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Clinical Vignettes (clinical + vignette)
Selected AbstractsHypercalcemia and Overexpression of CYP27B1 in a Patient With Nephrogenic Systemic Fibrosis: Clinical Vignette and Literature Review,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 6 2009Vivian Y Pao Abstract Nephrogenic systemic fibrosis (NSF) is a disease of thickened, hard, hyperpigmented skin lesions with or without systemic fibrosis occurring in patients with renal insufficiency and associated with the administration of gadolinium-containing contrast. The pathogenesis of this disease is unclear, and there is no definitive treatment. We describe a 71-yr-old patient with stable chronic lymphocytic leukemia (CLL), end-stage renal disease (ESRD), and NSF who presented with hypercalcemia in 2006. Before onset of renal insufficiency in 2002, serum calcium, phosphorus, and PTH levels were normal. In 2004, the patient began hemodialysis, and he was diagnosed with NSF in 2005, shortly after undergoing an MRI with gadolinium contrast administration. Over the next 6 mo, albumin-corrected serum total calcium levels rose from 9.9 to 13.1 mg/dl (normal range, 8.5,10.5 mg/dl) with normal serum phosphorus levels. On admission in September 2006, 1,25-dihydroxyvitamin D [1,25(OH)2D] levels were elevated at 130.7 pg/ml (normal range, 25.1,66.1 pg/ml). Biopsy of an NSF lesion showed increased 25-hydroxyvitamin D3,1-, hydroxylase (CYP27B1) immunostaining compared with the biopsy from a normal control. This is the first reported association of NSF with hypercalcemia caused by elevated 1,25(OH)2D levels. This metabolic disturbance should be sought in future cases to determine a connection between NSF, 1,25(OH)2D metabolism, and CYP27B1 activation in the skin, which may shed light on the pathogenesis of this unusual local and systemic fibrosing disorder. [source] Clinical Vignette: Intraosseous Meningioma,A Mimicry of Paget's Disease?JOURNAL OF BONE AND MINERAL RESEARCH, Issue 6 2001Kandaswamy Jayaraj No abstract is available for this article. [source] THERAPY WITH LESBIAN AND GAY PARENTS AND THEIR CHILDRENJOURNAL OF MARITAL AND FAMILY THERAPY, Issue 4 2000Jane Ariel This article explores some of the social and clinical issues facing the many different kinds of gay and lesbian families that are becoming increasingly visible in the United States. Research findings are discussed that dispel popularly held myths and sterotypes concerning these families, gays and lesbians as parents, and their children. Clinical vignettes are presented to illustrate issues often encountered in the consulting room, some unique to gay and lesbian families and some common to all families. [source] Precocious puberty in Turner syndromeJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 11 2007Matthew A Sabin Abstract: Turner syndrome (TS) affects approximately 1 in 2000 liveborn girls. It is a common cause of short stature and is often, but not universally, associated with characteristic dysmorphic features and ovarian dysgenesis. Genotype/phenotype correlation in TS is generally poor and girls with TS may occasionally have normal functioning ovarian tissue, with approximately 30,40% entering puberty, 4% achieving menarche and 1% being fertile. In this report, we describe a girl with mosaic TS who unusually experienced spontaneous precocious puberty with associated accelerated longitudinal growth during mid childhood. This case acts as a useful clinical vignette with which to highlight important aspects of diagnosis and treatment in children with TS, particularly in relation to future growth potential and issues relating to fertility. [source] A survey of clinical productivity and current procedural terminology (CPT) coding patterns of pediatric hematologist/oncologistsPEDIATRIC BLOOD & CANCER, Issue 2 2004Timothy C. Griffin MD Abstract Background Subspecialty-specific normative values for clinical productivity of practicing pediatric hematologist/oncologists have not been well established. This information could be a useful adjunct in administrative decision-making in areas such as necessary levels of physician staffing and development of compensation plans. Methods Current procedural terminology (CPT) coding information was obtained from 27 pediatric hematology/oncology groups. Clinical productivity was assessed by overall number of patient encounters and the total number of physician work relative value units (RVU) as defined by the resource-based relative value scale. The average physician productivity within each individual program was calculated. To determine uniformity of CPT coding, an additional survey solicited mock patient encounter documentation and CPT coding for a simple clinical vignette. Results A broad range of clinical productivity was observed for both numbers of patient encounters and RVU. Evaluation of the CPT coding data of the surveyed groups revealed differences in usage of certain evaluation and management (E/M) codes and procedural and specimen interpretation codes. Within individual categories of E/M service codes, a wide variation in assigned CPT code levels was also observed. This observation was supported by differences in the E/M coding for the clinical vignette. Conclusions Assessment and tracking of physician productivity can provide useful information for the administrative management of pediatric hematology/oncology programs. Caution must be exercised, however, when making productivity comparisons with other subspecialties or even between pediatric hematology/oncology programs. Such comparisons should take into account the number of patient encounters, characteristics of E/M coding patterns, the use of physician extenders, as well as overall RVU production. © 2004 Wiley-Liss, Inc. [source] Analytic practice: Convergences and divergences,THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 2 2010Cláudio Laks Eizirik The author discusses current convergences and divergences concerning analytic practice. After presenting a clinical vignette that can be understood differently according to different theoretical approaches, he discusses Wallerstein's proposal of a common ground in psychoanalysis and suggests that the present state of the art indicates that psychoanalysis is a pluralistic discipline, with different ways of training and practising it, and that the main challenge is to improve our ability to listen to and to learn from different approaches. [source] Thinking in the space between Winnicott and LacanTHE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 5 2009Deborah Anna Luepnitz The author, following André Green, maintains that the two most original psychoanalytic thinkers since Freud were Donald Winnicott and Jacques Lacan. Winnicott, it has been said, introduced the comic tradition into psychoanalysis, while Lacan sustained Freud's tragic/ironic vision. Years of mutual avoidance by their followers (especially of Lacan by Anglophone clinicians) has arguably diminished understanding of the full spectrum of psychoanalytic thought. The author outlines some basic constructs of Winnicott and of Lacan, including: their organizing tropes of selfhood versus subjectivity, their views of the "mirror stage", and their definitions of the aims of treatment. While the ideas of Winnicott and Lacan appear at some points complementary, the goal is not to integrate them into one master discourse, but rather to bring their radically different paradigms into provocative contact. A clinical vignette is offered to demonstrate concepts from Lacan and Winnicott, illustrating what it might mean to think and teach in the potential space between them. [source] The mother in the text: Metapsychology and phantasy in the work of interpretation,THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 3 2008Fausto Petrella In this paper the author discusses some characteristics of a psychoanalytic text on the basis of two pages of Freud's essay, Delusions and dreams in Jensen's ,Gradiva' (Freud, 1906), on the concept of the return of the repressed. Analysis of the text shows that the four references (Horace, Rops, Rousseau, and a clinical vignette) occurring in it present unexpected connections both with each other and with the phenomenon they illustrate. There thus emerges a hidden scenario that reveals a concealed level of the text, relating to the maternal imago. Particular attention is devoted to the importance of the figurative apparatus and images (examples in the form of narrations and visual images, metaphors, and similes) that accompany the metapsychological and conceptual construction of Freud's text. Representation in visual form is necessary for the description and construction of the psyche and for conferring life on its conceptual formulations. However, metapsychological definition also reveals a phantasy dimension underlying the text. In addition, the author shows how certain textual constraints limit the intrinsic intuitive and arbitrary nature of interpretation. Finally, the complexity of the psychoanalytic text (with its various planes and levels) is emphasized, as well as the network of possible connections fundamental to the work of interpretation. A diagram illustrates the spatio-temporal aspects of the interpretive process, as defined by the interaction between conceptual factors and specific flights of the imagination which also have to do with unconscious affects, whether in the text, the author, or the reader. [source] Towards a theory of the integration of the Other in representationTHE JOURNAL OF ANALYTICAL PSYCHOLOGY, Issue 3 2005François Martin-Vallas Abstract:, In this article1, the author tries to uncover the elements of a theoretical model which would take into account the psychic transformations necessary to facilitate the emergence of representation. Toward this end, he firstly relies on Jung's notion of the archetype and Freud's idea of hallucinatory wish fulfilment, which he reconsiders in the light of the writings of Fordham (de-integration and re-integration of the primary self), and of Jean Laplanche (primary seduction), and linking it to the model based on chaos theory as developed in physics. He thus concludes that under the influence of primary seduction, the archetype is able to become a veritable, strange psychic attractor, enabling the determining factor of the instinctual axis of the archetype to open up to the possibility of symbolization, a necessary underlying feature for the occurrence of subjectivity. He ends his argument with a brief clinical vignette which illustrates the effect of openness to the psychic unknown constituted by primary seduction in the transference. [source] An evaluation of nursing practice models in the context of the severe acute respiratory syndrome epidemic in Hong Kong: a preliminary studyJOURNAL OF CLINICAL NURSING, Issue 6 2006Engle Angela Chan PhD Aim and objective., Like other health-care workers, Hong Kong nurses had their professional knowledge and skills seriously challenged during the SARS outbreak. Could current nursing practices support the care of SARS or SARS-like patients in the future? If not, alternative practices would be needed. Providing a preliminary understanding, this paper compares the conventional with different nursing delivery models in a simulated SARS ward and focuses on nurses' efficiency, infection control practices and views of the two models. Design and methods., This study was conducted in three phases. First, a baseline understanding of nursing practices was achieved through four workflow observations. In an eight-hour day, four research assistants observed nursing activities in the medical and fever wards. These data were used in the second phase to construct two sets of clinical vignettes, pertaining to SARS patient care in both conventional and alternative practice models. These scripts were discussed with nine nurses of various ranks from the hospital under study for their expert validation and input. In the third phase, nurse participants and patient actors enacted the vignettes in a simulated setting. Video-taped observations and four nurse participant interviews were employed. Observational data were analysed through descriptive statistics and independent t -tests. Textual data were coded and categorized for common meanings. Results., Conventional practice from the findings consisted of cubicle and named nurse nursing. While the former reflected modified team and functional nursing, it did not confine patient care within a cubicle as suggested by its name. The latter depicted a modified primary nursing approach in a team, with delegation of care. Preliminary findings concerning infection control and nurse satisfaction revealed that the alternative model had an advantage over the conventional. Relevance to clinical practice., This study findings lay the foundation for clinical trials, which would evaluate the significance of patient-care quality, cost-effectiveness and better human resource management by restructuring current nursing practices. [source] Activating the corrective emotional experienceJOURNAL OF CLINICAL PSYCHOLOGY, Issue 5 2006Michael R. Bridges Since the concept of the corrective emotional experience was first introduced, an impressive body of research has supported the contention that patient in-session processing of painful emotional conflicts within a safe and empathic relationship is necessary for therapeutic change. In this article, I summarize what we know about how emotions can be accessed, expressed, and processed within the therapeutic relationship to bring about a corrective emotional experience. I then provide clinical vignettes and data on three patients, all of whom displayed distinct patterns of arousal, experience, expression, and depth of processing that were differentially related to outcome in short-term emotion-focused therapy. © 2006 Wiley Periodicals, Inc. J Clin Psychol: In Session 62: 551,568, 2006. [source] Measuring physiotherapists' guideline adherence by means of clinical vignettes: a validation studyJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2006Geert M.J. Rutten MPH Abstract Rationale, aims and objectives, To assess the criterion validity of paper-and-pencil vignettes to assess guideline adherence by physiotherapists in the Netherlands. The evidence-based physiotherapy practice guideline for low back pain was used as an example. Methods, Four vignettes were constructed and pre-tested. Three vignettes were found to represent an adequate case-mix. They described one patient with specific low back pain, one with non-specific low back pain and a normal recovery process and one with non-specific low back pain and a delay in the recovery process. Invited to participate were 113 primary care physiotherapists who had joined an randomized controlled trial study 8 months before, in which guideline adherence had been measured by means of semi-structured treatment recording forms. The criterion validity was determined with Spearman's rs, using Cohen's classification for the behavioural sciences to categorize its effect size. Results, Of the 72 physiotherapists who agreed to participate, 39 completed the questions on the vignettes. In the end, both adherence measures were available for 34 participants, providing 102 vignettes and 268 recording forms. Mean guideline adherence scores were 57% (SD = 17) when measured by vignettes and 74% (SD = 15) when measured by recording forms. Spearman's rs was 0.31 (P = 0.036), which, according to Cohen's classification, is a medium effect size. Conclusion, Vignettes are of acceptable validity, and are an inexpensive and manageable instrument to measure guideline adherence among large groups of physiotherapists. Further validation studies could benefit from the use of standardized patients as a gold standard, a more diverse case mix to better reflect real physiotherapy practice, and the inclusion of longitudinal vignettes that cover the patients' course of treatment. [source] SYSTEMIC TRAUMATIC STRESS: THE COUPLE ADAPTATION TO TRAUMATIC STRESS MODELJOURNAL OF MARITAL AND FAMILY THERAPY, Issue 2 2005Briana S. Nelson Goff Research traditionally has focused on the development of symptoms in those who experienced trauma directly but overlooked the impact of trauma on the families of victims. In recent years, researchers and clinicians have begun to examine how individual exposure to traumatic stress affects the spouses/partners, children, and professional helpers of trauma survivors. However, empirically supported, theory-based literature that identifies the mechanisms by which interpersonal or "secondary trauma" occurs in response to traumatic events is limited. Here, we present the Couple Adaptation to Traumatic Stress Model, a systemic model of the development of interpersonal symptoms in the couple dyad based on empirical literature. Potential mechanisms and clinical vignettes are included to describe the systemic processes that occur with trauma couples. Areas for future research and clinical implications also are identified. [source] Leaps of faith: Is forgiveness a useful concept?THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 5 2008Henry F. Smith Using detailed clinical vignettes, the author argues that, despite the current idealization of the concept of forgiveness, the term has no place in psychoanalytic work, and there are some hazards to giving it one. Clinically, the concept of forgiveness is seductive, implying that there should be a common outcome to a variety of injuries, stemming from different situations and calling for different solutions. Every instance of what we call forgiveness can be seen to serve a different defensive function. While the conscious experience of what is called forgiveness is sometimes confused with the unconscious process of reparation, the two can only be described at different levels of psychic life. Despite the fact that in ,the unconscious' there is no such thing as forgiveness, the term has an adhesive quality in our thinking that also blunts the analyst''s appreciation of the aggressive components in the work. In a final vignette, the author illustrates an analytic outcome that has the appearance of forgiveness, but is best understood as the complex result of the everyday work of analysis. [source] The logic of turmoil: Some epistemological and clinical considerations on emotional experience and the infiniteTHE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 4 2008Pietro Bria The idea of the infinite has its origins in the very beginnings of western philosophy and was developed significantly by modern philosophers such as Galileo and Leibniz. Freud discovered the Unconscious which does not respect the laws of classical logic, flouting its fundamental principle of non-contradiction. This opened the way to a new epistemology in which classical logic coexists with an aberrant logic of infinite affects. Matte Blanco reorganized this Freudian revolution in logic and introduced the concept of bi-logic, which is an intermingling of symmetric and Aristotelic logics. The authors explore some epistemological and clinical aspects of the functioning of the deep unconscious where the emergence of infinity threatens to overwhelm the containing function of thought, connecting this topic to some of Bion's propositions. They then suggest that bodily experiences can be considered a prime source of the logic of turmoil, and link a psychoanalytic consideration of the infinite to the mind,body relation. Emotional catastrophe is seen both as a defect,a breakdown of the unfolding function which translates unconscious material into conscious experience,and as the consequence of affective bodily pressures. These pressures function in turn as symmetrizing or infinitizing operators. Two clinical vignettes are presented to exemplify the hypotheses. [source] On the edge: The psychoanalyst's transference,THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, Issue 5 2007Aira Laine Countertransference is a central topic in analytic work and in the literature. The concept of countertransference includes a basic question which has been understood in different ways. The author attempts to differentiate between the psychoanalyst's transference and his countertransference in the analytic process. It is hard to draw a line between them; analysts are always on the edge. The analyst's transference will be explored and described using three approaches: narcissism, regression profile and the analyst's phase of life. Regression profile is a new concept developed by the author, which may help us to understand the core of the analyst's transference in the analytic situation. She illustrates the topic by clinical vignettes. [source] OCNOPHILIA AND THE INTERPRETATION OF TRANSFERENCEBRITISH JOURNAL OF PSYCHOTHERAPY, Issue 4 2000Jackie Gerrard ABSTRACT This paper examines Balint's statements regarding ocnophilia and transference interpretations; namely his proposition that making transference inter pretations the over-riding focus of psychoanalytic technique encourages an ocnophilic way of being and relating in the patient. The author is not convinced that this is so and presents her argument, which is later illustrated with four clinical vignettes. [source] 15 Assessing the Clinical Reasoning Skills of Emergency Medicine Clerkship Students Using a Script Concordance TestACADEMIC EMERGENCY MEDICINE, Issue 2008Aloysius Humbert Fourth-year medical students in emergency medicine (EM) clerkships are evaluated by various methods. Multiple choice examinations are frequently used to supplement clinical evaluations. These are limited in their ability to evaluate students' clinical reasoning skills. The Script Concordance Test (SCT) is an innovative assessment method developed to evaluate clinical reasoning. The SCT consists of a series of clinical vignettes, each followed by a series of specific questions that present an additional piece of data (a lab result, a physical finding, etc.) to the student. The students then indicate how the additional data affect their thinking regarding a possible diagnosis, an investigational strategy, or a therapeutic intervention, using a 5 point Likert scale (-2,-1,0,+1,+2). SCT questions have no single correct answer; instead, students receive credit based upon the level of agreement between their answers and those of a panel of 10 to 20 expert physicians who take the test to derive the answer key. The SCT is easily administered. In other disciplines, the SCT has demonstrated the ability to differentiate between the clinical reasoning skills of experienced and novice clinicians. The clerkship directors developed an EM SCT using an expert panel of 10 EM attending physicians. For the 07-08 academic year, SCT questions have been incorporated into the EM clerkship end-of-rotation written examination. The EM SCT shows promise as a measure of a student's clinical reasoning ability. Future studies will assess in greater detail the performance and statistical properties of the SCT in the setting of the EM clerkship. [source] | |||||||||||||