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Arts and health s common impact on both the community and the individual is the clear point from which their intersection grows generic 100 mg amantadine with visa. The creative process ignites our passions discount 100 mg amantadine with amex, drives our perspectives of the world buy 100mg amantadine free shipping, and pushes us to challenge accepted conventions. In the end, the arts and health intersection is founded on the use of creativity to gain insights about what it is to be human to experience life from birth to death. Today, arts and health programs continue to grow both in number and scope as they focus on promoting well-being and enhancing quality of life in the broadest sense for both individuals and communities. Community Partnership for Arts and Culture 10 Creative Minds in Medicine case study cleveland clinic arts and medicine institute At Cleveland Clinic, board-certifed music therapists treat patients to improve symptoms and conditions associated with illness and injury. Music therapy has been shown to decrease pain and anxiety, and improve quality of life, mood, and speech. Photo by Kulas Foundation & Taxel Image Group, 2008 Community Partnership for Arts and Culture 11 Creative Minds in Medicine lifing the spirit You expect to see and feel certain things when you go to the hospital: white coats; cold stethoscopes; hard, sterile, gleaming surfaces; worry. You don t generally expect to fnd musicians playing there or spaces flled with colorful art. The surprise you get when you walk into the arts-flled Cleveland Clinic may be part of your treatment. The Arts and Medicine Institute was formed in 2008 to build on Cleveland Clinic s solid tradition of mixing art with health care, she says. Since its founding in 1921, Cleveland Clinic has been known for displays of fne art on its walls and of artistic talent from its employees. With the Institute in place, arts of all kinds have become an offcial part of Cleveland Clinic s health mission and programming, explains Maria Jukic, executive director of Arts and Medicine. Those goals have allowed the Clinic s range of arts therapies and programs to expand and deepen: Jukic and her colleagues are making more art available on Clinic campuses, fnding more ways of using it to heal, and identifying more people who need its good effects. And art improved their few things take you out of yourself or cheer you up faster than an unexpected delight: mood... Jukic calls it normalizing, a process art can create that helps people feel more in control, less fearful. True, the sick remain the Clinic s central concern and patients are measurably benefting from the presence of art and musicians a 2012 Clinic survey found 91 percent of patients responding reported that visual art improved their mood during hospital stays of two to three days. That program, which focuses on visual art, manages Cleveland Clinic s existing art collection, This is something and adds to that collection by commissioning and acquiring new pieces. Many of the programs and works of art have been subsidized by donations from grateful patients and visitors to Cleveland Clinic. Committees of experts including curators select the pieces to be bought and/or displayed. The quality of the art selected must be high, says Cohen, because it needs to stand the test of time. Those who choose the art aim for eclectic media and subject matter, because Cleveland Clinic has a global reach, and staff and patients from all over the world. It wants to refect those many different viewpoints, which is also far more interesting and engaging to a diverse population across Cleveland and other geographic areas, she adds. Yet the something-for-everyone approach does contain one other qualifcation: Cleveland Clinic art needs to have something positive to say about the human condition and spirit. Art that s collaborative and/ or environmentally conscious, art that calms, comforts, amuses or uplifts these are the kinds of images and objects that contribute to healing. Water, landscapes, sunlight such subjects tend to mellow people s moods and brighten their outlooks. Cohen says that one of Cleveland Clinic s most successful pieces is a video by Jennifer Steinkamp of a tree that went through seasonal changes. Others danced in front of it, and the wall had to be repainted frequently because so many viewers tried to touch and hug it. They can also help decrease the amount of staff turnover by making the workplace less stressful. So there are economic benefts to having an arts program but the value of the Arts and Medicine Institute is much greater than that, Fattorini says. Photo by Cleveland Clinic Photography Below: Docents lead tours of the Cleveland Clinic art collection several times per week. Patients suffering from memory loss and their caregivers enjoy a special tour program monthly. Photo by Jim Lang Community Partnership for Arts and Culture 14 Creative Minds in Medicine the intersection of arts and health What is the Arts and Health Intersection? From writing poetry or playing music with friends to taking photos or experiencing theater, arts and culture serve as outlets for individual learning, expression and creativity. Participation in arts and culture has been shown to yield positive cognitive, social and behavioral outcomes for human development and for overall quality of life throughout the human lifespan. Because of its ability to span both personal and public spheres in varying degrees, arts and culture participation can yield far-reaching results. At another level, the paintings can be developed into public murals that call attention to areas or issues in need of improvement. Even further, the paintings can become an exhibition that rallies the broader community, encouraging it to take actions that address neighborhood challenges. In this way, a multifaceted view of impact is critical to develop a full understanding of the ways in which arts and culture infuence the human condition on a personal and global scale. In a similar way, an inquiry into the nature of the arts and culture / health and human services intersection (referred to hereafter as the arts and health intersection, for simplicity) requires4 a multifaceted approach. In this general sense, the terms arts and health can be ambiguous because their defnitions are dependent on the manner through which they intersect. Defnitions are ultimately determined by who is participating in the arts and health intersection, where the intersection takes place and what the intersection s goals are. Clinical outcomes in physical and mental health, improved health and human services delivery and personal enjoyment of arts and culture all exist on the continuum of this creative intersection. Artistic practice commonly challenges convention, organically develops new methods and accepts subjective outcomes, while protocols for health practice and clinical outcome measurement demand greater rigidity. In these ways, arts and culture have the10 ability to span multiple disciplines and be applied through a wide range of methods. This ability makes arts and culture interventions useful in responding to the unique needs and concerns of individuals that arise in multiple healthcare situations. Arts and Health in Cleveland Cleveland is fortunate to be home to world-class sets of healthcare and cultural institutions. Meanwhile, Cleveland s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for both local and international audiences. The Framework of this White Paper While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices illustrating the many ways in which arts and culture contribute to healthcare practice and human services delivery:11 Arts integration in healthcare environments. Community Partnership for Arts and Culture 16 Creative Minds in Medicine Arts and health integration with community development, public health and human services. In the following chapters, these categories will be defned more fully and will highlight key examples of arts and health collaborations that are happening in Cleveland.

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Such assays are not commonly available but are of discriminatory value when properly performed amantadine 100mg online. If a bronchial provocation challenge is deemed necessary amantadine 100mg overnight delivery, it is preferable to have the employee perform a job-related task that exposes him or her to the usual concentration of occupational chemicals amantadine 100mg without prescription. Subsequent blinding may be necessary as well, and successive challenges may be needed. Exercise-induced Asthma Exercise-induced asthma occurs in response to either an isolated disorder in patients with mild asthma or an inability to complete an exercise program in symptomatic patients with chronic asthma. Control of the latter often permits successful participation in a reasonable degree of exercise. Airway hyperresponsiveness does not occur, but there is an increase in expired nitric oxide ( 196). However, such declines also occurred on days in which no exercise challenge was conducted (197). In general, greater declines in spirometry and the presence of respiratory symptoms are seen directly proportional to the level of hyperventilation and inversely proportional to inspired air temperature and extent of water saturation. The exact mechanism of bronchoconstriction remains controversial, but it is thought that postexertional airway rewarming causes increased bronchial mucosal blood flow as a possible mechanistic explanation ( 198). Clinically, it has been recognized that running outdoors while inhaling dry, cold air is a far greater stimulus to bronchospasm than running indoors while breathing warmer humidified air or than swimming. It is thought that the hyperventilation of exercise causes a loss of heat from the airway, which is followed by cooling of the bronchial mucosa. The resupply of warmth to the mucosa causes hyperemia and edema of the airway wall (198). Exercise-induced bronchospasm can occur in any form of asthma on a persistent basis but also can be prevented completely or to a great extent by pharmacologic treatment. In prevention of isolated episodes of exercise-induced bronchospasm, medications such as inhaled b-adrenergic agonists inspired 10 to 15 minutes before exercise often prevent significant exercise-induced bronchospasm. Cromolyn by inhalation is effective, as to a lesser extent are oral b-adrenergic agonists and theophylline. For patients with chronic asthma, overall improvement in respiratory status by avoidance measures and regular pharmacotherapy can minimize exercise symptoms. Pretreatment with b-adrenergic agonists in addition to regular antiasthma therapy can allow asthma patients to participate in exercise activities successfully. Antitussives, expectorants, antibiotics, and use of intranasal corticosteroids do not suppress the coughing. Pharmacologic therapy can be successful to suppress the coughing episodes or sensation of dyspnea, but often, when inhaled, b-adrenergic agonists have not been effective; the best way to suppress symptoms is with an inhaled corticosteroid. If using an inhaler produces coughing, a 5- to 7-day course of oral corticosteroids often stops the coughing (124). At times, even longer courses of oral corticosteroids and antiasthma therapy are necessary. Factitious Asthma Factitious asthma presents diagnostic and management problems that often require multidisciplinary approaches to treatment ( 158,200). The diagnosis may not be suspected initially because patient history, antecedent triggering symptoms, examination, and even abnormal pulmonary physiologic parameters may appear consistent with asthma. Nevertheless, there may be no response to appropriate treatment or in fact worsening of asthma despite what would be considered effective care. Some patients are able to adduct their vocal cords during inspiration and on expiration emit a rhonchorous sound, simulating asthma. Other patients have repetitive coughing paroxysms or seal barking coughing fits. A number of patients with factitious asthma are physicians and paramedical or nursing personnel or have an unusual degree of medical knowledge. Psychiatric disease can be severe, yet patients seem appropriate in a given interview. Factitious asthma episodes do not occur during sleep, and the experienced physician can distract the patient with factitious asthma and temporarily cause an absence of wheezing or coughing. Invasive procedures may be associated with conversion reactions or even respiratory arrests from breath holding. In the latter case, the patient may have a diagnosis of asthma and be hospitalized, but although symptoms are present, the patient has limited wheezing to a quiet chest (but blood gases or pulse oximetry are not abnormal for the degree of symptoms) and unwillingness to phonate the vowel e for more than 3 seconds. In the series of 95 patients, many were health care providers and females who were obese ( 134). Thirty-eight percent of the 95 patients had a history of abuse, such as physical, sexual, or emotional ( 134). When there is no benefit from oral corticosteroids, it is advisable to taper and discontinue them. The lack of bronchodilator responsiveness or peripheral blood eosinophilia does not preclude a response to a 2-week course of prednisone. Emergency department visits for asthma in adults in New York City were found to peak 2 days after increases in ozone in ambient air ( 204). The effect was most in patients who had smoked more than 14 pack-years of cigarettes (204). There was no ozone effect for adult nonsmokers or light smokers (<13 pack-years) with asthma. In this study, most patients had severe asthma, and there was no effect of relative humidity on emergency department visits. These data support an effect of ozone on patients with severe asthma who were cigarette smokers. Effective management of patients with asthma may permit patients to tolerate most inadvertent exposures with little troubling effects. Further, these particles were able to induce isotype switching from IgM to IgE antibodies in B cells ( 205). The public health effects of diesel exhaust particles may be very great on emergence of allergen responses. Reflux of gastric acid into the lower esophagus can precipitate symptoms of asthma or cough without frank aspiration, perhaps by an esophagobronchial vagal reflex ( 206). An acute episode of asthma can cause increased negative intrathoracic pressures, which can increase reflux. Surgical intervention is indicated rarely but has been successful in varying degrees with either laparoscopic fundoplication or open procedures in patients with large hiatal hernias or strictures or previous surgery (206). Left-sided congestive heart failure has been associated with exacerbations of asthma. Bronchial hyperresponsiveness has been recognized in nonasthmatic patients who developed left ventricular failure. When patients with asthma develop congestive heart failure, at times, sudden episodes of wheezing dyspnea can occur in the absence of neck vein distention or peripheral edema, which would support a diagnosis of left ventricular failure. Similarly, long-term treatment regimens depend on the type of asthma and its severity.

No further description of the randomization process Allocation concealment (selection bias) Unclear risk Not enough information in the text discount amantadine 100mg with mastercard. However if the study medication is unblinded it should not incur unacceptable bias into the outcomes Incomplete outcome data (attrition bias) Low risk Of the 88 participants who enrolled order 100 mg amantadine amex, nine All outcomes - drop-outs? Low risk Baseline characteristics of participants be- tween groups was similar with no signicant differences noted Co-interventions avoided or similar? Low risk Participants were allowed to supplement the trial medications with Tramadol liquid buy amantadine 100 mg with amex. In the treatment group, these included unpleasant local heat sensation in two participants and pruritus in one participant Risk of bias Bias Authors judgement Support for judgement Random sequence generation (selection Low risk Randomization completed by computer- bias) ized randomization list. Chrubasik 2010 (Continued) Blinding (performance bias and detection Low risk Participants were randomized to treatment bias) groupswith interventionand placebomed- All outcomes - patients? Blinding (performance bias and detection Low risk Outcome assessment unblinded but un- bias) likely to inuence outcomes All outcomes - outcome assessors? Incomplete outcome data (attrition bias) Low risk There were seven participants who with- All outcomes - drop-outs? Low risk Baseline characteristics of participants be- tween groups was similar with no signi- cant differences noted Co-interventions avoided or similar? Period: 15 days Participants Twenty participants allocated to Brazilian arnica gel (N = 10) or placebo gel (N = 10). All participants went through a screening process coordinated by the physiotherapist responsible for the orthopaedics, traumatol- ogy, and rheumatology sector of the clinic. After screening, participants were submitted to medical evaluations to diagnose the nature of their lumbago before being allowed to participate in the research program. Secondary outcome: lumbar exibility, as determined by the modied Schober method Notes Total quality score: 5/12 Adverse effects: nothing reported. Risk of bias Bias Authors judgement Support for judgement Random sequence generation (selection High risk No method of randomization described. Blinding (performance bias and detection Low risk Participants were blinded to treatment group bias) and were unaware of which compound was All outcomes - patients? Low risk There were no signicant differences noted in baseline comparisonsbetweenthe placeboand intervention group Co-interventions avoided or similar? Circulatory and laboratory variables were not affected by either treatment Risk of bias Bias Authors judgement Support for judgement Random sequence generation (selection Low risk Randomization was computer generated. Frerick 2003 (Continued) Incomplete outcome data (attrition bias) Low risk There were seventy withdrawals in the All outcomes - drop-outs? Low risk With the exception of slightly more fe- male participants in the placebo group, the groups were comparable Co-interventions avoided or similar? Period: ve days Participants 120 patients allocated to Kytta-Salbe (a cream containing Comfrey root extract) (N = 60) or a matched placebo cream (N = 60). In the treatment group, two participants experienced headaches and one participant experienced pruritus. Blinding (performance bias and detection Low risk The trial medication and placebo ointments bias) were similar in appearance All outcomes - patients? Blinding (performance bias and detection Low risk The clinicians were blinded to treatment bias) group. Incomplete outcome data (attrition bias) Low risk All participants completed baseline to end of All outcomes - drop-outs? Low risk Groups were well balanced at baseline, with slightly more female participants than males Co-interventions avoided or similar? No other analgesic, anti-inammatory drug or physical treatment was allowed during the 12-week period. Methodofparticipantsselection:clinicalexamination,standardradiologicalexamination of the lumber spine, routine laboratory tests Interventions Rado-Salil ointment (containing 17. Local erythema and burning, three in the Rado-Salil group Risk of bias Bias Authors judgement Support for judgement Random sequence generation (selection Unclear risk The exact method used for randomization bias) was not described. Ginsberg 1987 (Continued) Blinding (performance bias and detection Low risk Participants were given either a treatment bias) ointment or a placebo that are identical in All outcomes - patients? Blinding (performance bias and detection Low risk Outcome assessments unblinded but un- bias) likely to inuence outcomes All outcomes - outcome assessors? Incomplete outcome data (attrition bias) Low risk No withdrawals noted in the trial. Low risk Participants were given paracetamol tablets in addition to study medication or placebo. Period: one plaster per day at maximum pain site for four to 12 hours for three weeks Participants One hundred and fty-four participants were randomly allocated to a placebo plaster group (N = 77) and a capsicum plaster group (N = 77). A total 22 participants were excluded due to premature discontinuation of the treatment (N = 19) failure to meet the inclusion criteria (N = 2) or unauthorized concurrent treatment (N = 1). Matched placebo plaster Outcomes Primary outcome measure: Arhus Low Back Rating Scale. Secondary outcome measures: global assessment of efcacy and tolerance by physician and patient Notes Total quality score: 6/12 Adverse events: a total of 24 adverse events were reported (C = 15; P = 9). The C group had ve cases of severe adverse events (inammatory contact eczema, urticaria, minute haemorrhagic spots, and vesiculation or dermatitis) and the P group had two such cases (vesiculation or allergic dermatosis). Blinding (performance bias and detection Low risk Study medication and placebo were identi- bias) cal in appearance. Incomplete outcome data (attrition bias) Low risk Out of 154 participants, 22 were excluded All outcomes - drop-outs? Krivoy 2001 Methods Thirty-ve participants randomized to two groups and a further 16 participants acted as controls. Period: four weeks Participants Fifty-one participants with 19 in the Salix alba group, 16 in a placebo group, and 16 in an acetylsalicylate group. Blinding (performance bias and detection Low risk Participants were blinded from treatment bias) groupallocation,andstudymedicationand All outcomes - patients? Krivoy 2001 (Continued) Blinding (performance bias and detection Low risk Outcome assessors were unblinded. How- bias) ever knowing the outcome of interest, All outcomes - outcome assessors? Low risk The groups were similar in baseline mea- suresexcept gender; there were more female participants in the placebo group (P = 0. Low risk Participantswere disallowed the use of anti- inammatory drugs within the trial pe- riod. Period: seven days Participants One hundred and sixty-one participants were randomly allocated to either group. The trial medications were not available to the providersinthe trial country at the time and all stakeholders assumed both medica- tions held active ingredients Blinding (performance bias and detection Low risk This was a double-blinded trial. While bias) there were reservations with the blinding All outcomes - outcome assessors?

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