Good-Enough Therapeutic Space Design: A Literature Review and Considerations for Expressive Arts Therapy

This thesis investigates the role of therapeutic space in expressive arts therapy through an interdisciplinary and international literature review. Definitions of therapeutic space and therapeutic space design are explored. This paper is theoretically grounded in the notion of good-enough therapeutic space, which is adapted from Winnicott’s (as cited in Davis & Wallbridge, 2004/1981) concept of a good-enough holding environment and Moskowitz-Corrois’s (2018) understanding of therapeutic space. Personal internship experiences of not-good-enough therapeutic space and a personal arts-based inquiry conceptualizing good-enough therapeutic space are discussed. Research from non-therapeutic and therapeutic settings, for both general and specific populations, are surveyed. The literature establishes the positive impact that therapeutic space design can have on the therapeutic relationship. A checklist of good-enough therapeutic space design considerations for the expressive arts therapist, inspired by Liddicoat (2018), is drafted and presented. These considerations are accessible, adaptable, and applicable to the expressive arts. The roles of the therapist and client in the design process, limitations of this paper, and directions for further research are identified

Tratamiento quirúrgico de las enfermedades de transición cervicotorácica

OBJETIVO: avaliar o resultado do tratamento cirúrgico de pacientes portadores de doenças na transição cervicotorácica da coluna vertebral. MÉTODOS: foram avaliados, retrospectivamente, 20 pacientes: nove (45%) apresentavam lesões traumáticas, sete (35%) lesões neoplásicas e quatro (20%) doenças degenerativas. No grupo de pacientes com lesões traumáticas, foi realizada fixação posterior em cinco deles (55,5%), fixação anterior em um (11,1%) e abordagem combinada (anterior e posterior) em três (33,3%). Dos sete pacientes com lesões tumorais, quatro (57,1%) foram submetidos ao tratamento cirúrgico pela abordagem combinada e três (42,8%) pela abordagem posterior isolada. No grupo de pacientes com doenças degenerativas da coluna vertebral, três (75%) foram tratados pela abordagem posterior e um (25%) de forma combinada. Todos os pacientes foram avaliados por meio de parâmetros clínicos (dor e déficit neurológico), radiológicos (manutenção da redução, soltura ou quebra dos implantes) e funcionais (SF-36, escala de dor e trabalho de Denis). RESULTADOS: os 20 pacientes foram seguidos por um período que variou de seis meses a 11 anos (média de 44,6 meses ± 29,02). Dos 13 pacientes que apresentavam déficit neurológico, oito apresentaram melhora do nível na escala de Frankel (61,5%) e cinco pacientes (38,4%) permaneceram com o quadro inalterado. Como complicações um paciente (5%) apresentou soltura do implante e quatro pacientes evoluíram com infecção pós-operatória (20%). Segundo as escalas de dor e trabalho de Denis, 80% dos pacientes apresentavam pouca ou nenhuma dor (P1 e P2) e 70% dos pacientes tinham retornado ao trabalho (W1, W2 e W3). Os pacientes que não apresentavam déficit neurológico (Frankel E) obtiveram escores mais altos de qualidade de vida pelo questionário SF-36, quando comparados aos escores dos pacientes que mantinham alterações neurológicas (Frankel A-D). CONCLUSÃO: o tratamento das doenças da transição cervicotorácica da coluna vertebral apresenta detalhes adicionais aos demais segmentos da coluna vertebral. Na vigência de tratamento cirúrgico, existem pontos a serem respeitados como a anatomia relacionada ao acesso cirúrgico, as características anatômicas peculiares das vértebras e a biomecânica singular desse segmento da coluna vertebral.OBJECTIVE: to assess the results of the surgical treatment of patients with disease in the cervicothoracic junction of the spine. METHODS: twenty patients were retrospectively evaluated. Nine patients (45%) had traumatic lesions, seven (35%) neoplasic lesions and four (20%) degenerative arthropathies. In the group of patients with traumatic lesions it has been accomplished the posterior fixation in five patients (55.5%), anterior fixation in one patient (11.1%) and the combined approach (anterior and posterior) in three patients (33.3%). In the seven patients with neoplasic lesions, four (57.1%) underwent to the surgical treatment through the combined approach and 3 (42.8%) through the posterior approach. In the group of patients with spinal degenerative disease, three (75%) were treated through the posterior approach and one (25%) in a combined way. The patients were evaluated on the basis of clinical (pain and neurological deficit), radiological (reduction maintenance and implant loosening or break) and functional parameters (SF-36, Denis scale of work and pain). RESULTS: twenty patients were followed-up for a period of time ranging from six months to 11 years (44.6 months ± 29.02). From 13 patients which presented neurological deficit, eight patients presented improvement in Frankel scale level (61.5%) and five patients (38.5%) remained with the same level. As complications, one patient (5%) presented implant loosening and four patients presented postoperative infection (20%). In pain and work assessment, 80% of the patients presented few or no pain (P1 and P2) through Denis scale of pain, and 70% of the patients had returned to work (W1, W2 and W3) through Denis scale of work. The patients without neurological deficit (Frankel E) presented higher scores of life quality through the SF-36 questionnaire compared to the patients who had neurological deficit (Frankel A-D). CONCLUSION: the treatment of the diseases of the cervicothoracic junction of the spine presents additional details compared to the others segments of the spine. The surgical treatment has aspects to be respected as the anatomy related to the surgical access, the peculiar anatomic characteristics of the vertebrae and the unique biomechanics of this spinal segment.OBJETIVO: evaluar el resultado del tratamiento quirúrgico de pacientes portadores de enfermedades de transición cervicotorácica de la columna vertebral. MÉTODOS: fueron retrospectivamente evaluados veinte pacientes. Nueve pacientes (45%) presentaron lesiones traumáticas, 7 (35%) lesiones neoplásicas y 4 enfermedades degenerativas (20%). En el grupo de pacientes con lesiones traumáticas fue realizada una fijación posterior en 5 pacientes (55.5%), una fijación anterior en 1 paciente (11,1%) y abordaje combinado (anterior y posterior) en 3 pacientes (33.3%). De los 7 pacientes con lesiones tumorales, cuatro (57.1%) fueron sometidos al tratamiento quirúrgico por abordaje combinado y 3 (42.8%) por abordaje posterior aislado. En el grupo de pacientes con enfermedades degenerativas de la columna vertebral, tres (75%) fueron tratados por abordaje posterior y uno de forma combinada (25%). Todos los pacientes fueron evaluados por medio de parámetros clínicos (dolor y déficit neurológico), radiológicos (mantenimiento de la reducción, soltura o quiebra de los implantes) y funcionales (SF-36, escala de dolor y trabajo de Denis). RESULTADOS: los veinte pacientes fueron seguidos por um periodo que varió de 6 meses a 11 años (promedio de 44.6 meses ± 29.02). De los 13 pacientes que presentaron déficit neurológico, ocho presentaron una mejora en el nivel de la escala de Frankel (61.5%) y cinco pacientes (38.4%) permanecieron con un cuadro inalterado. Como complicaciones un paciente (5%) presentó soltura del implante y cuatro pacientes evolucionaron con infección postoperatoria (20%). Según las escalas de dolor y el trabajo de Denis, el 80% de los pacientes presentaron poco o nada de dolor (P1 y P2) y el 70% de los pacientes regresaron al trabajo (W1, W2 y W3). Los pacientes que no presentaron déficit neurológico (Frankel E) tuvieron escores mas altos de calidad de vida por el cuestionario SF-36, cuando comparados con los pacientes con alteraciones neurológicas (Frankel A-D). CONCLUSIÓN: el tratamiento de las enfermedades de la transición cervicotorácica de la columna vertebral presenta detalles adicionales a los demás segmentos de la columna vertebral. En la vigencia al acceso quirúrgico existen puntos a ser respetados como la anatomía relacionada al acceso quirúrgico, las características anatómicas peculiares de las vértebras y biomecánica singular de ese segmento de la columna vertebral

Outcome of paediatric supracondylar humeral fractures treated by surgery at the University Teaching Hospital of Kigali, Rwanda

Background: Supracondylar humeral fractures are common elbow injuries in children. When these fractures are managed improperly, patients end up having complications that interfere with daily activities. Objective: This study was conducted to evaluate the functional outcome of supracondylar humeral fractures treated with surgery at the University Teaching Hospital of Kigali, Rwanda. Methodology: This was a combined retrospective and cross-sectional observational study. The sample size was 108. Theatre logs and OPD files were used to obtain patients' clinical information. Functional outcome was evaluated using QuickDASH score. Results: Children having 6 to 10 years of age were predominant (54.6%). Male to female ratio was 1.9:1. The left elbow was most affected (60.2%). Seventy five patients (69.4%) were within normal range, 27 (25.0%) patients had mild disability, 5 (4.7%) patients had moderate disability, and 1 (0.9%) patient had severe disability. There were no patients with very severe disability. The most common complication was elbow stiffness (59.3%), followed by gunstock deformity (27.1%). The only determinant of functional outcome found was the time (within 4 days or beyond) from injury to management (OR: 0.993, 95% CI: {0.987-1.000}, p-value: 0.048). Conclusion: For operable supracondylar humeral fractures in children, operation within 4 days and good follow up of patients in postoperative period are crucial for good functional outcome

Accidental organophosphate poisoning: A case series of 2 pediatric coumaphos exposures

IntroductionPediatric organophosphate insecticide poisonings are rare in the United States, and life-threatening toxicity is rarely seen. We report 2 accidental ingestions of the organophosphate insecticide coumaphos that resulted in life-threatening symptoms.Case reportsA 7-year-old boy and 10-year-old girl both presented from home after accidental ingestion of 1 "spoonful" of coumaphos 20% liquid (Asuntol; Bayer de Mexico, S.A. de C.V., Mexico D.F., Mexico). There were no other known ingestions. Both became rapidly symptomatic, with the boy developing dyspnea, vomiting, and depressed mental status and the girl developing headache and nausea. Soon afterward, the boy had witnessed cardiopulmonary arrest and the girl developed altered mental status and flaccid paralysis. Both were treated initially with atropine, but required no additional doses. On arrival to the pediatric intensive care unit (ICU), both patients received pralidoxime with subsequent plasma exchange and continuous venovenous hemodiafiltration (CVVHDF). Transient anemia, coagulopathy, transaminitis, and hyperglycemia developed in both patients. The girl was extubated on hospital day 6 and the boy on hospital day 11. The girl's course was complicated by aspiration pneumonia and an isolated seizure. The boy's course was complicated mainly by anoxic brain injury, associated seizures, neuroagitation, spasticity, and autonomic instability. The girl was discharged on hospital day 16 and remains asymptomatic 32 days after ingestion. As of 90 days after ingestion, the boy remains admitted to inpatient rehabilitation.DiscussionThe clinical benefit of pralidoxime, plasma exchange, and CVVHDF is uncertain in these cases. The optimal treatment regimen for organophosphate insecticide toxicity remains poorly defined

Telehealth Emergency Department Transition-of-care Program: A Value-based Innovation 

Introduction: Our Emergency Department (ED) and Population Health Services Organization developed a telehealth ED-transition of care program (TOC) for patients insured through value-based contracts. This study’s goal was to determine the association of our ED-TOC on ED revisits. We hypothesized that the ED-TOC would decrease ED revisits. Methods: This was a retrospective cohort study conducted between August 1, 2021 and July 31, 2023 at two EDs where an ED-TOC is available. Included were ED visits among discharged Medicare beneficiaries that occurred one year before and after the launch of the ED-TOC program.  ED visits involving Medicaid beneficiaries served as the control.  A difference-in-differences (DID) strategy was used to compare Medicare and Medicaid visits. The primary outcome measure was the association of the program with 14- and 30- day ED revisit rates. Secondary outcomes were the association of the ED-TOC with post-discharge PCP visits and hospitalizations and estimated cost-savings associated with the program. Results: Our sample size was 23,696 ED encounters (13,553 treatment group and 10,143 control group).  At 14-days after ED discharge, Medicare beneficiaries were associated with a 1.77% decrease in the rate of ED revisits in the year after the ED-TOC launch relative to the control (p=0.03) or a 15.8% reduction relative to baseline (11.2% to 9.4%).  At 14-days after ED discharge, PCP visits were associated with a 1.51% increase in the year after program launch relative to the control (p=0.03) or a 10.3% increase relative to baseline (14.6% to 16.1%).  No difference was associated with Medicare beneficiaries’ ED revisits or hospitalizations at 30-days. PCP visits were associated with a significant increase at 30-days (p=0.005). Conclusion: An ED-TOC is associated with a reduction in Medicare ED revisits during days 8-14 after an index ED visit but not during days 1-7 days or at 30-days.   Cost savings over a 24-week period are conservatively calculated to be $215,779