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Art For Patient's Sake
Art for Patient's Sake
Is the partnership of exhibition galleries with hospitals successful in creating a patient-centric experience?
Urooj Shakeel
Arts Organizations in Society
Galleries in hospitals are an example of one of the earliest forms of partnership models between arts programs and healthcare facilities that are focused on a patient-centric experience. By establishing such partnerships with healthcare institutions, the arts are an important catalyst for people to regain personal value and in turn reverse the influences of neoliberalism, understood in this context as an economic movement that devalued the public's stance on healthcare. The gallery model in particular has proven to not only be a sustainable alliance, but also a vital tool of placemaking that allows for community development. This paper examines the benefits and limitations of galleries in hospitals, looking specifically at the Dr. David Flinker Pavilion Art Gallery at Virtua Memorial Hospital in Mount Holly, New Jersey as a case study. The Pavilion Art Gallery began as an exhibition space for local artists to showcase artworks for patients and then later emerged into a public space for community events. As a tool for cultural placemaking, hospital galleries have a tremendous effect in advancing cultural policy by reviving the duality of arts and medicine as a healing practice. The importance of examining the positive and negative outcomes of the gallery and hospital partnership in particular, is a relevant study that promotes recent efforts to reform the US healthcare system through new strategies that include arts programs as a tactic to meet the "patient as a consumer" driven demand for efficient health care.
In a neoliberal turn of events, the United States Healthcare system was accordingly modified with the demise of universal healthcare. This turn not only succeeded on a political level, but also allowed supporters of neoliberalism to execute a persuasive argument against universal healthcare from an economic lens. The public was left with the assumption that universal healthcare is a surplus of government funds, and since then, the healthcare system has been aiming to reform in a political climate that it is continuously affected by. Recent efforts have forced the healthcare industry to reconsider patients as customers in order to reposition the role of the hospital and medical practice as a whole, to meet the demand for more patient-centric healthcare services. New strategies that align with this approach are calling for innovative methods, and the implementation of arts programs has proven to be successful on many levels, making it difficult to deny its ability in achieving a patient-centric experience. Increasingly, more healthcare facilities are looking to establish partnerships with different kinds of arts programs, all of which supplement the healthcare facility to accomplish its mission and goals. These programs emphasize on patient self-evaluation and self-confidence through viewing, experiencing, and making art. Redesigning the hospital environment into gardens, maintaining collections of arts created specifically for patient healing, and developing programs that allow patients to interact with or create their own art are all different models of arts programs in healthcare facilities.
Exhibition galleries are one of the earliest forms of these models and were created and sustained mainly by community members due to insufficient hospital budgets. Art works were placed in impersonal hospital settings and proved to add a calming and stress-reducing environment. Finding an existing space within the hospital to showcase artworks from local artists that patients and staff could purchase allowed for a more affordable way to bring in the arts into a hospital setting, thus creating the notion of exhibition galleries in healthcare facilities. The Virtua Memorial Hospital in Mount Holly, New Jersey was a pioneer hospital to establish and sustain this model by creating the Dr. Flinker Pavilion Gallery in 1980. The gallery exhibits art that aids in the healing process and maintains its mission statement in conjunction with the hospital's mission statement to create an experience that is patient-centric. However, what has emerged from this arrangement is now an apparatus for creative placemaking in hospitals that may prove to be problematic. The complications that arise from this complex partnership can consequently defy the initial goals and objectives of the hospital and gallery by prioritizing artists who may long for fame and validation for their work over patient needs. The integration of the Dr. Flinker Pavilion Gallery in Virtual Memorial hospital is an example of a successful partnership that leads to cultural policy change, but fall shorts in maintaining a sustainable patient-centric experience.
Neoliberalism and the turn of the United States healthcare system
The neoliberal economic revolution established laws that transformed the US healthcare system through phases that occurred congruently with political and economic events in American history. The Affordable Care Act falls short of establishing universal healthcare and, "should be considered through the lens of key neoliberal economic beliefs."[1] It is important to understand these beliefs because they restructured not only the entire American healthcare system, but also the mentality of how the public began to view its own self worth. The key beliefs that insinuated the slow closure of the window for universal healthcare include the "moral hazard" of free care, primacy of health consumerism, and the necessity for private health insurance.
The Social Security Act of 1935 was enacted by Franklin Roosevelt who had consciously left universal healthcare out of the plan but later recalled the idea in his 1944 State of the Union Address calling for "the opportunity to achieve and enjoy good health."[2] After his death, Harry S, Truman re-initiated the campaign for a national insurance program, but was unsuccessful because of resistance from the American Medical Association that accused his administration of communist sympathies. In the midst of Cold War politics, the US moved to an expansion of employer-provided private health insurance and by postwar period, neoliberalism had become a well-funded movement. Its primary thinkers founded key organizations and published works that forged new identity, both politically and ideologically, and heavily nurtured by American capital. In his 1960 The Constitution of Liberty, economist and philosopher, Friedrich Hayek argued, "we all have different preferences for how much healthcare we want in proportion to other 'material advantages' in life."[3] In other words, if our desires for healthcare are not universal then why should we have universal healthcare? This is the root of the neoliberal ideology on healthcare that changed the very notion of healthcare into a commodity, allowing for an individual to have the right to customize their healthcare coverage. The neoliberal undesirability of universal healthcare became part of the mainstream healthcare discourse and such ideas became increasingly dominant in later years.
In 1968, economist Mark Pauly published The Economics of Moral Hazard to construct a case against universal healthcare, arguing the notion of "moral hazard," or the idea that people would use healthcare unnecessarily just because their insurance made it free. He further argued that there would be a "welfare loss" from this "excess use" as people used care that they didn't actually value, and in turn generating a surplus of government funds. His argument additionally stated that there would be "utility gain" from buying personalized insurance because, "being insured against uncertainty had some intrinsic value itself, for which it was worth paying."[4] This value transformation was translated into policy and led to the corporatization of the American healthcare system by convincing people they had to use their own money to buy health care. Cost-sharing programs such as deductibles and co-pays were developed, eventually giving rise to the ideology of the healthcare "consumer" that directly emerged from the "moral hazard" idea. By the 1990s, health insurance was privatized and the power of free market was unleashed with personal tax-deductible health savings accounts, giving people an incentive to spend their money however they pleased. The transformation of the American healthcare system was solidified through neoliberal efforts that convinced society it has buying power and free choice by expressing, "the necessity that capital has to expand by commodifying every aspect of our lives."[5] Likewise, the baby boomer generation began to view themselves as healthcare consumers and subsequently healthcare facilities reorganized themselves to meet the demands of the "patient as a consumer" ideology.
Why change now? The healthcare reform strategy
In recent years market forces have driven increasing numbers of hospital mergers and acquisitions due to rising costs, lower reimbursement rates, and uneven quality. Healthcare leaders and policy makers have attempted numerous solutions that have had little impact and approaches such as reducing costs, enforcing practice guidelines, trying to make patients better consumers, and implementing electronic medical records, all of which have been proven to be ineffective. The need for a new strategy at this point became a pivotal necessity, requiring the healthcare industry to shift focus from volume and profitability of services provided to patient outcomes achieved by restructuring how healthcare delivery is organized, measured, and reimbursed. A new strategy called, The Value Agenda, was introduced in the book Redefining Health Care[6] and focuses on creating value for the patient by putting patients' needs first. The tools to implement the value agenda start with establishing the shared goal of improving value for patients for each stakeholder. Value in this context is defined as health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Either improving one or more outcomes without raising costs or lowering costs without compromising outcomes can achieve improving value.
The results of this shift have proven successful with improvements in outcomes, efficiency, and growth in market share. The challenge for healthcare organizations to increase value of care is a transformation that happens within because, "ultimately value is determined by how medicine is practiced."[7] The goal of creating value for the patient responds directly to the patient as a consumer driven mentality and positioning the value agenda as a crucial component of medical practice calls for precise execution of the strategy. There are six components of The Value Agenda (see fig. 1) that assist in moving to a high value healthcare delivery system and are all interdependent and mutually reinforcing. The components include, 1. Organize into integrated practice units (IPUs), 2. Measure outcomes and costs for every patient, 3. Move to bundled payments for care cycles, 4. Integrate care delivery across separate facilities, 5. Expand excellent services across geography, and 6. Build an enabling information technology platform. The first two components are necessary to consider for inclusion of arts programs in hospitals.
Integrated practice units are made up of both clinical and nonclinical personnel teams who provide full care for the patient's condition that results in faster treatment, better outcomes, and lower costs. IPUs often partner with community providers or local organizations to achieve better outcomes, which brings us to the second component of the model, measuring outcomes. The types of outcomes measured include health status achieved, nature of care cycle and recovery, and sustainability of health. Arts Programs fit in effortlessly in these parts of the value agenda model because their primary focus is the patient, and aside from being cost effective, arts programs and organizations help healthcare facilities in achieving their goals from within the hospital delivery system. Arts programs are valuable stakeholders in the strategy for value transformation and must require strong leadership and commitment to improving health outcomes. It is essential to understand why arts programs demonstrate positive outcomes in patient recovery and why they are sought after to implement in the healthcare reform strategy.
Intrinsic value of arts: counteracting the influences of neoliberalism?
The neoliberals convinced us that the insurance benefits once provided to us by universal healthcare are an excess waste of capital. They converted our intrinsic values by giving us freedom to create our own value definitions and pushed for customizable insurance that aligns with our personal care ethics. Reestablishing intrinsic value of wellbeing can be challenging but recent scientific research and evidence has concluded that the arts do play a major role in empowering patients to reevaluate certain aspects of their value system. While the methods of measurement and data collecting are debated and comprehensive, there is no denying that, "the arts actually have a value that goes beyond their intrinsic artistic metric, such as potential to improve public health."[8] The qualitative over quantitative benefits are more important in this case to determine these answers. Alain de Botton and John Armstrong examine art's purpose in their book Art as Therapy, stating that art is "a tool that serves an important purpose in our existence."[9] It allows us to connect to our own psychology and lets us exercise and better understand our emotions. Arts provide self-esteem building, a sense of identity, and belonging by connecting people and celebrating life, facilitating the healing process.
The concept of human wellbeing can be acquired through the arts because the arts have the ability to further non-arts goals. This notion is deeply rooted in the capability approach, which "assumes wellbeing derives from people's ability to make choices that allow them to lead a life that they have a reason to value."[10] Indian economist and philosopher Amartya Sen first articulated the capability approach in the 1980s, stating that the capability to live a good life is defined in terms of the set of valuable 'beings and doings.'[11] The states of being and doing are analyzed in terms of functionality, such as being well nourished and having shelter, and the collective set of valuable functionings that a person has access to is capability. (see fig. 2). The functioning combinations here do not include the commodities needed to achieve the states of being and doing, and thus, a person's capability represents the effective freedom of an individual to choose between different functioning combinations that one has reason to value. Therefore, by integrating arts programs into the hospital patient-centric strategy, the arts play a major role in restoring the value of healthcare as a right of entitlement. Arts programs are secretly executing value motives that allow patients to make better choices for their wellbeing and accessible healthcare, these are the very values that were once lost with the commodification of healthcare through neoliberalism in the first place!
Integrating arts programs into healthcare facilities
How exactly do the arts in a hospital setting transform our intrinsic values and help us make independent choices? There are two ways in which patients interact with arts in a hospital setting, first by visual experience or Environmental Arts and second by Participatory Arts. The "aesthetic experience" [12] of arts is what happens to individuals as they see, hear, and feel art. This experience is created in a hospital setting through visual aspect like architecture and design, gardens, and artwork collections. Participatory arts programs give patients an active engagement in arts creation by allowing them to create their own works, and are more effective compared to environmental art. The creative action of making art gives patients a satisfaction of compiling a finished work along with embedding self-confidence in them. Artists who work with patients in participatory arts should not focus on producing their own work, rather they serve as catalyst for patients' creativity to make art. This self-esteem building helps patients communicate more openly and allows doctors to reach a diagnosis faster. The role of art is a contributing factor in creating a caring environment of healing that directly correlates with our intrinsic values and has consecutively begun to change the face of healthcare as a business.[13]
Hospitals are more open to incorporating arts programs into their strategy for these reasons and now have the funds to support them internally, mostly thanks to advanced data that has shown an increase in positive outcomes. Aside from their recognizable value, arts programs are easy to implement, they are a cost-effective way to treat, and attract more funding from foundations and corporations for the healthcare facility. Arts programs support six domains of quality[14] in conjunction with The Value Agenda. (see fig. 3). They ensure effectiveness as healing modalities, increase safety by eliminating or reducing use of anesthesia and pharmaceutical drugs, and they exist for patient-centric needs and utilize patient's own resources for healing. Arts program are also praised for their efficiency to reduce the need for expensive medical personnel, allow procedures to be completed more quickly, and anticipate patient needs in a timely manner. Lastly, they are equitable because art is a universal language that communicates with no boundaries. These six dimensions provide any healthcare organization with a low cost opportunity to improve performance and increase patient value.
As healthcare organizations seek to implement more arts programs in their facilities, arts programs are also establishing concrete business models on their end to ensure partnership longevity. Because of their high demand and efficient implementation, arts programs are easily replaceable, which is why it is important for arts programs to strategize on their end in order to successfully align with the mission and goals of the healthcare facility. A roadmap on how to create an effective and sustainable arts program[15] is provided as a guideline for how the arts program should collaborate with the healthcare organization it is aligned with. (see fig. 4). The principle aspect for a successful partnership for arts programs is detailed under step 2, Develop a Mission Statement and Strategic Goals, where the arts program's mission and goals have to be in agreement with the mission and goals of the healthcare organization in order to ensure a sustainable and long-term partnership.
Case study: The Dr. Flinker Pavilion Art Gallery and placemaking
One way to incorporate art into a hospital setting is by displaying paintings on the walls of the corridors and lobby. Executed through either exhibition galleries or collection galleries, both models should include paintings that follow a criteria guided through the viewpoint of the patient's needs in the healing process and the overall mission of the institution and the arts program and "not for art for art's sake."[16] Curating a collection gallery requires selecting art that is specifically intended for patient wellbeing and is meant to honor their humanity and recognize them as a whole person, not a person that is diseased or disordered. Themes centering on hope, inspiration, empowerment, recovery, peace, resilience, and celebration that share the mission and values of the hospital supplement the healing environment. Many collection galleries also include artworks created by patients themselves, ultimately making the patient feel included in the hospital community.
Exhibition galleries differ from collection galleries because they provide a continuous renewal and variety of artworks for sale, usually from local artists. The Pavilion Art Gallery in Virtua Memorial Hospital Burlington County in Mount Holly[17], New Jersey, which was later named The Dr. David Flinker Pavilion Gallery, after its benefactor, was formed in 1980 in a lobby of the hospital for patients, visitors, and hospital staff to come across art daily as part of the hospital experience. The gallery operates as a professional self-contained exhibition space where invitational and juried shows feature works by artists from New Jersey and surrounding states, along with small solo shows by local artists. (see fig. 5). The idea for a hospital gallery began with Bette Johnson, a printmaker and hospital volunteer who taught art to psychiatric patients, and wanted to create a less stressful hospital environment. She partnered up with Pat Stefanini, a painter, and both women presented their research findings to the hospital authorities and pushed to establish an exhibition space in well-trafficked areas of the hospital. Both women were hired as gallery directors, under the public relations department, and initially funded the project through a grant from the New Jersey State Council on the Arts.[18] Johnson and Stefanini claim that the gallery is committed to showcasing and selling only professional art, and have even collaborated with various institutions and local artists to help launch artists' careers saying, "We are not art agents, but we have helped start some good careers by encouraging artists through their developmental stages."[19] Along with solo shows and artist openings, the Burlington County Art Guild also utilizes The Pavilion Gallery space to hold its Annual Summer Members' Exhibit, therefore serving as a community space. The Pavilion Gallery is a multi-functioning gallery space that supports collaboration with community and local artists within the facility, thus creating a powerful tool for placemaking that expresses the hospital's culture through aspects of a physical environment.[20]
As a community-centric hospital[21], Virtua Memorial and The Pavilion Gallery share a common mission to improve the lives of the not only the patients but also the community in which they are situated. Collaborating to bring in a visual healing experience for patients warrants the hospital to bring in a diverse group of community members who all take part, one way or another, in cultivating a society that is interlocked in relationships and invested in the wellbeing of its citizens. The exhibit content serves to make patients feel more at home by visually connecting them with their community in a space that encourages creativity through socializing and meets the needs of community activities. Virtua Memorial Hospital plays a vital role in engaging its community in a space devoted to advancing the quality of life that also reflects its values, thus staying incompliance with its mission statement.
The Pavilion Gallery is also a vehicle for new and upcoming local artists to gain high-level visibility, with many artists citing the gallery in their resumes. It also gives artists an advantage in finding meaning to show art that fits into the patient-centric criteria and possibly, "giving a voice and forum to artists who may be outside the mainstream due to physical or medical challenges."[22] However, because of this artist incentive, the focus can easily turn to the artist's self-driven claim for fame and away from the patient-centric care as stated by The Value Agenda. If the artist serves as a catalyst for patient's creativity and the exhibition gallery does not give patients agency to make art, then by denying the act of the creative process of art making itself, the exhibition gallery may in fact be contradictory in its goal to help patients recognize their ability to improve their quality of life and consequently may be turning the attention solely to the artist's mainstream goals of success. If neoliberalism expresses the need for commodifying every aspect of our lives, then the artists using The Pavilion Gallery as a vehicle to gain visibility cannot escape, "society's competitiveness and drive for individual achievement." [23] While the exhibition gallery model may be an enabler in reversing neoliberal mentality by creating value for people through the visual arts to, it can also easily enable the neoliberal capital desire by providing a space that allows for marketplace incentives. This complication begs to ask the question; at what point is it not about the patient anymore?
In part of being a community center, The Pavilion Gallery is an arts delivery system[24] that is enclosed within the hospital delivery system where staff and patients can purchase works that speak directly to them. This form of community empowerment makes the Virtua Memorial Hospital a cultural institution associated with arts services, which in turn sets a grandiose responsibility on the hospital as a key investor in cultural policy. This could possibly turn the arts delivery system focus towards servicing the public, rather than the creativity and healing of the patient, and consequently go against the initial intent of an arts program, which is based precisely on, "not arts for art's sake." Aside from the community benefits of the gallery, these complexities of the exhibition gallery model can easily arise if the hierarchy of patient-centric care and wellbeing outcomes are not the primary concern of all stakeholders involved. It is important to keep patient value a top concern if the institution wants to sustain its mission and goals. If the mission statement is the driving force of the program, then the institution's provisions for equitable care can easily be built on social equality, providing an agent for cultural policy change.[25]
Cultural policy and change
Considering the role of arts programs in hospital as an advocate for cultural change, Hamilton argues that the arts are proven to be one of the intersectoral[26] interventions important in addressing social and health inequalities and can aim to achieve wider public health objectives, but demand a scientific approach to evaluating the intended health wellbeing outcomes. Data of outcomes achieved is necessary in order to make any further policy decisions and if proven effective, then policy makers will be more receptive to change. What makes The Pavilion Gallery a complex case for policy change is that it falls into a paradox of the spectrum between delivery and creation. Is it a source for creating meaning for the patient or a delivery space for artists' artworks to be sold as goods? The privatization of the community as a healing support system is an entanglement of discourse between administration and the ongoing privatization of culture the nation is experiencing. Bedoya states, "This privatization is linked to administrating cultural 'goods' at the expense of knowing culture as a source of knowledge and meaning."[27] As exhibition galleries that sell artworks continue to increase in hospitals, the problem then becomes of placing art in a setting that allows it to be confined and reduced to a financial purpose as a product, ultimately going against its potential to redefine personal values that aim to rebuild misconstrued concepts of capitalism. The cultural phenomenon of arts programs in healthcare facilities needs to again, maintain its initial mission by staying focused on its patient-centric goals to make any kind of positive cultural policy change.
Focusing on the positive aspects of The Pavilion Gallery as a nontraditional art institution, it is a link for cultural activity with community development and a type of placemaking that relates to US cultural policy initiatives in many ways. By emphasizing the importance of cross-sector partnerships between arts programs and hospitals and the instrumental value to non-arts stakeholders, "creative placemaking broadens the scope of cultural policy from its conventional focus on funding for non-profit arts and cultural organizations."[28] While healthcare institutions have included arts programs to make themselves more attractive to patients and funders, they have also become new territory for creative placemaking that is headed in a complete cultural revitalization. The gallery accomplishes what the NEA has named increased community "livability" by improving value and quality of life, greater creative activity, stronger community identity, sense of place, and economic development. Therefore it cannot be denied that the formation of this type of partnership between arts programs and healthcare facilities has some cultural and political will.
Conclusion: reviving the duality of arts and healthcare practice
Healthcare environments continue to become part of the cultural engagement fabric of community by integrating arts programs in the healing process, calling for a whole cultural shift for ways in which medicine is practiced, and the role community has in the healthcare sector. The incorporation of this model in culture can be done through attempting to integrate culture into capability approach, or ensuring a way to create communal value for wellbeing by developing policies that support these aspects of the healthcare sector. Neoliberalism gave us consumer-buying power and how we chose to utilize that power depends on what we as individuals value. The arts play a vital role in establishing confidence that creates value for our own wellbeing and in turn wanting to create a healthcare system available for all fellow community members as we move towards a cultural "we."[29] It is through art one makes a claim upon society, or cultural citizenship, and art can change or produce progressive public policy.
The incorporation of arts into healthcare facilities starts with their design and efforts need to be made for future planning of hospitals as spaces that manifest a cultural paradigm that combines medicine and community. Creating a cultural policy for this partnership relates to how communities want to imagine spaces that are open to their agency in shaping their personal values. The relationship between arts and hospitals is not something new, rather it is a design that has regenerated from historical relationships between community-focused health care early as the 15th century. The first hospital, which is accredited to the Islamic medieval civilization,[30] called Bīmāristāns, were community wellness centers that took care of the sick, poor, and elderly as part of the charitable care compulsory in Islam and Christianity. Society's social identity and values were constructed through these charitable bīmāristāns as they were a complex institution of medical care that included gardens, theatres, and libraries as part of their structural design that was literally situated in the nucleus of the city. By incorporating the arts into modern healthcare environments, the revival of this type of medicinal practice gives agency to policy change and formation that encourages not only renovating the design of healthcare facilities, but also calls for collective impact. The healthcare sector has taken a considerable step in incorporating arts programs as part of their strategy in aiming to reform. However, it is suggested to be cautious in turning delivery systems, such as hospital exhibition galleries, into spaces that sell goods in order to avoid the natural commodification that can take place of a service that started with good intentions.
[1] Adam Gaffney, "The Neoliberal Turn in American Health Care." Jacobin, April 15, 2014. https://www.jacobinmag.com/2014/04/the-neoliberal-turn-in-american-health-care.
[2] Gaffney. "The Neoliberal Turn."
[5] Humphrey Mcqueen, "Healthcare is not a product, no matter what neoliberalism has taught
us." The Guardian, May 22, 2014. https://www.theguardian.com/commentisfree/2014/may/22/healthcare-is-not-a-product-no-matter-what-neoliberalism-has-taught-us.
[6] Michael E. Porter, and T. Lee. "The Strategy That Will Fix Health Care." Harvard Business
Review. October 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care
[7] Porter. "The Strategy That Will Fix Health Care."
[8] C. Hamilton, S. Hinks, and M. Petticrew. "Arts for Health: Still Searching for the Holy Grail." Journal of Epidemiology and Community Health 57 (2003): 401.
[9] Maria Popya. "Art as Therapy: Alain de Botton on the 7 Psychological Functions of Art." Brain
Pickings, accessed November 1, 2017. https://www.brainpickings.org/2013/10/25/art-as-therapy-alain-de-botton-john-armstrong/.
[10] Katie Ingersoll, and John Carnwath. "A New Way to Think About Intrinsic vs. Instrumental Benefits of
the Arts." Create Equity, March 13, 2015. http://createquity.com/2015/03/a-new-way-to-think-about-intrinsic-vs-instrumental-benefits-of-the-arts/
[11] Thomas Wells. "Sen's Capability Approach." Internet Encyclopedia of Philosophy. accessed November 10, 2017. http://www.iep.utm.edu/sen-cap/.
[12] Alan S. Brown, and Jennifer L. Novak-Leonard. "Measuring the Intrinsic Impacts of Arts Attendance." Cultural Trends 22, nos. 3-4 (2013): 224.
[13] Pamela D. Lambert. Managing Arts Programs in Healthcare. London: Routledge, 2016.
[14] Blair L. Sadler, Annette Ridenour, and Donald M. Berwick. Transforming the Healthcare Experience Through the Arts. (San Diego: Aesthetics, 2009), 6-7.
[15] Sadler, Ridenour, and Berwick. Transforming the Healthcare Experience, 195.
[16] Lambert. "Managing Arts Programs in Healthcare." 93.
[17] "Virtua Health is a multi-hospital healthcare organization headquartered in Marlton, NJ. Its mission is to deliver a world-class patient experience through its programs of excellence in women's health, pediatrics, cancer, cardiology, orthopedics and geriatrics. A non-profit organization, Virtua employs 7,100 clinical and administrative personnel and has 1,800 physicians as medical staff members." https://www.virtua.org/
[18] Patricia Malarcher. "Art Galleries in Hospital Aim at 'Communication'." The New York Times, November 10, 1991.
http://www.nytimes.com/1991/11/10/nyregion/art-galleries-in-hospital-aim-at-communication.html
[19] Malarcher. "Art Galleries in Hospital"
[20] Lambert. "Managing Arts Programs in Healthcare."
[21] "Throughout South Jersey, Virtua strives to improve the community. Virtua's mission to help the community be well, get well and stay well directly supports the findings of our Community Health Needs Assessment (CHNA)." https://www.virtua.org/about/community
[22] Lambert. "Managing Arts Programs in Healthcare." 101.
[23] Justin Kenrick. "Is Collaboration the Cure?" In Extraordinary Everyday Exploration in Collaborative Art In Healthcare, ed. Angela Kingston (Edinburgh: Artlink, 2005).
[24] Roberto Bedoya. U.S. Cultural Policy: Its Politics of Participation, Its Creative Potential. New Orleans, National Performance Network, 2004.
[25] Mcqueen. "Healthcare is not a product"
[26] Intersectoral action refers to actions affecting health outcomes undertaken by sectors outside the health sector, possibly, but not necessarily, in collaboration with the health sector. C. Hamilton, S. Hinks, and M. Petticrew. "Arts for Health." 402.
[27] Bedoya. "U.S. Cultural Policy." 9.
[28]Anne G. Nicodemus "Fuzzy Vibrancy: Creative Placemaking as Ascendant US Cultural Policy." Cultural Trends 22, nos. 3-4 (2013): 214.
[29] By cultural "we" the author alludes to the ideologies that reside in the arts delivery and arts creation systems that are concerned with consumption and creation. A complexity in its meaning, I intend to use it in terms of focusing on moving towards a consumer driven society that makes better choices. Bedoya. "U.S. Cultural Policy." 10.
[30] Ahmed Ragab. The Medieval Islamic Hospital: Medicine, Religion, and Charity. (New York: Cambridge University Press, 2015).
Figure 1: The Value Agenda
Figure 2: The Capability Approach
Figure 3: Six Domains of Quality
Figure 4: Roadmap to Create Effective and Sustainable Art Programs
Figure 5: Dr. Flinker Pavilion Gallery, Mount Holly, NJ
And Once Again, The Heart Searches
Art + Science = Better Math
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When you talk about the photo editors, Adobe Photoshop comes to mind. However, many people do not want to spend money and install software which consumes a lot of memory. Fortunately, there are different ways, which allow you to do photo editing online in a browser using an online photo editor and that without paying anything.
It is an online photo editing software which runs in the browser. You find it easy to use and it offers you a large range of tools. You can easily create new image from the scratch, upload image from system or can even import image from URL of your choice. This online tool is available in two different variations. You can either use express or an editor. Editor has layout like Photoshop and utilize the same tools while express allows you the fast changes to the photos and perfect for people who don't want to get too bogged down.
You only feel the drawback of lack of tutorials. Blog can offer you the basic information but you have to manage most of the work on your own. This software is user-friendly, but you can get best results if you are familiar with photo editing software.
Adobe Photoshop express is good in the list but you need to understand that it's different from Photoshop. This is a basic tool but offers a clean interface which is user friendly. You cannot expect more than applying the filters and have enhancements for your instagram. It offers similar functionality like web based version and it is available for android and iOS platforms. If you want something extra, then you can utilize the add on packs which can offer you additional tools and some remarkable extra feature.
Polarr offers robust tinkering and it is aimed to help the professional photographers. You find automatic filters in free version and filters can be used according to preference of user. It is a powerful application and you can get free version with fewer features. It is applications which will entice you to buy full version as full version offer most of the smart features. You find Polarr perfect if you want to have complete control on contract, saturation and gamma. You can also read the tutorials to learn different features and functions during your use.
PicMonkey is another good photo editing tool which makes the editing tasks simple. It provides a user friendly interface with beautiful and colorful buttons that are labeled. You can remove small icons if you feel frustrated. This application is used to make graphic designing simple, easy and efficient. You can use this application easily as it take lots of cues from instagram. Anyone can use this app easily and you can get the editing work done very quickly.
It is one of the best and most used tools for the photo editing. You can do complex tasks and it has many tools in common with the Photoshop. You can't expect to go in too much minor details but it is free unlike Photoshop. This app is not for the people who just want single filter on image. You may need to experiment and have understanding of manipulation in some of its features. Most of the features are free of cost but some features need unlock through payment by card. If you are looking for investing money and time in purchasing Photoshop, then you need to give a trial to the Sumopoint.
These are some of the software programs which are trusted by people for photo editing worldwide. When you are looking to select one among them, then you need to look at the features and your personal requirements. Each and every software tool has some pros and cons, so you need to give a try to few before getting used to any one of them. Choose the one which can give a perfect look to your photos.


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Laboratory glassware refers to a variety of equipment used in scientific work, and traditionally made of glass. Glass can be blown, bent, cut, molded, and formed into many sizes and shapes, and is therefore common in chemistry, biology, and analytical laboratories.  Many laboratories have training programs to demonstrate how glassware is used and to alert first–time users to the safety hazards involved with using glassware.

History

Ancient era
The history of glassware dates back to the Phoenicians who fused obsidian together in campfires making the first glassware.  Glassware evolved as other ancient civilizations including the Syrians, Egyptians, and Romans refined the art of glassmaking. Mary the Jewess, an alchemist in Alexandria during the 1st century AD, is credited for the creation of some of the first glassware for chemical such as the kerotakis which was used for the collection of fumes from a heated material.  Despite these creations, glassware for chemical uses was still limited during this time because of the low thermal stability necessary for experimentation and therefore was primarily made using copper or ceramic materials.

Early modern era
Glassware improved once again during the 14th-16th century, with the skill and knowledge of glass makers in Venice. During this time, the Venetians gathered knowledge about glassmaking from the East with information coming from Syria and the Byzantine Empire. Along with knowledge about glassmaking, glassmakers in Venice also received higher quality raw materials from the East such as imported plant ash which contained higher soda content compared to plant ash from other areas. This combination of better raw materials and information from the East led to the production of clearer and higher thermal and chemical durability leading towards the shift to the use of glassware in laboratories.

Modern era
Many glasses that were produced in bulk in the 1830's would quickly become unclear and dirty because of the low quality glass being used.
During the 19th century, more chemists began to recognize the importance of glassware due to its transparency, and the ability to control the conditions of experiments. Jöns Jacob Berzelius, who invented the test tube, and Michael Faraday both contributed to the rise of chemical glassblowing. Faraday published Chemical Manipulation in 1827 which detailed the process for creating many types of small tube glassware and some experimental techniques for tube chemistry. Berzelius wrote a similar textbook titled Chemical Operations and Apparatus which provided a variety of chemical glassblowing techniques. The rise of this chemical glassblowing widened the availability of chemical experimentation and led to a shift towards the dominate use of glassware in laboratories. With the emergence of glassware in laboratories, the need for organization and standards arose. The Prussian Society for the Advancement of Industry was one of the earliest organizations to support the collaborative improvement of the quality of glass used.

Most laboratory glassware was manufactured in Germany up until the start of World War I.  Before World War I, glass producers in the United States had difficulty competing with German laboratory glassware manufacturers because laboratory glassware was classified as educational material and was not subject to an import tax.  During World War I, the supply of laboratory glassware to the United States was cut off.

In 1915 Corning Glassworks developed borosilicate glass, introduced under the name Pyrex, and was a boon to the war effort in the United States.  Though after the war, many laboratories turned back to imports, research into better glassware flourished.  Glassware became more immune to thermal shock while maintaining chemical inertness.  Further important technologies impacting the development of laboratory glassware included the development of polytetrafluoroethylene, a corrosion resistant material, and a drop in price to the point laboratory glassware is, in some cases, more economical to throw away than to re-use.

Laboratory glassware selection
Laboratory glassware is typically selected by a person in charge of a particular laboratory analysis to match the needs of a given task.  The task may require a piece of glassware made with a specific type of glass.  The task may be readily performed using low cost, mass-produced glassware, or it may require a specialized piece created by a glass blower.  The task may require controlling the flow of fluid.  The task may have distinctive quality assurance requirements.

Type of glass

Laboratory glassware may be made from several types of glass, each with different capabilities and used for different purposes. Borosilicate glass is a type of transparent glass that is composed of boron oxide and silica, its main feature is a low coefficient of thermal expansion making it more resistant to thermal shock than most other glasses. Quartz glass can withstand very high temperatures and is transparent in certain parts of the electromagnetic spectrum.  Darkened brown or amber (actinic) glass can block ultraviolet and infrared radiation.  Heavy-wall glass can withstand pressurized applications. Fritted glass is finely porous glass through which gas or liquid may pass.  Coated glassware is specially treated to reduce the occurrence of breakage or failure. Silanized (siliconized) glassware is specially treated to prevent organic samples from sticking to the glass.

Scientific glass blowing
Scientific glass blowing, which is practiced in some larger laboratories, is a specialized field of glassblowing.  Scientific glassblowing involves precisely controlling the shape and dimension of glass, repairing expensive or difficult-to-replace glassware, and fusing together various glass parts. Many parts are available fused to a length of glass tubing to create highly specialized piece of laboratory glassware.

Controlling fluid flow
When using glassware it is often necessary to control the flow of fluid.  It is commonly stopped with a stopper. Fluid may be transported between connected pieces of glassware.  Types of interconnecting components include glass tubing,  T-connectors, Y-connectors, and glass adapters.  For a leak-tight connection a ground glass joint is used (possibly reinforced using a clamping method such as a Keck clips).  Another way to connect glassware is with a hose barb and flexible tubing. Fluid flow can be switched selectively using a valve, of which a stopcock is a common type fused to the glassware. Valves made entirely of glass may be used to restrict fluid flows. Fluid, or any material which flows, can be directed into a narrow opening using a funnel.

Quality assurance

Metrology
Laboratory glassware can be used for high precision volumetric measurements. With high precision measurements, such as those made in a testing laboratory, the metrological grade of the glassware becomes important.  The metrological grade then can be determined by both the confidence interval around the nominal value of measurement marks and the traceability of the calibration to an NIST standard. Periodically it may be necessary to check the calibration of the laboratory glassware.

Dissolved silica
Laboratory glassware is composed of silica.  Silica is considered insoluble in most substances with a few exceptions such as hydrofluoric acid.  Though insoluble a minute quantity of silica will dissolve which may affect high precision, low threshold measurements of silica in water.

Cleaning

Cleaning laboratory glassware is sometimes necessary and may be done using multiple methods.  Glassware can be soaked in a detergent solution to remove grease and loosen most contaminations. These contaminations are then scrubbed with a brush or scouring pad to remove particles which cannot be rinsed. Sturdy glassware may be able to withstand sonication as an alternative to scrubbing. For certain sensitive experiments glassware may be soaked in solvents, such as aqua regia or mild acids, to dissolve a trace quantities of specific contaminations known to interfere with an experiment. When cleaning is finished it is common practice to triple rinse glassware before suspending it upside down on drying racks.

Examples
There are many different kinds of laboratory glassware items:

Examples of glassware containers include:
 Beakers are simple cylindrical shaped containers used to hold reagents or samples.
 Flasks are narrow-necked glass containers, typically conical or spherical, used in a laboratory to hold reagents or samples. Examples flasks include the Erlenmeyer flask, Florence flask, and Schlenk flask.
 Reagent bottles are containers with narrow openings generally used to store reagents or samples. Small bottles are called vials.
 Jars are cylindrical containers with wide openings that may be sealed. Bell jars are used to contain vacuums.
 Test tubes are used by chemists to hold, mix, or heat small quantities of solid or liquid chemicals, especially for qualitative experiments and assays
 Desiccators of glass construction are used to dry materials or keep material dry.
 Glass evaporating dishes, such as watch glasses, are primarily used as an evaporating surface (though they may be used to cover a beaker.)
 The Petri dish is a flat dish filled with a nutritious gelatin that allows for microorganisms to quickly grow, its named after its inventor Julius Petri in the 1880's.
 Microscope slides are thin strips used to hold items under a microscope.

Examples of glassware used for measurements include:
 Graduated cylinders are thin and tall cylindrical containers used for volumetric measurements.
 Volumetric flasks are for measuring a specific volume of fluid.
 Burettes are similar to graduated cylinders but have a valve at the end used to disperse precise amounts of liquid reagents often for titrations.
 Glass pipettes are used to transfer precise quantities of fluids.
 Glass Ebulliometers are used to accurately measure the boiling point of liquids.

Other examples of glassware includes:
 Stirring rods are glass rods used to mix chemicals.
 Condensers are used to condense vapors by cooling them down and turning them into liquids.
 Glass retorts are used for distillation by heating, they have a bulb with a long curved spout.
 Drying pistols are used to free samples from traces of water, or other impurities.

References

External links

 Smithsonian Science Under Glass
 Chemistry Laboratory Glassware at About.com
 Project Gutenberg - On Laboratory Arts by Richard Threlfall (1898)
 Project Gutenberg - Laboratory Manual of Glass-Blowing by Francis C. Frary (1914)
 Project Gutenberg - A Handbook of Laboratory Glass-Blowing by Bernard D. Bolas (1921)

redpajama_set_name: RedPajamaWikipedia


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ThoughtGallery.org > A Gallery Talk with the Curators of the Exhibit Will Eisner
A Gallery Talk with the Curators of the Exhibit Will Eisner
Join us for a special gallery talk by the curators of the exhibit WILL EISNER: The Centenial Celebration.
Kitchen Sink Press' Denis Kitchen and John Lind will take guests through the exhibit and discuss the life and work of groundbreaking comics creator Will Eisner. Eisner was a pioneer in the creation of comics during the "Golden Age" of comics during the 1930s and '40s, achieving fame with his iconic crime-fighting hero The Spirit. Many comic greats worked with Eisner, including Jules Feiffer, Jack Kirby, and Al Jaffee. After the Spirit ceased publication, Eisner devoted himself to creating educational and instructional sequential art, a term he coined. In 1978, Eisner once again reinvented himself- and the comic art medium-with his graphic novel, A CONTRACT WITH GOD. Will Eisner's 19 graphic novels and 3 textbooks are still in print in 15 worldwide languages. The prestigious Will Eisner Comic Industry Awards are presented annually at San Diego Comic-Con.
When: Sat., Apr. 22, 2017 at 2:00 pm - 3:00 pm
Where: Society of Illustrators
Buy tickets/get more info now
See other events in these categories:

redpajama_set_name: RedPajamaCommonCrawl


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Posted on December 7, 2015 by Pomeroy Daily Sentinel
Southern rolls Lady Rebels, 54-15
By Alex Hawley - ahawley@civitasmedia.com
Southern senior Haley Hill (11) drives past South Gallia's Ashley Northup (3) during the second half of the Lady Tornadoes' 54-15 victory, Monday night in Mercerville.
MERCERVILLE, Ohio — A wire-to-wire win for the Purple and Gold.
The Southern girls basketball team scored in the opening minute of Monday night's Tri-Valley Conference Hocking Division tilt at South Gallia, and the Lady Tornadoes never looked back en route to a 54-15 victory.
Southern (4-1, 3-0 TVC Hocking) outrebounded the Lady Rebels (0-3, 0-2) 16-to-3 in the opening period, helping the Lady Tornadoes grab a 12-3 advantage on the scoreboard. The Purple and Gold outscored SGHS 19-to-6 in the second quarter, pushing the advantage to 31-9 at halftime.
The Lady Rebels managed only one point in the third period, as the SHS lead grew to 43-10 with eight minutes left in regulation. Southern ended the game on a 11-5 run, capping off the 54-15 victory.
"We did a real nice job defending (Mikayla) Poling and (Erin) Evans," said SHS head coach Kent Wolfe. "We pushed the ball a little bit and got into the running game that we wanted. We outmatched them on the glass and our three-point shooting was really good, the best it's been all year long."
SHS senior Ali Deem led the Purple and Gold with 15 points, followed by Faith Teaford with 13 and Jansen Wolfe with eight. Haley Hill posted seven points, Sierra Cleland and Josie Cundiff each added five, while Shelbi Dailey finished with one marker.
Evans led the Lady Rebels with seven points, followed by Poling with five. The South Gallia scoring was rounded out by Olivia Hornsby and Aaliyah Howell with two points and one point respectively.
Southern was led on the glass by Wolfe with 13 rebounds, followed by Hill with 10 and Teaford with eight. Hill and Deem each had five assists to lead SHS, followed by Cleland with three. Wolfe led the defense with six blocked shots, while Teaford added three and Dailey marked two. Deem posted a team-high four steals, followed by Hill with three and Macie Michael with two.
South Gallia's rebounding was led by Poling and Evans with five each, followed by Northup with three. Evans led the defense for SGHS with four steals, followed by Hornsby with three. Poling had two steals and a block, while Northup came away with two steals. Poling and Brooke Campbell each had an assist in the setback.
"Give Southern credit, they played really good defense," SGHS head coach Corey Small said. "We couldn't hit shots, they could and that's the result you get. We need to get in better shape, we need to learn to box out and we need to work on shooting."
The Lady Tornadoes shot 4-of-9 (44.4 percent) from the free throw line and 21-of-53 (39.6 percent) from the field, including 8-of-22 (36.4 percent) from beyond the arc. As a team the Purple and Gold finished with 48 rebounds, 17 assists, 10 steals, 11 blocks and 20 turnovers.
South Gallia shot 2-of-8 (25 percent) from the charity stripe and 6-of-48 (12.5 percent) from the field, including 1-of-13 (7.7 percent) from beyond the arc. As a team the Red and Gold finished with 20 rebounds, two assists, 13 steals, one block and 15 turnovers.
South Gallia and Southern will meet again on January 14, in Racine. Both teams to action on Thursday, with the Lady Tornadoes hosting Trimble and the Lady Rebels visiting Eastern.
http://aimmedianetwork.com/wp-content/uploads/sites/14/2015/12/web1_12.9-SHS-Hill.jpgSouthern senior Haley Hill (11) drives past South Gallia's Ashley Northup (3) during the second half of the Lady Tornadoes' 54-15 victory, Monday night in Mercerville. Alex Hawley/OVP Sports
ahawley@civitasmedia.com
Hi! A visitor to our site felt the following article might be of interest to you: Southern rolls Lady Rebels, 54-15. Here is a link to that story: http://www.mydailysentinel.com/sports/3157/southern-rolls-lady-rebels-54-15


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University of Jos
Main Menu Left Half
Unijos At A Glance
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Pro-Chancellor's Speech
Unijos Anthem
Unijos Color & Logo
Main Menu Right Half
UNIJOS Academics Glance
Campus Life Glance
National University Commission
University of Jos Consultancy Services
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Secondary Menu Left
Secondary Menu Right
Media & Gallery
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Giving/Donations
Imoh Proposal
Running Heading: Subclinical Atherosclerosis and CVD risk Factors in HIV
The Prevalence of Subclinical Atherosclerosis and Cardiovascular Risk Factors Among HIV Infected Individuals in Jos.
Dr Imoh Lucius Chidiebere
Department of Chemical Pathology
Jos University Teaching Hospital
Background: Cardiovascular disease (CVD) is the leading cause of death and morbidity globally. Atherosclerosis is a fundamental vascular disease process underlying the development or progression to CVDs. HIV/AIDS is fast gaining reputation as a leading cause of CVDs in sub-haran Africa. The burden of HIV/AIDS remains high in sub-Saharan Africa (SSA) and Nigeria is among the countries with the highest prevalence. Yet there are no established strategies for screening or preventing CVDs in many SSA countries. The burden of cardiovascular disease in People living with HIV (PLWH) is Nigerian population is not well-known.Little is known about the correlation between the traditional CVD risk factors or the various population-based CVD risk prediction algorithms with the presence of CVD endpoint like subclinical atherosclerosis.
Objectives:To determine the the prevalence of subclinical atherosclerosis and its association with cardiovascular disease risk factors and prediction models among HIV Infected individuals in a Nigerian hospital setting.
Method: This will be a cross-sectional comparative study to be carried out at the APIN-supported HIV clinics at Jos University Teaching Hospital (JUTH) and Faith Alive Foundation (FAF) over a period of two years. Consecutive HIV patients who satisfy the inclusion criteria and gives consent will be recruited into the study. Apparently healthy HIV negative controls who meets the inclusion and matching criteria will also be studied.
Socio-demographic data, cardiovascular risks factors, relevant present and past medical history will be assessed. Information regarding HIV related factors shall be obtained from patients records. Biophysical and anthropometric measurement, Carotid Intimal Media Thickness, and relevant laboratory parameters (Fasting Lipid profile, Fasting Plasma Glucose, CD4 Count, Viral Load) will be studied and Cardiovascular risk prediction Models including: 10-year Framingham CVD risk score; 5-year DAD risk estimation; Prospective Cardiovascular Munster study (PROCAM) and Systematic Coronary Risk Evaluation (SCORE) will be computed.
Data will be analyzed with the Statistical Package for Social Sciences (SPSS® Incorporated Chicago Version 18.0) software. Frequency tables will be generated for the variables of interest. Descriptive statistics will be presented as mean values + standard deviation (SD) or medians with interquartile ranges (IQRs) for non-normal continuous variables, and proportions (as percentages) for categorical variables. Unpaired students t-test or Mann-whitney U test will be used to test the difference in means or medians of continuous variables between groups. Bivariate analysis and multivariate logistic regression will be used to examine the relationship between CVD risk factors or CVD risk prediction models and subclinical atherosclerosis. Difference in proportions of subclinical atherosclerosis in cases and control groups will be tested using Z-test. A p value of < 0.05 will be taken as a measure of statistical significance.
OF PRINCIPAL INVESTIGATOR
NAME: Imoh Lucius Chidiebere
eRA COMMONS USER NAME (credential, e.g., agency login):
POSITION TITLE: Consultant Chemical Pathologists/Metabolic physician
INSTITUTION AND LOCATION
MM/YYYY
NnamdiAzikiwe University, Anambra State
Medicine and Surgery
Jos University Teaching Hospital, Plateau State
FMCpath
A. PERSONAL STATEMENT
The goal of this research is to determine the prevalence of subclinical atherosclerosis and to assess the underlying risk factors in HIV-infected individuals in two HIV treatment centres in Jos. I have spent a good part of the six years as a resident doctor and now as a consultant chemical pathologists and metabolic physician in managing both metabolic and laboratory aspects of HIV patients' care. During this time, I haveincreasingly noticed the presence of one or more traditional risk factors for CVDs in HIV patients. However, it is not clear if the presence of these risk factors actually translate to vascular disease and subsequently CVDs. I have also noticed gaps in risk assessment for CVDs among HIV-patients evidence by lack of national policy for routine CVDs risk assessment. This is study is designed to provide data to fill the knowledge gap in our understanding of risk assessment for CVDs in Nigerian PLWH. I am confident that my experience in metabolic medicine and HIV treatment and care research has equipped me with the necessary expertise and motivation to successfully execute this research project.
Ikechebelu IJ, Udigwe GO, Ikechebelu N, Imoh LC. The Knowledge, Attitude And Practice of Voluntary Counselling and Testing (VCT) For HIV/AIDS Among Undergraduates in A Polytechnic in Southeast, Nigeria. Niger J Med. 2006 Jul-Sep;15(3):245-9
Imoh LC, Inaku KO, Abu A and Amadu NO. Lipid Profile and Insulin Resistance in Pregnant Women with Family History of Diabetes Mellitus. Jos Journal of Medicine. 2014; 8(1): 19-22
Imoh LC, Ocheke AN. Correlation between Maternal Weight and Insulin Resistance in Pregnant Women in North Central Nigeria. Nigerian Medical Journal. Nov 2014; 55(6):465-468
Imoh LC, Amadu NO, Abu A and Asorose SA. Appraisal of timing for Oral Glucose Tolerance Testing in relation to risk factors for Gestational Diabetes Mellitus in pregnant women in a Nigerian Teaching Hospital. Nigerian Journal of Clinical Practice. Nov-Dec 2015;18(6): 771-4
Isichei, C.O., Isichei, M.W., Njab, J.E., Rotimi, J.I., Oyebode, T.A., Anyaka, C.U., Enwerem, K.E., Affi, A.I., Imoh, L.C., Abu, A.O., Asorose, S.A., Amadu, N.O., Okonkwo, P.I. and Okoro, N.I. Baseline Laboratory Profile of HIV Positive Patients on Antiretroviral Therapy in Jos North Central Nigeria: Implications for Prevention, Treatment, Care and Support. World Journal of AIDS. 2015; 5: 328-334. http://dx.doi.org/10.4236/wja.2015.54036
Imoh LC, Ogunkeye OO, Isichei CO, Gadzama AA, John C, Ocheke AN. Severe maternal insulin resistance in pregnancy: An independent predictor of fetal macrosomia. J Med Trop [Epub ahead of print] [cited 2016 Oct 6]. Available from: http://www.jmedtropics.org/preprintarticle.asp?id=188531
B. POSITIONS AND HONORS
Positions and Employments
2009 – 2011 – Registrar, Chemical Pathology
2011-2013 – Senior Registrar and Chief Resident, Department of Chemical Pathology, JUTH
2013 – Fellow, National Postgraduate Medical College of Nigeria, Consultant Chemical Pathologist, JUTH
2014 – to date- Assistant Secretary, College of Nigerian Pathologists, JUTH CHAPTER
2014 to date- Public Relations Officer, Christian Medical and Dental Association, Plateau State
September 2016 to date - Secretary, Christian Medical and Dental Association, Plateau State
Other Experience and Professional Memberships
2005- Member, Nigeria Medical Association
2005 -Member, Medical and Dental Council of Nigeria
2013- Fellow, National Postgraduate Medical College of Nigeria
2013- Member Medical and Dental Consultants of Nigeria
2014- Member, College of Nigerian Pathologists (CNP), formerly Association of Pathologists of Nigeria (ASSOPON)
2014- Member Association of Clinical Chemists of Nigeria
1997- Best Graduating Student Newland Secondary School Tolu, Lagos
2005- 3rd Best Graduating Student, College of Health Science, NnamdiAzikiwe University, 2005
2013- Distinction in Medical Toxicology (Cardiff)
2013-Best Candidate in Part II Examination (Chemical Pathology), National Postgraduate Medical College of Nigeria
BREAKDOWN OF BUDGET FOR THE STUDY
Laboratory Tests/ Carotid Doppler Ultrasound – 1,905,000 NAIRA
Data Collection / Analysis – 100,000 NAIRA
Research Assistant – 100,000 NAIRA
Laboratory Technician- 60,000 NAIRA
Total – 2,165,000 NAIRA
BREAKDOWN OF THE BUDGET FOR THE TESTS
Item/Test
Unit Cost (Naira)
Total Cost (Naira)
Fasting Lipid profile
Fasting Plasma Glucose
Carotid Doppler Ultrasound
CD4 Count
APIN/FAF Database
Cryovast
Pastuer pipette
Vacutainer needles
Methylated Spirit
2bottles
5mls Syringe
BUDGET JUSTIFICATION
1. Data collection and analysis
Printing of Questionnaire
Data Management and analysis by statistician
2. Research Assistant – would be involved in educating participants, administering the questionnaire, and taking anthropometric measurements and collecting blood samples
3. Laboratory Technician – Will help to process samples for biochemical analysis.
PROJECT NARRATIVE
This award will help fund the documentation of the prevalence of subclinical atherosclerosis and its correlations with cardiovascular disease risk factors and prediction models among HIV-infected individuals in a Nigerian hospital setting. Data from this initial study will provide baseline information on cardiovascular risk among Nigerians PLWH and help source for funding for future research work that will focus on understanding the role of non-traditional cardiovascular risk in atherosclerosis and CVDs among PLWH as well as developing models to assess and predict CVD risk in Nigerian populations.
GENERAL AIM
To determine the the prevalence of subclinical atherosclerosis and its association with cardiovascular disease risk factors and prediction models among HIV Infected individuals in a Nigerian hospital setting in Jos University Teaching Hospital
SPECIFIC AIMS
To determine prevalence of subclinical atherosclerosis in HIV Infected individuals and healthy non- HIV-infected controls
To determine the significant predictors of subclinical atherosclerosis in HIV Infected individuals and healthy non- HIV-infected controls
Assess the CVDs prediction models based on their correlation/association with CIMT/ subclinical atherosclerosis in HIV Infected individuals and healthy non- HIV-infected controls
BACKGROUND AND SIGNIFICANCE
Cardiovascular disease (CVD) is the leading cause of death and morbidity globally.1,2 CVD is a generic term for a group of diseases of the heart and vascular diseases including of the brain and peripheral circulation. It includes diseases such as Ischaemic heart disease, cerebrovascular disease (e.g. stroke), peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism, cardiomyopathy and cardiac arrthymias.3
Globally, CVDs are responsible for more than 17.5million deaths annually, nearly half of all deaths caused by Non communicable diseases (NCD) and nearly 80% of those who die annually from CVDs and diabetes mellitus (DM) live in resource limited settings.3,4,5 There is therefore growing apprehension about rising incidence mortalities from CVDs in the low and middle income countries.1,6 The rapid epidemiological transition in the burden of diseases from communicable to Non communicable diseases (NCDs) like hypertension, DM and their related complications in sub-haran Africa (SSA) is well documented and this is anticipated to increases the incidence and mortality of CVDs.1 This trend has been attributed to urbanization and a drift towards westernized lifestyle.7
Atherosclerosis is a fundamental vascular disease underlying the development or progression to CVDs.3 It involves a complex pathophysiologic process resulting in deposition of fatty materials, thickening of the intima and narrowing of blood vessels. The combination of endothelial dysfunction, chronic inflammation and dyslipidemias are central to the pathogenesis of atherosclerosis.8 These processes are often present in conditions of interrelated metabolic disorders including insulin resistance, obesity, impaired glucose tolerance and hypertension which are known to heighten cardiovascular disease risk. This association is widely regarded as as cardiometabolic syndrome.9
HIV/AIDS is fast gaining reputation as a leading cause of CVDs in SSA.10,11 In addition to the usual risk factors for CVDs in the general populations, People Living With HIV (PLWH) may possess addition risk factors related to endothelial dysfunction, metabolic effects of antiretroviral drugs (dyslipidemias, Insulin resistance) and the chronic inflammation induced by Human Immunodeficiency Virus (HIV) which heightens their predisposition to CVDs.7,12
The burden of HIV/AIDS remains high in SSA and Nigeria is among the countries with the highest prevalence with about 3.5 million people infected with HIV.13Although there appear to be some success regarding the prevention of new infections and increasing survival of AIDs- related deaths due to treatment of with Antiretroviral Therapy (ART), a new kind of challenge in the rising incidence of NCDs especially CVDs in PLWH is emerging.7 The high burden of HIV in Nigeria coupled with the increasing life expectancy of PLWH due to treatment with ARTs is setting the stage for a likely increased incidence of NCDs and CVDs among PLWA in Nigeria. Understandably, there are concern that the rising CVDs burden could mitigate or even reverse the improvement in morbidity and life expectancy being recorded among PLWH.7
In view of the foregoing, research on HIV/AIDs is beginning to focus on the risk factors and their role in development of CVDs and other NCDs. However, data on CVDs among PLWH in SSA countries remain sparse. Most of the studies to understand the burden and mechanism of CVDs in HIV has been in carried out among populations of high income countries who usually have a different risk profile to that of people of Nigerian and African ancestry. The few studies in Nigeria have investigated the presence of risk factors of CVDs without relating them to cardiovascular endpoints therefore it is not clear if these risk factors are actually associated with vascular changes suggesting vascular diseases or a high risk of progression to CVDs.14-16
The presence of Subclinical Atherosclerosis which can determine by Carotid Intimal Medial Thickness (CIMT) is a harbinger for CVDs.17-19 CIMT is a well validated surrogate imaging marker for cardiovascular assessment and future cardiovascular morbidity and mortality risk.19-25 It does appear that there is population based significance of CIMT in HIV infected subject.18,26,27 This may be related to varying socio-demographic, genetic factors and the profile of traditional risk factors across populations.18,20 The two Previous studies on Subclinical atherosclerosis among PLWH in SSA (Uganda and south Africa) where limited by a lack of an HIV-negative control group which made it impossible to draw any conclusions on the true effect of HIV infection on CIMT.18,20 Also the cut-off CIMT used to demarcate Subclinical atherosclerosis in these studies were not obtained from the local population, and this may have influenced their findings.
We do not know what proportions of PLWH have subclinical atherosclerosis and if this is related to the traditional cardiovascular risk factors of CVDs. Indeed it has been suggested that mean CIMT is elevated even among normal Nigerians.28 It is not clear how the CIMT in Nigerian PWLH compares with that of the non-diabetic, non-hypertensive, HIV negative individuals.
Risk factor assessment and management have been the cornerstones of preventive strategies. Although CVDs risk prediction models have been used for decades to prevent CVDs in both HIV and non HIV patients,24,29 there are no established strategy for screening or preventing CVDs in many SSA countries.18 Also Cardiovascular screening and prevention are currently not part of routine HIV care in Nigeria. This may be due to a lack of evidence of the predictive ability of any of the CVDs in Nigerian populations.
Recent data suggest prediction for cardiovascular disease among PLWH may not been very accurate with established CVDs risk prediction models like the Framingham Risk score and the Systematic Coronary Risk Evaluation (SCORE).25,26,30 A case for the use of the 5-year Data Collection on Adverse Effects on Anti-HIV Drugs Cohort (D.A.D) has been made in a number of studies.25 However, the performance of the various risk scoring models has not been well studied in Nigerian populations.
This study therefore is attempting to fill these gaps in our understanding of CVDs among PLWH. The prevalence of subclinical atherosclerosis will be determined and this will provide the much need baseline information that will help to predict the burden of CVD among PLWH in Nigeria. The CVDs risk prediction models will be assessed in the light of the presence of Subclinical atherosclerosis. Although prediction models were designed to forecast future CVDs, a robust predictive model is expected to correlate well with the existence of vascular disease in the present even if subclinical. It is hoped that this study will reveal any peculiarities in CVDs assessment among Nigerian PLWH.
EXPERIMENTAL DESIGN AND METHODS
This is a comparative cross sectional study to determine the prevalence of subclinical atherosclerosis in HIV Infected individuals and normal healthy controls and to assess how cardiovascular disease risk factors and prediction models correlates with subclinical atherosclerosis in HIV Infected individuals and normal healthy controls.
SAMPLE SIZE DETERMINATION
The sample size was determined by the formula for chi square test comparing 2 independent proportions.
The sample size was estimated using the formula;
n = {P1 (1-P1) + P2 (1-P2)} X (Z α +Z β)2
(P1-P2)2
n: number of sample size in each of the group
P1= proportion of subclinical Atherosclerosis among cases (0.18 in the Ugandan study).20
P2= Assumed proportion of subclinical Atherosclerosis among controls = 0.06 (Assumed ratio of Case : Control = 3:1)
Z-α/2= value of standard normal distribution corresponding to a significance level of alpha (1.96 for two-sided test at the 0.05)
Z-β/2=value of standard normal distribution corresponding to the desired level of power (0.84 for a power of 80%)
n = {(0.18×0.82 + (0.06 × 0.94)} x (1.96 + 0.84)2
n≈ 114
This was confirmed using statistical software STATA version 13.
The sample size was adjusted to 120 for the cases (120 ART-treated subjects) and 120 for (120 HIV-negative apparently healthy controls) to compensate for an attrition rate of 5%.
This will be a cross sectional comparative study to be carried out at the AIDS Prevention Initiative in Nigeria (APIN)-supported HIV clinic at the Jos University Teaching Hospital (JUTH). The JUTH HIV clinic is located in the urban city of Jos, plateau state. It serves a population of over 22 million people from Plateau and the neighboring north central states of Nigeria. The clinic commenced HIV services in 2002, and has cumulatively enrolled over 17,000 adults for HIV care and treatment; with over 10,000 on follow up31.
Faith Alive Foundation is a non-governmental faith-based organization in Jos (www.faithalivenigeria.org) that provides primary healthcare for about 10,000 patients a month and ongoing care for HIV/AIDS patients, as well as care for emergencies, opportunistic infections such as TB and Malaria.
Consenting HIV-infected adults will be stratified by sex and age interval of 5yrs on a proportionally representative basis from a sampling frame obtained from the register of patients attending HIV clinics at JUTH and FAF who satisfy the inclusion criteria. Consenting HIV-infected adults randomly selected e.g. using computer- generated assigned numbers will be included in the study until the sample size is attained.
For the controls, eligible non HIV-negative individuals stratified by sex and age interval of 5yrs to mach for each case will be selected proportionally from a sampling frame of individuals obtained from the register of JUTH and FAF out-patient clinics. The recruitment of the controls will be done randomly e.g. using computer- generated assigned numbers.
Inclusion Criteria for subjects
All ART-treated HIV-infected adults between 20 and 70 years (inclusive) enrolled at JUTH and FAF HIV clinic
Patients who give an informed consent
Non-diabetic- based on Medical records, Random Blood Glucose (RBG) < 11.1mmol/L and/or Fasting Blood Glucose < 7.0 mmol/L.
Non-hypertensive - Systolic Blood Pressure (SBP) < 140mmHg and Diastolic Blood Pressure (DBP) < 90 mmHg.
Viral load undetectable (plasma HIV-1 RNA < 20 copies per milliliter) at last testing (within 1 yr of the study).
Exclusion Criteria for subject
Patient who did not give consent
HIV-naïve patients
Diabetic- based on Medical records, RBG ≥ 11.1mmol/L and/or FBG ≥ 7.0 mmol/L
Hypertensive- SBP ≥ 140mmHg and/or DBP ≥ 90 mmHg
Patients with confirmed CVD (stroke, myocardial infarction, and/or peripheral vascular disease), malignancy and active infection (as per the attending physicians and medical records), receiving glucocorticoids, growth hormone or other anabolic agents within the past 6 months.
Patient who are too sick to partake in the study
Patients on current ART regimen for less than 6 months
Inclusion Criteria for controls
Non HIV-infected (based on negative HIV screening) adults between 20 and 70 years (inclusive)
Non-diabetic- based on Medical records, RBG < 11.1mmol/L and/or FBG < 7.0 mmol/L
Non-hypertensive- SBP < 140mmHg and DBP < 90 mmHg
No previous history of CVD
Exclusion Criteria for controls
Unable to provide consent
Confirmed CVD (stroke, myocardial infarction, and/or peripheral vascular disease), malignancy, active infection (as per the attending physicians and medical records), receiving glucocorticoids, growth hormone or other anabolic agents within the past 6 months.
Too ill to partake in the study
STUDY PROTOCOL
All consecutive patients who satisfy the inclusion criteria and give consent will be recruited into the study and those not willing to participate in the study will be excluded. All eligible participants will be advised on the participation dates and time (Between 8:00am to 9:30am) at their clinic and will be advised to provide a fasting blood sample. Participants who could not come on the scheduled date will be rescheduled if they give prior notice to be excused or replaced if no notice was given.
Relevant clinical data will be obtained from each participant with the aid of a standardised questionnaire. The questionnaire was filled by the researcher or his trained assistant. The questionnaire will address the following areas; socio-demographic data, cardiovascular risks factors, previous diseases and co-medications. Information regarding HIV related factors shall be obtained from patients records: known duration of HIV infection, WHO stage, start date of ART, current ART regimen, and previous changes in regimen. Hepatitis B or C co-infection. The latest CD4 cell count and HIV viral load will be recorded if done within the last 12 months taking into account the routinely follow-up duration of 12 months for viral load testing for stable patients in the treatment programme for HIV/AIDS.
Also relevant history of CVD risk factors will be sought for, including: lifestyle characteristics (exercise, diet, history of smoking and alcohol use), family history of CVD (hypertension, stroke, myocardial infarction and sudden death) as well as any concurrent medication that might affect CVD risk (anti-hypertensive drugs, non-steroidal anti-inflammatory drugs (NSAIDs), and lipid lowering drugs).
Biophysical examination will include measures such as Height, weight, waist circumference, and blood pressure will be measured according to standard procedures. Body mass index (BMI) was calculated. Obesity and overweight were defined as a BMI ≥30 and ≥25 kg/m2, respectively. Hypertension was defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg and/or the use of antihypertensive medication. Diabetes mellitus (DM) will be determined by medical history of confirmed DM (from patients' records), in the absence of which FBG ≥ 7.0mmol/L and/or RBG ≥ 11.1 mmol/L will suffice. Metabolic syndrome (MetS) will be defined according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATPIII) guidelines.9
Blood samples will be collected in the morning after a 10-12 hr overnight fast. Four mls of blood will be drawn into a plain vacutainer for lipid profile; 3mls into a fluoride oxalate vacutainer for glucose assay. The specimens will be centrifuged at 4000rpm for 10minutes and the supernatant, plasma or serum separated out. Plasma glucose will be analysed daily while aliquots for lipid profile and assays will be stored at -70°C in a well-monitored freezer for one month until the analyses are performed. Heavily haemolysed, icteric or lipaemic samples were excluded.
Biochemical analysis
Fasting plasma glucose concentration will be measured using Glucose oxidase method, Total cholesterol (TC), Triglyceride (TG) and High Density Lipoprotein-Cholesterol (HDL-C) will be analyzed with standard enzymatic methods, while Low Density Lipoprotein-Cholesterol (LDL-C) will be determined by a direct, homogenous assay. All assays will be ran on a Roche Cobas C111 analyzer (Roche diagnostics, Germany). The LDL-C method will be employed to avoid the limitation of the routinely used Friedewald equation,32 which cannot be applied when TG > 400mg/dl as a very likely scenario in HIV patients on ARTs.
CIMT Measurement
This will be done (Within one week of the collection of blood samples) by a certified and experienced radiologist using high resolution real time ultrasound scanner GE Logic 5 color Doppler scanner (2007) with 7.5MHz linear probe. The right and left carotid arteries will be studied with the subject in spine position, head in the midline position and hyperextended. The common carotid artery (CCA) will be located, its origin traced as proximally as possible and the probe traced along the artery to the carotid bifurcation. Multiple transverse views (to obtain the near and far walls) and longitudinal views (to obtain the maximal luminal diameter) of the artery will be undertaken. The IMT will be taken in the longitudinal plane at the point of maximal thickness on the far wall of the CCA, at a point 1cm proximal to the bifurcation. The machine will be frozen and using its caliper markers, the IMT will be measured as the distance between the inner echogenic line representing the intima-blood interface and the outer echogenic line representing the media-adventitia junction. Magnification of the image will be used to improve accuracy of the caliper placement. The average value of three different measurements will be recorded for both left and right common carotid arteries respectively. Permission will be obtained from one in every 10 subjects, for a rescan for quality control purposes.
Subclinical atherosclerosis will be defined using a cut-off value of CIMT ≥ 0.78 mm, based on the previous study which showed that on average, a healthy adult reaches a CIMT of 0.78 mm at the age of 76 years.33
Cardiovascular risk prediction Models
The cardiovascular risk prediction models and there required variables are summarised in table 1 below:
10-year Framingham CVD risk score (FRS10).34,35
5-year Data Collection on Adverse Effects on Anti-HIV Drugs Cohort;(DAD ) risk score.36
Prospective Cardiovascular Munster Study (PROCAM) 10-year CVD risk.37
Systematic Coronary Risk Evaluation (SCORE)
10-year CVD.38
HDL-C
Smoking Status (past)
Smoking Status (current )
Current treatment of High blood pressure
family history of CVD
family history of coronary heart disease
current use of abacavir, indinavir, or lopinavir
Duration on PI (indinavir and lopinavir )
Other Requirements/
≥ 20 years, No
no diabetes and no history of CVD,
≥2 risk factors
Duration on NRTI
Risk classifications
Low= <10%
Moderate= 10–20%
High= >20 %
Low (<1 %), Moderate (1–5 %),
High (5–10 %),
Very high (>10 %)
Medium= 10–20%
Risk chart for High-risk countries will be used
To simplify comparison, High- and very high-risk 5-year DAD risk score will be subsequently reclassified into a single high-risk category (≥ 5%).
The DAD risk score will be calculated using web based risk calculator (http://www.cpHIV.dk/ TOOLS/tabid/437/Default.aspx).The PROspectiveCArdiovascularMünster study (PROCAM) wil be calculated using web based risk calculator http://www.thecalculator.co/health/PROCAM-Score-For-Cardiovascular-Risk-Calculator-985.html. The SCORE will be computed via an application available at: http://www.heartscore.org/Pages/download.aspx
DATA PROCESSING AND STATISTICAL ANALYSIS
Data will be entered in Microscoft Excel® version 2.0 and exported to Statistical Package for Social Sciences (SPSS® Incorporated Chicago Version 18.0) software for analysis. Descriptive statistics will be presented as mean values + standard deviation (SD) or medians with interquartile ranges (IQRs) for none normal continuous variables, and proportions (as percentages) for categorical variables. Kolmogorov-Smirnov test will be used to test for normality of continuous variables. unpaired students t-test or Mann-whitney U test will be used to test the difference in means or medians of continuous variables between groups. Subclinical atherosclerosis, defined as CIMT ≥0.78 mm, will be the primary outcome variable. Other outcomes variables will include risk classification of the various cardiovascular risk assessment scoring systems (low, moderate or high risk). Chi square test will be used to compare the proportions of subclinical atherosclerosis in cases and control groups. Bivariate analysis (chi square) and multivariate logistic regression will be used to examine the relationship between risk factors and CVD risk prediction models with subclinical atherosclerosis. The agreement between different CVD risk assessment algorithms will be assessed using the kappa coefficient. The significance level was set at p≤ 0.05.
This study will be carried out after due approval from the Ethical Committee of the Jos University Teaching Hospital (JUTH) and FAF Jos. Informed consent will obtained from all participants after due explanation of the research work and procedure.. Anonymity and confidentiality of the information obtained from the participants in this study will be assured and maintained.
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