Art has the power to bring together communities of people who have suffered from traumatic experiences, and allow them to heal, and overall dismantles the stigma associated with it. My work delves into the emotional side of living with pediatric cancer from the child’s perspective, particularly my own experiences as a brainstem tumor survivor, and the overall concerns of fragility. This paper explores these perspectives that are severely lacking throughout studies, while also taking a closer look at how artists, such as Frida Kahlo and Jamie Bates Slone, have used art to reflect on and express emotions concerning personal traumas. My thesis project demonstrates how art, or in my case clay, can emphasize the resiliency of young children in overcoming pediatric cancer, and fosters a greater understanding, by focusing on the hopeful side of the diagnosis, in those who may only recognize fragility.

FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / O sucesso do tratamento endodÃntico depende de muitos fatores, sendo a reduÃÃo ou eliminaÃÃo da infecÃÃo bacteriana o mais importante desses fatores. Portanto, o uso de substÃncias capazes de agir nesses microorganismos e em seus subprodutos torna-se uma etapa importantÃssima no tratamento. O objetivo deste ensaio clÃnico âsplit-mouthâ foi comparar a eficÃcia da clorexidina gel 1% e do hidrÃxido de cÃlcio associado ao paramonoclorofenol canforado (Callen PMCCÂ), como medicaÃÃo intracanal, e do tratamento executado em sessÃo Ãnica (grupo controle), contra Estreptococos do grupo mutans (EGM) e bactÃrias anaerÃbias presentes no interior dos canais radiculares de molares decÃduos com necrose pulpar. Um total de 21 crianÃas (37 dentes) participou do estudo. Amostras iniciais (prÃ-tratamento) e finais (apÃs a permanÃncia das substÃncias por 14 dias no interior dos canais) foram coletadas para anÃlise microbiolÃgica e incubadas em placas de Mitis Salivarius Bacitracina, em aerofilia, para a observaÃÃo dos nÃveis de EGM, assim como em placas de Brucella Ãgar, em anaerobiose, para verificaÃÃo de bactÃrias anaerÃbias. Os nÃveis de sucesso da pulpectomia apÃs um perÃodo de acompanhamento de atà 12 meses foram analisados baseados em parÃmetros clÃnicos e radiogrÃficos. A clorexidina gel a 1% reduziu significantemente os nÃveis de EGM (p= 0,010, teste de Wilcoxon) e o Callen PMCC reduziu significantemente os nÃveis de bactÃrias anaerÃbias (p=0,002, teste de Wilcoxon). Observou-se diferenÃa significativa na comparaÃÃo da reduÃÃo dos nÃveis de EGM obtidos pelo grupo da clorexidina e pelo controle (p=0,032, Mann-Whitney). A taxa de sucesso do tratamento foi de 81,71% no grupo do Callen PMCCÂ, 78,57% para o grupo da clorexidina gel 1% e 77,77% no grupo controle. Concluiu-se que a clorexidina gel a 1%, assim como o hidrÃxido de cÃlcio associado ao paramonoclorofenol canforado, possui eficÃcia limitada na reduÃÃo de bactÃrias dos canais radiculares decÃduos infectados. Os presentes resultados sugerem que uma possÃvel associaÃÃo entre as medicaÃÃes testadas em estudos futuros pode eliminar de maneira mais eficaz estas bactÃrias. / The success of endodontic treatment depends on many factors, and the reduction or elimination of bacterial infection is the most important one. Therefore, the use of substances that act against these microorganisms and their products becomes an important stage in treatment. The aim of this in vivo split-mouth study was to compare the efficacy of a 1% chlorhexidine gel, calcium hydroxide/camphorated paramonochlorophenol (Callen PMCCÂ) as intracanal medications, and a Control group (1-visit endodontic treatment) against mutans streptococci (EGM) and anaerobic bacteria found in primary molars with necrotic pulps. A total of 21 children (37 teeth) participated in this study. Initial (pre-treatment) and final (14 days post-treatment) intra-canal samples were collected for microbiological analysis and were incubated in Mitis Salivarius Bacitracin plates under microaerophilic conditions for EGM counting; as well as in Brucella-agar plates, anaerobically, to allow growth of anaerobic bacteria. The success rate of the pulpectomies after a 12 months follow-up were also evaluated based on clinical and radiographic parameters. Chlorhexidine gel significantly reduced EGM levels (p=0,010, Wilcoxon test), whereas Callen PMCC significantly reduced anaerobic bacteria levels (p=0,002). Significant difference was observed when comparing EGM reduction levels between the Chlorhexidine and Control groups (p=0,032, Mann-Whitney test). The success rate was 81,71% in the Callen PMCC group, 78.57% in the Chlorhexidine group and 77.77% in the control group. We concluded that 1% chlorhexidine gel, as well as calcium hydroxide/camphorated paramonochlorophenol, has limited efficacy in the reduction of bacteria from deciduous infected root canals. The present results suggest that a possible association between these two medications in future studies may eliminate more efficiently these bacteria.

Progressive Neuromuscular Diseases (PNDs) are relentless, debilitating, incurable diseases that cause nerves and muscles to atrophy. A large portion of the population who experience PNDs are adolescents. These adolescents progressively lose physical abilities and increasingly rely on caregivers at a time in their life when, paradoxically, normative adolescent development prescribes a move towards independence and autonomy. There is little research examining this experience from the adolescents’ perspectives. The purpose of this interpretive phenomenology study was to understand the experience of adolescents with PNDs when making decisions in relation to their health. Data collection consisted of 10 semi-structured interviews with 5 adolescents, 16-19 years of age, who were living with a PND (two interviews with each of the 5 participants). These interviews lasted an average of 60 minutes. Data were analysed using interpretive strategies, including the development of themes using exemplars, and paradigm cases. Findings revealed that the adolescents separated health decisions into two distinct categories, Big and Small, based upon level of perceived risk and physician involvement. Big referred to high-risk decisions, included physicians, and involved a medical/surgical procedure or intervention. Small referred to lower risk decisions, did not include physicians, and involved personal care. An expert emerged with each category of decision. In Big Decisions, the physician was perceived as the expert who made recommendations, provided information, and introduced the decision. In Small Decisions, the adolescent perceived himself as the expert. With Big Decisions, the physician expertise was typically respected, and the recommendations were followed. With Small Decisions, parents typically respected adolescent expertise. However, the adolescents commonly experienced not having their expertise respected by health professionals. In the context of Big and Small decisions, the theme Joint Ownership captured the sense that with the progressive loss of abilities and resulting dependence, the physical disability and illness were not experienced solely by the adolescent but by the adolescent and his parent(s). As the parent(s) and adolescent shared these experiences, the decisions, ownership of the physical body, and the responsibility for the care of the body also became shared. The findings suggest that health care professionals need to include the adolescents in the Small Decisions, and also acknowledge that adolescents may desire parental involvement in Big Decisions. / Applied Science, Faculty of / Nursing, School of / Graduate

Class of 2016 Abstract / Objectives: The specific aims of this study were: 1) describe the frequency of off-label medication use in pediatric discharge medication regimens, 2) compare the frequency of FDA-approved and off-label medication use in pediatric discharge medication regimens, and 3) identify potential patient-specific risk factors, including use off-label use of medications, associated with 90-day readmission. Methods: This was a retrospective chart review of pediatric patients admitted to a tertiary academic medical center during a 6-month period. Inclusion criteria included age less than 18 years of age and admission between January 1, 2014 and June 30, 2014. Exclusion criteria included admission for oncology chemotherapy, admitted < 24 hours, admission to NICU only and patient expiration prior to discharge. Data collection included patient demographics, types and number of medications, and FDA approved and off-label indication of medications. Data analyses were completed on STATA 11.0 (College Station, TX) including student t-test/Mann Whitney U and Chi square/Fisher Exact test with a priori of α= 0.05. Results: A total of 706 admissions were included in the study. There were no significant differences in demographic characteristics between groups (readmitted within 90 days of discharge vs. not readmitted within 90 days of discharge) except sex (males vs. females, 56.3% vs. 44.2%, p=0.034). Length of hospital stay was significantly higher in subjects readmitted within 90 days of discharge compared to those who were not (8.55 ± 12.5 vs. 3.79 ± 4.43 days, p<0.001). Number of medications at discharge (7.31 ± 5.92 vs. 2.91 ± 2.93, p<0.001) and total number of non-FDA approved medications (3.16 ± 3.81 vs. 1.12 ± 1.44, p<0.001) were all significantly higher in subjects readmitted within 90 days of discharge compared to those who were not. The percentages of patients taking medications related to cardiovascular (6.1% vs. 2.4%, p=0.002), electrolytes and nutrition (12.2% vs. 8.5%, p=0.007), and gastrointestinal (19.2% vs. 14.3%, p=0.004) disorders were significantly higher in the subjects readmitted within 90 days of discharge compared to those who were not. Additonally, subjects readmitted within 90 days of discharge (versus those not readmitted within 90 days) demonstrated less use of medications related to neurology (17.7% vs. 25.8%, p<0.001) and respiratory (16.4% vs. 21.4%, p=0.008) disorders. A significantly higher percentage of subjects whose third party payor was Medicaid, were readmitted within 90-days of discharge (69.7% vs. 58.3, p=0.045). Conclusions: In comparing several characteristics of pediatric patients readmitted to a tertiary medical center within 90 days of discharge versus those who were not, it was noted that several factors may be associated with readmission, including: sex, length of initial hospital stay, third-party payor, and the number of medications as well as the types of medication a patient takes. Future research may be warranted to further investigate these potential patient-specific factors in helping identify children at increased risk for readmission and develop more effective approaches to patient education, discharge planning, and continuity of care to reduce preventable readmission.

Magister Scientiae Dentium - MSc(Dent) / Teething, a common subject of discussion among nursing mothers has been held responsible for a variety of childhood ailments by both health professionals and parents. It appears to be a social construct coined by society to express the experience the child goes through during early days of childhood. Teething to the dental profession is the biological expression of tooth movement, in a predominantly axial direction, from the tooth's developmental position within the jaws to its emergence in the oral cavity. Several studies have reported both health professionals and parents to attribute local and systematic disturbances to the eruption of the primary dentition. The mothers experience and understanding of teeting have not been reported on. The aim of this study was therefore to explore the mothers experience of their child's teething. The objectives of the study were to determine what mothers understood by the term teething; to establish the signs and symptoms mothers associate with teething; to ascertain the treatment sought by mothers for their child's teething; to investigate how mothers in different setting understand and respond to teething. / South Africa

Juvenile idiopathic arthritis (JIA) is a common chronic disease of childhood. Children with JIA have lower peak oxygen consumption (V0₂ peak) than healthy children. In order to examine the cardiorespiratory response during aerobic exercise and the anaerobic to aerobic ratio (metabolic index), maximal exercise tests were performed in JIA subjects and age- and sex-matched controls (CON). Thirteen children aged 10 to 17 years with JIA and 9 CON participated. Peak powe r(watts, W) and total work (Joules, j) were determined with the Wingate anaerobic cycling test. VO₂ peak was measured by a maximal staged exercise test on a cycle ergometer. Cardiac output (CO, liters/minute) was measured with Doppler echocardiography. Arterial — mixed venous oxygen index (A-V0₂) and systemic vascular resistance (SVR) were calculated. Patient questionnaires included habitual activity, visual analog scale for joint pain and the childhood health assessment questionnaire. Physician completed data included active joint count and articular severity index. Compared to CON and reference age-matched norms, JIA subjects had lower aerobic fitness. VO₂ peak in JIA was 31.3 ml/min/kg (20.2-49.9), Z score -1.4 (-.06--2.4) and in CON was 47.9 ml/min/kg (32.7-54.1), Z score of -0.17 (-1.6-.87). [p = 0.013 V0₂ peak, p=0.011 Z score]. There were no significant differences in CO, A-V0₂ or SVR buttrends towards lower CO and higher SVR in JIA subjects were observed. During anaerobic exercise JIA subjects completed less total work (168.5 j/kg (107-252) JIA, 224 j/kg (180-248) CON, p=.036) but had similar peak power (9.7 W/kg (5.6-13.7) JIA, 11.3 W/kg (9.8-14.5) CON, p=.095). The metabolic index did not differ between JIA and CON. There was no significant correlation between disease activity, function and fitness measures in JIA subjects. Children with JIA have moderate impairments in aerobic fitness. CO and A-V0₂ during aerobic exercise did not significantly differ between JIA subjects and CON. Anaerobic fitness was mildly impaired with less total work completed by JIA subjects. Further research with larger numbers is required to determine factors contributing to limited fitness in JIA. / Education, Faculty of / Kinesiology, School of / Graduate

Obesity is a growing concern in North America and current research suggests that for addressing childhood obesity, family-based behavioural interventions targeting children are the treatment of choice. Due to the lack of clinics that offer face to face treatment, the Internet may serve as a viable method for the delivery of such interventions. Three studies are presented in order to explore the viability of the internet as a treatment modality for delivering family-based interventions for children who are overweight. The first study attempted to deliver a family-based behavioural intervention via the internet - the Healthy Eating and Active Living Throughout Youth (HEALTHY) - for children aged 8 to 14 (M = 10.5). The initial goal was to evaluate the effectiveness of the internet as a treatment modality for childhood obesity. A total of 20 families consisting of 25 child-parent dyads consented to the intervention. However, adherence and attrition were significant issues throughout the 3-month intervention and only two child-parent dyads (8%) completed the 3-month intervention. Therefore the goals of this study changed to become primarily exploratory, with the aims of identifying factors related to treatment adherence and attrition. For the second study, the parents of the 20 families who consented to the HEALTHY intervention were invited to participate in a telephone interview around their impressions of the study, barriers to participation, and their needs in seeking services for their children. Sixteen families (80%) provided consent and thematic analyses were conducted. Four categories of themes emerged from the data and included: 'Knowledge and Education', 'Social Supports', 'Tools for Success', and 'Program Goals'. These categories, and the themes embedded within each category are presented and discussed. For the third study a systematic review of exclusively web-based studies for paediatric obesity was conducted. Five health and social sciences databases were search between 1995 and March 2012 (including an initial and updated search). A total of 2432 bibliographic records were identified (following de-duplication) and were subjected to title and abstract screening, and a further 120 records were subject to full-text screening. Two reviewers independently assessed the eligibility of each bibliographic record at these multiple levels and conflicts were resolved by third party. Three records were included in the review, and a further three records were identified as noteworthy in that they reported on one larger web-based study with a minimal face-to-face component (i.e., 4 sessions over 2 years). Data regarding attrition, adherence, and body composition changes were extracted by two independent reviewers. Attrition rates from the included studies ranged from 43% to 85%. The noteworthy study reported 18% overall attrition at six months (following randomization: 18% from the intervention group) and 34% overall attrition at two years (following randomization: 36% from the intervention group). Adherence measures were varied, but suggested low adherence to study components. Body composition changes were marginal in the short-term, but then lost in the longer-term. Implications for research and practice will be discussed. The contributions of this thesis include examining whether family-based interventions for pediatric obesity delivered over the internet are feasible. This question will be answered by exploring baseline characteristics that are related to treatment adherence and attrition, investigating barriers that interfere with adherence and contribute to attrition, and reviewing other research conducted in the field. Following from this thesis, and other relevant research, implications and recommendations for future research and clinical practice will be discussed

This research aims to assess the practice pattern of Canadian emergency physicians for management of anaphylaxis and investigate the clinical predictors for biphasic reactions in children with anaphylaxis. We conducted two studies: a national survey and a multicenter Health Records (HR) review of emergency department visits. Of the 608 physicians surveyed, 340 (56%) responded. Overall, 211(62%) of the physicians correctly agreed that both hypothetical scenarios in the survey were consistent with anaphylaxis, and 206(61%) chose to administer epinephrine. In our HR review, we found five independent predictors of biphasic reactions: age 6-9 years (OR 3.60; 95% CI 1.5-8.58), time from onset of the anaphylactic reaction to ED presentation >90 minutes (OR 2.58; 95% CI 1.47-4.53), wide pulse pressure at triage (OR 2.92; 95% CI 1.69-5.04), treatment of the reaction with >1 dose of epinephrine (OR 2.7; 95% CI 1.12-6.55), and administration of inhaled salbutamol in ED (OR 2.39; 95% CI 1.24-4.62).

Class of 2008 Abstract / Objectives: This was a retrospective chart review and survey of pediatric residents. This study aimed to examine standards for aminoglycosides in obese pediatrics; increase awareness of drug monitoring in obese populations; and reduce medication errors. Methods: 101 patients aged three to seventeen that received aminoglycoside treatment were included. Subjects were divided into three groups based on weight and height percentiles as defined by growth charts. Collecting retrospective data provided measured concentrations of aminoglycosides in order to evaluate pharmacokinetics. Data collected included: dose and frequency; time dose was given; length of infusion; two measured concentrations (peak and trough); and time concentration was measured. ANOVA allowed comparisons between aminoglycoside volumes of distribution to weight (based on specific weight groups). Tukey’s post hoc analysis further tested the significance of the pair-wise comparisons (p<0.05). Secondly, a questionnaire was administered to 26 pediatric medical residents at University Medical Center to assess current treatment protocols and attitudes towards medication dosing in obese pediatric patients. Results: The volume of distribution was not significantly different between normal weight and overweight patients (p=0.927); normal weight and obese patients (p=0.174); or overweight and obese patients (p=0.211). Most (81.8%) study participants have some difficulty finding references on dosing in overweight and obese patients. Conclusions: The positive correlation between volume of distribution and total body weight was not statistically significant. Pediatric residents agree that there is a lack of resources regarding obese pediatric medication dosing. Further research is warranted to ensure the reliability and validity of aminoglycoside dosing in obese children.

The aim of this diploma thesis is to present psychosocial aspects of acute phase treatment of childhood cancer. The literary briefing section is divided into four chapters. The first chapter presents the general medical characteristics of childhood malignancies and the principles of treating pediatric oncology diseases. The second chapter captures key findings of developmental psychology to ontogenesis in childhood and adolescence. The third chapter focuses on the psychosocial aspects of oncological treatment and psychological interventions applied during this treatment. The fourth chapter deals with palliative care in pediatric oncology and the psychological context of the child's death and family bereavement. Qualitative research consists of a set of four descriptive case reports of patients and their parents who are in the acute phase of cancer treatment or are shortly after its completion. The case reports present the experience of these patients and parents. Keywords Pediatric oncology, pediatric hematooncology, pediatric oncopsychology, pediatric patient, adolescent patient.