Gastroschisis is a full thickness abdominal wall defect, usually to the right of the umbilicus, through which a variable amount of viscera herniates, without a covering membrane. Newborns with gastroschisis present challenging problems to paediatric surgeons. The incidence of gastroschisis is rising worldwide. In developed countries, advances in neonatal intensive care have improved survival of patients with gastroschisis. In the few reported studies from Africa, mortality rates of patients with gastroschisis are high. The aim of this study was to evaluate outcome of gastroschisis from a centre in Africa with modern neonatal intensive care facilities. Methods: A retrospective analysis of all neonates admitted with the diagnosis of gastroschisis at Inkosi Albert Luthuli Central Hospital (IALCH) over a 6-year period (2002-2007). Proportions in percentages were used for categorical variables. For continuous variables the mean with standard deviation (SD) were derived. Two sampled t-test was used to show the pvalue for the time to reduction between the non-survivors and survivors with a 95% confidence interval. Results: There was a significant increase in the prevalence of gastroschisis among neonatal surgical admissions from 6.2% in 2003 to 15.2% in 2007. There were more females 53.4%, the majority (71.7% had low birth weight and 64.2% were born prematurely. Although 75% (n=79) of the mothers attended antenatal clinic, antenatal diagnosis by ultrasound was made in only 13 (n=12%)). Most of the babies 90.6% were out-born, with 70.8% delivered by normal vaginal delivery (NVD), and 57.4% of the mothers were primiparous. Primary closure was achieved in 73.5% of the patients. The overall mean (SD) time from birth to primary surgical intervention was 16 (13.04) hours and was higher 17(9.1) hours in those who died compared to survivors 15 (16.0), but the difference was not statistically significant, p=0.4465 and mortality was 43% with sepsis as the leading cause. Staged closure with a plastic silo bag was associated with more than double the mortality as compared to primary closure. Conclusion: The prevalence of gastroschisis among neonatal surgical admissions has increased in accordance with international trends. Due to lack of antenatal diagnosis, most of the babies were out-born resulting into delay in offering surgical treatment. Mortality is still high despite the presence of modern intensive care. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2008.

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. / Arts, Faculty of / Psychology, Department of / Graduate

A decisão da cirurgia cardíaca paliativa é um processo crítico para os pais pois envolve risco de vida para o filho. Esta pesquisa investigou aspectos das atitudes maternas na tomada de decisão da cirurgia, com a suposição de que atitudes de recusa podem estar presentes. A partir do referencial teórico da Psicanálise, entende-se que o diagnóstico médico e a indicação cirúrgica podem provocar impactos psíquicos traumáticos. A iminência de perda pela doença de prognóstico ruim, a relação risco-benefício não claramente favorável da cirurgia e o contexto do tratamento, em geral permanente e realizado fora do domicílio de origem, são aspectos que influenciam as decisões da mãe. O processo decisório (tratamento versus não tratamento) foi discutido à luz de noções da Bioética, como autonomia, participação ativa no tratamento, decisões de representação, bem como das implicações jurídicas. A não aceitação da cirurgia pode trazer conflitos de interesse na relação médico-paciente/cuidador, fazendo refletir sobre como se dão, na sociedade atual, as relações entre processos médico-biológicos e processos subjetivos. A partir da abordagem de pesquisa clínico-qualitativa utilizou-se a entrevista semi-dirigida individual. As participantes foram duas mães de crianças cardíacas que passaram por cirurgia paliativa e que estavam hospedadas na Associação de Assistência à Criança Cardíaca e à Transplantada do Coração. Observou-se atitudes de hesitação, questionamento, recusa da cirurgia e atitudes de não pensamento e aceitação imediata do procedimento. Verificou-se a presença de atitudes de recusa da cirurgia, apesar de sua posterior aceitação. Discutiu-se como tais atitudes podem ser entendidas como recusa-reflexão e não apenas como defesas psíquicas ou reações precipitadas. À medida que abre um espaço de pensamento, a recusa-reflexão teria uma função importante para o psiquismo pois auxilia na assimilação dos acontecimentos relativos ao processo decisório. Como conclusão se propõe entender a decisão como um processo e, desta perspectiva, é considerada um momento oportuno de reflexão para a mãe. Sugere-se, então, que na prática psicológica a recusa da cirurgia seja abordada como uma atitude materna possível ao processo decisório, considerando que o encaminhamento na direção do cuidado e do bem-estar global do filho não necessariamente pressupõe a aceitação da cirurgia no momento de sua indicação, da mesma forma que a recusa inicial não significa que seja definitiva. Indica-se o suporte psicológico na decisão da cirurgia que, por legitimar as ambivalências psíquicas, as dúvidas e hesitações desse processo, poderá favorecer um espaço de reflexão e elaboração subjetiva onde se abra a possibilidade de se tomar uma decisão ponderada, consequente, e com a qual a mãe, o pai, a criança, a família, poderão conviver / Decision-making before palliative heart surgery is a critical process for parents because it involves a risk to their childs life. This study investigated aspects of maternal attitudes in deciding about surgery, and takes into account the assumption that attitudes of refusal may be present. Based on Psychoanalysis theoretical framework, we understand that medical diagnosis and indication for surgery may cause psychic trauma. The imminence of loosing ones child due to the poor prognosis associated with the condition, the risk-benefit relationship not clearly favorable to surgical intervention, and the context of treatment, which is in general permanent and carried out outside the patients city of residence, are aspects that influence maternal decision-making. The decision-making process (treatment versus non-treatment) is discussed in the light of notions from the field of Bioethics, such as autonomy, active participation in treatment, proxy decision-making, as well as in the light of the legal implications. Refusing surgery can cause conflicts of interest in the doctor-patient/caregiver relationship, which engenders thinking about how the relationship between medical and biological processes, and subjective processes take place in todays society. The qualitative research design comprised an individual semi-structured questionnaire survey. The two participants were mothers of cardiac children who went through palliative heart surgery and were staying at the Associação de Assistência à Criança Cardíaca e à Transplantada do Coração [Association for Assisting Cardiac and Heart-Transplanted Children]. The attitudes observed were attitudes of hesitation, questioning, refusal of surgery, and attitudes of not thinking, and of immediate acceptance of the surgical procedure. The presence of refusal of surgery was found, despite being followed by acceptance. We discuss how such attitudes can be understood as reflective refusal and not merely as defense mechanisms or unthought reactions. As space is made for thinking, reflective refusal plays a major role in the mental processes because it helps in assimilating events concerning the decision-making process. As a conclusion this study proposes understanding decision-making as a process and, from this perspective, it is considered an opportune moment for maternal reflection. Therefore, it is suggested that during psychological practice, refusal of surgery be approached as a possible maternal attitude during decision-making, taking into account that the caring and global well being of the child do not necessarily presuppose acceptance of surgery at the moment of indication. Likewise, initial refusal does not mean such refusal is final. This study further recommends psychological support for making such decision, which, in bringing about psychological ambivalence, doubt, and hesitation concerning the decision-making process, can promote a place for subjective reflection and elaboration, where there is the possibility of making a wise and pondered decision, with which the mother, the father, the child, and the family, can live with

A decisão da cirurgia cardíaca paliativa é um processo crítico para os pais pois envolve risco de vida para o filho. Esta pesquisa investigou aspectos das atitudes maternas na tomada de decisão da cirurgia, com a suposição de que atitudes de recusa podem estar presentes. A partir do referencial teórico da Psicanálise, entende-se que o diagnóstico médico e a indicação cirúrgica podem provocar impactos psíquicos traumáticos. A iminência de perda pela doença de prognóstico ruim, a relação risco-benefício não claramente favorável da cirurgia e o contexto do tratamento, em geral permanente e realizado fora do domicílio de origem, são aspectos que influenciam as decisões da mãe. O processo decisório (tratamento versus não tratamento) foi discutido à luz de noções da Bioética, como autonomia, participação ativa no tratamento, decisões de representação, bem como das implicações jurídicas. A não aceitação da cirurgia pode trazer conflitos de interesse na relação médico-paciente/cuidador, fazendo refletir sobre como se dão, na sociedade atual, as relações entre processos médico-biológicos e processos subjetivos. A partir da abordagem de pesquisa clínico-qualitativa utilizou-se a entrevista semi-dirigida individual. As participantes foram duas mães de crianças cardíacas que passaram por cirurgia paliativa e que estavam hospedadas na Associação de Assistência à Criança Cardíaca e à Transplantada do Coração. Observou-se atitudes de hesitação, questionamento, recusa da cirurgia e atitudes de não pensamento e aceitação imediata do procedimento. Verificou-se a presença de atitudes de recusa da cirurgia, apesar de sua posterior aceitação. Discutiu-se como tais atitudes podem ser entendidas como recusa-reflexão e não apenas como defesas psíquicas ou reações precipitadas. À medida que abre um espaço de pensamento, a recusa-reflexão teria uma função importante para o psiquismo pois auxilia na assimilação dos acontecimentos relativos ao processo decisório. Como conclusão se propõe entender a decisão como um processo e, desta perspectiva, é considerada um momento oportuno de reflexão para a mãe. Sugere-se, então, que na prática psicológica a recusa da cirurgia seja abordada como uma atitude materna possível ao processo decisório, considerando que o encaminhamento na direção do cuidado e do bem-estar global do filho não necessariamente pressupõe a aceitação da cirurgia no momento de sua indicação, da mesma forma que a recusa inicial não significa que seja definitiva. Indica-se o suporte psicológico na decisão da cirurgia que, por legitimar as ambivalências psíquicas, as dúvidas e hesitações desse processo, poderá favorecer um espaço de reflexão e elaboração subjetiva onde se abra a possibilidade de se tomar uma decisão ponderada, consequente, e com a qual a mãe, o pai, a criança, a família, poderão conviver / Decision-making before palliative heart surgery is a critical process for parents because it involves a risk to their childs life. This study investigated aspects of maternal attitudes in deciding about surgery, and takes into account the assumption that attitudes of refusal may be present. Based on Psychoanalysis theoretical framework, we understand that medical diagnosis and indication for surgery may cause psychic trauma. The imminence of loosing ones child due to the poor prognosis associated with the condition, the risk-benefit relationship not clearly favorable to surgical intervention, and the context of treatment, which is in general permanent and carried out outside the patients city of residence, are aspects that influence maternal decision-making. The decision-making process (treatment versus non-treatment) is discussed in the light of notions from the field of Bioethics, such as autonomy, active participation in treatment, proxy decision-making, as well as in the light of the legal implications. Refusing surgery can cause conflicts of interest in the doctor-patient/caregiver relationship, which engenders thinking about how the relationship between medical and biological processes, and subjective processes take place in todays society. The qualitative research design comprised an individual semi-structured questionnaire survey. The two participants were mothers of cardiac children who went through palliative heart surgery and were staying at the Associação de Assistência à Criança Cardíaca e à Transplantada do Coração [Association for Assisting Cardiac and Heart-Transplanted Children]. The attitudes observed were attitudes of hesitation, questioning, refusal of surgery, and attitudes of not thinking, and of immediate acceptance of the surgical procedure. The presence of refusal of surgery was found, despite being followed by acceptance. We discuss how such attitudes can be understood as reflective refusal and not merely as defense mechanisms or unthought reactions. As space is made for thinking, reflective refusal plays a major role in the mental processes because it helps in assimilating events concerning the decision-making process. As a conclusion this study proposes understanding decision-making as a process and, from this perspective, it is considered an opportune moment for maternal reflection. Therefore, it is suggested that during psychological practice, refusal of surgery be approached as a possible maternal attitude during decision-making, taking into account that the caring and global well being of the child do not necessarily presuppose acceptance of surgery at the moment of indication. Likewise, initial refusal does not mean such refusal is final. This study further recommends psychological support for making such decision, which, in bringing about psychological ambivalence, doubt, and hesitation concerning the decision-making process, can promote a place for subjective reflection and elaboration, where there is the possibility of making a wise and pondered decision, with which the mother, the father, the child, and the family, can live with

Les transfusions de globules rouges représentent le traitement principal de l’anémie. La décision de transfuser représente un vrai dilemme clinique. L’anémie et les transfusions de globules rouges sont toutes les deux associées à des risques et à un moins bon devenir des patients, alors que le bénéfice des transfusions sanguines reste difficile à démontrer. C’est pour cela que la décision de transfuser ne doit pas être pris à la légère et qu’elle doit tenir compte de la balance antre les risques des transfusions de globules rouges et les risques de l’anémie. L’anémie, définie comme un taux d’hémoglobine sous la moyenne pour l’âge, est fréquente chez les enfants en péri-opératoire de chirurgie cardiaque. Les conséquences de l’anémie sont une diminution du transport en oxygène vers les cellules. Le taux d’hémoglobine sous lequel la demande tissulaire en oxygène est compromise n’est pas connue et dépend de l’état de santé du patient et de ses comorbidités. Les causes peropératoires de l’anémie sont surtout le saignement et l’hémodilution. Une diminution de la production d’érythropoïétine endogène, une dérégulation du métabolisme du fer, une production défectueuse de la moelle et la répétition des prélèvements sanguins contribuent à l’anémie postopératoire. L’anémie est associée à des évènements indésirables et un moins bon devenir, mais cette association semble en grande partie expliquée par la pathologie sous-jacente, elle-même associée à l’anémie. Les transfusions en globules rouges sont fréquentes en chirurgie cardiaque pédiatrique. Le rapport bénéfice-risque des transfusions sanguines reste difficile à évaluer. Alors que les études rapportant des bénéfices clairs des transfusions sanguines restent rares, plusieurs travaux observent une association entre les transfusions en globules rouges et une augmentation de la morbidité et mortalité. En outre, les transfusions sanguines demeurent une ressource rare et chère. <p>Le but de ce travail est de contribuer à une meilleure utilisation des transfusions sanguines chez les patients de chirurgie cardiaque pédiatrique. Dans la première partie du travail, nous avons étudié les déterminants des transfusions en globules rouges et du saignement, qui représentent une des causes principales de transfusion sanguine chez ces patients. Une meilleure identification et une prise en charge adéquate des facteurs qui mènent aux transfusions sanguines devraient diminuer le nombre de transfusions inappropriées. Dans la deuxième partie de ce travail, nous nous sommes penchés sur l’association entre les transfusions sanguines et le mauvais pronostic des patients en étudiant deux approches :l’âge des globules rouges transfusés et l’indication transfusionnelle. Une meilleure compréhension des facteurs associés à un moins bon pronostic devrait permettre de mieux définir les patients qui bénéficieraient réellement de transfusions en globules rouges. <p>En ce qui concerne les déterminants des transfusions sanguines, nous avons démontré que l’anémie préopératoire était significativement associée aux transfusions sanguines péri-opératoires. Les enfants qui saignent reçoivent beaucoup de produits sanguins. Nous avons déterminé les patients à risque de saignement afin de les reconnaître et les soumettre à des tests de coagulation rapides pour orienter le type de produits sanguins à transfuser en fonction des anomalies de coagulation mises en évidence. Puisque l’anticoagulation par héparine est systématique chez les patients opérés sous circulation corporelle, nous avons étudié si notre protocole de neutralisation de l’héparine avec de la protamine était adéquat. En effet, la persistance d’héparine circulante ainsi qu’un surdosage en protamine sont associés à des saignements postopératoires. Un ratio protamine-héparine de 1:2 semble permettre une neutralisation adéquate de l’héparine chez la majorité des patients sans les exposer à un surdosage en protamine. Finalement, nous avons démontré qu’une stratégie transfusionnelle restrictive en postopératoire permettait de diminuer l’exposition aux transfusions sanguines sans augmenter la morbidité et mortalité de ces enfants. Cela signifie qu’on pourrait éviter des transfusions en globules rouges en prenant en charge l’anémie préopératoire, en développant un algorithme de prise en charge précoce du saignement peropératoire et en diminuant le seuil transfusionnel postopératoire. <p>La deuxième partie de ce travail avait pour but de préciser l’association qu’il existe entre les transfusions en globules rouges et la morbidité et mortalité postopératoire. L’âge du sang n’a pas l’air d’être un facteur influençant le pronostic des enfants opérés de chirurgie cardiaque. Par contre, ce travail a permis de montrer que c’est probablement l’indication transfusionnelle ou la raison qui mène à la transfusion, plutôt que la transfusion en elle-même qui est associée à un moins bon pronostic. L’association entre les transfusions sanguines et un moins bon pronostic est probablement surestimée par la présence de facteurs confondants comme l’indication transfusionnelle. Les transfusions en globules rouges seraient plutôt un marqueur de risque qu’un facteur de risque de mauvais pronostic.<p>En conclusion, ce travail contribue au développement de stratégies transfusionnelles plus rationnelles en chirurgie cardiaque pédiatrique. Reposant sur une approche multidisciplinaire, elles assurent une prise en charge structurée et orientée permettant de diminuer l’exposition des enfants aux produits sanguins, avec pour objectif une amélioration du pronostic et une réduction des coûts de prise en charge de ceux-ci. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

The field of structural design optimization is one with great breadth and depth in many engineering applications. From the perspective of a designer, three distinct numerical methodologies may be employed. These include size, shape, and topology optimization, in which the ordering typically (but not always) corresponds to the order of increasing complexity and computational expense. This, of course, depends on the particular problem of interest and the selected numerical methods. The primary focus of this research employs density-based topology optimization with the goal of improving structural resistance to failure. Beginning with brittle fracture, two topology optimization based formulations are proposed in which low weight designs are achieved with substantially increased fracture resistance. In contrast to the majority of the current relevant literature which favors stress constraints with linear elastic physics, we explicitly simulate brittle fracture using the phase field method during the topology optimization procedure. In the second formulation, a direct comparison is made against results obtained using conventional stress-constrained topology optimization and the improved performance is numerically demonstrated. Multiple enhancements are proposed including a numerical efficiency gain based on the Schur-complement during the analytical sensitivity analysis and a new function which provides additional path information to the optimizer, making the gradient-based optimization problem more tractable in the presence of brittle fracture physics. Subsequently, design for ductile failure and buckling resistance is addressed and a numerically efficient topology optimization formulation is proposed which may provide significant design improvements when ductile materials are used and extreme loading situations are anticipated. The proposed scheme is examined regarding its impact on both the peak load carrying capacity of the structure and the amount of external work required to achieve this peak load, past which the structure may no longer be able to support any increase in the external force. The optimized structures are also subjected to a post-optimization verification step in which a large deformation phase field fracture model is used to numerically compare the performance of each design. Significant gains in structural strength and toughness are demonstrated using the proposed framework. Additionally, the failure behavior of 3D-printed polymer composites is investigated, both numerically and experimentally. A large deformation phase field fracture model is derived under the assumption of plane-stress for numerical efficiency. Experimental results are compared to numerical simulations for a composite system consisting of three stiff circular inclusions embedded into a soft matrix. In particular, we examine how geometric parameters, such as the distances between inclusions and the length of initial notches affect the failure pattern in the soft composites. It is shown that the mechanical performance of the system (e.g. strength and toughness) can be tuned through selection of the inclusion positions which offers useful insight for material design. Finally, a size optimization technique for a cardiovascular stent is proposed with application to a balloon expandable prosthetic heart valve intended for the pediatric population born with Congenital Heart Disease (CHD). Multiple open heart surgical procedures are typically required in order to replace the original diseased valve and subsequent prosthetic valves with those of larger diameter as the patient grows. Most expandable prosthetic heart valves currently in development to resolve this issue do not incorporate a corresponding expandable conduit that is typically required in a neonate without a sufficiently long Right Ventricular Outflow Tract (RVOT). Within the context of a particular design, a numerical methodology is proposed for designing a metallic stent incorporated into the conduit between layers of polymeric glue. A multiobjective optimization problem is solved, not only to resist the retractive forces of the glue layers, but also to ensure the durability of the stent both during expansion and while subject to the anticipated high cycle fatigue loading. It is demonstrated that the surrogate-based optimization strategy is effective for understanding the trade-offs between each performance metric and ultimately efficiently arriving at a single optimized design candidate. Finally, it is shown that the desired expandability of the device from 12mm to 16mm inner diameter is achievable, effectively eliminating at least one open heart surgical procedure for certain children born with CHD.

La coagulopathie induite par la circulation extracorporelle (CEC) chez les enfants porteurs d’une cardiopathie congénitale et bénéficiant d’une chirurgie cardiaque est complexe et multifactorielle. La prise en charge de ces enfants est délicate et doit être spécifique aux caractéristiques de cette population. De plus, cette prise en charge doit être multimodale, basée sur la prévention et le traitement précoce et ciblé. <p>Dans la première partie de ce mémoire, nous avons étudié la place de l’acide tranexamique, agent antifibrinolytique, dans la prévention de la fibrinolyse chez les enfants bénéficiant d’une chirurgie cardiaque avec CEC. Nous avons évalué les propriétés pharmacocinétiques et pharmacodynamiques de la molécule dans cette population particulière. Notre hypothèse étant que l’utilisation de schémas adaptés pourrait permettre d’optimaliser la balance bénéfice/risque de l’utilisation prophylactique de l’acide tranexamique. <p>Nous avons également développé un modèle expérimental susceptible d’améliorer la sensibilité des tests viscoélastiques pour la détection de la fibrinolyse et qui pourrait être utilisé pour estimer la concentration minimale d’acide tranexamique nécessaire pour inhiber la fibrinolyse. <p>Dans la seconde partie de ce mémoire, nous avons étudié l’importance de l’implémentation d’une prise en charge adaptée de la coagulopathie, en utilisant un algorithme défini en tenant compte des caractéristiques de la population cible. Si le ROTEM® s’avère être un outil important, son utilisation doit être limitée aux enfants qui présentent un saignement anormal afin de guider l’administration de produits hémostatiques. L’ensemble de nos travaux contribue à l’amélioration de nos connaissances dans la prise en charge de l’enfant à risque de saignement en période péri-opératoire de chirurgie cardiaque. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

The aim of this study was to develop a Gestalt play therapy based hospital preparation program for children undergoing the surgical procedures of grommet insertion, or grommet insertion and adenoidectomy, at Tygerberg Hospital. Literature was reviewed according to relevant topics, namely otitis media in children, Gestalt play therapy, theories of child development, and children's experience of illness and hospitalisation. Semi-structured interviews were conducted with four subject groups and the data obtained was qualitatively analysed. Research findings were discussed and integrated with reference to the literature. This information was applied in the development of the proposed program. The aim, underlying principles, objectives and components of the program were discussed and guidelines for implementation were provided. The program was implemented and evaluated in a single subject pilot study, which yielded a positive response. Recommendations for both practical implementation in a therapeutic context and further study in a research context were made. OPSOMMING Die doel van hierdie studie was om `n Gestalt spelterapie-gebaseerde hospitaalvoorbereidingsprogram te ontwikkel vir kinders wat die chirurgiese prosedures van ventilasiebuis-plasing of ventilasiebuis-plasing en adenoïdektomie by Tygerberg-hospitaal ondergaan. `n Literatuurstudie is uitgevoer rakende relevante onderwerpe; naamlik, otitis media in kinders, Gestalt spelterapie, kinderontwikkelingsteorieë, en kinders se ervaring van siekte en hospitalisasie. Semi-gestruktureerde onderhoude is met vier subjekgroepe uitgevoer en die data wat verkry is, is kwalitatief geanaliseer. Navorsingsbevindinge is bespreek en geïntegreer met verwysing na die literatuur. Hierdie inligting is toegepas in die ontwikkeling van die voorgestelde program. Die doel, onderliggende beginsels, doelstellings en komponente van die program is bespreek en riglyne vir die implementering daarvan is verskaf. Die program is geïmplimenteer en geëvalueer in `n enkelsubjek loodsstudie, waar `n positiewe respons verkry is. Aanbevelings vir beide praktiese implementering in `n terapeutiese konteks en verdere studie binne navorsingskonteks is gemaak. / Social Work / M.Diac.

The aim of this study was to develop a Gestalt play therapy based hospital preparation program for children undergoing the surgical procedures of grommet insertion, or grommet insertion and adenoidectomy, at Tygerberg Hospital. Literature was reviewed according to relevant topics, namely otitis media in children, Gestalt play therapy, theories of child development, and children's experience of illness and hospitalisation. Semi-structured interviews were conducted with four subject groups and the data obtained was qualitatively analysed. Research findings were discussed and integrated with reference to the literature. This information was applied in the development of the proposed program. The aim, underlying principles, objectives and components of the program were discussed and guidelines for implementation were provided. The program was implemented and evaluated in a single subject pilot study, which yielded a positive response. Recommendations for both practical implementation in a therapeutic context and further study in a research context were made. OPSOMMING Die doel van hierdie studie was om `n Gestalt spelterapie-gebaseerde hospitaalvoorbereidingsprogram te ontwikkel vir kinders wat die chirurgiese prosedures van ventilasiebuis-plasing of ventilasiebuis-plasing en adenoïdektomie by Tygerberg-hospitaal ondergaan. `n Literatuurstudie is uitgevoer rakende relevante onderwerpe; naamlik, otitis media in kinders, Gestalt spelterapie, kinderontwikkelingsteorieë, en kinders se ervaring van siekte en hospitalisasie. Semi-gestruktureerde onderhoude is met vier subjekgroepe uitgevoer en die data wat verkry is, is kwalitatief geanaliseer. Navorsingsbevindinge is bespreek en geïntegreer met verwysing na die literatuur. Hierdie inligting is toegepas in die ontwikkeling van die voorgestelde program. Die doel, onderliggende beginsels, doelstellings en komponente van die program is bespreek en riglyne vir die implementering daarvan is verskaf. Die program is geïmplimenteer en geëvalueer in `n enkelsubjek loodsstudie, waar `n positiewe respons verkry is. Aanbevelings vir beide praktiese implementering in `n terapeutiese konteks en verdere studie binne navorsingskonteks is gemaak. / Social Work / M.Diac.