A Young adolescent with undiagnosed ADHD-inattentive presentation and co-morbid anxiety and depression: A case report.

This case report discusses a young adolescent with attention deficit hyperactivity disorder (ADHD) - inattentive presentation, and comorbid anxiety and depression that was not diagnosed until age 13. However, most ADHD is diagnosed before age 12. Anxiety and depression are common comorbidities of ADHD that present in primary care and can mimic the symptoms of ADHD. Due to the shortage of trained pediatric behavioral and mental health specialists, primary care pediatric nurse practitioners often diagnose and manage children and adolescents with ADHD and various comorbid conditions. It is essential to look for red flags in young children, especially in ADHD inattentive presentation, because symptoms are often masked and go unrecognized, undiagnosed, and untreated for years, resulting in academic and social problems causing the child and family stress, frustration, and reduced quality of life.

A Near Miss in the Emergency Department: Atypical Presentation of Acute Coronary Syndrome.

Acute coronary syndrome is an umbrella term encompassing three types of coronary artery disease that affect millions worldwide annually. Despite the availability of diagnostic tests (blood analysis, imaging, electrocardiogram, and screening tools), the diagnosis of myocardial infarction (MI) is still sometimes missed. According to the Centers for Disease Control and Prevention, the reported prevalence of heart disease is higher among males than females, with adults over the age of 75 having the highest prevalence. Typical "heart attack" features include chest pain that feels like pressure or squeezing, pain or discomfort in one or both arms that can radiate to the neck or jaw, shortness of breath, diaphoresis, nausea, vomiting, and lightheadedness. However, there are three subgroups where the typical warning signs do not always present: the elderly, individuals with diabetes, and females. The following is an atypical case presentation of unstable angina and non-ST-elevation MI.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation.

OBJECTIVE: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings. METHODS: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated. RESULTS: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care. CONCLUSIONS: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Priapism in a Young Adult With Sickle Cell Disease.

This article presents a case study focusing on priapism in a patient with sickle cell disease, with repeated emergency department (ED) visits and hospitalizations. The patient was successfully identified and treated by the ED nurse practitioner (NP) with aspiration of the corpus cavernosum. Priapism is a persistent penile erection that continues for an extended time. There is some argument about what that length of time is, but generally, the consensus is more than 4 hr beyond sexual stimulation or unrelated to sexual stimulation or sexual interest (Bivalacqua et al., 2022). Priapism is a fairly common but underrecognized complication of sickle cell disease. It represents a urological emergency in which timely diagnosis and appropriate treatment are vital to preserving penile tissue and sexual function. The diagnosis is made clinically with a comprehensive history, physical examination, and appropriate laboratory test values. Initial management can be conservative with hydration and analgesics or, if necessary, more invasive with needle aspiration to promote detumescence. Permanent tissue damage or erectile dysfunction can result if priapism is unrecognized, untreated, or not treated immediately. The NP plays an integral role in treating and preventing permanent damage. Patient education should focus on instructions for preventing priapism and managing episodes at home.

Analytical HDR prostate brachytherapy planning with automatic catheter and isotope selection.

BACKGROUND: High dose rate (HDR) brachytherapy is commonly used to treat prostate cancer. Existing HDR planning systems solve the dwell time problem for predetermined catheters and a single energy source. PURPOSE: Additional degrees of freedom can be obtained by relaxing the catheters' pre-designation and introducing more source types, and may have a dosimetric benefit, particularly in improving conformality to spare the urethra. This study presents a novel analytical approach to solving the corresponding HDR planning problem. METHODS: The catheter and dual-energy source selection problem was formulated as a constrained optimization problem with a non-convex group sparsity regularization. The optimization problem was solved using the fast-iterative shrinkage-thresholding algorithm (FISTA). Two isotopes were considered. The dose rates for the HDR 4140 Ytterbium (Yb-169) source and the Elekta Iridium (Ir-192) HDR Flexisource were modeled according to the TG-43U1 formalism and benchmarked accordingly. Twenty-two retrospective HDR prostate brachytherapy patients treated with Ir-192 were considered. An Ir-192 only (IRO), Yb-169 only (YBO), and dual-source (DS) plan with optimized catheter location was created for each patient with N catheters, where N is the number of catheters used in the clinically delivered plans. The DS plans jointly optimized Yb-169 and Ir-192 dwell times. All plans and the clinical plans were normalized to deliver a 15 Gy prescription (Rx) dose to 95% of the clinical treatment volume (CTV) and evaluated for the CTV D90%, V150%, and V200%, urethra D0.1cc and D1cc, bladder V75%, and rectum V75%. Dose-volume histograms (DVHs) were generated for each structure. RESULTS: The DS plans ubiquitously selected Ir-192 as the only treatment source. IRO outperformed YBO in organ at risk (OARs) OAR sparing, reducing the urethra D0.1cc and D1cc by 0.98% ( p = 2.22 ∗ 10 - 9 $p\ = \ 2.22*{10^{ - 9}}$ ) and 1.09% ( p = 1.22 ∗ 10 - 10 $p\ = \ 1.22*{10^{ - 10}}$ ) of the Rx dose, respectively, and reducing the bladder and rectum V75% by 0.09 ( p = 0.0023 $p\ = \ 0.0023$ ) and 0.13 cubic centimeters (cc) ( p = 0.033 $p\ = \ 0.033$ ), respectively. The YBO plans delivered a more homogenous dose to the CTV, with a smaller V150% and V200% by 3.20 ( p = 4.67 ∗ 10 - 10 $p\ = \ 4.67*{10^{ - 10}}$ ) and 1.91 cc ( p = 5.79 ∗ 10 - 10 $p\ = \ 5.79*{10^{ - 10}}$ ), respectively, and a lower CTV D90% by 0.49% ( p = 0.0056 $p\ = \ 0.0056$ ) of the prescription dose. The IRO plans reduce the urethral D1cc by 2.82% ( p = 1.38 ∗ 10 - 4 $p\ = \ 1.38*{10^{ - 4}}$ ) of the Rx dose compared to the clinical plans, at the cost of increased bladder and rectal V75% by 0.57 ( p = 0.0022 $p\ = \ 0.0022$ ) and 0.21 cc ( p = 0.019 $p\ = \ 0.019$ ), respectively, and increased CTV V150% by a mean of 1.46 cc ( p = 0.010 $p\ = \ 0.010$ ) and CTV D90% by an average of 1.40% of the Rx dose ( p = 8.80 ∗ 10 - 8 $p\ = \ 8.80*{10^{ - 8}}$ ). While these differences are statistically significant, the clinical differences between the plans are minimal. CONCLUSIONS: The proposed analytical HDR planning algorithm integrates catheter and isotope selection with dwell time optimization for varying clinical goals, including urethra sparing. The planning method can guide HDR implants and identify promising isotopes for specific HDR clinical goals, such as target conformality or OAR sparing.

Facemask and Rapid Maxillary Expansion With Alternative Rapid Maxillary Expansion and Constriction Protocol in the Management of Skeletal Class III Malocclusion.

The correction of skeletal class III malocclusions is one of the most difficult orthodontic treatments. Skeletal Class III malocclusion may result from a combination of maxillary deficits and mandibular prognathism, mandibular prognathism alone, or maxillary deficits alone. Treatment options include an orthopedic appliance (facemask and chin cup), orthodontics with camouflage, a combination of orthognathic surgery and orthodontics, and the recently introduced bone-anchored maxillary protraction. This case report describes the treatment of a young, growing patient with a retrognathic maxilla using Hyrax with an acrylic splint using the alternative rapid maxillary expansion and constriction protocol and a Petite type facemask.

Ureterolithiasis in Adolescents: A Case Report.

A 13-year-old patient presented to the emergency department with a history of abdominal pain and right flank pain. Two days before, she was evaluated at her pediatrician's office and was diagnosed with acute gastroenteritis and sent home. In the emergency department, the patient was diagnosed with ureterolithiasis after a physical examination, laboratory work, and imaging findings. She was treated successfully with conservative medical management. Symptomatic presentation of ureterolithiasis can include abdominal pain, flank pain, hematuria, dysuria, urgency, nausea, and vomiting. Nurse practitioners need to recognize nonspecific symptoms of ureterolithiasis for accurate diagnosis and treatment. Risk factors, signs and symptoms, prevention, and treatment options for ureterolithiasis are discussed.

Improving Telehealth Knowledge in Nurse Practitioner Training for Rural and Underserved Populations.

BACKGROUND: Telehealth is an emerging technology for the delivery of health care services. Providers need to be trained to maximize the potential benefits for rural and underserved populations. METHOD: A quality improvement approach to curricular redesign was used to integrate telehealth in a family nurse practitioner program. The intervention consisted of telehealth learning outcomes and a lecture-style presentation in a role transition course. A Plan-Do-Study-Act cycle informed faculty decision making in a small test of change. Self-reported confidence in telehealth knowledge was measured with a knowledge survey to determine whether the change was an improvement. RESULTS: Student confidence in telehealth knowledge increased following the intervention. The change provided an opportunity for faculty to consider additional approaches to integrating telehealth learning experiences in practicum courses. CONCLUSION: This project provided an improvement framework on which faculty can build and test effective pedagogical approaches to training graduate nursing students on the use of telehealth technology. [J Nurs Educ. 2019;58(1):57-60.].

Atypical or Incomplete Kawasaki Disease in a Young Child: A Case Report.

This case report describes an atypical or incomplete presentation of Kawasaki Disease. Kawasaki Disease is an inflammatory process that can affect all blood vessels and result in cardiac complications; particularly coronary artery aneurysms. Patients are typically young children, usually younger than 5 years of age, who initially present with a high fever and nonspecific rash. The child in this case presented with an atypical or incomplete presentation, and was diagnosed with Kawasaki disease after multiple provider encounters. Signs and symptoms of Kawasaki disease versus atypical or incomplete Kawasaki disease, differential diagnoses, and potential complications from Kawasaki disease are discussed in this case report.