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The International Dyslexia Association estimates that on average, as many as 15% to 20% of the population may display symptoms of dyslexia, which include inaccurate or laborious reading, and weak spelling and writing. Unfortunately, many individuals with dyslexia have found themselves surrounded by school and community members who do not understand this pervasive and well-documented language-learning disability. Data on experiences of diverse practitioners attempting to gain expertise in dyslexia are one critical path for identifying potential mechanisms for mitigating these challenges. In this article, the authors report on a multiple-case study designed to better understand the experiences and contexts of graduate students enrolled in an online dyslexia assessment and intervention professional development program. Analysis revealed common contextual barriers to practice across unique settings and also common supports acquired as participants built their internal capacity through their online learning experiences.

Anticipation is an inheritance pattern where disease severity increases and/or age of onset decreases in successive generations. It has been documented in neurodegenerative disorders [1,2], autoimm...

Background Epidermolysis bullosa (EB) is a rare disease characterized by blistering and erosion of the skin and mucus membranes in response to minor external forces. Research focusing on daily skin care in EB patients is sparse. Two international clinical practice guidelines (CPGs) have been published in English, but they have not yet been translated into other languages such as Japanese. Therefore, their recommendations have not been adapted to multiple geographic regions in the world. This multiple case series describes our approach to the skin care of 3 Japanese patients with EB. Results All 3 patients were diagnosed with genetic EB. A 13-year-old male patient had dominant dystrophic EB and suffered skin breakdown covering nearly 1% to 6% of his total body surface area (TBSA) during a 21-week data collection period. A 3-year-old male patient had EB simplex; he suffered skin breakdown covering 2% to 40% of his TBSA during a 36-week data collection period. The third case was a 5-year-old male patient with recessive dystrophic EB who experienced skin breakdown covering 2% to 40% of his TBSA during a 35-week data collection period. Blisters were punctured daily and treated with a soft silicone dressing. Daily application of moisturizers was undertaken to prevent the skin from drying out and itching. Conclusion Our experience suggests that application of published CPGs promoted wound healing. Nevertheless, given the nature of the disease, a complete resolution to an individual's vulnerability to skin lesions even with relatively minor trauma remains elusive. Additional research is needed to explore interventions for skin and ulcer care, along with symptom management, including pain and pruritus.

Resumen Objetivo . El propósito de esta investigación fue conocer las prácticas evaluativas diferenciadas que realiza el profesorado chileno de educación especial para estudiantes que presentan necesidades educativas especiales derivadas de discapacidad intelectual, quienes se integran en escuelas de educación general básica a través de los Proyectos de Integración Escolar (PIE). El estudio pretendió, además, analizar los significados que los equipos docentes de educación especial atribuyen a sus propias prácticas de evaluación. Metodología . La investigación se realizó desde un enfoque metodológico cualitativo con un diseño de estudio de caso múltiple. Las personas participantes fueron 10 docentes de educación especial en servicio, de 9 establecimientos educacionales diferentes de la región del Biobío, Chile. El instrumento utilizado para la recopilación de información fue la entrevista semiestructurada. La información recogida fue analizada a través de la técnica de análisis de contenido temático. Resultados . Los hallazgos muestran que los educadores y las educadoras especiales que se entrevistaron utilizan procedimientos de evaluación diferenciada alineados con los principios de la evaluación general, pero con una participación incipiente de elementos propios de la especialidad, para dar respuesta a las necesidades educativas especiales del estudiantado que presenta discapacidad intelectual. Conclusiones. Se concluye que es necesario que los centros reflexionen sobre los procesos de enseñanza y prácticas de evaluación que llevan a cabo, con el fin de establecer mejoras en sus dinámicas y procesos de aprendizaje del estudiantado con discapacidad intelectual que asiste a centros regulares de enseñanza. Abstract Objective. The purpose of this research was to know the differentiated evaluation practices implemented by the special education teachers for students with special educational needs deriving from intellectual disability and are integrated into basic general education schools through the School Integration Projects (PIE). The research also analyzed the meanings that the special education teachers attribute to their own practices. Method. The research was conducted under a qualitative approach with a multiple case study design. The participants were 10 Special Education teachers in service from nine different educational establishments. The instrument used to gather information was a semi-structured interview. The information was analyzed through the thematic content analysis technique. Results. The findings show that most of the differential educators interviewed perform differentiated evaluation procedures for students with intellectual disability; these procedures are aligned with the principles of the general evaluation in order to respond to the special educational needs of the students. Conclusions . It is concluded that the centers need to conduct a reflexive analysis of teaching processes and evaluation practices that they implement in order to establish improvements in their dynamics in favor of students with intellectual disabilities who attend regular teaching centers. Resumo Objetivo . O objetivo desta pesquisa foi conhecer as práticas diferenciadas de avaliação realizadas pelo corpo docente de Educação Especial para estudantes integrados nas escolas de educação básica, que apresentam necessidades educacionais especiais derivadas de deficiência intelectual, por meio dos Projetos de Integração Escolar (PIE). Outro propósito dessa pesquisa também foi analisar os significados que o corpo docente de Educação Especial atribue às suas próprias práticas de avaliação. Metodologia . A pesquisa foi conduzida sob uma abordagem metodológica qualitativa, com um desenho de estudo de caso múltiplo. Participaram 10 professores de Educação Especial de nove diferentes estabelecimentos de ensino. O instrumento utilizado para coletar informações foi a entrevista semiestruturada. As informações foram analisadas pela técnica de análise de conteúdo temático. Resultados. Os resultados mostram que a maioria dos educadores especiais entrevistados realiza procedimentos de avaliação diferenciados para os estudantes que apresentam deficiência intelectual, alinhados aos princípios da avaliação geral, com o objetivo de responder suas necessidades educacionais especiais. Conclusões . Conclui-se que é necessário que os centros realizem uma análise reflexiva dos processos de ensino e práticas de avaliação que realizam, a fim de estabelecer melhorias em sua dinâmica em favor dos estudantes com deficiência intelectual que frequentam os centros regulares de ensino.

Purpose: Participatory design (PD) is a collective creative design process involving designers and nondesigners. There is limited reporting on the experience of using PD for adolescent and young adult (AYA) care. This study summarizes lessons from employing PD to develop care for AYAs with cancer.Methods: A qualitative multiple-case study method was conducted of three PD processes addressing food (FfC), intimacy and sexuality (I&S), and integrative medicine (IM) in caring for AYAs with cancer.Results: Local key stakeholders, who were exposed to a problem and had not been successful at solving it individually, were recruited to “dream” together. Through this synergy, a shared understanding of the problem and a joint mission emerged to find a solution. PD tools were used to develop a problem definition. An open mind and explorative research helped to understand the problems, and stakeholders were managed such that idea-sharing and learning were enabled. Designers translated ideas into prototypes. The PD process was prolonged due to the hierarchical hospital environment, business considerations, and additionally required evidence. The FfC program produced an effective new food service for the whole hospital. The I&S initiative developed a podcast, two articles, and a prototype website. The IM project developed a pilot study.Conclusions: For a PD process to successfully develop care for AYAs, one needs to use designers and skilled people, PD tools, and an open-ended approach to visualize and materialize new forms of care. Furthermore, recruitment and facilitation techniques help leverage knowledge and create a synergy in a democratic environment between stakeholders.

The purpose of this study was to examine how secondary students with severe disabilities (i.e., severe intellectual disability or autism, multiple disabilities) participate in extracurricular school clubs. Using a qualitative multiple case design, the experiences of three high school students were examined. Data were collected through interviews, observations, and document reviews. A single-case inductive open-coding strategy was utilized across all data sources in which codes and categories emerged, and a final cross-case thematic evaluation was conducted. The cross-case thematic analysis resulted in the following four overarching themes: (a) going with the flow; (b) social obstacles: on the outside looking in; (c) supports provided: too much, too little, just right; and (d) safety in numbers.

BACKGROUND There is increasing evidence regarding the wound healing potential of platelet-derived autologous by-products. We provide preliminary data regarding the use of a new plasma rich in growth factors-derived autologous topical ointment for the management of hard-to-heal wounds. CASES Four patients suffering from difficult-to-heal wounds were treated with the autologous ointment. Within 2 to 8 weeks, all wounds healed completely with no signs of infection or functional impairment of the affected limbs. No adverse events were reported. CONCLUSION Randomized and controlled trials are needed to determine the clinical efficacy of the autologous ointment. Nevertheless, results from this multiple case series indicate that this approach may be useful for accelerating the re-epithelization of difficult-to-heal wounds.

The review analyzes the data of scientific publications on the effects of molecular mechanisms initiated by physical exertion on thefunction of the cardiovascular system and the course of cardiac diseases. As practice and a number of evidence-based studies haveshown, the beneficial effects of physical activity on the outcomes of diseases in a number of cardiac nosologies are comparable todrug treatment. Numerous mechanisms mediate the benefits of regular exercise for optimal cardiovascular function. Exercises causewidespread changes in numerous cells, tissues, and organs in response to increased metabolic demand, including adaptation of thecardiovascular system. Physical exercises, which include various types of aerobic exercises of varying intensity and duration, is animportant component of the therapeutic treatment of patients with cardiovascular diseases. Knowledge of the molecular basis ofthe physical activity impact on the cardiovascular system makes it possible to use biochemical markers to assess the effectiveness ofrehabilitation programs.

Summary Background : Computed Tomography Angiography (CTA) is utilised in pre-operative work up in adults undergoing microsurgical reconstruction. The evidence for the use of CTA pre-operatively in the paediatric population prior to reconstruction remains unclear so far as there are limited studies. Arguably the use of CTA in place of conventional angiography avoids vessel damage, which can be amplified in the paediatric population due to smaller vessel calibre. Materials and Methods : Four papers satisfying inclusion criteria were identified through PubMed, EMBASE, Cochrane database, Google Scholar and citation searching. Results : There is low grade evidence from multiple case series describing the use of CTA pre-operatively in paediatric extremity trauma prior to microsurgical reconstruction. Literature suggests that CTA may be utilised effectively in such cases. Conclusion : Evidence suggests CTA can be useful in pre-operative work-up for paediatric patients undergoing extremity reconstructive microsurgery. However, the evidence is obtained from several small case series in which selection bias is suspected thus making generalisation to larger populations difficult. Although evidence for the use of pre-operative CTA exists in the adult population which can be sensibly extrapolated into the paediatric population, higher level studies looking further at the application in paediatrics are required.

SummaryIntersectoral policymaking to improve public health includes integrated health promotion (HP) intervention packages that address a variety of health behavior determinants. The involvement of different partners is assumed to be necessary to implement such integrated packages. We examined how partnership diversity was associated with the composition of intervention packages implemented in Dutch municipalities. In a longitudinal multiple-case study (2012–14), we collected questionnaire data among 31 project leaders and 152 intervention implementers in 31 (alliances of) municipalities. Package composition was assessed in terms of intervention strategies, implementation settings and targeted behavioral determinants. Partnership diversity during the adoption and implementation phases was assessed in terms of the actors and sectors, as well as private partners and citizens involved. The association between partnership diversity and package composition was examined using crosstabs. Almost all packages integrated multiple strategies, but mostly education, facilitation and case finding, in multiple, but mostly health and public settings, such as schools. The packages targeted diverse behavioral determinants, although mainly personal and social environmental factors. A variety of partners from multiple sectors was involved, during both adoption and implementation of the packages. However, partners from the health, welfare and education sectors were mostly involved. More partnership diversity, especially during implementation, was associated with more integrated intervention packages. In intersectoral policymaking, investment in diversely composed partnerships seems worthwhile for implementing integrated intervention packages. However, investments in other conditions, like framing health issues and network management, are also needed to make environmental determinants of health behavior the object of HP.

Background Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Methods Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Results Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Discussion Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Conclusions Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

Objectives: In this study, we investigated the effects of bilateral and unilateral deep brain stimulation of the subthalamic nucleus (STN-DBS) in PD patients on neural responses associated with two aspects of spoken language processing: semantics of action-related verbs and morphosyntactic processing. Materials and methods: Using a passive unattended paradigm to present spoken linguistic stimuli, we recorded magnetoencephalographic (MEG) responses in three PD patients in four DBS conditions: left unilateral STN-DBS, right unilateral STN-DBS, bilateral STN-DBS, and no STN-DBS. To ensure that any observed effects of DBS on the neuromagnetic responses could be attributed to the linguistic context per se and were not merely induced by the electrical stimulation, we assessed the effects of STN-DBS on linguistic contrasts within each stimulation condition. Hence, we contrasted the processing of action vs. abstract verbs as well as the processing of correct vs. incorrect morphosyntactic inflections within each DBS condition. Results: The results revealed that, compared to the DBS-off state, both bilateral and right unilateral stimulation of the STN yielded significant dissociations in the processing of action and abstract verbs, with greater neuromagnetic responses for action verbs compared to abstract verbs. For morphosyntax processing, only left unilateral stimulation yielded significant dissociations (relative to the DBS-off state), with greater neuromagnetic responses to the incorrect inflections compared to the correct inflections. Conclusion: The results reflect differential effects of unilateral and bilateral STN-DBS on neuromagnetic responses associated with the processing of spoken language. They suggest that different specific aspects of linguistic information processing in PD are affected differently by STN-DBS.

Neurodevelopmental disorders are seen quite commonly by general pediatricians. They should be managed with a multi-professional approach. The potential beneficial effect of poly-unsaturated fatty acids (PUFAs) has been reported in recent literature, but guidelines describing their use in everyday practice are still lacking. We describe four cases as examples of the possible integration of a supplementation with PUFAs in the management of four relatively common clinical situations (i.e., children too young to receive pharmacological treatment for ADHD, children with nonspecific neurodevelopmental disorders, children whose parents refuse consent for pharmacological treatment of ADHD, and children for whom methylphenidate is not sufficient to achieve expected results).

The COVID-19 pandemic has significantly affected all aspects of life around the world including both the medical system as a whole and individual medical specialties. Understandably, medical rehabilitation was forced to adapt to the new disease, to develop adequate algorithms and technologies that can increase the level of independence and quality of life being disrupted as a result of coronavirus infection. Aim. To analyze, organize and present the results of in-patient rehabilitation of patients after severe forms of COVID-19 infection by reporting the real cases from the clinical practice. Material and methods. COVID-19 infection is a multi-systemic disease, which, in many cases requires for inpatient multidisciplinary rehabilitation program. Patients after severe forms of infection suffer different symptoms in variable combinations. According to main disabling signs we can classify all our patients in 3 groups: (1) general weakness or deconditioning, (2) respiratory disorders due to lung disease, and (3) patients with different neurological complications. Patients in all groups demonstrate serious psychological compliances which indefinitely have negative influence on rehabilitation process. The paper presents clinical cases specific to each of the groups. Results. All hospitalized patients showed good functional improvement through quite standard length of stay in the department All patients were discharged home with the opportunity to return to relatively normal daily activities. Conclusions. Patients after severe COVID-19 infection require professional multidisciplinary in-patient rehabilitation. All of them demonstrate good functional improvement and, after quite short period of hospitalization, can be discharged home.

Psychological assistance is strongly needed in relation to the recovery of the psychological state of children who are in conflict with the law. Semarang City has developed a school-based restorative justice program as a response to such needs. This research aims to explore the factors which could potentially obstruct the psychological recovery process of these children during the implementation of the program. The study adopts a qualitative design through multiple case studies, with the participation of three children and those close to them. The case study data analysis was conducted based on Yin's (2015) techniques, consisting of pattern matching, explanation building, logic models, and cross-case synthesis. The results show that negative support from peers, drug abuse, negative role models, emotional detachment from close friends and relatives, and negative stigma were the factors obstructing the recovery process of the participants. These findings could be essential for practitioners’ design of psychological interventions which are more relevant to the children’s recovery needs.

The burden of post COVID rehabilitation is and will be a strong concern for healthcare stakeholders. The Traditional Chinese Medicine is suggesting the application of acupuncture as a dependable tool to be inserted in the rehabilitation project. Libralux, an ultra-low-level-laser stimulator has proven its effectiveness as acupuncture stimulator. In this paper we report the respiratory cycle modifications obtained through the stimulation with Libralux of the acupoint LU7 LieQue of three healthy individuals. Modifications were observed instrumentally by means of an innovative high-resolution camera plotting the chest expansion vs. time. The results demonstrate a remarkable increase in respiration depth and in the contemporary reduction of the respiration frequency within 20 minutes from the 20 sec bilateral stimulation of LU7 LieQue acupoint. The worthiness of a specific full double-blind trial is suggested also in view of the marginal contra-indications, the rapid execution and, most of all, the great potential benefit of the inclusion of a laser acupunctural stimulation in the post COVID rehabilitation project.

Purpose Social approaches to intervention for aphasia are being increasingly employed to address the functional communication barriers experienced by persons with aphasia. One specific approach is the use of conversation-based treatment in both group and two-person dyads. Although there are several methods to measure improvement for stimulation and cognitive neurolinguistic approaches, researchers have consistently indicated a need for outcome measures that can objectively demonstrate improved communication following conversation treatment. This study aims to demonstrate the utility for examining the patterns of conversation trouble source and repair as indices for improved communication as a positive response to intervention. Method The conversations of 20 consecutive participants, before and after 3 months, or 40 hr, of group and individual conversation-based treatment, were transcribed using conventions of conversation analysis, and sociolinguistic discourse analysis was applied. Measures of trouble source and repair were aggregated and subjected to statistical analysis. Results Persons with aphasia demonstrated statistically significant improvement in patterns of conversation trouble source and repair posttreatment for the rate of conversation trouble source and the length of repair. However, measures of self-initiation and self-completion of repair did not reach significance. Conclusion The study indicates that, following conversation-based treatment, the conversations of persons with aphasias were more efficient, experiencing fewer trouble sources and shorter repair sequences. These findings suggest that measures of conversation for the rate of trouble source and length of the repair sequence are valid indices of improved conversation.

Adequate dose homogeneity and full prescription dose delivery to the scalp still remains a dosimetric problem during scalp irradiation due to the anatomical shape of the cranium. Confounding variables such as gravity, the irregular and convex shape of the cranium, air gaps between scalp surface and commercial bolus, and potential inconsistencies in a 3D printed bolus can negatively impact the dose delivered to the scalp surface during scalp irradiation. The purpose of this retrospective case study was to implement the use of a 3D milled rigid bolus technique combined with volumetric modulated arc therapy (VMAT) treatment planning and evaluate the dosimetric efficacy in delivering dose to the surface of the scalp. The 8-patient retrospective case study consisted of patients with a scalp lesion treated using a 3D milled bolus, VMAT, 6 megavoltage (MV) photon beams, and aligned for treatment using daily conebeam computed tomography (CT) and 6° of freedom couch positioning. Dose volume histograms (DVHs) were used to evaluate maximum dose delivered to the planning target volumes (PTVs) while the dose homogeneity index (DHI) was calculated and compared to that of an ideal value of 1. The researchers evaluated the minimum dose delivered to the individual PTVs after plan normalization. The researchers found that the 3D milled bolus coupled with volumetric modulated arc therapy increased surface dose homogeneity, while also increasing the percentage of planning target volumes receiving full prescription dose. With statistically significant results, patient specific 3D milled rigid bolus offers a viable bolus option for treatment of superficial scalp lesions when combined with volumetric modulated arc therapy treatment planning. However, a larger sample size used in a scientific research study across multiple institutions would be desirable to validate these case study findings.

Objective: The study’s aim was to gain insights into factors influencing sustainable return to work following total knee arthroplasty (TKA). Design: A descriptive multiple-case design was used. A case was defined as a worker’s following TKA work disability situation. Settings: The cases came from public hospitals in urban and semi-urban areas in Quebec (Canada) and involved mostly non-work-related TKAs. Subjects: Workers had to be between 6 and 12 months post-TKA, have physical/manual jobs and currently employed. Their rehabilitation professionals and workplace representatives (employer and/or union) were also recruited, based on the work disability paradigm. Main measures: Semi-structured interviews, questionnaires on pain, physical work demands (workers only), and observation of the work activities of those workers back at work were used. Cases were compared and categorized for worker-perceived levels of difficulty in returning to or staying at work: little or no difficulty ( n = 8); some difficulty ( n = 5); not back at work due to excessive difficulty with their knee ( n = 4). Results: A total of 17 cases were constituted. In only one case, the worker benefitted from an interdisciplinary work rehabilitation approach. Results highlight the interplay among these factors: (1) the workers’ perceptions of their residual symptoms and ability to manage them, (2) the interaction between work adjustments and tools offered by the employers and the workers’ own strategies, and (3) perceptions of the workers’ physical capacities. Conclusion: Workers’ who face high levels of work demands/difficulties and who have limited access to work adjustments and tools should be referred for work rehabilitation.

We describe the knowledge translation strategies in two projects and share lessons learned about knowledge sharing and uptake. To generate findings for dissemination: (1) the Republic of Cote d’Ivoire (RCI) project relied on a multiple case study design to document barriers and facilitators to implementing a community-led prevention strategy targeting Ebola virus disease; and (2) the Tunisia project used several designs to assess a mental health training’s effectiveness, and a case study design to explore contextual factors that may influence anticipated outcomes. To share findings with participants, the RCI project relied on workshops and a pamphlet, and the Tunisia project relied on a structured half-day dissemination workshop and research summary. Facilitators that may have encouraged sharing and using findings include involving champions in dissemination activities, ongoing collaboration, and developing/implementing context-specific knowledge sharing strategies. Barriers include omitting to assess strategies, limited consideration of a wider audience, and the exclusion of a knowledge translation training component. Our experiences might be useful to contexts involved in global and public health research that wish to address the “know-do gap.”

Group-based programs have the potential to help patients manage their diabetes and prevent complications. However, participant retention has been identified as one of the major issues hampering these programs. Previous empirical studies have identified factors related to retention, such as age and body mass index. However, there has been little investigation on the factors that contribute to retention in group-based diabetes programs. This study explored the perspectives of diabetes program educators on the factors that lead to participant retention in group-based diabetes programs. A qualitative multiple case study design was employed to understand retention factors across six purposefully selected group-based diabetes programs. Diabetes educators participated in a one-time, in-depth, semi-structured phone interview. Data was analyzed inductively using within and cross-case thematic analysis. Four major themes were identified that impact retention in these programs, including individual factors, logistical factors, social factors, and program factors. The findings of this study shed insight on the factors impacting participant retention across group-based diabetes programs. These findings have the potential to inform diabetes educators on how to improve retention in ongoing or future diabetes programs.

Background: Lymphedema (LE) is a chronic condition of swelling due to lymphatic impairment and is characterized by edema and fibro-adipose tissue deposition. LE may be caused by an anomalous development of the lymphatic system, known as primary LE, or may develop secondary to traumatic, infectious, or other external events. Knowledge is increasing about the plural and bidirectional relationship between LE and obesity. The rate of obesity is increasing worldwide, and bariatric surgery offers the most effective and durable treatment, as this surgery exhibits positive effects on many obesity-related diseases. We explored whether bariatric surgery could improve leg volumes in morbidly obese LE patients. Patients: Between 2013 and 2019, 829 patients were hospitalized in our Center of Expertise for Lymphovascular Medicine for intensive treatment of their LE. Nine patients with end-stage primary, secondary, or obesity-induced LE underwent a bariatric procedure related to their morbid obesity. Methods and Results: Data concerning age, gender, medical diagnosis, LE stage, type of bariatric treatment, body weight, body mass index (BMI), and limb volumes were retrospectively collected from the patient files. At the individual patient level, body weight, BMI, leg volumes, and their percent reduction between presurgery and postsurgery were calculated. At the group level, paired sample t-tests were conducted to compare the mean body weight, BMI, and volumes of both legs between postsurgery and presurgery. The data demonstrate a significant decrease in body weight, BMI, and leg volumes in morbidly obese end-stage primary, secondary, and obesity-induced LE patients following bariatric surgery. Conclusions: Our multiple case study indicates that bariatric surgery provides a good indication for concomitant treatment of morbid obesity and LE.

In a theory-driven, qualitative, multiple-case study, we examined the implementation of national dementia plans (NDPs) in Denmark, Germany, and Italy to determine how stakeholders involved in implementing the NDPs evaluate contextual factors in light of the World Health Organization’s seven action areas of dementia-focused policy. To analyse the NDPs, we used a driver diagram of large-scale change and conducted both document analysis and semi-structured interviews, after which we performed three-way open coding to analyse the methods. The results show that the implementation of NDPs has increased awareness of dementia in all three countries by positioning the disease as a national public health concern. The study also reveals that resources, the use of change theory, and the monitoring of implementation and fragmentation are crucial factors to consider for countries when implementing NDPs. Although stakeholders find the NDPs useful, many challenges remain for their successful implementation due to the highly limited means for implementation and evaluation. Moreover, present NDPs all lack a communication plan that encompasses all layers of society to address ways of achieving change. Patients with dementia, and their informal caregivers, should be included more in the design, implementation, and evaluation of NDPs in order to improve their usefulness and effectiveness.

ObjectivesWhile patients’ symptom experiences have been widely investigated, there is a lack of contextualized studies investigating how symptoms circulate in the medical consultation, how patients present them, what they convey, how physicians respond, and how patients and physicians negotiate with each other to find ways to address them. The aim of this study is to explore patients and physicians handling of symptoms throughout oncological consultations with a multiple case study approach.MethodsFive consultations, purposively selected from an existing dataset of audiotaped consultations with patients with advanced cancer, were analyzed by means of an inductive analytical approach based on a sensitive framework from the literature.ResultsPatients’ symptoms showed multiple dimensions such as medical, cognitive, emotional, psychological, interactional, symbolic, experiential, and existential.Significance of resultsDifferent symptom dimensions remained unnoticed and unaddressed in the consultations. The physician-centered symptom approach that was observed leads to consumed time and missed opportunities for relationship building with the patient. Physicians showed a lack of sensitivity regarding the multiple dimensions of symptoms. Based on the findings, strategies for a more comprehensive symptom approach can be conceived.

Prison-based dog training programs (DTPs) aim to improve successful rehabilitation after detention. However, empirical evidence for their effectiveness is lacking. To evaluate the effectiveness of a DTP—Dutch Cell Dogs (DCD)—on externalizing behavior, stress, self-esteem, empathy, and treatment motivation, a pilot study with a Multiple Case Experimental Design in six adolescents residing in a juvenile justice center (JJC) was conducted. Results did not provide convincing evidence for DCD’s effectiveness. Further research is needed to determine whether and for whom DCD could be a useful addition to regular JJC programming.

To understand mental illness in cultural contexts, research should focus on locally informed concepts of illness and the lived experiences of such conditions. Understanding mental illness, its prevalence, and its influence on people’s lives in Namibia represents one such context where attention to the lived experience of mental illness remains understudied. The purpose of the current study was to build upon ethnographic findings about mental illness as madness ( eemwengu) among the Namibian Aawambo. To that end, a multiple case study design was used to explore the lived experience of being omunanamwengu (the mad one). Data were collected from four cases that were bound by the experience of mental illness. Within each case, the individual experiencing illness ( omunanamwengu), family members, and both omunanamwengu and family members were interviewed formally (via a semi-structured interview protocol) or informally due to participants’ preferences for not being recorded. Using Stake’s suggested approach to multiple-case study cross-case analysis, each individual case is described and cross-case themes (Development and Symptoms of Mental Illness; Marginalization and Omunanamwengu; Family Roles in the Lives of the Distressed and Eemwengu; Belief in Treatment) were identified. Findings are discussed in light of the role of beliefs in treatment as well as family involvement, the potential influence of discrimination on mental illness, and implications for practice and cross-cultural psychology.

Children with autism often exhibit difficulties with reading comprehension. Recent studies have demonstrated positive outcomes for typical learners from the internet-based reading comprehension program, Headsprout Reading Comprehension®. In the present study, a preliminary evaluation of HRC was conducted with six children with autism. The primary aim was to investigate whether it would be feasible to use HRC with children with autism and whether any adaptations to the standard teaching procedure and extra support would be needed. A secondary aim was to investigate the potential of HRC to improve reading comprehension skills. The study used a multiple case series design with six children. Results are discussed with reference to increased reading comprehension ability in the six children and the practical strategies required to support children with autism so that they may benefit from the program.

The article examines the experience of parenting a child with a diagnosis of autism with a focus on scripts and intentions in relation to the parents’ own childhood experiences of being parented. Five parents participated in a multiple case study design involving in-depth interviews, Adult Attachment Interviews and a parenting intentions scaling task. The findings revealed that all of the parents had experienced significant adverse events in their own childhoods, including trauma and losses. They also expressed intentions to offer parenting that was ‘corrective’ in terms of providing a better emotional environment for their children. Their corrective attempts and also intentions to repeat positive aspects of being parented were moderated by unconscious aspects of their early childhood experiences and also by the autistic features of their children. The interplay between early embodied experiences, theories of autism, parenting experiences and intentions is discussed along with clinical implications.

The rising number of students in schools identified as being on the autism spectrum has placed pressure on school leaders and staff to gain knowledge and take on new practice. A school-wide autism ...

The psychodynamic treatment approach for patients newly diagnosed with cancer provides a uniquely effective model for understanding the onset of psychiatric symptoms and planning a psychotherapeutic intervention. The words "you have cancer" often disrupt the patient's usual customary defenses and can result in the onset of psychiatric symptoms. The psychiatric symptoms will depend on the patient's usual defenses, past history, and characteristic style of relating to others. Multiple case examples of the cancer patient's journey from diagnosis to survivorship will be offered in this article to demonstrate the value of including a psychodynamic point of view in any treatment of cancer patients. This article will concern itself with patients who achieve survivorship.

End-stage renal disease (ESRD) is a prevalent disease that results from kidney failure in the last stage of chronic kidney disease. This disease has many chronic and debilitating symptoms, including muscle wasting. Unfortunately, current methods to diagnose muscle wasting, in this patient population, are rather imprecise and/or expensive. To develop a better method, this study examined the use of sonography across four separate patients with ESRD in a typical clinical setting. Multiple muscle measurements were taken in the patients’ upper arm via sonography, which were compared to laboratory test results and skinfold measurements. This multiple case comparison demonstrates the feasibility of using sonography to measure subcutaneous tissue and muscle mass in this patient population. It also has the potential to correlate with or support other clinical measures of disease severity. Further study is recommended to examine these correlations and to identify clinical implications for sonographic measurement of overall muscle wasting.

Using a new approach to the analysis and synthesis of a clinically focused mixed-methods multiple case study of aneurysmal subarachnoid haemorrhage (aSAH), we explored barriers and facilitators to timely treatment. In this paper we provide guidance for the multiple steps of analysis and synthesis of qualitative and quantitative data from across and within 27 case studies. Results showed that median (IQR) time to treatment was 15.1 (9.0, 24.1) hours. Only 37% of cases had treatment within 12-hours of onset. Early recognition of aSAH, good coordination, and availability of resources for treatment were main facilitators for treatment within 12 hours from onset. Lack of recognition of aSAH at onset and lack of resources for immediate in-hospital treatment were major barriers.

Background Memory deficits and concentration difficulties are common in almost all patients with Huntington’s Disease (HD) and often occur early in the disease. People with HD may also show a loss of initiative. Healthcare technology is increasingly being used to support the self-reliance and well-being of patients in long term care facilities. Tessa is a small social robot that looks like a flowerpot. Giving pre-set reminders, Tessa functions as a spoken diary. The applicability and effects of Tessa in patients with HD in order to stimulate them in their activities and chores is unknown. Case History Two HD patients (one male 23 years and one female 43 years) residing in a skilled nursing facility participated in this study. Both patients were motivated to try Tessa for 12 weeks. Tessa invited the female patient for coffee, tea and meals in the living room and Tessa reminded the male patient of chores with spoken messages. Observation showed both patients followed up on spoken instructions of Tessa and both patients indicated that they liked Tessa. Caregivers and nursing staff also noticed the patients responded on spoken instructions of Tessa, but only if they wanted to. Tessa’s neutral tone was considered great value by caregivers and nursing staff. After 12 weeks, both patients wanted to keep Tessa. Conclusions In both cases social robot Tessa motivated the patients to initiate activities. The patients were able to follow instructions given by Tessa or to ignore Tessa when they felt like it. It might be worthwhile to further explore the possibilities of social robots in patients with HD.

The probability of undergoing treatment with curative intent according to the hospital of diagnosis has been shown to vary considerately for esophagogastric cancer and was related to survival. However, little is known which factors attribute to this variation. In this study we aimed to gain in-depth understanding of the organization of clinical pathways and in particular factors and processes determining the organization of healthcare for esophagogastric cancer patients. Methods A mixed method study design consisting of quantitative and qualitative data was conducted. Quantitative data was gathered by the Netherlands cancer registry (e.g., outpatient clinic consultations and performed diagnostics). A thematic content analyses of the current sub-study focused on clinician’s perspectives using semi-structured interviews (n = 30), and observations of outpatient clinic consults (n = 26) as well as multidisciplinary team meetings (n = 16) in eight hospitals. Results Quantitative analyses showed that surgeons were more often consulted in hospitals with a high probability whereas geriatricians were more often consulted in hospitals with a low probability of receiving treatment with curative intent. Qualitative analyses showed that the organization of clinical pathways were analyzed according to three levels: regional, local and patient level. Hospitals differed regarding triage, patients discussed during an multidisciplinary team meeting, the revision of radiological images, and restaging after neoadjuvant treatment. Furthermore, assessment of patients physical and cognitive condition by fitness tests, pre-habilitation and/or geriatric assessment differed significantly. Conclusion Specific parts of the clinical pathways differed significantly between hospitals such as the consultation of a geriatrician and pre-habilitation. These results might provide implications for further research in order to optimize clinical pathways.

The purpose of this explanatory retrospective case study was to report clinically significant increases in bone mineral density in a female and a male over 70 years of age with osteoporosis, following 16 weeks of hardstyle kettlebell training. Both case subjects were insufficiently active prior to participating in the BELL trial. Subjects trained five days a week accruing a large training load volume (calculated as kettlebell mass multiplied by repetitions performed) during structured group-based classes (74,872 kg and 110,132 kg, respectively). Regional dual-energy X-ray absorptiometry was used to assess BMD at the hip and lumbar spine. Increases in BMD of 12.7% and 5.9% at the femoral neck and lumbar spine (L2-L4) respectively were observed for the female, and 2.5% and 6.0% respectively for the male. Magnitude of change in BMD (g/cm2) at the lumbar spine was 2.0 and 1.9 times larger than the least significant change for the female and male respectively, and sufficient to advance the female subjects’ status from osteoporosis to osteopenia. Although these results do not show a definitive causal relationship between kettlebell training and increased BMD, further investigation of the effects of kettlebell training on BMD in older adults with osteoporosis and osteopenia is warranted.

It was hypothesized that variants in underexplored homologous recombination repair (HR) genes could explain unsolved multiple-case breast cancer (BC) families. We investigated HR deficiency (HRD)-associated mutational signatures and second hits in tumor DNA from familial BC cases. No candidates genes were associated with HRD in 38 probands previously tested negative with gene panels. We conclude it is unlikely that unknown HRD-associated genes explain a large fraction of unsolved familial BC.

Background: Understanding what makes a ‘good death’ in the child with life shortening illness is important, as it informs appropriate and effective end-of-life care. Above play, peer contact and opportunities for assent, prior literature review found meeting needs and managing control were critical. The influence of disease types, location of death and palliative care support remains unclear. Aim: Explore how a good death for children can occur in the real-world context and identify factors influencing it. Design: A qualitative multiple-case study. The case was defined as family and professional caregivers of children who died, stratified across disease categories (cancer or non-cancer) and palliative care contact. Data collection included (1) interviews, (2) artefacts, (3) clinical notes. Framework Analysis facilitated in-depth within and cross-case analysis. Setting/participants: Singapore health-care context. Respondents included bereaved parents, health and social care providers from hospital, and a community palliative care service. Results: Five cases were constituted, with eight parents and 14 professionals as respondents. Eight common themes were identified, sub-categorised under three domains and interpreted theoretically: (1) Antecedents: Letting go, Acknowledging the child, Closure (2) Determinants: Suffering, Control, Systems and processes (3) Attributes: Comfort, Dying not prolonged. These factors were consistent across all cases, regardless of individual diagnoses, place of care and palliative care access. Conclusions: Elements that universally influence a good death are revealed within an ecologically sound and holistic conceptual framework. The impact of attitudes among healthcare professionals, and service delivery at systems level highlighted in this study have immediate applications in practice and policy.

BackgroundThe demand for more flexible and person-centered models of oral healthcare delivery is increasing and while mobile and domiciliary dental services have the potential to increase access to oral healthcare among dependent elderly and people with disabilities; the uptake of this service model by dentists remains low. Therefore, the aim of this study was to closely examine existing mobile clinics that are leading the practice of domiciliary dentistry in a specific context. MethodsWe used a qualitative descriptive multiple case study design. We studied three independent domiciliary dentistry clinics in the province of Quebec, Canada. Data were collected using non-participant observations and semi-structured interviews with dental professionals, patients, and caregivers. We performed a qualitative content analysis using a deductive/inductive coding framework. ResultsWe presented a detailed description of the physical and service features of the studied cases. Physical features included the set-up of the mobile clinics, the portable equipment used, and the domiciliary locations of visits. For service features, we described the roles, attitudes, and interactions among those involved on both the providers’ and recipients’ sides, as well as, the logistical and financial aspect of the domiciliary dental services.ConclusionsThis case study showed domiciliary dentistry to be feasible, profitable, and highly valued by a growing segment of the population. Additional research in different contexts would further contribute to building evidence-based models to help increase the uptake of this type of practice by current and future dental professionals.

Background: Pulmonary actinomycosis is a rare and slowly progressive bacterial infection that is often mistaken for lung cancer. Multiple case reports caution against premature diagnosis of malignancy without proper consideration of potential Actinomyces infection. However, no cases in the English literature have been reported that demonstrate the possible coexistence of Actinomyces and lung cancer. Case Description: We present two cases of patients with culture-positive Actinomyces who were later found to have concomitant biopsy-proven lung adenocarcinoma. Conclusions: In the workup of a newly identified lung mass, positive culture for Actinomyces does not rule out an underlying malignancy.

Objective: Multiple case reports have implicated the use of heparin for deep vein thrombosis (DVT) prophylaxis with bilateral adrenal hemorrhage. Only 1 previous report has described this with the low molecular weight product, dalteparin. We report a case following bilateral hip arthroplasties. Methods: Clinical and laboratory data are presented. Results: A 69-year-old woman underwent bilateral total hip arthroplasties with dalteparin 5,000 international units subcutaneously daily for 30 days postoperatively. The patient's past medical history was unremarkable. She was discharged 5 days post-surgery and required readmission 1 day later for epigastric pain, nausea, and vomiting. Her platelet count was 91 × 109/L (normal, 150 to 400 × 109/L). She was discharged after 4 days with pain resolution. She presented 4 weeks later with nausea and vomiting for several days. Serum sodium was 123 mmol/L (normal, 133 to 145 mmol/L), potassium was 6.0 mmol/L (normal, 3.7 to 5.3 mmol/L), total calcium was 3.37 mmol/L (normal, 2.25 to 2.80 mmol/L), creatinine was 404 μmol/L (normal, 0 to 85 μmol/L), and her platelet count was normal. On short adrenocorticotropic hormone stimulation test, baseline plasma cortisol was 123 nmol/L and the peak was 129 nmol/L. She was treated with hydrocortisone, fludrocortisone, and 0.9% saline with resolution of symptoms and normalization of electrolytes, calcium, and renal function. Computed tomography showed bilateral adrenal masses. Core needle biopsy was consistent with necrosis. There were no bleeding disorders on hematologic work 3 months later. The most likely etiology of bilateral adrenal hemorrhage was heparin-induced thrombocytopenia from dalteparin. Conclusion: This case highlights the importance of vigilance for the complication of bilateral adrenal hemorrhage with adrenal insufficiency in patients receiving dalteparin for DVT prophylaxis.

Although otolaryngology became a subspecialty only since the middle of the nineteenth century, many diseases of ENT system, their clinical symptoms, universality and potential seriousness have been described since over 3000 years ago. Texts of the medical school of Cos and its founder Hippocrates (460–370 BC) collected in the Corpus Hippocraticum also contain multiple case reports and treatments for ear diseases. The aim of this study is to analyse an extract of one of Hippocrates’ treatise, which apparently describes the first case of cholesteotoma. We analysed a case from Epidemic by Hippocrates (VII, V, 1–9) from its English translation. Analysis of the description of symptoms allows us to diagnose a complicated cholesteatoma with facial palsy and neuro-meningitis manifestation. The meticulously detailed observations of the corpus give us a precious insight into the early perception of diseases and their evolution. The study of its history is of high interest to the fields of medicine, especially otorhinolaryngology. It also highlights the diseases and the suffering the diseases have inflicted on mankind since antiquity.

The traditional sonographic characteristic used to distinguish polyorchidism (PO) has been its homogeneous echotexture, which is similar or identical to the normal testicle. PO is most commonly found in the left hemi-scrotum but can also be identified in the right hemi-scrotum, inguinal canal, or abdominal cavity. The mediastinum of a testicle represents where the tunica vaginalis and tunica albuginea that encases a testicle folded back in on itself. The identification of a mediastinum in a scrotal lesion implies that testicular tissue is present. This series review presents three cases where PO was identified in the left hemi-scrotum. In addition to the classic homogeneous echotexture that is typically identified in an accessory testicle, a mediastinum was also appreciated in two of the cases, which helped to solidify the diagnosis of polyorchidism.

Background/Aims Many people with intellectual disability fall frequently. Understanding fall prevention intervention characteristics will assist efficacy trials to target appropriate people. An exploration of two exercise-based fall prevention interventions is reported, focusing on viability and acceptability. Methods A multiple case study of adults with intellectual disability completing either the group Otago Exercise Programme or the Prevention of Falls for Adults with Intellectual Disability intervention was performed. Integrated data sources were used: semi-structured interviews with participants and support workers, observations, attendance/adherence, falls, adverse events and balance measures. Results In total, seven adults with varying intellectual disability levels participated. Overall, three themes enabled understanding of suitability of people to each intervention: suitability of the exercises; role of the environment; and benefits to participants. Conclusions Educating adults with intellectual disability and their support workers of the importance of regular exercise is key to participation. Both programmes required high levels of support and prioritisation to ensure exercises occurred and were carried out safely.

Background Recent revisions to the pressure injury staging system include guidance on differential diagnoses for deep tissue pressure injury (DTPI). Accurately identifying DTPI is critical; however, purpura in the setting of vascular disorders and systemic infectious processes can share similar features confounding diagnosis. Cases In this three-case series, we describe suspected DTPI with an uncharacteristic shape or occurring in the presence of additional lesions distributed outside of typical pressure areas prompted further evaluation. Conclusions The interdisciplinary approach we adapted was useful in determining the cause of purpura when the DTPI was ruled out by the certified wound care nurse.

This paper investigates the transition experiences of students with intellectual disability, as they move from primary to secondary school in New South Wales, Australia. Employing a multiple case s...