A Review of Nitinol’s Application in Vascular Stents

heatmaps allow for a comparison of larger features of the script at a glance, while the focus on Hinge features allows for a more careful analysis of subtler details. Differences in these subtle details can be quantified and translated into feature vectors, which can then be plotted on a three-dimensional graph. The plot of Hinge vectors that the researchers derived from the Great Isaiah Scroll showed a complete break in style between the first half and the second half of the manuscript, with a statistical analysis of each half supporting this visual separation. The differences in style within and between each half of the scroll consist entirely of very minute distances, as they constitute slight variations in hand movement. What might not be viewed as a significant variation by a human being is made much clearer thanks to the computer program, allowing researchers to draw more definitive conclusions than have been made previously (2). Combining the findings from both the algorithmic and Hinge analysis methods allowed the researchers to conclude that two separate scribes composed the Great Isaiah Scroll. The researchers posit that theirs is the most comprehensive study on writer identification of the Dead Sea Scrolls using modern computing techniques, and so the fact that such a definitive conclusion can be reached is unprecedented. While a human could conceivably discern significant differences between writing styles, when multiple writers possess exceedingly similar styles, the ability to analyze the minute details is something that can only be achieved with algorithmic analysis, especially for a text containing as many characters as one of the Dead Sea Scrolls (2). Thus, the utility of algorithmic approaches for any future research in the field is assured, as ever-advancing technology allows for ever-closer examinations of text. As such analysis gets closer to the level of comparing individual pixels to one another, the accuracy of authorial identification will continue to increase.

Binary Pixel Patterns

While the heatmap method proved useful in identifying the authorship of the Great Isaiah Scroll, it served only to distinguish two authors of a single text, thus leaving room for algorithmic analysis to expand its scope in terms of both the number of authors and the number of texts. Arad is an archeological site from the ancient kingdom of Judah, dating back to around 600 BCE, which has long been known to have hosted an assortment of writers. The site has yielded to archeologists a large corpus of tablets which were written over a short amount of time, and previous analyses determined that around four to seven writers composed these texts. However, algorithmic technology has advanced significantly since the previous examination of the corpus, and thus a team of researchers led by Arie Shaus of Tel Aviv University decided to reexamine the texts. Utilizing a novel algorithmic approach

Figure 4 The

Great Isaiah Scroll is one of the longest Dead Sea Scrolls. developed by Shaus, they were able to identify at least a dozen unique authors who were either stationed at, or wrote to, the site. When examining the Arad Corpus, Shaus and his team used two algorithms to examine similar details of script as were explored in the Great Isaiah Scroll study, such as legibility, size, spacing, and punctuation. The first of the algorithms restored the strokes a given writer used to write a given character, and then compared these to instances of said character across the whole corpus. The end result of the character reconstruction is a binary, or black and white, digital recreation of the original letter. After the binary image is created, the algorithm analyzes the distance between the character and the characters surrounding it. Finally, the algorithm is set to determine the probability that two texts were written by the same writer. Different letters were analyzed independently of each other, and only two texts were compared to one another at the same time (3). This method is fairly similar to the heatmap method in the level of detail that it can analyze. While it does not aggregate all instances of a given letter across the corpus, it does equalize each instance of the letter by creating the binary images. While a byhand analysis of these images is possible, the computer programs are able to compare details in a way that would otherwise be impossible. To further this point, the second algorithm utilized by Shaus and his team examines a level of detail that is completely impossible for a human to ever discern. A few years prior to the reexamination of the Arad corpus, Shaus developed a novel algorithmic approach that uses the same statistical approach as the previously discussed algorithm, but differs in that it analyzes letters with a level of detail far beyond that algorithm, or the heatmap and Hinge analyses of the Great Isaiah Scroll study. Rather than simply analyze the strokes used to write each letter, and then the spatial relationship between the letters, this second algorithm involves the creation of binary pixel patterns: three pixel by three pixel patterns derived from the letters. All possible patterns that could be formed from each letter were used to form normalizing histograms, after which the individual patterns are compared statistically. This allows for an analysis of the individual features of letters, allowing for a much greater degree of accuracy when identifying authorship (4).

The pair of algorithms were found to agree on authorial identity in every case. A forensic, non-algorithmic, analysis also performed by the researchers aligned with these same results and the combined results allowed the researchers to identify as many as twelve authors among the Arad corpus, which consists of only eighteen texts. Based on the meanings of certain texts, which appear to be written by presumably Judahite commanding officers of various mercenary groups employed by the Kingdom of Judah, at least three of the writers can reasonably be assumed to have been stationed at Arad. Since the site was only large enough to house twenty to thirty soldiers, this suggests that at least ten percent of the garrison was literate (3). As such, the researchers posited that this remarkably high literacy rate is indicative of an advanced education system that existed in the kingdom, which would have educated members of the military and other elites. This era of high literacy also aligns with the time period of the dissemination and composition of various biblical texts, such as the Books of Deuteronomy, Joshua, Judges and Samuel. Furthermore, an education system akin to what the researchers posit existed in the Kingdom of Judah would allow for more of the populace to appreciate such important cultural touchstones in their written form without having to rely on oral tradition for transmission (3). Such a clear and revelatory understanding of the cultural life of an ancient society would not have been possible without the advancement of algorithmic technology that allowed for the half-dozen new authors to be discovered.

Conclusion

Ever-advancing technology allows for a wide variety of approaches for analyzing ancient handwriting, and to an exponentially greater degree of accuracy than anything a human could hope to do by hand. Whether it’s through wholly computerized methods, or through syntheses of traditional techniques and modern technology, previously obscure information regarding the authorship and transmission of ancient, culturally significant works can be revealed for the first time. Although human analysis remains adequate when interpreting the meaning of ancient texts, it is completely outclassed in the field of author identification. Algorithmic analysis allows for cultural and historical secrets to be illuminated in a way that they might otherwise never have been, and thus their use in the field will only increase as technology continues to advance.

References

1. F. Höflmayer, et al., Early alphabetic writing in the ancient near east: the ‘missing link’ from Tel Lachish. Antiquity 95, 705-719 (2021). doi: 10.15184/aqy.2020.157. 2. M. Popović, M. Dhali, and L. Schomaker, Artificial intelligence based writer identification generates new evidence for the unknown scribes of the Dead Sea Scrolls exemplified by the Great Isaiah Scroll (1qisaa). PLoS ONE 16, 1-28 (2021). doi: 10.1371/journal.pone.0249769. 3. A. Shaus, et al., Forensic document examination and algorithmic handwriting analysis of Judahite biblical period inscriptions reveal significant literacy level. PLoS ONE 15, 1-15 (2020). doi: 10.1371/journal.pone.0237962. 4. A. Shaus and E. Turkel, Writer identification in modern and historical documents via binary pixel patterns, kolmogorov–smirnov test and fisher’s method. Journal of Imaging Science and Technology 61, 0104041-0104049 (2017).

Images retrieved from:

1. https://collectionapi.metmuseum.org/api/collection/v1/iiif/473396/1536172/main-image 2. https://www.cambridge.org/core/journals/antiquity/article/early-alphabetic-writing-in-the-ancient-near-east-the-missing-link-from-tel-lachish/C73F769B7CF3A7E4E2607958A096B7D8 3. https://collectionapi.metmuseum.org/api/collection/v1/iiif/473396/1536173/main-image 4. https://commons.wikimedia.org/wiki/File:The_Great_Isaiah_Scroll_MS_A_(1QIsa)_-_Google_Art_Project-x4-y0.jpg 5. https://collectionapi.metmuseum.org/api/collection/v1/iiif/473396/1536171/main-image

JUZER VASI `24

Introduction

One of the most pressing issues facing health institutions around the world today is cancer. It is estimated that by 2040, new cases of cancer will rise to 26 million – posing grave physiological ramifications on patients (1). Fortunately, art therapy has the potential to greatly improve both the physical symptoms associated with chemotherapy and the psychological issues of cancer diagnoses. Due to the synergy of the techniques in its unique protocol in reducing pain and increasing quality of life, research suggests that mindfulness-based art therapy (MBAT) is more effective than its traditional counterparts, and understanding the biological mechanism behind art therapy allows medical professionals to personally tailor MBAT to maximize efficacy.

What is Art Therapy?

Through active art-making such as drawing and creative thinking, combined with applied psychotherapy, art therapy is used to improve cognitive and sensory-motor functions, foster self-esteem, cultivate emotional resilience, reduce conflicts and distress, and promote insight into core issues faced by the patient (2). A subset of art therapy that has recently arisen is mindfulness-based art therapy (MBAT). According to Dr. Caroline Peterson from the Joan Karnell Cancer Center, MBAT integrates general art therapy exercises with mindfulness skills-training and programs that are wellness – rather than illness – focused, such as gentle yoga practice, body scan meditation, and breathing exercises. As a result of the psychological distress of cancer diagnoses, chronic hyperarousal (a symptom of PTSD) can occur, which leads to negatively biased memory and emotions, disruptive thinking, and adverse behavioral inhibition. Additionally, the physical symptoms of treatment can include extreme fatigue, nausea, anemia, and infection. Peterson reveals that MBAT succeeds by activating the body’s rest and repair system, improving psycho-physiological self-regulation, attention, decision-making skills, positive emotion states, and immune functioning, leading to an increase in overall quality of life (3).

MBAT Increases Quality of Life

Receiving an initial diagnosis of cancer evokes sentiments of anger, anxiety, and trauma in patients, often leading to the development of mental health disorders. According to Dr. J.T. Bosman and Dr. Zoe Bood at the Department of Medical Oncology at Amsterdam University, anxiety and depressive disorders are particularly common among cancer patients. In fact, anxiety disorders are estimated to exist in 10% of cancer patients and depression to exist in 20% of cancer patients. Additionally, non-Diagnostic and Statistical Manual of Mental Disorders (DSM)-certified disorders such as insomnia and distractibility are even more common. Thus, quality of life (QoL) is adversely affected (4). QoL, as defined by the World Health Organization, consists of physical, mental, and social health, as well as cognitive

and sexual functions, working ability, and lifelong pleasure (5). MBAT may have positive implications for breast cancer patients. A 2019 study conducted by Dr. Zeinab Jalambadani from the Department of Public Health at Neyshabur University of Medical Sciences and Dr. Abasalt Borji from the Department of Basic Medical Sciences set out to determine the effectiveness of MBAT in increasing quality of life (QoL) in women with breast cancer. The researchers divided 100 female participants with breast cancer into a control group that did not receive MBAT intervention and an experimental group that was exposed to an MBAT art therapy course. QoL was measured both before and after treatment using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Each group met for 90 minutes per week for 12 weeks. Activities during therapy sessions included self-picture assessment tasks, exploration of different art materials, yoga, body scan meditation, breathing exercises, freestyle art-making, and group discussions. As measured by the WHOQOL‑BREF stress management subscales, patients under MBAT treatment reported significant increases in physical health, psychological health, and social relationships. Specifically, there was a 20% increase in the level of physical and psychological health, and a 12.7% increase in social relationships between participants. Mindfulness-based art therapy Ultimately, the study displays encouraging data that integrates general art therapy MBAT is an effective means for reducing symptoms of exercises with mindfulness skills distress and improving key aspects of the lifestyle of training...leading to an increase in women with breast cancer. Furthermore, the results overall quality of life. indicate a possible advantage over standard art therapy approaches when comparing WHOQOL-BREF results of recent studies (5). To determine if MBAT is a possibly more effective approach to alleviating cancer symptoms than traditional art therapies, it is necessary to study cancer patients engaging in strictly traditional art forms without the component of mindfulness. In a 2017 study conducted by Dr. Hakan Bozcuk and Dr. Hulya Oczan at the Medical Park Hospital in Turkey, QoL was measured in 48 patients after undergoing a painting art therapy program (PATP), which was facilitated by a professional watercolor painting artist during patients’ chemotherapy sessions. According to QoL domains of the European Organization for Research and Treatment of Cancer (EORTC) questionnaire and changes in Hospital Anxiety and Depression Scores (HADS), patients who underwent the PATP program experienced a 30% increase in global QoL and a 50% increase in depression scores, which are statistically significant. Additionally, according to the EORTC questionnaire values, among patients who had never been exposed to PATP therapy before, there was a 6.8 and 9.9 increase in emotional and cognitive functioning, respectively, and significant decreases in symptoms such as fatigue, insomnia, dyspnea, and overall pain. Not only did the act of painting enable the catharsis of negative feelings, but patients who participated in PATP were also more likely to engage in open dialogue to discuss problems due to the social and interactive environment that was regularly provided by the program. Interestingly, patients with the poorest

well-being at the start of the experiment (lowest QoL, highest depression) experienced the greatest improvements, indicating that in clinical practice PATP may benefit patients who are relatively in more need of help. However, according to the limitations of the study, the effect of PATP on global quality of life and depression in cancer patients undergoing chemotherapy may be compounded by a number of factors such as gender, motivation status, and disease factors. Additionally, the results indicate an overall physical functioning decrease, implying that patients subject to PATP mostly benefited psychologically (6). Bozcuk and Oczan cede that because art is a subjective experience, it is possible that different forms of art therapy may affect different patients in different ways. Another study, conducted in 2021 at the Sant Pau Research Institute by Dr. Nadia Collete, set out to evaluate the benefits of art therapy intervention in adult cancer patients in a palliative care unit, a type of care that focuses on the reduction of symptoms rather than curative treatment. By evaluating the intensity of pain, anxiety, depression, and well-being before and after three trials consisting of 83 patients, it was revealed that the intermodal expressive art therapy intervention, consisting of both fine arts, as well as aspects of MBAT such as breath-based body awareness, was beneficial in reducing symptom intensity. In fact, compared to starting levels determined by Edmonton Symptom Assessment Scale (ESAS), pain intensity decreased by 54%, depression by 38%, anxiety by 48%, and overall distress by 35%. According to Collete et al., the perceived benefits of art therapy mostly consisted of the positive experience when making art, leading to relaxation, self-satisfaction, and the sentiment of being capable and active. Through mindfulness activities and the aesthetic interpretation of created art, participants described a deeper self-knowledge, a strengthening of identity, and a spiritual connection with their own creations, especially important for patients in hospice care. Since the patients in this study were under palliative care, they had a higher rate of improvement involving greater motor skills, social function, and autonomy due to the absence of chemotherapy-driven bodily stress (8). Out of the three studies discussed, Colette et al. displayed the most significant decreases in psychological and physical issues, supporting that the inclusion of MBAT activities is beneficial to cancer patients, even those not undergoing chemotherapy. Although traditional art therapy, such as PATP, has its merits in reducing psychological symptoms, the inclusion of MBAT compared to strictly using PATP in cancer patients represents an opportunity for patients to ameliorate pyschogically and physically more effectively. However, understanding the biological mechanism is necessary to determine the best therapy course for each patient.

Art Therapy and the Brain

While research suggests that incorporating mindfulness-based components into art therapy sessions is beneficial and increases the efficacy of reducing psychological and physical ailments, numerous studies indicate that

understanding the physiological effect of art therapy is crucial for the greater fine-tuning of treatments to determine where MBAT is most advantageous to use. Art therapy relies on a series of core tenets, including the corollary that different art media activate various brain regions. For instance, the amygdala, an area of the brain involved with experiencing emotions, is activated by less resistive media such as water-colors and clay. On the contrary, more resistive media (ie., pencils and rulers) affect the more cognitive areas of the brain including the frontal lobe. Neuroimaging can be used to prove the localized stimulation of the brain by different art media (8). In a 2017 study, Dr. Juliet King, professor of art therapy at George Washington University, worked with collaborators to measure cortical (cerebrum) activation patterns in subjects immediately following art making and rote motor tasks using electroencephalography (EEG) recordings. Ten consenting subjects underwent EEG recordings to establish a baseline value that was compared against EEG recordings taken after participation in art making and rote motor movement (coin tossing and pencil rotation). Ultimately, after performing a series of t-tests, the study displayed that in the left hemisphere, the increase in EEG power (a measure of the activity in a signal) was statistically significant from 4-32 Hz, and exceeded the threshold (0.045) for random variance from 6-16 Hz. Similarly, in the right hemisphere, the increase in power was statistically significant from 2-32 Hz exceeding the threshold from 6-16 Hz – the area of greatest difference between the baseline EEG and post-art-making value. While EEG power increased as a result of rote motor tasks as well, the increase in power seen after art making was greater quantitatively with increased mean differences. Furthermore, cortical activation changes in different frequencies (namely, Figure 1 Meditation is heavily incorporated into MBAT exercise, unlike traditional art therapy sessions. alpha, theta, and beta ranges) may provide insight into neurophysiological mechanisms and processing specific to those frequencies. For instance, a significant mean difference in the alpha region (8-12 Hz) displays the activation of the occipital region of the brain associated with relaxation. Theta frequency (4–7Hz) is associated with drowsiness, meditative states, and light stages of sleep. Beta frequency (12.5-30Hz) is associated with active thinking and concentration. Thus, the study displays an exploration of the relationship between frequency changes and neuro-physiological brain function, which is necessary in understanding how specific areas of the brain are activated during art-making and art therapy. This study contributes empirical evidence necessary for the scientific validation of art therapy, and strongly suggests that art therapy is not a placebo, but involves complex cognitive processes which lead to the apparent psychological and physical results (9). In another 2017 study, Dr. Girija Kaimal and her colleagues at Drexel University explored how coloring, doodling, and drawing affect brain activity using functional near-infrared spectroscopy (fNIRS) given the principle that visual self-expression helps with attention, health, and well-being. The study found that the three visual art tasks resulted in significant activation (measured by mean oxygenated hemoglobin of the medial prefrontal cortex) with a mean increase of 0.388 for coloring, 0.473 for free drawing, and 0.521 for doodling, all with statistically significant p-values after repeated ANOVA tests. In fact, Kaimal found that compared to a mean baseline value of 0.047, a doodling value of 0.521 corresponded to an approximately 1066% increase in brain activation, measured by blood oxygen in the brain using fNIRS. An important implication of this study is that art-therapy evokes reward pathways; even short spans of artistic activity greatly improve self-perceptions, offering a way to regulate mood and enhance pleasure. This finding corroborates the efficacy of art therapy on the perceived psychological and physical side effects of cancer diagnosis and chemotherapy (10). While Dr. King and Dr. Kaimal’s studies displayed that areas composing the cerebrum are heavily activated by art, a recent 2020 study conducted by Frances J. Griffith at Bowling Green State University utilized an activation likelihood estimation (ALE) meta-analysis to test, when drawing, whether specific brain regions were associated with expression at different levels of the expressive therapies continuum (ETC) – a model of creative functioning used by art therapists to describe and assess an individual’s level of creative functioning. Using neuroimaging and fNIRS, Griffith et al. analyzed two different drawing types: cognitive drawing (internally cued stimulus or objective content) and perceptual drawing (externally cued stimuli and non-objective content). The major findings illustrate that cognitive drawing is associated with prefrontal and cingulate cortex activation, perceptual drawing was associated with cerebellum, frontal, and parietal activation, with the dorsal visual stream being activated for both drawing types. Ultimately, the study suggests that rather than art therapy influencing specific and localized brain regions, larger brain networks are involved with tasks in art therapy and influence health outcomes in patients (11). All three studies analyzing the biological explanation for the high efficacy of art therapy conclude that increased understanding of brain processes and networks activated during art tasks enable art therapists to better understand why specific exercises are successful, and be better equipped to select effective art media. While clinical studies display that MBAT has improved betterment in both psychological and physical symptoms, the biological data demonstrates that certain art media are responsible for the activation of different brain networks, resulting in different sensations of pain reduction. While future research directly measuring brain activity during MBAT is necessary, current research conveys that to achieve maximal efficacy in treatment, the symptoms unique to each cancer patient must be first identified to determine specific areas of the brain to activate, which would determine the specific MBAT course needed.

Conclusion

Cancer is undoubtedly one of the most pressing medical challenges of the time, and while art therapies such as MBAT do not pose as a cure, the implementation of simple exercises involving a myriad of media activate areas of the brain, alleviating the effects of cancer diagnoses and chemotherapy. Today, art therapy continues to be heavily researched, as its implementation has the potential to be revolutionary in cancer treatment, representing an efficient, non-invasive, and inexpensive outlet to struggling patients. However, be-

Today, art therapy...has the fore clinical implementation, increased research on the conpotential to be revolutionary nection between MBAT and the brain is necessary to corin cancer treatment, roborate its reviewed efficacy and to determine any possible representing an efficient, non- harmful implications it may have. Nonetheless, art therapy invasive, and inexpensive epitomizes the interconnectedness of science and art and is outlet to struggling patients. tethered to the future of cancer treatment, remedying patients one brush stroke and breath at a time. References 1. C. Jarach, More than 50 percent rise in chemotherapy demand by 2040. Cancerworld, (2019). 2. About Art Therapy, The American Art Therapy Association, (2017). 3. C. Peterson, Mindfulness-based art therapy: applications for healing with cancer. Mindfulness and the Arts Therapies, (2014). 4. H. Bozcuk, et al., A comparative study of art therapy in cancer patients receiving chemotherapy and improvement in quality of life by watercolor painting. Complementary Therapies in Medicine 30, 67-72 (2017). doi: /10.1016/j.ctim.2016.11.006. 5. Z. Jalambadani and A. Borji, Effectiveness of mindfulness-based art therapy on healthy quality of life in women with breast cancer. Asia-Pacific Journal of Oncology Nursing 6, 193-197 (2019). doi: /10.4103/apjon.apjon_36_18. 6. N. Collete, et al., Art therapy in a palliative care unit: symptom relief and perceived helpfulness in patients and their relatives. Journal of Pain and Symptom Management 61, 103-111 (2021). doi: /10.1016/j.jpainsymman.2020.07.027. 7. C. Beans, Science and culture: searching for the science behind art therapy. Proceedings of the National Academy of Sciences of the United States of America 116, 707-710 (2019). doi: /10.1073/ pnas.1821297116. 8. J. King, et al., Cortical activity changes after art making and rote motor movement as measured by eeg: a preliminary study. Biomedical Journal of Scientific & Technical Research 1, 1-21 (2017). doi: 10.26717/BJSTR.2017.01.000366. 9. G. Kaimal, et al., Functional near-infrared spectroscopy assessment of reward perception based on visual self-expression: coloring, doodling, and free drawing. The Arts in Psychotherapy 55, 85-92 (2017). doi: /10.1016/j.aip.2017.05.004. 10. F. Griffith and V. Bingman, Drawing on the brain: an ale meta-analysis of functional brain activation during drawing. The Arts in Psychotherapy 71, 1 (2020). doi: /10.1016/j.aip.2020.101690. Image retrieved from: 1. https://pixabay.com/vectors/meditation-meditate-crossed-legs-303260/

Figure 2 Painting is commonly included in art therapy to treat the psychological and physical side effects of cancer diagnoses and chemotherapy.

Graphics Illustrated by Isra Ahmed `23