Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case.

There is a growing body of evidence on the impact of the environment on health and well-being. This study focuses on the impact of visual artworks on the well-being of psychiatric patients in a multi-purpose lounge of an acute care psychiatric unit. Well-being was measured by the rate of pro re nata (PRN) medication issued by nurses in response to visible signs of patient anxiety and agitation. Nurses were interviewed to get qualitative feedback on the patient response. Findings revealed that the ratio of PRN/patient census was significantly lower on the days when a realistic nature photograph was displayed, compared to the control condition (no art) and abstract art. Nurses reported that some patients displayed agitated behaviour in response to the abstract image. This study makes a case for the impact of visual art on mental well-being. The research findings were also translated into the time and money invested on PRN incidents, and annual cost savings of almost $US30,000 a year was projected. This research makes a case that simple environmental interventions like visual art can save the hospital costs of medication, and staff and pharmacy time, by providing a visual distraction that can alleviate anxiety and agitation in patients.

Modified release verapamil induced cardiogenic shock.

Cardiogenic shock due to acute myocardial infarction is commonly seen in the accident and emergency department. Refractory cardiogenic shock has been reported after a therapeutic dose of modified release verapamil with concomitant use of beta blocker, metoprolol, but not after a single therapeutic oral dose of modified release verapamil alone. We report what we believe to be the first case of potentially life threatening cardiogenic shock resulting from the myocardial depressant effect of a single therapeutic oral dose of modified release verapamil. The patient made a dramatic recovery minutes after an injection of intravenous calcium chloride. The case is a reminder of the negative inotropic effect of verapamil and how it should be treated.

Measures of outcomes for children and youth.

OBJECTIVE: To provide an overview of the issues related to the measurement of disability outcomes among children and on an assessment of selected instruments. DATA SOURCES: Published scientific English literature in the area of child development, public health, and outcomes research. STUDY SELECTION: Studies selected were those that provide global measures of health outcomes focusing on children. Those selected allowed data collection to address the effects of intervention on individual children or populations of children. Psychometric characteristics were also a part of the selection process. DATA EXTRACTION: Specific guidelines for assessing the instruments include the number of scales and index capability, breadth of domains, inclusion of norms, capacity to measure elements of the World Health Organization model of functioning and disability, item and scaling bias, respondent burden, administrative burden, and retest reliability. DATA SYNTHESIS: Thirteen instruments were included. The measures vary in their utility for broad versus specific applications, eg, clinical and public health uses. Children themselves are often not part of the assessment process. In addition, environmental influences on health outcomes of children are not adequately addressed. CONCLUSION: Although it is challenging to evaluate outcomes associated with children with disabilities, there are frameworks and instruments that will advance outcome measurement. Approaches that include children should be explored further, and the environmental influences including and beyond the family require further measurement development.

Health-related quality of life. A guide for the health professional.

The importance of evaluating health care in terms of patients' quality of life has only recently been acknowledged in the context of outcomes research and the measurement of quality of care. As a health professional, trying to choose the appropriate health status or health-related quality of life (HRQOL) measure can be daunting, as one is faced with a bewildering array of choices. The purpose of this article is to describe the process by which professionals might make a choice about measures in outcomes research. The article includes examples and rationale for using generic or disease-specific HRQOL measures. In addition, examples are provided of HRQOL assessment in two adult chronic disease applications: asthma and congestive heart failure.

Return of fertility following discontinuation of Norplant-II subdermal implants. ICMR Task Force on Hormonal Contraception.

A total of 627 women who had discontinued the use of the Norplant-II implants for various reasons and were exposed to the risk of pregnancy were followed-up for two years for return of fertility. The cumulative conception rates in women who had discontinued due to planning pregnancy were 80.3 per 100 women at one year and 88.3 per 100 women at two years. The majority of women who did conceive (90 percent), had full-term normal live births; about 4 percent of women had spontaneous abortions, the remaining 6 percent decided on elective termination of pregnancy (ETP). The cumulative conception rates in women who discontinued due to bleeding irregularities and 'other reasons' were 64.5 and 55.8 per 100 women at one year and 77.9 and 75.1 per 100 women at two years, respectively. These rates were significantly lower as compared to those observed in women who discontinued due to planning pregnancy. A large proportion, about 40 percent, of women who conceived after discontinuation of the method due to bleeding irregularities and "other reasons," opted for ETP indicating that many women in these two groups did not desire another child and that such women need to be counselled for adopting another method of contraception. The spontaneous abortion rates observed in ex-users of Norplant-II implants (1.7 to 4.4% pregnancies) were comparable to the spontaneous abortion rates prior to Norplant-II implant use (3.6% pregnancies) indicating that ex-users of Norplant-II implants were not at a higher risk of spontaneous abortion.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Researchers at 15 Human Reproduction Centres of the Indian Council of Medical Research followed 627 women aged 18-35 who stopped using the subdermal Norplant-II system for different reasons, and thus were exposed to the risk of pregnancy, for 2 years to determine return of fertility. 20% conceived within 1 month of Norplant-II implant removal. The 6-month, 1-year, and 2-year pregnancy rates were 63.4%, 80.3%, and 88.3%, respectively. Neither duration of Norplant-II implant use nor bleeding patterns had an adverse effect on return of fertility. The 1-year and 2-year cumulative pregnancy rates for women who stopped due to bleeding irregularities and other reasons were lower than those who stopped due to planning a pregnancy. Return of fertility was delayed in women whose implants were removed after age 30 compared to those younger than 30 (1-year pregnancy rate, 66.3% vs. 83%; median time to conception, 6 vs. 3.8 months; p 0.05). The difference was not significant at 2 years, however. 89.7% of women who wanted pregnancy and became pregnant after discontinuation delivered full-term live infants. 4.4% had a spontaneous abortion. Women who discontinued the implant system to conceive were less likely to opt for an induced abortion than those who discontinued for irregular bleeding and other reasons (5.9% vs. 36.4-41.6%), suggesting that many women did not want another child and need to be counseled about adopting and offered another contraceptive method. The spontaneous abortion rates for women who discontinued for irregular bleeding and other reasons were 1.7% and 2.7%. No group of former Norplant II users suffered a spontaneous abortion rate greater than the pre-Norplant II use rate (3.6%). These findings show that the Norplant-II implant system does not delay return to fertility in women who stop using it to become pregnant.

Randomized clinical trial with intrauterine devices (levonorgestrel intrauterine device (LNG), CuT 380Ag, CuT 220C and CuT 200B). A 36-month study. Indian Council of Medical Research Task Force on IUD.

A total of 1905 subjects were randomly allocated to four types of intrauterine devices (IUDs) and were observed for 45,683 woman-months of use. While no method failure was observed with levonorgestrel (LNG) IUD, 11 women became pregnant with other devices; 4 with Copper T 380Ag, 1 with Copper T 220C, and 6 while using Copper T 200B, indicating method failure rates of 1.0, 0.3 and 1.6, respectively, at 36 months of use. These rates were within acceptable range. Continuation rates were significantly lower with LNG IUD (74.5, 58.7, 38.8 at 1 year, 2 years and 3 years, respectively) as compared to other copper devices, which ranged between 82.4 to 84.4 at 1 year, 66.6 to 69.9 at 2 years and 45.4 to 50.4 at 3 years. The difference in continuation rates was mainly due to menstrual disturbances (e.g. amenorrhoea, irregular bleeding) which were higher with LNG IUD (27.9 per 100 users) as compared to the copper devices (13.4-15.4 per 100 users) at 36 months of use. The risk of expulsion ranged between 8.3 to 10.6 per 100 users and was comparable for all the devices. The observations from the present study based on 36 months of experience with different intrauterine devices do not indicate the need to replace CuT 200, the device currently in use in the National Programme.

Phase III-clinical trial with Norplant-2 (covered rods). Report of a 24-month study. National Programme of Research in Human Reproduction. Division of Human Resource Development Research Indian Council of Medical Research Ansari Nagar, New Delhi, India.

In a phase III multicentre clinical trial, the subdermal implant NorplantR-2 was studied for its clinical use effectiveness, safety and bleeding pattern. A total of 1466 healthy volunteers, with no contraindication to steroid use, were observed for 29,669 woman-months of use. One method failure was reported at 18 months of NorplantR-2 use. The method was associated with altered menstrual pattern with a trend towards reduced blood loss. The continuation rates were 88.1 and 73.5 per 100 users at 12 and 24 months of use, respectively. Menstrual disturbance, mainly prolonged bleeding, accounted for the majority of the discontinuations. Removal of NorplantR-2 due to local infection was rare (0.4 per 100 users at 24 months). In similar clinical trial conditions, the continuation rate with NorplantR-2 is significantly higher than those observed with LNG IUD and injectable contraceptives, norethisterone oenanthate 200 mg given every 60 +/- 5 days, and is comparable to that of CuT 200 IUD.

Serum lipid profile in women using levonorgestrel contraceptive implant, Norplant-2.

Cholesterol content of major lipoprotein fractions along with total cholesterol (Tc) and triglyceride (Tg) were measured in 65 samples from 35 women using levonorgestrel contraceptive implant, Norplant-2 from the third month of implantation until the end of second year along with twenty-five healthy controls. There were significant decreases in all the fractional lipid values, Tc and Tg, up to the sixth month followed by a gradual rise of all lipid parameters except HDLc which remained much below the control level. Interestingly, VLDLc exhibited a significant rise at the end of the second year.

PIP: Total cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and very low density lipoprotein (VLDL) were measured in 35 Indian women using the levonorgestrel-containing implant, Norplant, and in 25 controls. 65 blood samples were taken from the 35 Norplant users at 3,6, 12 and 24 months after placing the implants. Assays were done by quantitative fractionation methods. Serum HDL fell significantly at 3 months (p0.02), and further over 6-24 months of use (p0.001), from 40.0 to 31.8 mg/dl. The control value was 49.2. LDL and VLDL fell to a minimum at 6 months, and rose somewhat at 12 and 24 months. Total cholesterol also was depressed to a mean of 128.8 at 6 months, then rose to 148 mg/dl at 24 months. Control total cholesterol was 190.1. Triglyceride levels followed a similar pattern. The ratios of HDL/total cholesterol and VLDL/total cholesterol in this series suggest increased risk of coronary heart disease. In contrast, the fall in total cholesterol to values below 100 mg/dl in some subjects is cause for concern. These data add to the widely discrepant findings of serum lipoproteins in different studies on Norplant users.

Vaginal cytology and ferning of cervical mucus studies after intra-uterine instillation of solutions for medical termination of pregnancy.

PIP: The effectiveness of intrauterine instillation of solutions for midtrimester abortions is well established, but the mechanism for triggering the onset of labor is unclear and represents a challenging problem for obstetricians and physiologists. Vaginal cytology reflects the hormonal status. Of the total of 78 cases in this study, 20% sodium chloride solution was used in 55 cases, glucose 50% in 5 cases, and 0.1% unacredil with Foley's catheter in 18 cases. Vaginal smear was taken and stained with Papanicolaou's staining method. In the vaginal smear the following aspects were studied: presence of Doderlein bacilli; cytolysis; tendency of the cells to unfold and separate; degenerative changes in the cells, inducing perinuclear halo; fragmentation of nuclei; flatness and loss of haziness of cell border; Karyopyknotic index; and parabasal cells. Cervical mucus was taken, dried, and examined under the microscope for appearances of ferning. The cervical mucus and vaginal smear were taken before instillation and after instillation every 8 hours until abortion. In unacredil no significant changes in vaginal cytology were observed until abortion even when it was repeatedly instilled. The usual changes observed in vaginal cytology were observed until abortion even when it was repeatedly instilled. The usual changes observed in vaginal cytology in this series were within 8-24 hours in all saline instilled cases except the discreteness of cells which was not found in 11 cases until abortion. Karyopyknotic index rising above 10 from the baseline smear was observed in all cases but more than 30 Karyopyknotic index was noted in 26 cases. Parabasal cells appeared prior to abortion in 11 cases. Perinuclear halo was found in 1 case. In hypertonic glucose all identified changes were noted except the appearance of parabasal cells and perinuclear halo. With unacredil, the changes in vaginal cytology could not be appreciated until abortion. Ferning in pregnancy indicates placental insuffiency. In this study ferning was positive (atypical) in 2 cases before giving intraamniotic saline. After saline instillation ferning appeared in cervical mucus within 8-40 hours in all cases. In glucose instilled cases ferning appeared in all cases within 16-40 hours. Instillation of hypertonic saline probably is damaging the placenta and thus withdrawing progesterone blocks, which is reflected in vaginal cytology and cervical mucus ferning. In cases of hypertonic glucose this placental damage is not as extensive as revealed in vaginal cytology and cervical mucus fern test. In case of unacredil, it has no effect on hormonal function of placenta as is evident by no change in vaginal cytology and ferning.^ieng