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Art therapy and art psychotherapy are often offered in Child and Adolescent Mental Health services (CAMHS). We aimed to review the evidence regarding art therapy and art psychotherapy in children attending mental health services. We searched PubMed, Web of Science, and EBSCO (CINHAL®Complete) following PRISMA guidelines, using the search terms (“creative therapy” OR “art therapy”) AND (child* OR adolescent OR teen*). We excluded review articles, articles which included adults, articles which were not written in English and articles without outcome measures. We identified 17 articles which are included in our review synthesis. We described these in two groups—ten articles regarding the treatment of children with a psychiatric diagnosis and seven regarding the treatment of children with psychiatric symptoms, but no formal diagnosis. The studies varied in terms of the type of art therapy/psychotherapy delivered, underlying conditions and outcome measures. Many were case studies/case series or small quasi-experimental studies; there were few randomised controlled trials and no replication studies. However, there was some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma or who have post-traumatic stress disorder (PTSD) symptoms. There is extensive literature regarding art therapy/psychotherapy in children but limited empirical papers regarding its use in children attending mental health services. There is some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma. Further research is required, and it may be beneficial if studies could be replicated in different locations.

Median arcuate ligament syndrome (MALS) is a rare benign condition typically affecting young females. It usually presents with abdominal symptoms of pain, nausea, and unintentional weight loss. They are usually diagnosed incidentally on CT of the abdomen done for abdominal pain. Here we present a rare case of MALS which presented with an anginal type of chest pain without any abdominal symptoms leading to an extensive workup and incidental diagnosis.

Gastrointestinal pathology can cause cardiac symptoms and disorders. We present a case of a patient who had worsening of her palpitations with food intake. She was found to have a high burden of premature ventricular contractions in the setting of hiatal hernia and gastro-oesophageal reflux disease. After extensive investigations and ruling out cardiac causes, her arrhythmia resolved with the surgical correction of hiatal hernia.

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Patent foramen ovale (PFO) is a cardiac defect with a prevalence of 25-30%, which notably decreases with age. A study done in 2018 showed an increased incidence of PFO in patients with pulmonary hypertension (pHTN). It is suggested that the presence of PFO in these individuals is a reflection of dilated and dysfunctional right atrium and ventricles, leading to an increased right to left gradient, stretching open a communication between the two atria. CASE PRESENTATION:We present a 96 year old female with heart failure with preserved ejection fraction, chronic respiratory failure secondary to moderate persistent asthma, on 4L of O2 at baseline, recurrent venous thromboembolic disease on apixaban, severe untreated OSA, initially admitted for septic shock due to acute cholecystitis requiring percutaneous cholecystostomy and broad spectrum antibiotics. On admission she also had significant hypoxia with cyanosis requiring intubation. The level of hypoxia was discordant with the clinical picture, with chest x-ray only showing atelectasis. She was extubated to high flow nasal cannula five days later, however we faced challenges in weaning her oxygen requirements. She received systemic steroids, anticoagulation and diuresis without improvement. Subsequently, the patient underwent an echocardiogram that showed a pulmonary artery systolic pressure (PASP) of 79mmHg (previously 47 mmHg in a study done 8 months ago). Given the degree of hypoxia and associated increase in PASP, intracardiac shunting was suspected. A repeat TTE with bubble study confirmed the presence of a small PFO. We discussed surgical closure, however invasive measures were deferred given her advanced age. Instead, the patient was treated with short acting diltiazem every 6 hours and furosemide daily with the goal of reducing pulmonary pressures and R to L shunting of deoxygenated blood. Although diltiazem is associated with negative outcomes in patients with heart failure, there was no evidence of pulmonary vascular congestion, and the immediate benefit outweighed the risk. Many days after initiating our plan, her oxygen requirements suddenly dropped from 60L/min to 4L/min and we were able to discharge her successfully.DISCUSSION: It is postulated that sepsis can lead to pHTN from elevated pulmonary vascular resistance through various mechanisms. Opening of PFO in severe pHTN is a common occurrence -resulting in resistive hypoxemia. Although we lack definitive evidence without right heart catheterization, we were able to exclude other etiologies of hypoxia through trial and error, strengthening our theory that PFO was the main driver of the clinical presentation. CONCLUSIONS:To summarize, hypoxia due to intracardiac shunting is an important cause of hypoxia, not to be missed on our list of differential diagnoses, with timely identification and appropriate therapy being the key to positive outcomes.

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