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Includes bibliographical references. / 1 v. : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / A thesis based on collective clinical, basic research material and publications in endoscopic paediatric surgical procedures. Discusses the application of adult percutaneous renal surgical techniques for managing renal calculi disease in children, and modifications to this technique. Describes the introduction to laparoscopic surgery and the author's contribution to this technique. Also includes publications on paediatric urology. / Thesis (M.D.)--University of Adelaide, Dept. of Surgery, 2000

published_or_final_version / Nursing Studies / Master / Master of Nursing

published_or_final_version / Paediatrics / Master / Master of Medical Sciences

This thesis deals with some of the legal and ethical issues that arise when an individual’s genital and gonadal anatomy does not match what is perceived to be the biological (or sometimes culturally determined) norm. I focus on intersex individuals, particularly infants, who may undergo genital surgery, to ‘normalise’ genital anatomy. I compare this type of surgery to other forms of genital cutting on those too young to consent, male circumcision and female genital mutilation (FGM). I discuss how sex is complex and not yet fully understood; intersex challenges the idea that sex is a simple binary entity and the history of ‘sex testing’ in sport illustrates that there are, rarely, individuals for whom categorisation as biologically male or female is impossible. Gender is also a complex entity, but institutions such as medicine and the law still endorse a simple bipolar model of sex and gender. I argue that the assumptions on which medical practice in intersex is based are based on these simplistic gender norms. I argue that one form of intersex surgery, refashioning the clitoris, continues to be seen as a valid treatment option despite the paucity of outcome data and is not treatment for an illness but for an anatomical difference. At least some individuals who have had this procedure perceive that they have been harmed by it. Therefore I argue that the current medical and surgical approach to anatomical genital variation in intersex is ethically questionable. Furthermore it is possible to construct an argument that it is not in the best interests of the young child to undergo this procedure and that it therefore may be unlawful, even when carried out with parental consent. I also argue that, if FGM is unlawful, as it is, then other analogous procedures, such as clitoral surgery for intersex and male circumcision for non-medical reasons should similarly be unlawful. Male circumcision is held to be lawful in England at present, but the English courts have not considered genital surgery in intersex infants. If they did, then the logical conclusion ought to be to proscribe it. I argue that documents such as driving licences and passports should permit a neutral gender and that birth certification ought to permit registration without specifying sex for intersex infants. It is possible that at least some of this may come about in the future, since a recently published report from the House of Commons Women and Equalities Committee on Transgender Equality has suggested change in the current situation, one indication of the current rapid pace of change in this area of Law. I argue that education about intersex and sex and gender diversity is important for healthcare professionals and for everyone.

This study was designed to gather information about the nature and content of post-surgical play behaviour displayed by hospitalized pre-school children. Four questions were explored: Are common themes expressed in the play behaviour of hospitalized pre-school children after major surgery? Does the quality and intensity of the play behaviour demonstrated by pre-school children follow a similar pattern? Will pre-school children use play therapy as a medium through which to express fears and concerns about their hospital experience? Do children tend to act out their perceptions of what has happened to them in hospital? The population selected for the study were four girls and one boy between the ages of three and five years, who were admitted for major surgery on the heart or great vessels. During the recovery period after surgery each child had the opportunity to take part in at least five play therapy sessions lasting approximately one hour each. Play therapy took the form of situational play using real or simulated hospital equipment and various dolls representing children and adults. Each child chose the direction and content of play. The investigator took part in play as directed by the child. Parents could join in if they wished. The verbal and non-verbal behaviour displayed by each child during play therapy was recorded by audio tape and by process recordings. Four out of five children in the study participated actively in play therapy. In the course of play they expressed five common themes: intrusive procedures; re-enactment of procedures; testing reality; autonomy: regaining control; separation from home and family; and nurturing activities. The quality and intensity of the children's play behaviour followed a pattern from intense to more relaxed and from aggressive to more gentle play. During play each child expressed some individual fears and concerns about his hospitalization. Intrusive procedures were the most frequent topic of play for all the children. Finally, each child tended to act through specific procedures so that play behaviour became a factual account of the child's hospital experience. One child, the only boy in the study, did not want to participate in play therapy. The reasons for this were not investigated. It was concluded that play therapy is a useful technique which can assist nurses understand the pre-school child's perception of his hospital experience. Play therapy also has potential as a therapeutic intervention to help a child come to terms with the traumatic events of his hospitalization. / Applied Science, Faculty of / Nursing, School of / Graduate

Traveling teams of cardiovascular specialists visit poor countries to treat children born with life-threatening heart defects. Working within challenging settings, volunteers may need to build temporary operating theaters and neonatal intensive care units before beginning their work. They also try to extend their humanitarian reach beyond the confines of an in-country visit: they train locally-based personnel in surgical and critical care techniques considered routine in rich countries yet locally unavailable; they donate machines, hardware, and disposable materials to local hospitals; they even build permanent surgical centers. Pediatric heart surgery missions thus define a new context where medical technologies circulate globally. It is well-known that medical technologies have far-reaching effects, transforming societies while at the same time being transformed by them, but few scholars have explored these processes in medical humanitarian arenas. This study investigates the moral logic, medical logistics, and unanticipated effects of short-term surgical missions. The setting is Honduras: a known hub of medical mission activity. The study begins with an examination of why Honduras attracts scores of medical missions, and why children with heart defects have emerged as central objects of humanitarian concern. I argue that humanitarian sentiments dovetail with other interests and desires on the part of surgical volunteers, such as adventure travel, learning, and the allure of practicing an alternative, low-tech version of biomedicine as a corrective to disappointments, frustrations, and lulls in their everyday professional lives. I then describe how this humanitarian ethos reconfigures biomedical practice. This is followed by a discussion of the implications of pediatric heart surgery missions for host countries, such as how they inadvertently re-inscribe social hierarchies and place strain on existing health services. Finally, I follow the lives of pediatric heart patients after their surgeries, show how their parents contest any stereotypical assumptions about humanitarian aid beneficiaries, and unpack the logic underpinning consent for especially high-risk procedures. My analysis emerges from 13 months of ethnographic field research primarily in Tegucigalpa, the nation’s capital, during which I participated in six pediatric heart surgery missions, and observed and interviewed volunteer clinicians, locally-based clinicians, and the parents of pediatric heart surgery patients.

The incidence of surgical site infection (SSI) in pediatric spinal deformity has been reported to remain high in the United States in spite of efforts made to reduce SSI. The risk of SSI is associated with multiple factors. For example, the heterogeneity of patients with different clinical and surgical characteristics in this population imposes challenges to identify the most beneficial preventive strategies for individual patients. This dissertation sought to advance understanding of risk factors and preventive strategies for SSI in individual pediatric patients undergoing spinal deformity surgery. Although the literature reports various risk factors and preventive strategies associated with SSI, there are no reliable review papers using formal methodology to aggregate evidence. The first aim of the dissertation was to conduct a systematic review and a meta-analysis to assess published literature investigating associations between various risk factors and SSI in pediatric patients undergoing spine surgery. The systematic review and the meta-analysis were conducted among peer-reviewed journals published in English between January 2000 - April 2019 using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA-P). Studies included pediatric patients with spinal deformity undergoing surgical procedures in North America and were assessed for risk factors of SSI. Of 763 articles identified, thirteen met inclusion criteria after abstract or full manuscript review, and seven studies were rated as average and six as poor based on the quality checklist. The meta-analysis identified obesity/overweight, neuromuscular etiology, gastrostomy tube, non-ambulatory status, pelvic instrumentation, and high estimated blood as significant risk factors for SSI. Because the published literature does not identify which individual patients are at high risk for SSI, the second aim of this dissertation was to create a calculator using prediction modeling including patient, surgical and hospital characteristics to quantify the risk of SSI in individual patients. A retrospective cohort study was conducted using a database from seven centers that included 3,092 pediatric patients (0-21 years of age) with spinal deformity who underwent primary, revision, or definitive spinal fusion from 2004 to 2018. A total of 132 SSI (4.5%) within 90 days after surgery were identified. Candidate risk factors in this study included 31 patient, 12 surgical and 4 hospital factors that were present or determined before the surgery and unlikely to be modifiable. The final prediction model achieved adequate predictive ability (area under the curve [AUC]: 0.76) and included 10 risk factors: overweight/obese, neuromuscular etiology, American Society of Anesthesiologist Physical Status Classification System (ASA) >1, non-ambulatory status, abnormal hemoglobin (HGB) level, high white blood cell (WBC) count, revision surgery, presence of pelvic instrumentation, procedure time for ≥7 hours, and <100 spine surgical case per year per institution. Based on these findings, a risk probability calculator to predict the risk of SSI in individual patients was developed. There are a number of preventive strategies that have been recommended in consensus-based guidelines in the United States. The third aim of this dissertation was to investigate the association between preventive care measures and SSI and predict the reduction of SSI probability in individual patients by these preventive strategies. The database used in Aim 2 was also utilized to investigate the association between preventive care measures and the risk of SSI. Examined preventive strategies were the use of topical vancomycin, povidone-iodine irrigations, multilayered closure, impermeable dressing, the enrollment in Children’s Hospitals’ Solutions for Patient Safety (SPS) program or in the Comprehensive Unit-based Safety Program (CUSP), and adherence to the institutional perioperative antibiotic prophylaxis guideline. None of these preventive strategies were included in the risk model from Aim 2. When the CUSP/SPS enrollment alone was in the model, patients whose procedures were performed when sites were enrolled in the programs had 49.4% decrease in SSI (odds ratio [OR]:0.51, [95% CI: 0.32; 0.81], p=0.005) and AUC of 0.56. When CUSP/SPS enrollment was added to the risk model from Aim 2, the model revealed that patients whose procedures were performed when sites were enrolled in the CUSP/SPS had an average 48.9% decrease in SSI (odds ratio: 0.51, [95% CI: 0.29; 0.82]). The final prediction model demonstrated adequate predictive ability (AUC: 0.77). This dissertation highlighted factors associated with an increased risk of SSI and preventive strategies related to a reduced risk of SSI in pediatric patients undergoing spinal deformity surgery. The results of this study will enable healthcare providers to calculate the risk of SSI and effects of preventive strategies in reducing the risk of SSI in individual patients. In the long term, the information from this study could be used to enhance personalized care in clinical practice to prevent SSI in individual patients as well as to facilitate patient education and shared decision-making.

Bibliography: leaves 156-173 / x, 173 leaves, [6] leaves of plates : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (D.M.)--University of Adelaide, 1986

Despite the increasing acceptance of biopsychosocial models of pain and multidisciplinary treatments for pain, relatively little is known about the specific psychological variables and social processes related to postoperative pain in children, especially in an outpatient setting. The present study examined demographic, medical, and psychological predictors of children's pain and parents' administration of pain medication. Two hundred and thirty-six families with children aged 2 to 12 undergoing day surgery participated in the study. This included a subset of 100 children aged 6 to 12, who were asked to complete self-report measures of anxiety, expected pain, coping style, and pain. Parents of all children completed measures of expected pain, expected benefit from medication, perspective taking, and negative attitudes towards analgesics. Parents and school-aged children completed pain diaries on the day of surgery and two days following surgery. The prevalence of clinically significant pain was somewhat lower than in previous studies, but both pain and undertreatment (parents who gave less than the recommended amount of pain medication) remained common. Predictors of pain were examined by multiple regression, using data from the subset of 100 children aged 6 to 12. More intense pain was related to more invasive surgery, a constellation of analgesic-related variables (more doses of analgesia given, the use of a regional block, the use of local infiltration), high anxiety, high expectations of pain, and a tendency to cope with pain by acting out and catastrophizing. Predictors of dosing were examined by multiple regression, using data from the entire sample of 236 children. Parents gave more medication when their children had invasive surgery and high levels of pain, when they expected a lot of pain, and when they were relatively unconcerned about the negative effects of pain medication. In each case, the psychological variables, entered as a block, were significant predictors of pain even after controlling for demographic and medical variables. Health care providers should be aware of psychological factors predicting pain, as they may help to identify families that are at "high risk" for pain and undermedication. In addition, the variables identified in this study are appropriate targets for further research on psychological factors that cause, mediate or contribute to pain processes, and as such may contribute to the development of theoretical models of pain and pain management.