Developing a framework for arts in health programs targeting individuals with chronic pain: a mixed-methods study of practitioners

OBJECTIVES

Chronic pain is a leading cause of morbidity and disability across the world. Cultural engagement may be a valuable tool in addressing the social disconnection that often accompanies chronic pain. This study sought to develop a framework for arts in health programs targeting individuals with chronic pain.

STUDY DESIGN

Sequential explanatory mixed-methods study.

METHODS

Web-based, cross-sectional survey sent to arts and cultural professionals to assess their experience with arts in health programming. Semi-structured interviews conducted with a sample of survey respondents to explore their perspectives on targeted arts in health programming for individuals with chronic pain.

RESULTS

Between October 2019 and January 2020, 208 surveys were completed by arts and cultural professionals. One hundred and twenty (58%) of the respondents indicated that they currently run an arts in health or museums in health program. Among these 120 respondents, 52 (43%) targeted older adults, 50 (42%) targeted individuals with mental health concerns, and 18 (15%) targeted individuals living with pain. Improving well-being (101 [84%]) and reducing social isolation (90 [75%]) were the most common intended program outcomes, while improving pain was the least common outcome (26 [22%]). Fifteen survey respondents were interviewed. Interviewees identified four interdependent themes regarding best practices for arts in health programs pertaining to (1) program content and structure, (2) program facilitation, (3) partnerships, and (4) programs for individuals with chronic pain.

CONCLUSIONS

The cultural sector can support chronic pain prevention and treatment efforts through the development of specialized programs. This study provides a framework for developing arts in health programs that support individuals living with chronic pain.

Updates in our understanding of local anaesthetic systemic toxicity: a narrative review

Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.

Challenges to the census: international trends and a need to consider public health benefits

The Canadian government decision to cancel the mandatory long-form census in 2010 (subsequently restored in 2015), along with similar discussions in the United Kingdom (UK) and the United States of America (USA), have brought the purpose and use of census data into focus for epidemiologists and public health professionals. Policy decision-makers should be well-versed in the public health importance of accurate and reliable census data for emergency preparedness planning, controlling disease outbreaks, and for addressing health concerns among vulnerable populations including the elderly, low-income, racial/ethnic minorities, and special residential groups (e.g., nursing homes). Valid census information is critical to ensure that policy makers and public health practitioners have the evidence needed to: (1) establish incidence rates, mortality rates, and prevalence for the full characterization of emerging health issues; (2) address disparities in health care, prevention strategies and health outcomes among vulnerable populations; and (3) plan and effectively respond in times of disaster and emergency. At a time when budget and sample size cuts have been implemented in the UK, a voluntary census is being debated in the US. In Canada, elimination of the mandatory long-form census in 2011 resulted in unreliable population enumeration, as well as a substantial waste of money and resources for taxpayers, businesses and communities. The purpose of this article is to provide a brief overview of recent international trends and to review the foundational role of the census in public health management and planning using historical and current examples of environmental contamination, cancer clusters and emerging infections. Citing a general absence of public health applications of the census in cost-benefit analyses, we call on policy makers to consider its application to emergency preparedness, outbreak response, and chronic disease prevention efforts. At the same time, we call on public health professionals to improve published estimates of monetary benefit (via either cost-benefit or cost-effectiveness analysis) to a given public health intervention.

The electronic structure of iridium oxide electrodes active in water splitting

Iridium oxide based electrodes are among the most promising candidates for electrocatalyzing the oxygen evolution reaction, making it imperative to understand their chemical/electronic structure. However, the complexity of iridium oxide's electronic structure makes it particularly difficult to experimentally determine the chemical state of the active surface species. To achieve an accurate understanding of the electronic structure of iridium oxide surfaces, we have combined synchrotron-based X-ray photoemission and absorption spectroscopies with ab initio calculations. Our investigation reveals a pre-edge feature in the O K-edge of highly catalytically active X-ray amorphous iridium oxides that we have identified as O 2p hole states forming in conjunction with Ir(III). These electronic defects in the near-surface region of the anionic and cationic framework are likely critical for the enhanced activity of amorphous iridium oxides relative to their crystalline counterparts.

Evaluation of different speech and touch interfaces to in-vehicle music retrieval systems

In-vehicle music retrieval systems are becoming more and more popular. Previous studies have shown that they pose a real hazard to drivers when the interface is a tactile one which requires multiple entries and a combination of manual control and visual feedback. Voice interfaces exist as an alternative. Such interfaces can require either multiple or single conversational turns. In this study, each of 17 participants between the ages of 18 and 30 years old was asked to use three different music retrieval systems (one with a multiple entry touch interface, the iPod, one with a multiple turn voice interface, interface B, and one with a single turn voice interface, interface C) while driving through a virtual world. Measures of secondary task performance, eye behavior, vehicle control, and workload were recorded. When compared with the touch interface, the voice interfaces reduced the total time drivers spent with their eyes off the forward roadway, especially in prolonged glances, as well as both the total number of glances away from the forward roadway and the perceived workload. Furthermore, when compared with driving without a secondary task, both voice interfaces did not significantly impact hazard anticipation, the frequency of long glances away from the forward roadway, or vehicle control. The multiple turn voice interface (B) significantly increased both the time it took drivers to complete the task and the workload. The implications for interface design and safety are discussed.

Receptor-independent actions of PPAR thiazolidinedione agonists: is mitochondrial function the key?

Agonists of the peroxisome proliferator activated receptor gamma (PPAR(gamma)) are currently used for treatment of type 2 diabetes due to their insulin sensitizing and glucose metabolism stabilizing effects. More recently some of these same agonists were shown to exert anti-inflammatory and anti-proliferative effects as well. Although PPAR(gamma) agonists can operate via receptor-mediated events occurring at the genomic level, thereby causing long lasting changes in gene expression patterns, recent studies demonstrate non-genomic as well as genomic actions, and receptor-dependent as well as receptor-independent effects of the thiazolidinedione (TZD) class of PPAR(gamma) agonists. In this review we will summarize data describing some of these novel, receptor independent actions of TZDs, review evidence that TZDs directly influence mitochondrial function, and attempt to reconcile how changes in mitochondrial function could contribute to other receptor-independent actions of these drugs.

Successful perinatal management of hydrops fetalis due to hemolytic disease associated with D-- maternal phenotype

We report the successful management of a case of hemolytic disease and hydrops fetalis secondary to anti Rh 17 antibodies in a woman with the rare D-- phenotype. We discuss the efficacy of intravenous immunoglobulins in treating hemolytic disease of the newborn infant.

The utility of buccal mucosa graft in salvage urethroplasty

OBJECTIVE

To evaluate our results with buccal mucosa free grafts in salvage urethroplasty.

PATIENTS AND METHODS

Retrospective chart review of autologous buccal mucosa grafts for urethral reconstruction at Winnipeg Children's Hospital and Children's Hospital of Eastern Ontario between November 1992 and March 2000.

RESULTS

Nine patients (median age 4 years) underwent such reconstruction. Seven of the nine patients had experienced failed previous attempts at hypospadias repair. Onlay grafts were used in all but one patient who required a tube graft. Urethrocutaneous fistula was the most common post-operative complication, affecting four of nine patients. Two patients developed urethral strictures and one a meatal stenosis. Satisfactory functional results were ultimately achieved in all patients. Harvest site complications were minimal.

CONCLUSIONS

Buccal mucosa is a readily available and useful source for urethral grafting material, but should only be used in patients with insufficient penile skin. Grafts may be used as onlays or tubes. It is our experience that despite precautionary measures, fistulae and strictures are common.

A 27-bp region of the inducible nitric oxide synthase promoter regulates expression in glial cells

The expression of inducible nitric oxide synthase (NOS2) in glial cells is inhibited by neurotransmitters such as norepinephrine (NE) which elevate cAMP levels. We examined the molecular basis for this effect using a 2.2-kb fragment of the rat NOS2 promoter transfected into rat C6 glioma cells. Promoter activation (up to six-fold) by lipopolysaccharide (LPS) and interferon-gamma (IFNgamma) was reduced by NE, which alone had no effect. However, a promoter construct extending to bp -130 and containing the proximal nuclear factor-kappa B (NF-kappaB) binding site was minimally activated by LPS and cytokines, but activated up to three-fold by NE. Deletion analysis identified a 27-bp region (bp -187 to -160) as critical for mediating this suppressive effect. This region also enhanced promoter activation by LPS and cytokines, and prevented activation by NE alone. Gel shift analysis revealed constitutive binding to this region, and induction by NE of additional complexes which could be blocked by an antibody against CREB. NE also increased levels of the IkappaBalpha protein which could contribute to its suppressive effects. These results identify a critical role for this 27-bp region in regulation of NOS2 promoter activation and suppression by cAMP.

Local anesthetics potentiate nitric oxide synthase type 2 expression in rat glial cells

Expression of the calcium-independent nitric oxide synthase (NOS2) contributes to damage in neurologic disease and trauma. The effects of local anesthetics on NOS2 expression have not been examined. The authors tested the effects of four local anesthetics on the expression of NOS2 in immunostimulated rat C6 glioma cells. Incubation with local anesthetics alone did not induce nitrite accumulation; however, the nitrite production induced by stimulation with bacterial endotoxin lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma) was increased in a dose-dependent manner by bupivacaine (maximal 3-fold at 360 microM), tetracaine (maximal 7-fold at 360 microM), and lidocaine at higher doses (5-fold increase at 3.3 mM). Significant increases in nitrite production were observed in concentrations of bupivacaine or tetracaine as low as 120 microM, which correspond to 30 microg/mL (.003% weight/volume). In contrast, ropivacaine had little effect on nitrite production (160% of control values) and only at the highest concentration (3.3 mM, corresponding to 890 microg/mL or 0.089% w/v) tested. Increased nitrite production was not caused by cytotoxic effects of the drugs used, as assessed by release of intracellular lactate dehydrogenase. Increased nitrite production was accompanied by increased NOS2 catalytic activity, steady state mRNA levels, and promoter activation. These results demonstrate that submillimolar doses of two commonly used local anesthetics can increase glial NOS2 expression.

Factors influencing participation in weekly support groups among women completing an HIV/STD intervention program

Over the past three decades, the influence and importance of social support has been well documented and the findings have suggested a beneficial effect on stress-related situations, mental and physical health, and social functioning. More recently, small group/skills training behavioral interventions have demonstrated success in changing behaviors which affect the transmission of sexually transmitted diseases, including HIV among populations at risk for these diseases. Studies of support groups to date have been conducted exclusively in research settings where women are offered financial incentives for participation. Little is known about the willingness of women to participate in ongoing support groups after successfully completing a skills training intervention. The present study examines the factors that may influence participation among women in a weekly support group after completing a structured, six session HIV/STD intervention. Both quantitative and qualitative data are collected from 265 women in the intervention arm of a multi-site randomized controlled behavioral intervention trial. Results reveal that less than a quarter (22%) of women participated in at least one support group. Participation varied significantly by site, ranging from 34% to 15% (p = .008). Participation was also strongly linked to recent use of domestic violence services. Qualitative data indicated that although monetary incentives play some role in the woman's decision to participate, other factors are also important. These include program outreach, support group size, salience of the group content, consistency of group leadership from the intervention to the support group, and use of peer leaders along with professional facilitators. Implications for design of post-intervention support groups programs are discussed.

Effects of ZDV-based patient education on intentions toward ZDV use, HIV testing and reproduction among a US cohort of women

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p < 0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p < 0.001) and to believe ZDV reduced transmission (p < 0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

Seat belt injury presenting as bilateral abdominal wall herniations in a child

The constellation of abdominal injuries caused by seat belts in automobile accidents usually consists of intraabdominal solid organ and hollow viscus injuries. We present a two-and-one-half-year-old patient with an unusual constellation of seat belt injuries that presented as bilateral abdominal herniations. We feel that an abdominal hernia caused by a seat belt injury should alert the clinician to the probability of other severe intraabdominal injuries. The uniqueness of this case is compounded by the way in which the seat belt was misused.

MRA of the intracranial circulation in asymptomatic patients with sickle cell disease

BACKGROUND

MR angiography (MRA) provides a mechanism for non-invasively studying blood flow, thus providing a new opportunity to study the intracranial circulation in asymptomatic sickle cell disease (SCD) patients. Although conventional angiography is the gold standard for the depiction of vascular anatomy, this is too invasive for an asymptomatic population.

OBJECTIVE

To establish the range of appearances in asymptomatic SCD patients and to correlate brain MRI results (either sub-clinical abnormalities or normal brain parenchyma) with the MRA findings.

MATERIALS AND METHODS

Brain MRI and MRA of the intracranial circulation was performed on 22 patients (13 male and 9 female, median age 7.5 years, range 1.3-20 years). Fourteen were homozygous SS and eight were SC. The median haematocrit at the time of MRI was 25.9 (range 13.8-33.3).

RESULTS

On MR imaging, four patients had infarcts in eight vascular territories (six anterior and two posterior). In 3/4 of anterior vascular territories with infarction, long ( >/= 6 mm) segments of abnormal signal were seen at the internal carotid artery bifurcation with associated reduced distal flow. Short focal areas of abnormal signal were commonly seen where vessels branched, bifurcated or curved and were not associated with infarcts. These areas probably represent turbulence-related dephasing secondary to high velocity flow found in SCD.

CONCLUSION

Long segments ( >/= 6 mm) of abnormal signal with reduced distal flow correlated with sub-clinical infarction.

Stabilizing the HIV/AIDS workforce: lessons from the New York City experience

The Ryan White Title I Personnel Needs Study described here is an evaluation of the human resource needs of HIV/AIDS service agencies in New York City. The research presented here was conducted in collaboration with researchers from the Medical and Health Research Association and the New York City Department of Health and the Planning and Evaluation Committee of the New York City HIV Health and Human Services Planning Council. The assessment is divided into two components. The first component is a survey of 100 key informants from HIV/ AIDS service agencies. The second component is a detailed staffing survey of 70 personnel directors of HIV/AIDS service agencies. HIV/AIDS service directors perceived staff recruitment as a more difficult process than staff retention, regardless of agency type. Vacancy rates at the surveyed agencies varied by professional category; they were especially high in the category of nurse practitioners (13%) and outreach/education workers (15%). Agencies stressed that incentives that would positively affect recruitment and retention should be tailored to address the concerns of varied health care and social service professionals. In addition, agencies were not routinely able to provide some incentives deemed effective such as higher salaries, housing subsidies, and smaller caseloads. To reduce recruitment and retention problems, agency informants recommended a variety of incentive programs including malpractice insurance for physicians, flexible hours for full-time employees (including case managers, nurses, physician's assistants), smaller caseloads, and a decrease in the proportion of staff time devoted to direct client contact. Overall health care trends including truncated federal budgets, state Medicaid cutbacks, and the rapid conversion to managed care all affect the quality of patient care and of the work setting for health care and social service providers serving persons with AIDS. Medical Subject Headings (MeSH): AIDS, health personnel, employment supported, employee workload, staff attitude.

Choledochal cyst. Imaging by Telepaque-enhanced computed tomography

A choledochal cyst is an uncommon anomaly of the biliary system requiring surgical intervention. A case of a choledochal cyst imaged by computed tomography following oral administration of cholangiography contrast material (Telepaque) is reported. Telepaque-enhanced computed tomography is an easy, noninvasive method to demonstrate pertinent preoperative anatomy in cases of choledochal cysts, and is especially useful in the pediatric patient.

Detection of a deep lipoblastoma by MRI and ultrasound

Lipoblastoma is a rare benign tumor of the soft tissue occurring predominantly during the first two years of life. We report here the application of MRI and ultrasound to the detection of a soft tissue lipoblastoma. By MRI and ultrasound, we precisely evaluated the extent of the tumor, the presence of atypical areas of cystic and mucoid degeneration within the tumor, and its lack of vascularity. Our patient's lipoblastoma did not demonstrate the signal characteristics of a fatty tumor on MRI.

Duodenal atresia presenting as hematemesis in a premature infant with Down syndrome. Case report and review of the literature

Congenital duodenal obstruction, a common complication of Down syndrome, most often presents as neonatal bilious vomiting. We report the first premature infant with Down syndrome whose duodenal atresia presented with a massive hematemesis secondary to duodenitis. Since a plain radiograph of the abdomen is diagnostic in the case of duodenal obstruction, it should be included in the diagnostic workup of hematemesis in newborn infants.

Observation of atomic steps on single crystal surfaces by a commercial scanning electron microscope

Atomic steps on (111) and (100) crystal surfaces of Pt were observed using a commercial scanning electron microscope (SEM) in secondary electron mode. By comparing the SEM images and those by reflection electron microscopy (REM), the observed contrast was confirmed to be that from atomic steps on crystal surfaces. The contrast mechanism is briefly discussed. One application of this imaging technique is also shown.

Necrotizing enterocolitis in infancy

The most common gastrointestinal emergency in the newborn is necrotizing enterocolitis. Premature babies are the most likely victims, but it also occurs in full-term infants. Although great strides have been made in elucidating some of the factors responsible for necrotizing enterocolitis, such as intestinal ischemia, bacterial overgrowth, and feeding dysfunction, the exact etiology is as yet unclear. The timing and indications for surgery differ from institution to institution, but the long-term outcome is similar in most large series. The overall mortality rate remains about 20% to 40%, and of the survivors, about one half seem to have no sequelae, the remaining infants having neurologic and gastrointestinal deficits of various degrees of significance.