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As the number of high-conflict separation cases continues to rise, mental health counselors are increasingly called upon to assist courts with child custody evaluations. Counselors can provide family courts with [...]

Mental health counselors encounter numerous complex situations when working with children and adolescents in anger management groups. This study promotes the use of Social Cognitive Theory to reduce cognitive distortions [...]

In the past 30 years high-conflict families seeking resolution of child custody disputes have inundated family courts. Custody-related evaluations conducted by mental health counselors provide family courts with a thorough [...]

To determine whether N-acetylcysteine rinse was safe and could improve thickened secretions and dry mouth during and after radiotherapy.

Background Endoscopic endonasal resection (EER) of sinonasal mucosal melanoma (SMM) is a newer surgical alternative to traditional external and/or open resection (OR). Studies on long-term outcomes are necessary to validate EER for this aggressive sinonasal malignancy.Objective To compare outcomes of EER versus OR in SMM.Methods A case series of patients who underwent surgical resection of SMM at a tertiary-care institution (2000–2015) was studied retrospectively. Demographics, tumor site and stage, surgical approach, surgical margin status, local control, and survival were compared between those who underwent EER and OR.Results Twenty-two patients met inclusion criteria. Nine underwent EER and 13 underwent OR. The mean age in the EER and OR groups was similar, 78.7 and 72.3 years, respectively. Two-thirds of patients were women (EER, 66.7%; OR, 61.5%). The nasal cavity was the most common primary tumor site (EER, 77.8%; OR, 84.6%). The local tumor stage in both groups was similar, with the majority of cases being T4 (EER, 55.6%; OR, 61.5%; p = 0.99). Negative margins were achieved in all EERs and in 69.2% of ORs. Median follow-up was 25.0 months for the overall group (range, 1.7–172.9 months), 32.6 months (range, 3.4–58.7 months) for EER and 14.1 months (range, 1.7–172.9 months) for OR cohorts. The 5-year overall survival was statistically similar in both groups (EER, 53.3%; OR, 22.7%; p = 0.214) as was disease-free survival (EER, 55.6%; OR, 22.8%; p = 0.178). Local control, however, was significantly higher in the EER cohort (EER, 85.7%; OR, 37.6%; p = 0.026).Conclusion In carefully selected patients with sinonasal melanoma, endoscopic surgery with an experienced team may offer comparable survival and improved local control over open surgery. Prospective, multicentered studies with larger cohorts are needed to validate these results.

Purpose: To report the outcomes of patients with favorable risk oropharyngeal cancer that underwent adjuvant radiation therapy with omission of the primary site from the clinical target volume (CTV).Material/Methods: A retrospective study of 40 patients treated with transoral surgery (TOS) followed by neck only radiation using intensity modulated radiation therapy (IMRT) with exclusion of the primary site. For all patients, a CTV of the primary surgical bed was contoured to obtain the estimated incidental dose to the primary site.Results: Median follow-up was 51 months (range, 13-155 months). The median radiation therapy (RT) dose to the neck was 6000 cGy (range, 5400-6400 cGy). The mean incidental dose to the primary tonsillar site was 4320 cGy (SD ± 480 cGy) and to the primary base of tongue site was 4060 cGy (SD ± 420 cGy). There were no local failures and only 1 regional failure, resulting in 97.5% locoregional control rate at 4 years. Two patients developed distant metastases, without evidence of locoregional recurrence, for a 4-year overall survival rate of 97%.Conclusions: Our analysis suggests that mucosal sparing RT after TOS in favorable risk oropharyngeal cancer patients may provide comparable oncologic and improved functional outcomes compared to conventional treatment in selected patients.

Objective: To report a single institutional series of high-grade neuroendocrine carcinoma of the larynx (NCL), a very rare yet aggressive tumor. To review the management of NCL, including discussion of clinical behavior, treatment outcome, and prognosis.Method: A retrospective chart review of high-grade laryngeal neuroendocrine carcinomas at a single institution, including small- and large-cell neuroendocrine carcinomas. A total of 8 patients with high-grade NCL treated at our institution from 1992 to 2014 were identified.Results: The median age at diagnosis was 65.5 years (range, 43-80). Five patients were male. Two patients had a known smoking history. Primary tumor location was supraglottic in 7 patients and glottic in 1 patient. Primary treatment consisted of surgery alone (3 patients), radiotherapy alone (1 patient), combination of chemotherapy and radiotherapy (1 patient), and surgery followed by postoperative chemoradiotherapy (3 patients). Locoregional recurrence followed by distant metastasis occurred in 6 patients. Median overall survival was 44.0 months (95% CI, 3-62.0).Conclusion: High-grade NCL is a rare diagnosis. Compared to well- and moderately differentiated NCL, high-grade NCL has a far more aggressive clinical course and associated with a worse prognosis. To our knowledge, this is the largest series of patients with high-grade NCL treated at a single institution. Prompt diagnosis and multimodality therapy including elective neck dissection may improve survival.

IMPORTANCE: The etiology and optimal treatment are unknown for angiosarcoma, an aggressive malignant tumor that affects vascular endothelial cells and can be mistaken for benign lesions such as hemangioma. OBJECTIVE: To determine the treatment outcomes of patients with angiosarcoma of the face or scalp treated with a combination of surgery, radiation therapy, and/or chemotherapy. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of 55 patients with angiosarcoma of the face or scalp treated between January 1, 1973, and December 31, 2012, at a tertiary-care academic medical institution. INTERVENTIONS: Surgery, radiation therapy, and/or chemotherapy. MAIN OUTCOMES AND MEASURES: Locoregional control (LRC), recurrence-free survival (RFS), and overall survival (OS). RESULTS: Fifty-five patients had angiosarcoma localized to the face or scalp. Forty of these patients (73%) received a combination of surgery, radiation therapy, and/or chemotherapy. Eight patients (15%) were treated with surgery alone, 1 (2%) with radiation alone, 5 (9%) with chemotherapy alone, and 1 (2%) with observation alone. Median (range) follow-up for surviving patients was 25.2 (4.7-227.1) months. Five-year LRC, RFS, and OS (95% CI) were 18% (7%-32%), 16% (6%-31%), and 38% (21%-54%), respectively. Of 36 patients with failed treatment, 34 had failure in a local and/or regional site. On univariate analysis, the use of multimodality therapy (vs no multimodality therapy) was associated with higher 5-year LRC (95% CI) (20% [3%-37%] vs 11% [0%-29%]; P = .04), higher RFS (19% [2%-36%] vs 10% [0%-27%]; P = .02), and higher OS (46% [26%-66%] vs 16% [0%-43%]; P = .04). Age 70 years or older (vs <70 years) was associated with lower 5-year LRC (95% CI) (5% [0%-14%] vs 48% [23%-74%]; P = .02) and lower RFS (5% [0%-13%] vs 49% [24%-75%]; P = .04). Radiation therapy (vs no radiation therapy) was associated with higher 5-year LRC (95% CI) (20% [3%-36%] vs 12% [0%-32%]; P = .02) and higher RFS (19% [2%-35%] vs 12% [0%-31%]; P = .004). On multivariable analysis, age younger than 70 years (vs ≥70 years) was associated with improved 5-year LRC (95% CI) (48% [23%-74%] vs 5% [0%-14%]; P = .03) and RFS (49% [24%-75%] vs 49% [24%-75%]; P = .04). CONCLUSIONS AND RELEVANCE: Multimodality therapy for angiosarcoma is associated with improved LRC, RFS, and OS. Younger patients with resectable disease undergoing multimodality therapy for angiosarcoma had the best clinical outcomes.

Successful management strategies are important for conservation and allow accurate surveying and monitoring of populations for presence, abundance, and trend. This becomes challenging for cryptic, low‐density species, and for animals that have complicated life histories where not every stage of the life cycle can be surveyed effectively. We used information from animal‐borne data loggers to characterize the dive‐surfacing behavior of cryptic loggerhead turtles (Caretta caretta) in the northwest Atlantic from 2009–2018. Our data covered a large geographic area off the east coast of North America, and allowed us to present estimates for and variation in 3 metrics that can be used to assess availability bias affecting visual surveys: average dive duration, average surface duration, and the proportion of time at the surface. We used a stochastic partial differential equation approach to construct spatiotemporal regression models for the availability bias metrics. Model predictions showed pronounced individual, spatial, and spatiotemporal (seasonal) variation among the 245 turtles. Overall, we estimated an average dive duration of 14.5 ± 1.36 minutes (SE), an average surface duration of 15.1 ± 2.77 minutes, and an average proportion of time at the surface of 0.50 (95% CI = 0.41–0.59). We made predictions of the 3 availability bias metrics on a 20‐km × 20‐km grid and further used predictions to explore seasonal variations. Our results contribute new insights into loggerhead turtle behavior and provide information that enables survey counts to be translated into more accurate abundance estimates. An important consideration in developing abundance estimates from line‐transect surveys is availability bias, where availability is the probability an animal is available for detection by the survey platform. Using spatiotemporal regression models and satellite tags, dive‐surfacing behavior was characterized to improve our understanding of vertical habitat use and to develop metrics of availability bias that can be used to improve population estimates of loggerhead turtles in the northwest Atlantic.

Multiple options for retreatment are available, which include whole-brain radiation therapy, stereotactic radiosurgery, surgery, chemotherapy, and supportive care. Size, number, timing, location, histology, performance status, and extracranial disease status all need to be carefully considered when choosing a treatment modality. There are no randomized trials examining the retreatment of brain metastases. Repeat whole-brain radiation has been examined in a single-institution experience, showing the potential for clinical responses in selected patients. Local control rates as high as 91 using stereotactic radiosurgery for relapses after whole-brain radiation are reported. Surgery can be indicated in progressive andor hemorrhagic lesions causing mass effect. The role of chemotherapy in the recurrent setting is limited but some agents may have activity on the basis of experiences on a smaller scale. Supportive care continues to be an important option, especially in those with a poor prognosis. Follow-up for brain metastases patients is discussed, examining the modality, frequency of imaging, and imaging options in differentiating treatment effect from recurrence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of the current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Juvenile sex offenders (JSOs) often appear unmotivated to change, which thus necessitates a therapeutic approach that matches “resistant” client characteristics. In this article, the authors review common traits of JSOs, introduce motivational counseling as an effective treatment modality, and offer a case illustration.

Malignant melanoma of the lacrimal sac is an exceptionally rare tumor with a poor prognosis. We report two cases of malignant melanoma of the lacrimal sac: a 73 year-old female treated with primary surgical resection and a 75 year-old male treated with surgical resection, adjuvant proton beam radiotherapy, and adjuvant immunotherapy. We discuss the role of post-operative proton beam therapy and recent advancements in immunotherapy. These cases highlight the importance of early diagnosis and multi-modality treatment in this aggressive malignancy.

Many American Indian (AI) and Alaska native (AN) patients do not complete guideline-concordant cancer care for the 4 most common cancers. Our aim was to better understand AI/AN attitudes toward radiation therapy (RT). Patients eligible for this survey study were AI/AN patients with cancer at the Phoenix Indian Medical Center who either received previous RT or were recommended to receive RT. An 18-item questionnaire was administered to each of the 50 participants from October 1, 2018, through February 15, 2019. Willingness to travel for RT was compared to respondent characteristics, concerns regarding RT, and obstacles to obtain RT. Duration of RT was important to 78% of patients: 24% would consider traveling 25 miles or more for a standard course, and 48% would travel that distance for a shorter course (P< .001). The top-ranked barriers to RT were transportation, cost of treatment, and insurance compatibility. The top-ranked concerns about RT were adverse effects, cost of treatment, and fear of RT. Concerns about adverse effects were associated with the radiation team’s inability to explain the treatment (P= .05). Transportation concerns were significantly associated with accessibility (P= .02), communication with the RT team (P= .02), and fear of RT (P= .04). AI/AN patients are concerned about the adverse effects of RT and the logistics of treatment, particularly costs, transportation, and insurance compatibility. Use of culturally specific education and hypofractionation regimens may increase acceptance of RT for AI/AN patients with cancer, and this hypothesis will be tested in a future educational intervention-based study.