body does not produce the lactase enzyme, making it difficult to digest dairy products. Environmental factors and mutations can both cause changes in the structure of an enzyme, which can affect how they function. The chosen environmental factor of study was salt concentration. We chose salt concentration because it was an interesting and challenging factor to look at. In the experiment, the results suggested that the salt concentration of 0.1% is optimal for enzymatic activity due to the salt concentration is an isotonic solution. Whereas if the salt concentration is anything below that the activity is slower therefore, they produce less glucose. If the salt concentration is higher than 0.1% the production of glucose increases (Table 1). In the pictures below, you can see the Diastixs on the paper towel. The colors of the Diastix correlate to the amount of glucose that was detected. The darker the color the more the glucose that was detected in the solution. This experiment concluded that salt concentration affects the lactase enzyme and the amount of glucose that is produced. The experiment did meet the goal of testing the enzymatic activity of lactose. The amount of glucose produced in each of the samples shows how the different [NaCl] affected the lactase enzyme. Our hypothesis was supported because the lactase enzyme and the NaCl reacted together to synthesize into glucose. We learned that enzymes have high specificity in terms of salt concentration and the enzyme lactase works best in a [NaCl] of 0.125%. We hypothesize change in structure impacts enzyme activity. To test this, we used 5 different concentrations of salt in a lactose and lactase solution and tested the amount of glucose in each solution. Sample DI Water, Lactose, and Lactase 0.5% NaCl 0.2% NaCl 0.125% NaCl 0.1% NaCl 0% NaCl MATERIALS AND METHODS We made six different test tubes for our experiment each with a total volume of 2 mL. There was 1 mL of 6% lactase mixed with DI water, and 1 mL of 6% lactose and salt. Four of the test tubes had lactase and lactose with varying salt concentrations. The concentrations were 0.5%, 0.2%, 0.125%, and 0.1% salt in 6% lactose. The salt was mixed into the lactose, which was put into the test tubes with lactase. The positive control test tube that had 1 mL of DI water + lactase and 1 mL of lactose. The negative control had 1 mL of DI water and 1 mL lactose. After mixing the test tubes and letting them develop for some minutes, we tested the glucose levels of each test tube using the Diastix. We tested the Diastix three times. After they developed, we recorded the glucose level. The process can be seen in Figure 2 below. Replicate 1 1 % Glucose Replicate 2 1% Glucose Replicate 3 1% Glucose % Glucose % Glucose 2% Glucose 1% Glucose % Glucose % Glucose 2% Glucose 1% Glucose % Glucose % Glucose 2% Glucose 1% Glucose Negative Glucose Negative Glucose Negative Glucose The implications of these findings show why a high sodium diet is unhealthy and advised against. Too much salt will denature proteins and negatively impact the enzyme. In Figure 3, if we had more time, we could have done molecular simulations of this experiment to get a closer look at the denaturation of the proteins on a molecular level. Figure 4: YASARA molecular simulation of GLY to SER in lactase Table 1: The table shows the results of the wet lab experiments and the percentage of glucose produced with certain percentages of NaCl. LITERATURE CITED Abstract Search. Abstract Search Utility, abstracts.societyforscience.org/. Accessed 1 Nov. 2023. Braham, Sabrina Ait, et al. Effect of Concentrated Salts Solutions on the Stability of Immobilized Enzymes: Influence of Inactivation Conditions and Immobilization Protocol. Molecules (Basel, Switzerland), U.S. National Library of Medicine, 12 Feb. 2021, www.ncbi.nlm.nih.gov/pmc/articles/PMC7918437/ . ACKNOWLEDGMENTS Figure 3: The graph on the left shows the data that we collected on the Diastix. They are used to test the level of glucose in the solution. There are no error bars on our graph due to the results being consistent across the replicates. - Dr. Justice for being so supportive and helpful in our experiments. - The Biology department for allowing us to create our own experiments and funding our supplies. - The College of Arts and Sciences for giving us the space ot work  ...

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... Stress & Shear MATLAB Learning Tool Nikalaas Kolosso College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 ABSTRACT MOHRS CIRCLE This study introduces a MATLAB-based learning tool to enhance engineering students' understanding of stress and shear forces in cantilever cylindrical beams. Utilizing graphical methods, including Mohr's Circle, the tool allows users to input beam parameters, triggering calculations for axial stress, bending moment, and shear stress. While successful, potential enhancements such as unit flexibility and support for different beam types are identified, offering valuable insights for further development. Mohr's Circle is a graphical representation used to analyze and visualize stress components acting on a material at different orientations. It aids engineers in understanding normal and shear stresses and is valuable for identifying principal stresses and maximum shear stresses. By providing a clear visual representation, Mohr's Circle enhances the interpretation of complex stress states and assists in making informed decisions in structural analysis and design. RESULTS FURTHER DIRECTION Unit Flexibility: Users can seamlessly choose metric and imperial units for personalized calculations. STRESS & SHEAR Stress and shear are fundamental mechanical concepts representing internal forces within structural elements. Stresses are perpendicular to the face of the stress element we are observing while shear stresses are parallel to the face of the stress element MATLAB APP CODE Versatile Support: Introducing support for various beam types and customization of supports, such as fixed and roller end supports, enhances the application's adaptability for a more comprehensive exploration of stress and shear forces in structural engineering. REFERENCES BUDYNAS, RICHARD G. Shigleys Mechanical Engineering Design. MCGRAW-HILL EDUCATION, 2019. Moebs, William, et al. 12.3 Stress, Strain, and Elastic Modulus - University Physics Volume 1. OpenStax, OpenStax, openstax.org/books/university-physics-volume-1/pages/12-3stress-strain-and-elastic-modulus. Accessed 1 Apr. 2023. Mohrs Circle - Illinois Institute of Technology, web.iit.edu/sites/web/files/departments/academicaffairs/Academic%20Resource%20Center/pdfs/Mohr_Circle.pdf. Accessed 1 Dec. 2023. ACKNOWLEDGMENTS I would like to thank Professor Xiaoping for his lectures and teaching me the material, along with Professor Sirikumara for her help through out progress of the project  ...

... Management of Diabetes Using MySugr Authors: Amy Avila, Kaya Favors, & Will Stewart App Rating Introduction According to the CDC, 29.7 million people in the U.S. population had diagnosed diabetes in 2021. In addition, 352,000 children under 20 years had diagnosed diabetes as well. (Center for Disease Control and Prevention, 2023). Having diabetes can come with a lot of lifestyle changes that can be difficult for patients to manage. One of the biggest challenges can be knowing how to accurately manage blood sugar levels. Not calculating insulin levels properly with meals can lead to the patient experiencing hyper or hypoglycemia. Along with providing education, it is important for healthcare providers to offer patients extra tools to involve them in managing their health. Overview MySugr helps with managing diabetes for anyone who needs it. This app contains a logbook where you can track blood glucose levels, carbohydrate intake, diet, and medications. Patients can also see what their estimated hemoglobin A1c is so that they can track their progress. This app also provides a feature that allows patients to share reports with their doctors if need be. This top 3 ranked app can also automatically transfer data from a glucometer for free. MySugr is a great tool for anyone who is trying to manage diabetes whether it is Type 1, Type 2, or gestational. Developed by mySugrGmbH Version: 3.85.0 Rating: 4.70 Last Update: Nov 26, 2023 Basic version is free of charge; mySugr PRO is $2.99/ month Used for all age groups Engagement rating: 4.2 Functionality rating: 4.75 Information rating: 5.0 Conclusion From a patient's point of view, this app seems to be manageable as long as the patient knows the type of insulin they use and their target blood sugar ranges. This app may be more manageable for a younger age group, but with proper education, it could also be used with older patients. It is also helpful that it gives the patient an option to set reminders that could be used to check blood sugar levels. From a nurse's point of view of MySugr, is a great tool for educating patients. A new diagnosis of diabetes can be hard for patients to adjust to. Providing them with an easy-to-use app to track blood 78glucose, diet, and carb intake can help with compliance. It is also a way for patients to always have important information with them constantly so that they are aware of treatment and can easily report findings. References Centers for Disease Control and Prevention. (2023, November 14). National Diabetes Statistics Report. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statisticsreport/index.html#:~:text=of%20Diagnosed%20Diabetes,Among%20the%20US%20population%20overall%2C%20crude%20estimates%20for%202021%20 were,304%2C000%20with%20type%201%20diabetes.  ...