No description available.

No description available.

No description available.

No description available.

No description available.

Asthma is a chronic disease of the lungs and respiratory passages. Hallmarks of asthma exacerbation, commonly referred to as an “asthma attack,” are bronchoconstriction, inflammation, and airway remodeling. Millions of people worldwide have asthma, with both children and adults affected by the disease. Asthma prevalence in the United States has been increasing on a yearly basis, and thus asthma is a serious health threat to people of all ages. Asthma can be controlled with short term bronchodilatory drugs and inhaled corticosteroids for long-term inflammation management. Pediatric asthma is particularly taxing, however, as it can cause numerous absences from school, frequent hospitalizations, and can be difficult for children to manage without close supervision. Many of these pediatric patients present in emergency departments, and are given oral or IV steroids to treat the asthma exacerbation. We specifically want to assess the effect of early administration of these steroids on the patient outcomes of admission rate and length of stay. We hypothesize that patients given steroids sooner rather than later are less likely to be admitted to inpatient status and will have a shorter stay in the emergency department. To test our hypotheses, we conducted a retrospective study in which we gathered pediatric patient data from August, 2011, to April, 2012. We included patients that presented with asthma exacerbation and recorded a number of metrics and variables for each patient, including time of steroid administration, admission status, and total length of stay in the emergency department. Steroid administration time was separated into two categories: administration pre or post-30 minutes of triage, and administration pre or post-60 minutes of triage. This data was logged, reviewed, and finally analyzed for statistical significance. Results of the study showed that there is no statistically significant association between time of steroid administration on admission rates. To assess the relationship of steroid administration time and length of stay in the emergency department, patients with the same admission status were compared against one another in order to eliminate potential confounding (i.e. length of stay for admitted patients who received steroids within 30 minutes was compared to that of admitted patients receiving steroids post-30 minutes, and so on). Overall, those patients receiving steroids tended to have a shorter mean length of stay in the emergency department. This finding was statistically significant for only one subset of the patient sample, however: discharged patients who received their steroids pre-60 minutes as opposed to post-60 minutes. While the data that we analyzed did not depict many statistically significant associations, it did reveal trends in outcomes that are associated with timing of steroid administration. With further study and an expanded sample size, these associations may prove to be of significance. From a clinical perspective, such findings could impact emergency asthma care, with early steroid administration becoming more of a priority in treatment protocols.

Purpose: Pediatrics and adolescents are at a higher risk to suffer an anterior cruciate ligament (ACL) injury in comparison to their adult counterparts. As well, the rate of injury is increasing. While some of this increased injury rate may be attributed to increased participation in sport, it remains unknown why only some children suffer an ACL injury. Traditionally, surface marker- based motion-capture would be used to determine this difference; however, due to the presence of soft tissue artifact, marker translation may exceed the physiological range of the knee itself. Using OpenSim, the range of motion of the knee was constrained to allow for soft tissue artifact to be reduced. Therefore, the two objectives of this thesis are 1) to create and validate a new OpenSim knee model, and 2) to use this knee model to determine whether differences in knee kinematics and ligament lengths exist between ACL injured and non-injured control pediatrics. Methods: Manuscript 1 (Chapter 5), focused on the first objective of creating and validating a new OpenSim knee model. Thirty-two healthy pediatric females performed squats, countermovement jumps, and drop-vertical jumps. OpenSim models were made and scaled to each participant and featured a 6-degree-of-freedom knee. Each knee was allowed to move in a manner dictated by published in vivo biplanar fluoroscopy studies. These resultant biplanar fluoroscopy-constrained knee kinematics were then compared to another series of in vivo constraints: bone pin-constrained kinematics. Finally, the length of the four main ligaments of the knee were tracked and compared to existing literature on healthy ligament lengths from extension to deep flexion. Manuscript 2 (Chapter 6) sought to answer the second question: Are there differences in kinematics and ligament lengths between ACL-injured and uninjured control participants? Forty ACL-injured (20 male, 20 female) and 40 uninjured control (20 male, 20 female) participants completed a countermovement jump, which drove inverse kinematics for the OpenSim model created in Manuscript 1. Knee kinematics and ligament lengths were compared between male injured to male control, and female injured were compared to female control. To isolate the effect of injury, males were not compared to females. Results: Starting with Manuscript 1, the squat task had the best agreement between biplanar fluoroscopy and bone pin kinematics, during periods of low knee flexion. At high flexion, the ACL length was shorter than literature data, for all tasks. For Manuscript 2, during the countermovement jump, female control participants obtained greater knee flexion and internal rotation when compared to female ACL-injured participants. For males, there were only small differences in countermovement jump kinematics. For ligament lengths, female controls had longer posterior cruciate ligament lengths, whereas for males, male ACL-injured participants presented with longer ligament lengths for all 4 ligaments. Conclusion: The thesis results identified how to use deep flexion biplanar fluoroscopy constraints to minimize soft tissue artifact. In comparison to previously established knee bone pin constraints, the biplanar fluoroscopy knee relied more on internal-external rotation and anterior-posterior translation to obtain the required bone positions in OpenSim. This additional anterior-posterior translation also led to the increased shortening of the ACL, as the linear distance between ligament insertion points decreased. Next, this thesis identified small differences in kinematics between ACL-injured and control pediatric females during a countermovement jump, where control participants obtained greater knee flexion in the preparatory and landing phase of the task. Few differences in kinematics were found in males. Differences in ligament lengths between injured and control groups were based on differences in knee kinematics, or by participant anthropometrics; taller participants had longer ligaments.

While family-centered care is the desired model for pediatric care in hospitals worldwide, it is not always used to guide practice in inpatient pediatric hospital settings due to three main barriers. These barriers include decreased communication and collaboration between families and healthcare professionals, decreased understanding of parents’ needs and expectations for involvement in care, and a lack of clinical guidelines for how to best incorporate families in care. In effort to bridge the communication gap between parents and healthcare professionals and gain an understanding of ways to effectively carry out a family-centered care model, a quality improvement project was conducted at Spaulding Rehabilitation Hospital on the Pediatrics unit in collaboration with the occupational therapy department. The project involved four components: interviewing parents regarding their preference for involvement in their child’s care, communicating these preferences to occupational therapists, administering a survey to parents to assess parent satisfaction with their involvement in care, and providing recommendations to Spaulding. Results indicated that parents at Spaulding are very satisfied with their communication with therapists and with their involvement in care. Results also indicated that all parents report a desire to be involved in their child’s care, however, that preference for type of involvement varies by family. This demonstrated the importance of asking families about their preference for involvement at the beginning of their hospital stay and communicating their preferences to the team. Recommendations include mechanisms that can be incorporated into occupational therapists’ daily workflow to operationalize a family-centered care model.

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Clostridium difficile infection (CDI) is the most common hospital-associated infection and is linked to increased morbidity, mortality and costs. Asymptomatically colonized patients may act as an infection reservoir and their numbers have been found to exceed symptomatic CDI cases. In addition to higher rates of CDI among children hospitalized with cancer compared to those without an oncologic diagnosis, these patients also experience substantially higher C. difficile colonization rates. However, the current published literature does not adequately address the natural history of C. difficile colonization in this population, in terms of who is at greatest risk for developing colonization, duration of colonization, or progression to CDI. A retrospective longitudinal cohort study of pediatric oncology patients admitted to the oncology ward at McMaster Children’s Hospital (MCH) was conducted from September 1 2016 to February 28 2018. Patients who were routinely screened for antibiotic-resistant organisms (AROs) upon admission per hospital policies had their stored samples subsequently tested for asymptomatic carriage of C. difficile. A retrospective analysis was completed to determine predictors of colonization and risk factors for progression to subsequent CDI. We observed a lower colonization rate than other studies have reported in the literature. Duration of colonization was likely brief and none of the colonized patients subsequently developed CDI. There were no statistically significantly associated predictors for asymptomatic colonization when colonized patients were compared to those who were never colonized. / Thesis / Master of Science (MSc)