Triage, which means "to sort", determine the priority of the patients need of care. The aim of the present study was to describe nurses’ perception of triage at a pediatric emergency department. A questionnaire with open- and closed-ended questions were distributed to all 25 nurses that worked at a pediatric emergency department. The answer frequency was 48 % (n=12). Open-ended questions were analyzed by qualitative content analysis and the closed-ended questions with descriptive statistics after which statistical correlations and differences were calculated. The nurses’ perception of triage was that this first assessment and prioritization of the patients’ need of care increased safety and control and that to refer patients to another level of care may reduce the waiting time however, were time consuming for the nurse. The perception of interception factors for referring patients to another level of care were lack of availability and negative reactions from parents and patients. To perform triage and at the same time be responsible for other patients was perceived as a difficult. As a support in the performance of triage a triage-system, easy to interpret, was needed. Any significant differences or association could not be detected regarding level of education or work experiences. The nurses perceived that a correct triage gave the patient correct care at right level. / Utifrån triagebedömning, där triage betyder "att sortera", prioriteras patientens behov av vård. Syftet med denna studie var att beskriva sjuksköterskors uppfattning om triagebedömning på en barnakutmottagning. En frågenkät med öppna och slutna frågor delades ut till samtliga 25 tjänstgörande sjuksköterskor vid barnakutmottagningen. Svarsfrekvensen var 48 % (n=12). De öppna frågorna analyserades med kvalitativ innehållsanalys och de slutna frågorna bearbetades med deskriptiv statistik därefter beräknades statistiska samband och skillnader. Sjuksköterskors uppfattning om triage var att denna första bedömning och prioritering av patientens vårdbehov gav en ökad säkerhet och kontroll samt att hänvisning av patienter till annan vårdnivå kunde minska väntetider men krävde stor tidsåtgång. Brist på tillgänglighet till primärvården och negativa reaktioner från föräldrar och patienter uppfattades som en hindrande faktor vid hänvisning. Sjuksköterskorna uppfattade att det var en svår arbetsuppgift att utföra triagebedömning samtidigt som man ansvarade för andra patienter. Som stöd i triagebedömningen önskades triagemallar som var lätta att tyda. Inga signifikanta skillnader eller samband kunde identifieras vad gäller graden av utbildning eller antal yrkesverksamma år. Sjuksköterskorna uppfattade att rätt utförd triage gav patienten rätt vård på rätt vårdnivå.

Low Dose Metronomic (LDM) chemotherapy, combined with VEGF pathway inhibitors, is a highly effective strategy to coordinately inhibit angiogenesis and tumor growth. We have tested the efficacies of daily oral LDM topotecan alone and in combination with pazopanib, in three pediatric extracranial solid tumors mouse models. We also investigated the effect of prolonged combination therapy with the combination on tumor behavior in a neuroblastoma mouse xenograft model. In-vitro dose-response study of topotecan and pazopanib was conducted on several cell lines. In-vivo antitumor efficacies of drugs, as single agents and combination, were tested in immunodeficient mice models. For studying the mechanisms of resistance to our therapy, a time-response study (28, 56 and 80 days) was conducted in SK-N-BE(2) xenografts model, treated in same way as earlier. In vitro, topotecan caused a dose-dependent decrease in viabilities of all cell lines, while pazopanib did not. In vivo, the combination of topotecan and pazopanib demonstrated significant anti-tumor activity compared to the respective single agents in all models. Reductions in the levels of viable Circulating Endothelial Progenitors and/or Circulating Endothelial Cells and tumor microvessel density were correlated with tumor response and therefore confirmed the antiangiogenic activity of the regimens. However, the combination also caused significantly higher myelotoxicity than single agents. Pharmacokinetic study did not reveal any interaction between the two co-administered drugs. In the time-response study, we found that only combination treated animals survived till 80 days. However, tumors in these animals started growing gradually after 50 days. Unlike single agents, all three durations of combination treatment significantly lowered tumor microvessel densities, compared to the control. However, tumors treated with the combination for 56 and 80 days had higher pericyte coverage. The combination increased the hypoxia, angiogenic expression and proliferative index and caused metabolic reprogramming of tumor cells. We conclude that the combination of LDM topotecan and pazopanib has superior efficacy than either single agents, which is attributed to superior antiangiogenic activity. However, prolonged treatment with the combination can have additive myelotoxicity and may encounter adaptive resistance associated with metabolic reprogramming and increased proliferation of the tumor cells.

Empathy for others’ pain is an important human capacity. Despite this, little is known about how children develop or express their empathy for another individual’s pain. Thus, this dissertation aimed to accomplish two primary objectives: 1) to describe and compare children’s expressions of empathy toward others’ pain and others’ sadness, and 2) to examine whether developmental (i.e., age and sex) or interindividual variables of interest (i.e., temperament, social-emotional variables, language abilities) predict children’s expressions of empathy for pain and empathy for sadness. To this end, 120 children (60 boys, 60 girls) between the ages of 18 and 36 months (M = 26.44 months; SD = 5.17 months) were assessed for their empathy-related behavioural responses to lab-based simulations of pain and sadness. Children’s responses were coded for: prosocial behaviours (e.g., sharing), attempts to understand the distress (e.g., hypothesis testing), self-distress behaviours (e.g., self-soothing), unresponsive/inappropriate responses (e.g., ignoring, showing anger), and miscellaneous responses (e.g., imitation). Children were also given an overall rating of global concern. Differences emerged when individual behavioural codes were compared between pain and sadness simulations. Specifically, children were more likely to be distressed by, but also more likely to be prosocially responsive to, another’s sadness. Interestingly, children were more likely to actively play during another’s pain. Two principal component analyses were conducted: one for the pain simulations and one for the sadness simulations. Three components emerged both for pain (Empathic Concern for Others’ Pain, Personal Distress to Others’ Pain, and Unresponsiveness to Others’ Pain) and for sadness (Empathic Concern for Others’ Sadness, Personal Distress to Others’ Sadness, and Social Referencing in Response to Others’ Sadness). While there was some overlap in the conceptualization of the first two components for both pain and sadness, the behaviours that loaded onto these components were different. Additionally, the third component for each analysis described very different phenomena. For pain, this final component described general unresponsiveness to the other’s distress. For sadness, the final component described a tendency to gauge one’s response on the reaction of a parent. Hierarchical regression analyses examining the influence of developmental (i.e., age and sex) and interindividual variables of interest (i.e., temperament, social-emotional variables, and language abilities) in children’s empathy-related responses were also conducted for each pain and sadness component. In general, age or sex differences only emerged for empathy-related responses to pain. Temperament, and to a certain extent social-emotional variables, showed some predictive value in how children would respond to another’s pain or sadness. Language showed very little predictive value in children’s expressions of empathy. While the findings of the current study indicate some conceptual similarities across children’s empathic responses to pain and sadness, they also show interesting and important differences in the behavioural expression of children’s empathic responses to pain and sadness. Additionally, developmental and interindividual variables predictive of children’s empathic responses to pain and sadness emerged. A developmentally appropriate model of empathy is proposed highlighting all of these influences on children’s expressions of empathy. / An examination of toddlers' expressions of empathy for pain versus sadness.

There is minimal information available regarding test characteristics of the Rourke and the NDDS, two tools commonly used to screen for developmental delay. The objectives are to (a) generate preliminary descriptive data about the population and outcomes of interest, (b) determine test characteristics of the tools compared to the gold standard assessment, BSITD-III. Thirty-six month old children at high risk of developmental delay were recruited from the Perinatal Follow-up Program at the IWK Health Centre in Halifax, NS. The Rourke and NDDS results were obtained via parental report, the BSITD-III via clinical assessment. Results suggest that both tools may possess appropriate test characteristics to screen for developmental delay. Both perform more accurately when the criterion for delay is extended to two flagged areas of concern on the assessment tools. In conclusion, both tools appear to be sensitive to detecting developmental delay. Further investigation via a full scale study is warranted.

Children are often required to repeatedly undergo painful medical procedures (e.g. immunizations) and their memories for pain are predictive of their health behaviours across the lifespan. Although trait anxiety has been shown to influence pain memories, little is known about the impact of state anxiety, and the influence of stable anxiety-related variables (e.g., anxiety sensitivity), on children’s memories for pain. Furthermore, although memory is often implicated in children’s reactions to future pain, there is a dearth of research directly examining the relationship between the two. The current dissertation project involved two studies. The first study investigated the impact of experimentally manipulated state anxiety, and the influence of anxiety-related variables, on children’s memories for a novel pain experience. The second study examined the influence of children’s pain memories on a subsequent pain experience. In Study 1, one hundred ten children (60 boys; 50 girls) between the ages of 8 and 12 years (Mage = 9.45 years, SD = 1.35) were randomly assigned to complete either a state anxiety induction task or a control task. Then, children completed a laboratory pain task (the cold pressor task) and provided pain ratings. Children also completed measures of state anxiety and stable anxiety-related variables. Two weeks following the laboratory visit, children were contacted by telephone and provided pain ratings based on their memories of the initial pain experience, as well as their expectancies about future pain. Results showed that children in the state anxiety induction group did not have more negative pain memories (i.e., they did not recall higher levels of pain) than children in the control group. However, irrespective of group assignment, children who had higher levels of state anxiety had more negative memories of pain intensity and pain-related fear than children with lower levels of state anxiety. Furthermore, state anxiety was a unique predictor of children’s pain memories over and above the influences of sex, stable anxiety-related variables, and experienced pain intensity and pain-related fear. Stable anxiety-related variables (anxiety sensitivity and trait anxiety) were also significant predictors of recalled pain-related fear. In Study 2, the same children once again completed the pain task and provided pain ratings one month following the initial laboratory visit. Results revealed that children’s memory of pain intensity was a better predictor of subsequent pain reporting than their actual initial experience of pain intensity; in fact, children’s pain memories mediated the relationship between reporting of pain intensity at Lab Session 1 and Lab Session 2. Children who had negatively estimated pain memories developed expectations of greater pain prior to a subsequent pain experience and showed greater increases in pain ratings over time than children who had accurate and positively estimated pain memories. Overall, these data highlight the importance of anxiety in the development of children’s memories for pain and present a model of acute pain memories that add to the growing literature on pain memories across development. Results also highlight the powerful influence of pain memories on healthy children’s pain expectancies and subsequent pain experiences, and extend predictive models of subsequent pain reporting to childhood.

Low Dose Metronomic (LDM) chemotherapy, combined with VEGF pathway inhibitors, is a highly effective strategy to coordinately inhibit angiogenesis and tumor growth. We have tested the efficacies of daily oral LDM topotecan alone and in combination with pazopanib, in three pediatric extracranial solid tumors mouse models. We also investigated the effect of prolonged combination therapy with the combination on tumor behavior in a neuroblastoma mouse xenograft model. In-vitro dose-response study of topotecan and pazopanib was conducted on several cell lines. In-vivo antitumor efficacies of drugs, as single agents and combination, were tested in immunodeficient mice models. For studying the mechanisms of resistance to our therapy, a time-response study (28, 56 and 80 days) was conducted in SK-N-BE(2) xenografts model, treated in same way as earlier. In vitro, topotecan caused a dose-dependent decrease in viabilities of all cell lines, while pazopanib did not. In vivo, the combination of topotecan and pazopanib demonstrated significant anti-tumor activity compared to the respective single agents in all models. Reductions in the levels of viable Circulating Endothelial Progenitors and/or Circulating Endothelial Cells and tumor microvessel density were correlated with tumor response and therefore confirmed the antiangiogenic activity of the regimens. However, the combination also caused significantly higher myelotoxicity than single agents. Pharmacokinetic study did not reveal any interaction between the two co-administered drugs. In the time-response study, we found that only combination treated animals survived till 80 days. However, tumors in these animals started growing gradually after 50 days. Unlike single agents, all three durations of combination treatment significantly lowered tumor microvessel densities, compared to the control. However, tumors treated with the combination for 56 and 80 days had higher pericyte coverage. The combination increased the hypoxia, angiogenic expression and proliferative index and caused metabolic reprogramming of tumor cells. We conclude that the combination of LDM topotecan and pazopanib has superior efficacy than either single agents, which is attributed to superior antiangiogenic activity. However, prolonged treatment with the combination can have additive myelotoxicity and may encounter adaptive resistance associated with metabolic reprogramming and increased proliferation of the tumor cells.

Background: Previous research suggests that children living on farms have a lower prevalence of asthma compared to their more urban counterparts. Four potential explanations may underlie this association: personal factors, health care access, health risk behaviours, and the environmental explanation. Objectives: The objective of this thesis was to first compare the prevalence of asthma between children living on farms and those living in small towns. The second objective was to identify and compare potential risk and protective factors for childhood asthma in rural and farm environments. Finally, we interpreted the findings in light of the above explanations in terms of which is most likely to explain previously observed differences in pediatric asthma prevalence. Methods: We used cross-sectional data (n=834) from a 2003 study conducted in Estevan, Saskatchewan as well as cross-sectional data (n=2,259) collected as part of the Saskatchewan Rural Health Study in 2011. We determined differences in asthma prevalence and examined the distribution of potential risk and protective factors between farm and small town children. Using multiple logistic regression, we identified a number of potential risk and protective factors for both pediatric asthma and wheeze among these populations. Results: No differences in prevalence of asthma or wheeze were identified by farm and small town status in both analyses. Risk factors that were identified included: male sex, parental history of asthma, personal history of allergy, home dampness, being overweight or obese, premature birth, living in a single parent home, difficulty accessing routine healthcare, previous daycare attendance, having a mother that previously smoked, having mice in the home, having an air filter in the home and feeding livestock. Protective factors included: previous daycare attendance, having pets in the home and having a dehumidifier present in the home. Farm-specific protective factors included: filling or emptying grain bins, cleaning or playing in pens, and living on a grain farm. Conclusions: No differences in asthma or wheeze prevalence were identified between small town and farm children in these study populations. Findings primarily supported the environmental explanation for geographic differences in asthma prevalence identified historically, with modest support for the health care access explanation. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-09-20 16:44:44.525

Background: Pediatric obesity is a serious health issue, with an exceedingly high prevalence, having both short and long-term consequences. The Family Lifestyle Program (FLP) provides treatment services to families struggling with pediatric overweight and obesity living in the Winnipeg Health Region. Purpose: To determine whether caregivers’ nutrition knowledge and/or their attitudes about nutrition change as a result of attending the family group education sessions of the FLP. Methods: In this quantitative exploratory research, 17 caregivers (68% female) attended at least four out of five family group education sessions and completed a self-administered survey over three time periods of the program intervention, spanning approximately eight weeks from Time 1 to Time 3. Results: Caregiver nutrition knowledge did not change. Significant changes in three of the four attitude measures across three time periods were observed, related to caregiver attitudes toward their child’s and their own eating habits, program specific nutrition content (label reading and meal planning), and the perceived effort in providing foods to family and in role modelling of healthy behaviours to family members. Conclusions: The family group education sessions assisted the caregivers apply nutrition knowledge through participation in the program intervention, to improve their confidence with following healthy eating principles and role modelling these behaviours to their family members.

The Winnipeg Children’s Hospital encounters delays within the surgical patient flow and cancellations due to a lack of available resources in the Pediatric Intensive Care Unit (PICU). Applying the concepts of lean thinking and the practices of simulation and statistical analysis, these problems were better understood and solutions were developed. Improvement projects were performed centralized on lean concepts and utilizing the tools of value-stream mapping and 7 forms of waste. Building and running a simulation model provided a capacity versus demand measure for the overall performance of the PICU. Simulation allowed for the study of hypothetical situations such as varying department resources and fluctuating patient levels. Statistical calculations were used to create a prediction tool to determine the probability of a PICU bed being available. This would enable a reduction in last-minute cancellations of surgical cases requiring a PICU bed.

There is a robust body of research regarding outcomes following pediatric acquired brain injury (ABI). However, these studies generally explore medium-term outcomes (i.e., 3 to 12-months postinjury), whereas functioning during acute stages following ABI is poorly understood. In particular, there is limited knowledge regarding caregiver functioning during a child’s hospitalization immediately after ABI. This study sought to identify and model caregiver and child predictors of ‘caregiver confidence’ in caring for their hospitalized child. Caregivers of 45 children with diverse types of new-onset acquired brain injuries completed self-report measures of their own psychological functioning, stress, and confidence levels, as well as their perceptions of their child’s stress and coping. Results showed that caregiver psychological functioning was negatively associated with caregiver confidence, and caregiver perceptions of child coping were positively associated with caregiver confidence. Child functional status did not serve as a significant mediator in this relationship as per the hypothesized model.