Clinical Case Examples Research Articles

Interdisciplinary teams: A model to support students with autism

AbstractTo present interdisciplinary teams (IDTs) as foundational to effective assessment for students with autism spectrum disorder (ASD). This conceptual paper encourages IDTs by (a) presenting practice guidelines and research supporting effective IDTs; (b) describing vital team characteristics; (c) introducing a new model of teaming practices with a clinical case example; and (d) discussing IDT implementation barriers and recommendations specific to professionals supporting students with ASD. IDT members (e.g., school psychologists, teachers, behavior analysts, occupational therapists, speech‐language pathologists) should use assessment results to navigate goal‐setting and intervention planning allowing students with ASD to benefit from several therapeutic and educational approaches. Skilled professionals support a student's educational trajectory, increasing the likelihood of meeting developmental and academic milestones, and, ultimately leading to better life opportunities.

Spine Artery Dissection as Another Puzzle of Covid-19 (Clinical case)

The article is devoted to the analysis of a clinical case of the development of vertebral artery (PA) dissection and acute cerebrovascular accident in a young patient as a part of the clinical picture of COVID-19. Coronavirus disease 2019 (COVID-19) is a new infectious disease, the pathogenetic mechanisms and clinical manifestations of which are still being studied. One of the infrequent but potentially fatal complications of the disease is the development of thrombotic complications: the cause of which, in some cases, is the arteries dissection. Among the various prothrombotic conditions, dissection can be one of the many manifestations that increase the risk of stroke. The objective: to describe the interconnection between the new coronavirus disease and development of the prothrombotic states, in particular – spine artery dissection, at the example of the real clinical case. Materials and methods. The analyze of the modern scientific sources concerning thrombotic complications of COVID-19 and clinical case of the coronavirus disease debut with the vertebrobasilar ischemic stroke symptoms and vertebral artery dissection is given. Results. The results of a few observations published in the scientific medical literature about the relationship of acute SARSCov-2 infection with the development of dissection of the vertebral artery and acute ischemic brain damage are confirmed. Conclusion. SARS-CoV-2 increases risk of the thrombotic states development, in particular – strokes and arterial dissections, including patients of young age, and it is confirmed by the given clinical case and analyze of the scientific publications.

Technical Note: Break-even dose level for hypofractionated treatment schedules.

PurposeTo derive the isodose line R relative to the prescription dose below which irradiated normal tissue (NT) regions benefit from a hypofractionated schedule with an isoeffective dose to the tumor. To apply the formalism to clinical case examples.MethodsFrom the standard biologically effective dose (BED) equation based on the linear‐quadratic (LQ) model, the BED of an NT that receives a relative proportion r of the prescribed dose per fraction for a given α/β‐ratio of the tumor, (α/β)T, and NT, (α/β)NT, is derived for different treatment schedules while keeping the BED to the tumor constant. Based on this, the “break‐even” isodose line R is then derived. The BED of NT regions that receive doses below R decreases for more hypofractionated treatment schedules, and hence a lower risk for NT injury is predicted in these regions. To assess the impact of a linear behavior of BED for high doses per fraction (>6 Gy), we evaluated BED also using the LQ‐linear (LQ‐L) model.ResultsThe formalism provides the equations to derive the BED of an NT as function of dose per fraction for an isoeffective dose to the tumor and the corresponding break‐even isodose line R. For generic α/β‐ratios of (α/β)T = 10 Gy and (α/β)NT = 3 Gy and homogeneous dose in the target, R is 30%. R is doubling for stereotactic treatments for which tumor control correlates with the maximum dose of 100% instead of the encompassing isodose line of 50%. When using the LQ‐L model, the notion of a break‐even dose level R remains valid up to about 20 Gy per fraction for generic α/β‐ratios and DT=2(α/β).ConclusionsThe formalism may be used to estimate below which relative isodose line R there will be a differential sparing of NT when increasing hypofractionation. More generally, it allows to assess changes of the therapeutic index for sets of isoeffective treatment schedules at different relative dose levels compared to a reference schedule in a compact manner.

26.4 WHEN EXCESSIVE SCREEN HABITS BECOME A DISORDER AND HOW TO RESPOND

This session aims to: 1) provide a comprehensive review of internet gaming disorder and related electronic media use disorders; 2) explore the conditions that separate media use disorders from more universally experienced concerns about media use; and 3) review the research findings relevant to planning treatment of media use disorders. Clinicians, researchers, and families have long considered how the quantity and quality of media exposure affects child development and the human experience. An ongoing review of clinical reports and scientific studies provides a foundational basis for recognition and understanding of media use disorders. This program will integrate summary findings from a review of the literature with lessons learned through direct patient care at a clinic specializing in the assessment and treatment of adolescents with disordered media use. Clinical case examples will represent evidence-based principles for approaching diagnosis and treatment of media use disorders. Sufficient evidence exists to support the formal recognition of problematic interactive media use as a unique form of mental disorder. DSM-5 recognizes one common form of disordered media use with the inclusion of internet gaming disorder in the section on conditions requiring further research. Other identified forms of media use disorder have been described, including problematic use of social media, pornography, and information binging. A solid understanding of media use disorders enables accurate diagnosis of disordered media use. An updated knowledge of biopsychosocial risk factors, comorbidities, and sequelae of media use disorders informs the treatment-planning process. Problematic interactive media use represents a unique form of mental disorder resulting in substantial suffering, functional impairment, and risks. Clinicians must develop and maintain the ability to differentiate disordered media use from the mundane problems related to media use that are common throughout development. When a media use disorder is identified, the ability to effectively respond requires an up-to-date understanding of the condition and evidence-based treatment.

3.5 BALANCING RISK AND BENEFIT IN MANAGING IRRITABILITY AND AGITATION IN AUTISM SPECTRUM DISORDER

This presentation aims to provide a systematic approach to the assessment of irritability and agitation symptoms in autism spectrum disorder (ASD) and to review the existing evidence for effective (and ineffective) treatments for irritability and agitation in ASD, highlighting both potential benefits and risks. A practice pathway, developed by expert consensus, for the assessment and management of irritability and problem behavior, will provide the organizing framework for the discussion. Systematic reviews and meta-analyses will provide an overview of the literature, with supplementation from individual randomized controlled trials. Clinical case examples will be used to highlight key concepts in assessment and treatment. Irritability and agitation are common but nonspecific outcomes of multiple underlying areas of difficulty, from pain to family conflict to communication difficulties. It is therefore critical to systematically evaluate potential contributions from the medical, psychiatric, psychosocial, communication, and behavioral domains for the individual patient. This multimodal assessment approach, combined with a careful evaluation of the severity and risk of the problem behavior, guides a multidisciplinary treatment approach. With regard to psychopharmacology in particular, the evidence of benefit for a medication must be carefully balanced with the potential risk that must be actively managed. Vignettes from clinical practice demonstrate the choice points for the use of particular behavioral and medication treatments in the management of irritability and agitation. Careful evaluation of irritability, agitation, and accompanying aggression in ASD requires integrating information across domains and settings. A systematic approach to assessment allows the child and adolescent psychiatrist or allied professional to consider each domain and develop an initial formulation that can be refined by response to intervention. Successful treatment will likewise require collaboration across disciplines, ranging from the management of medical problems to improving communication tools to optimizing behavioral management. In the real world, we must all balance risk and benefit to appropriately manage irritability and agitation in ASD.

Diagnostic Errors of Spinal Cord Injuries in Children with Combined Trauma on the example of Clinical Cases

Diagnostic errors of spinal cord injuries with combined trauma in children are facilitated by the patient’s age, which does not allow foran adequate neurological assessment of motor and sensitive disorders, a reduced state of consciousness in severe traumatic brain injury,the lack of modern methods of neuroimaging in primary hospitals, insufficient qualifications and experience of medical personnel. Aim. To demonstrate outcomes of diagnostic errors in traumatic spinal cord injury in children on clinical examples of two patients. Material and methods. The object of observation was children with severe combined trauma, whose post-traumatic spinal cord injurywas missed in the primary hospital. To diagnose the current condition, the following were used: clinical examination with a neurologicalassessment on the ASIA scale, assessment of motor functioning, laboratory monitoring, instrumental examination, ultrasoundmonitoring, X-ray, MRI, CT, CT densitometry, ECG, echocardiography, USDG. In addition, neuropsychological assessment was made so to evaluate cortical functions and to reveal consequences of traumatic brain injury. Results. The cause of errors in the diagnostics of spinal cord injury in children is the underestimation of state severity due to the combinedtype of injury or small age of the child. Conclusion. The experience of the multidisciplinary team of specialists in the diagnosis and medical rehabilitation of children withspinal cord injury missed in the primary hospital indicates the need to conduct a full-fledged neurological examination, CT accordingto the “head to toe” program and MRI, even if there is a slight suspicion of the spinal cord damage.Underestimation of the severity of the child’s condition with concomitant trauma, including spinal cord injury, leads to the deprivationnot only in the motor function restoration, but also to deterioration in the quality of life of the family and to the problems associatedwith patient’s integration into society.

Integrating EMDR and EFT To Treat Trauma In Couple Therapy: A Literature Review

ABSTRACT In this paper, we present a literature review on integrating Eye Movement Desensitization and Reprocessing (EMDR) and Emotionally Focused Therapy (EFT) to treat trauma in couple therapy. Both are highly effective therapeutic models (one mainly used for individual trauma treatment and the other for strengthening attachment bonds in couples) that have gained significant traction and ample empirical support in the last three decades. Mental health therapists are increasingly experimenting with integrating these two models and have found that they can complement each other well; however, their integration is not well understood due to scant literature. Thus, we include research findings, clinical case examples, and theoretical discussions to provide readers with a comprehensive overview of the state of affairs on integrating these two models. We hope that this paper will highlight prior and existing practices and inspire clinicians to consider the clinical potential of integrating EFT and EMDR to increase effective therapy for couples affected by trauma.

Update in Autoimmune Movement Disorders: Newly Described Antigen Targets in Autoimmune and Paraneoplastic Cerebellar Ataxia.

Movement disorders are a common feature of many antibody-associated neurological disorders. In fact, cerebellar ataxia is one of the most common manifestations of autoimmune neurological diseases. Some of the first autoantibodies identified against antigen targets include anti-neuronal nuclear antibody type 1 (ANNA-1 or anti-Hu) and Purkinje cell cytoplasmic antibody (PCA-1) also known as anti-Yo have been identified in paraneoplastic cerebellar degeneration. Historically these antibodies have been associated with an underlying malignancy; however, recently discovered antibodies can occur in the absence of cancer as well, resulting in the clinical syndrome of autoimmune cerebellar ataxia. The pace of discovery of new antibodies associated with autoimmune or paraneoplastic cerebellar ataxia has increased rapidly over the last few years, and pathogenesis and potential treatment options remains to be explored. Here we will review the literature on recently discovered antibodies associated with autoimmune and paraneoplastic cerebellar ataxia including adaptor protein-3B2 (AP3B2); inositol 1,4,5-trisphophate receptor type 1 (ITPR1); tripartite motif-containing (TRIM) proteins 9, 67, and 46; neurochondrin; neuronal intermediate filament light chain (NIF); septin 5; metabotropic glutamate receptor 2 (mGluR2); seizure-related 6 homolog like 2 (SEZ6L2) and homer-3 antibodies. We will review their clinical characteristics, imaging and CSF findings and treatment response. In addition, we will discuss two clinical case examples of autoimmune cerebellar ataxia.

Management of a patient diagnosed with ovarian cancer during pregnancy

Insufficient diagnosis of ovarian tumors during pregnancy and decreased oncological alertness constitute huge problems that can subsequently have an unfavorable outcome for both the pregnant woman and the fetus. The difficulties of diagnosing and treating ovarian cancer during pregnancy were demonstrated on the following clinical case example. In pregnant patient A. at 19-20 weeks of pregnancy, a lesion was found in the area of the right appendages (100.9 55.4 93.4 mm, V = 273 cm3), with many tissue partitions and parietal tissue inclusions. The growth of the neoplasm was noted (CA-125 884 U / ml) and the pain syndrome occurred in the patient at 23-24 weeks of pregnancy. Magnetic resonance imaging revealed a solid-cystic neoplasm of the right ovary (cystadenoma?) and surgery was performed in November 2019. Based on the results of histological examination, a high-grade serous ovarian cancer was diagnosed without signs of microsatellite instability MSI-H/dMMR (in the right ovary, in the biopsy of the left fallopian tube). The patient. received two cycles of polychemotherapy (TC scheme). The treatment was tolerated satisfactorily (CA-125 287.3 U / ml). At a gestational age of 34 6/7 weeks (January 2020), a simultaneous operation was performed, including a lower midline laparotomy, a lower uterine segment caesarean section, extirpation of the uterus with appendages, and an omentectomy. A boy was born (weight 2280 g, height 44 cm) with the Apgar score of 7/7 points, with no complications noticed in the postpartum period. Postoperative histological examination showed metastasis of carcinoma in the left ovary with signs of therapeutic pathomorphosis. The treatment was completed in March 2020 after six cycles of polychemotherapy.

ОДНОСТОРОННЯЯ МОШОНОЧНАЯ ГРЫЖА С ГЕРНИАЦИЕЙ УДВОЕННОГО МОЧЕТОЧНИКА: ПЕРВЫЙ ОПЫТ УСПЕШНОЙ ХИРУРГИЧЕСКОЙ КОРРЕКЦИИ

Objective of the study: the purpose of the research, based on the example of a specific clinical case, is to draw the attention of specialists to a specific approach to the diagnosis and treatment of the inguinal hernia with atypical contents. A rare, unpublished in the Slovak Republic, observation of the left-sided scrotum hernia with dual ureter herniation in combination with congenital kidney pathology in a 3-month-old boy is presented. The diagnosis was based on physical examination, ultrasound examination, radiography, scintigraphy, and urethrocystoscopy. This anomaly has been successfully corrected through several successive phases of the operation. Conclusion: the combination of scrotal hernia and congenital renal anomaly may indirectly indicate a possible hernia in the distal part of the ureter and requires a thorough examination, including additional imaging methods.

Intermediate Alpha-1 Antitrypsin Deficiency Can Play a Role in Pulmonary Exacerbation?

Background: Alpha-1 antitrypsin deficiency is generally suspected in young patients with pulmonary emphysema or chronic obstructive pulmonary disease (COPD). Patients often suffer from diagnostic delays or are misdiagnosed, for example, with COPD, asthma, or airway hyperresponsiveness because of the nonspecific nature of respiratory symptoms recognised with Alpha-1 antitrypsin deficiency (AATD). These pathologies develop in homozygous patients (both compromised alleles) with severely deficient protein; however, they are also frequently observed in heterozygous patients (only one compromised allele) for the gene mutation with a more or less deficient protein and functional anatomical damage of varying severity depending on the type of mutation and the exposure to environmental risk factors and/or professional that can trigger the repeated injurious inflammatory process. Case Description: We describe two cases of late diagnosis of alpha-1 antitrypsin deficiency, with many exacerbations and intermediate level of alpha-1 antitrypsin. Due to the peculiar clinical history, and the PLowell rare mutation, although intermediate AATD, the patients were subjected to replacement therapy and they obtained clinical improvement. Discussion: Both the cases carried a heterozygous PLowell mutation representing two interesting and rare examples of clinical cases with double heterozygosity. The presence in the other AAT allele of the S-mutation in the first case and a concomitant presence of another mutation in the cystic fibrosis gene in the second case contributed to the protease-antiprotease imbalance and, despite intermediate AATD, was the probable cause of the numerous exacerbations. Conclusion: Alpha-1 antitrypsin deficiency should always be suspected in patients with respiratory disease and an unclear or complex clinical history. It may be useful to recognize and evaluate treatment even outside the established parameters, in selected cases.

Manual medicine, manual treatment : Principles, mode of action, indications and evidence

Manuelle Medizin ist die medizinische Disziplin, die sich umfassend mit Diagnose, Therapie und Prävention reversibler Funktionsstörungen am Bewegungsorgan und anderen damit verbundenen Organsystemen befasst. Der Beitrag beleuchtet neuroanatomische und -physiologische Grundelemente der Wirkungsweisen manualmedizinischer Diagnostik und Therapie. Anhand neuester Literatur und Betrachtung verschiedener wissenschaftlicher Leitlinien wird die evidenzbasierte Wirksamkeit manualmedizinischer Verfahren dargestellt, im Einzelnen: akute und chronische Lumbalgie, zervikogener Kopfschmerz, Schulter- und Nackenschmerzen, radikulärer Armschmerz, dysfunktionelle thorakale Schmerzsyndrome, Erkrankungen der Rotatorenmanschette, Karpaltunnelsyndrom und Plantarfasziitis. Fallbeispiele veranschaulichen die klinische Vorgehensweise. Die Begrifflichkeit, die Provenienz und die klinische Präsenz der „Osteopathie“ werden ausführlich gewürdigt, und die nationalen und internationalen Vereinigungen und Gesellschaften der manuellen Medizin (Deutsche Gesellschaft für Manuelle Medizin [DGMM], European Scientific Society of Manual Medicine [ESSOMM], Fédération Internationale de Medicine Manuelle [FIMM]) werden lexikalisch dargestellt. Abschließend finden sich Kontraindikationen und ein Ausblick auf die Erfordernisse und Möglichkeiten der wissenschaftlichen Schmerzanalyse, wie sie in der Präambel der Leitlinie „Spezifischer Kreuzschmerz“ der Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC) postuliert werden.

Clinical case of aggressive malignant neoplasm of the upper jaw

The article discusses the issues of diagnosis and treatment of malignant tumors of the maxillofacial region on the example of a rare clinical case of aggressive malignant neoplasm of the upper jaw.

Supporting Romantic Relationships During COVID-19 Using Virtual Couple Therapy

The novel coronavirus disease pandemic (COVID-19) has profoundly impacted people’s lives, resulting in economic turmoil, death and suffering, and drastic changes to everyday life. The adjustment and strain of such challenges can spill over into couples’ relationship processes, including how partners spend time together, talk to one another, and manage conflict. Drawing from our experiences conducting virtual couple therapy (VCT) in a university-based training clinic and community-based clinic, as well as themes from an informal survey of 29 couple therapy clinicians, the current paper discusses the unique challenges that couples face in therapy during COVID-19. Such challenges include renegotiating quality time together, navigating less personal space and time alone, experiencing individual anxiety and stress prompted by the pandemic, and increases in conflict. We discuss our clinical recommendations for addressing these challenges for couples and utilize clinical case examples to illustrate our points. Despite these challenges, we also comment on several positive aspects of COVID-19 on couple relationships. Guided by these considerations and recommendations, our observations suggest that clinicians can effectively support couples’ growth and progress using VCT during COVID-19.

Understanding the Impact of Hypertension on Left Ventricular Assist Device Pump Function and Thrombotic Risk.

Understanding the Impact of Hypertension on Left Ventricular Assist Device Pump Function and Thrombotic Risk.

Marriages and remarriages: different stages of a dating relationship

Through a close exploration of a clinical case example, the authors intend to explore mutual frustrations inherent in the disruption of a marital relationship and how the illusions the couple deposited in it are reflected in a remarriage. The first marriage lived as a personal failure or defeat affects the establishment of the roles occupied in the second marriage, especially when the second marriage seeks to magically erase its predecessor.

Challenges in Providing Care for Parents of Transgender Youth during the Coronavirus Pandemic

ABSTRACT The COVID-19 pandemic has been stressful for many, increasing levels of anxiety, depression and other mental health concerns worldwide. With the spread of the virus, many youth found themselves physically isolated from their peers and confined to their homes, and medical and mental health services previously provided in person had to adapt by providing virtual sessions. The transition to virtual care created many new challenges for clinicians and patients, including some specific to transgender youth and their families. Pre-pandemic, transgender youth comprised a marginalized and vulnerable population, with elevated risk for adverse mental health outcomes. However, community support, strong group identification and family affirmation can serve as important mitigating factors. In this paper, we will discuss unique challenges encountered in working with the parents and caregivers of transgender youth during virtual visits that have the potential to interfere with development of a therapeutic alliance and the movement toward increased family acceptance. We will provide clinical case examples and propose methods through which to address difficulties and improve care.

Commentary: Rupture repair as a transtheoretical corrective experience.

This commentary highlights common principles shared across the diverse clinical case examples featured in this In Session issue on Rupture Repair in Practice. We discuss the importance of therapists recognizing subtle signs of rupture and responding to ruptures with curiosity and compassion. We also consider how therapists can use repair strategies responsively to facilitate a corrective experience for the patient. We explore the ways in which the specific resolution strategy of linking a rupture to larger interpersonal patterns can benefit the therapeutic process, and the ways in which it can constitute a form of avoidance. We conclude by noting promising future directions and celebrating the generosity evidenced by these insightful authors' willingness to share and explore challenging moments in therapy.

Bosniak classification of cystic renal masses, version 2019: interpretation pitfalls and recommendations to avoid misclassification.

The purpose of this review is to describe the potential sources of variability or discrepancy in interpretation of cystic renal masses under the Bosniak v2019 classification system. Strategies to avoid these pitfalls and clinical examples of diagnostic approaches are also presented. Potential pitfalls in the application of Bosniak v2019 are divided into three categories: interpretative, technical, and mass related. An organized, comprehensive review of possible discrepancies in interpreting Bosniak v2019 cystic masses is presented with pictorial examples of difficult clinical cases and proposed solutions. The scheme provided can guide readers to consistent, precise application of the classification system. Radiologists should be aware of the possible sources of misinterpretation of cystic renal masses when applying Bosniak v2019. Knowing which features and types of cystic masses are prone to interpretive errors, in addition to the inherent trade-offs between the CT and MR techniques used to characterize them, can help radiologists avoid these pitfalls.

Reading Comprehension in School-Age Children With Autism Spectrum Disorder: Examining the Many Components That May Contribute.

Purpose Reading comprehension is consistently poor in many school-age children with autism spectrum disorder (ASD). The purpose of this tutorial is to provide an overview from a multicomponent view on the many predictors that may contribute to reading comprehension difficulties in ASD. Method This tutorial reviews current literature on profiles and predictors of reading comprehension in ASD. The review is situated from a multicomponent theoretical view based on the "direct and indirect effects of reading" model that builds on the familiar "simple view of reading." Each component, including word reading, listening comprehension, morphosyntax, vocabulary, working memory, comprehension monitoring, inferencing, and theory of mind, is separately reviewed, with consideration of the current evidence for their contribution to reading comprehension in ASD. At the end of each section, key takeaways are provided. To conclude, a summary with general clinical implications, case examples, and recommendations for future research across all components is offered. Conclusions Reading comprehension in ASD may be affected by any one or several components in any given individual. Speech-language pathologists have expertise and play a critical role in assessing and intervening on these components. The age and language status (language impaired or not) of a child are emerging as important factors for what to assess and consider for intervention. However, more research is needed that intentionally examines language status, evaluates reading comprehension at targeted ages or narrower age ranges, and/or examines language and reading development longitudinally.