Juvenile idiopathic arthritis, JIA, is used as an umbrella term covering a heterogeneous group of chronic arthritis forms in children, many of which have important differences compared to adult arthritis, while others possibly represent similar diseases among children and adults. Classification aims to give a better understanding of the pathogenesis, patterns, disease trajectories and treatment responses. For the juvenile psoriatic arthritis, JPsA, the classification criteria are currently being debated. The distribution of affected joints in JIA differs greatly and it is unknown why some joints appear to be more affected than others. The temporomandibular joint (TMJ) can be affected early in the course of the disease and often the symptoms are mild and without obvious swelling. This thesis has its origin in the Nordic Study Group of Paediatric Rheumatology and the population-based prospective study of 510 children with newly diagnosed JIA included between 1997 and 1999. Totally 440 children were included in the eight-year follow-up, and in the TMJ study 265 patients were examined and underwent cone-beam computed tomography, CBCT, 17 years after onset. After eight years a considerable proportion of the children with definite psoriasis were classified as undifferentiated JIA based on the exclusion criteria in the ILAR classification. Our data also presents the heterogenicity of JPsA and the development over time of clinical variables supporting a psoriatic diathesis, as well as the overlap between JPsA and enthesitis-related arthritis in a group of patients.  We found that extensive symptoms and dysfunctions of the TMJ are seen in JIA 17 years after disease onset, even in patients registered with inactive disease or remission. Individuals with substantial condylar damage on CBCT were found in all JIA categories. The deeper understanding of a chronic disease over time is crucial for research initiatives to improve care as well as for clinical decisions and planning of the health care. Our findings suggest a need for a more appropriate classification of JPsA and also that aspects of TMJ involvement should be included in the general health assessment in JIA.

Bakgrund: I Sverige dör ca 90 000 människor varje år, varav 550 av dessa är barn.  Specialiserad palliativ vård samt specialistutbildningar inom palliativ vård är generellt inte utformad för vård av barn i livets slutskede. Bristfällig utbildning hos vårdpersonal samt liten erfarenhet av att ge palliativ vård till barn orsakade känslor av osäkerhet i  vårdsituationer med barn och familjer. Syfte: Att beskriva vårdpersonals erfarenheter av att vårda barn i livets slutskede på sjukhus. Metod: Litteraturstudie baserad på nio kvalitativa studier samlade från databaserna Cinahl och PubMed. En manuell sökning gjordes. Analys genomfördes med hjälp av Fribergs femstegsmodell. Resultat: Analysen resulterade i fyra huvudkategorier och elva underkategorier. Huvudkategorierna var: känslomässiga reaktioner, att hantera svåra situationer, utmaningar i mötet med familjer och möjligheter i mötet med familjer. Konklusion: Vårdpersonal önskar utbildning i palliativ vård av barn samt kommunikationsövningar med sörjande familjer. Vidare forskning behövs angående barns risk för lidande vid familjecentrerat förhållningssätt, nödvändiga organisatoriska åtgärder samt vårdutbildningars behov av att inkludera palliativ vård av barn. / Background: About 90,000 people die every year in Sweden and of those are 550 children. Specialized palliative care and specialist education in palliative care are generally not designed for end-of-life care of children. Inadequate education of healthcare professionals and little experience of giving palliative care for children caused feelings of insecurity in care situations with children and families. Aim: The purpose was to describe healthcare professionals experiences of providing end-of-life care for children in hospitals. Methods: Literature study based on nine qualitative studies collected from the databases Cinahl and PubMed. One manual search was performed. The analysis was implemented using Friberg's fivestep model. Results: The analysis resulted in four main categories and eleven subcategories. The main categories were: emotional reactions, to handle difficult situations, challenges in meeting families and opportunities in meeting families. Conclusion: Nursing staff want education in palliative care of children and communication exercises with grieving families. Further research is needed regarding children's risk of suffering from a family-centered approach, necessary organizational measures and the need for nursing education to include palliative care of children.

Neuroblastoma constitutes roughly 8% of all childhood cancers where 95% of all neuroblastoma cases occur before the age of 10. The survival rate of infants and young children is very poor, which alone contributes to research novel biomarkers for classification methods, improved diagnosis and better anti-tumor therapies. The aim of this meta-analysis was to identify dysregulated miRNAs in neuroblastoma that has the potential to be used as antioncogenic biomarkers for diagnostic interventions. Additionally, explore miRNA interconnectedness on a systemic level and conversely extend the support of using miRNAs as biomarkers. A comprehensive literature search was performed within NIH-PubMed, NCBI-PMC and in the reference list of already reviewed publications, which yielded 9 eligible publications. Quality of evidence was assessed according to the guidelines adapted from MIAME, MINSEQE and MIQE. miRNet 2.0 was used to find the most significantly enriched annotations linked to neuroblastoma. A total of 251 samples (Cancer: 141; Control: 110) was reported by the 9 studies. These involved 66 dysregulated miRNAs (Up-regulated: 43; Down-regulated: 23) which was used for enrichment analysis. Four miRNAs (miR-17-5p, -92a-3p -421, -125b) were significantly linked to neuroblastoma, and associated secondary diseases; medulloblastoma (-92a-3p, -125b), bladder cancer (-17-5p, -125b), acute myeloid leukemia (-92a-3p, -125b) and cardiac hypertrophy (- 125b). miR-125b showed exceptional interconnectivity with these diseases and a multidimensional potential in neural tumorigenesis. This study showed that dysregulation and biological processes of these miRNAs were concurrent with the original studies, endorsing that these miRNAs have potential as diagnostic indicators or classifiers of such diseases. / Popular scientific summary Neuroblastoma (NB) is one of the most common types of pediatric neurological cancers in children and constitutes roughly 8% of all childhood cancer types, in which 95% of all NB cases occur before the age of 10. Even with frequent advancements in medical diagnosis and anti-tumor therapies, the current treatment options for patients with NB offers a survival rate that is very poor. This alone is a reason to pursue developing novel classification methods, improve diagnosis and research better anti-tumor therapies. Micro Ribonucleic Acids (miRNAs) are small non-coding single stranded biomolecules that have gotten a lot of attention in recent years due to their ability to regulate genes involved in various biological cancer processes, such as; tumor growth and development. miRNAs regulate these processes by altering the function of messenger RNAs (mRNAs), which are single-stranded biomolecules that resembles a piece of genetic code from the DNA of an organism cell. When these mRNAs become dysregulated, their cancer-promoting genes are disrupted which prevent them from working properly, leading to tumor regression or termination. The effect of this biological event is then objectively measured by using the miRNA as an indicator, also known as a biomarker. miRNA biomarkers have massive potential to improve various medical applications, such as; faster and more accurate diagnosis, detailed disease-classification and more precise drug trial predictions. However, a lot of individual studies have been published about the same miRNAs, which report a variation of conclusions. This makes it more difficult to determine the true nature of miRNAs. This issue can be addressed with systematic reviews and meta-analyses, which could yield additional support and give a broader picture of how miRNAs regulate different biological processes in NB. A meta-analysis is a scientific statistical process that combines the results of many research publications associated with the same scientific question and presents the best collective estimate of truth with increased precision than what could be achieved from individual studies alone. Thus, meta-analysis is an important tool in research which makes sure that the most trustworthy effect estimate can be achieved among many similar answers. The aim of this meta-analysis was to identify dysregulated miRNAs in NB that has the potential to be used as anti-cancer promoting biomarkers for diagnostic interventions. Additionally, explore how different miRNAs are connected to NB and conversely extend the support of using miRNAs as biomarkers. The end goal of this meta-analysis is to provide more reliable evidence for further research that can improve the life expectancy of NB patients in the future. In this study, 4 miRNAs (miR-17-5p, -92a-3p -421 and -125b) were identified to be significantly linked to NB, and associated secondary diseases; medulloblastoma (-92a-3p & -125b), bladder cancer (-17-5p & -125b), acute myeloid leukemia (-92a-3p & -125b) and cardiac hypertrophy (- 125b). Specifically, miR-125b showed exceptional interconnectivity for these diseases and potential to indirectly down-regulate n-Myc in NB, a gene that promote cancer cell proliferation. miR-125b was also found to be a significant sole regulator and effector of the CDX2 gene responsible for cancer cell differentiation in acute myeloid leukemia, a relationship that has been supported by other publications. This meta-analysis showed that the reported dysregulation and biological processes of these miRNAs were concurrent with the original studies, endorsing that these miRNAs have potential as diagnostic indicators or classifiers of such diseases while warranting that the gene regulatory function of miRNAs are becoming more intricate than previously thought.

Bakgrund: Årligen diagnostiseras cirka 400 000 barn i världen med cancer, medvarierande överlevnadschanser beroende på var barnet bor. En cancerdiagnos medför ofta en stor livsomställning för alla inblandade och mötet med barncancer kan upplevas som svårt. Genom att undersöka barnens perspektiv och erfarenheter av cancer kan förståelsen och bemötandet till dessa barn förbättras. Syfte: Syftet var att beskriva barns erfarenheter av att leva med cancer. Metod: Litteraturstudien har en deskriptiv design och artiklarna i resultatet söktes fram via databasen PubMed. Totalt valdes 13 artiklar ut som svarade på syftet. Huvudresultat: Resultaten visade att barn med cancer genomgick många utmaningar som berörde dem fysiskt, psykiskt och socialt. Fysiska utmaningar innefattade främst smärta, rörelsebegränsningar, trötthet samt illamående och kräkningar. Psykiska utmaningar lyfte barnens olika känslor. Vanligast var rädsla, sorg och orättvisa. Sociala utmaningar inkluderade förändrade relationer samt upplevd isolering. Barnen hanterade utmaningarna genom olika strategier, innefattande positiv inställning och stöd från närstående samt vårdpersonal. De upplevde att cancern bidragit till personlig utveckling och givit nya livsperspektiv. Slutsats: Barns erfarenheter av att leva med cancer framställer åtskilliga utmaningar som de behövde hantera under sjukdomen. Känslorna speglades av cancerns olika faser och gjorde att barnen konstant pendlade mellan hopp och förtvivlan. Denna litteraturstudie kan ha en betydande roll för sjuksköterskor inför mötet med barn som lever med cancer. En ökad förståelse för barns cancererfarenheter kan underlätta bemötandet av barnens individuella behov, samt bidra till att främja barnens vårdupplevelser. / Background: About 400 000 children worldwide are annually diagnosed with cancer, with varying chances of survival depending on where the child lives. A cancer diagnosis often entails a major life change for everyone involved and the encounter with childhood cancer can be experienced as difficult. By examining the children's perspective and experiences of cancer, the comprehension and personal treatment of these children can be improved. Aim: The aim was to describe children's experiences of living with cancer. Method: The literature study has a descriptive design and the articles in the result were found through the database PubMed. A total of 13 articles were selected that responded to the aim. Main results: The results showed that children with cancer went through many challenges that affected them physically, psychologically and socially. Physical challenges mainly included pain, movement restrictions, fatigue as well as nausea and vomiting. Psychological challenges emphasized the children's different emotions. Most common were fear, sadness and injustice. Social challenges included changed relationships and perceived isolation. The children handled the challenges through various strategies, including positive attitude and support from relatives and health care professionals. They felt that the cancer contributed to personal development and gave new life perspectives. Conclusion: Children's experiences of living with cancer present several challenges that they needed to deal with during the illness. The feelings were reflected by the different phases of cancer, which caused the children to constantly oscillate between hope and despair. This literature study could have a significant role for nurses before facing children living with cancer. An increased understanding of children's cancer experiences can facilitate children's individual needs, as well as contribute to promoting children's health care experiences.

Bakgrund: Redan på 1790-talet visades positiva interaktioner med djur ge fördelar för människor. Djur har funnits vid människans sida sedan tusen år tillbaka och under de senaste 50 åren har implementeringen av djurassisterad terapi ökat. Omvårdnadsgrundaren Florence Nightingale talade tidigt om vikten av djurens närvaro inom vården för att underlätta behandlingsprocessen. Tidigare studier indikerar att vidare forskning behövs gällande undersökning av effekterna som djurassisterad terapi har på människans hälsa och välbefinnande.Syfte: Syftet med studien var att beskriva och sammanställa patienters mätbara och erfarna effekt på välbefinnande av djurassisterad terapi inom barnsjukvård.  Metod: En beskrivande litteraturstudie sammanställd från 11 vetenskapliga artiklar. Sju kvantitativa, två mixade och två kvalitativa artiklar.  Huvudresultat: Hundassisterad terapi ökade välbefinnande och påverkade barnens sjukhusvistelse positivt. Terapihundbesöken minskade barnens stress, ångest, irritation, depression och smärta. Barnens känslohantering underlättades och kommunikation samt social interaktion förbättrades av terapiformen enligt föräldrar och vårdpersonal.  Slutsats: Barn uppvisade uppmätta psykologiska, fysiologiska och sociala effekter av hundassisterad terapi som ökade deras välbefinnande samt påverkade deras sjukhusvistelse positivt. Erfarenheter visar att terapiformen uppskattas av både barn, föräldrar och vårdpersonal. Barnet fokuserade och distraherades av terapihunden vilket underlättade behandlingar och minskade komplikationer. Resultatet visar att hundterapi är en gynnsam terapimetod. / Background: As early as the 1790s, positive interactions with animals were shown to bring benefits to humans. Animals have been by man's side for thousands of years, and in the last 50 years, the implementation of animal-assisted therapy has increased. Nursing founder Florence Nightingale spoke early on about the importance of the presence of animals in nursing to facilitate the treatment process. Previous studies indicate that further research is needed regarding the investigation of the effects that animal-assisted therapy has on human health and well-being.Aim: The aim of the study was to describe and compile patients measurable and experienced effect on well-being of animal-assisted therapy in pediatric healthcare.  Methods: A descriptive literature study compiled from 11 scientific articles. Seven quantitative articles, two mixed-methods and two qualitative methods.  Main results: Dog-assisted therapy increased well-being and positively affected the children's hospital stay. The therapy dog ​​visits reduced the children's stress, anxiety, irritation, depression and pain. The children's emotional management was facilitated and communication and social interaction were improved by the form of therapy, according to parents and healthcare professionals. Conclusion: Children showed measured psychological, physiological and social effects of dog-assisted therapy that increased their well-being and positively affected their hospital stay. Experience shows that the form of therapy is appreciated by both children, parents and healthcare professionals. The child was focused and distracted by the therapy dog, which facilitated treatments and reduced complications. The results show that dog-therapy is a beneficial therapy method.

Bakgrund: 21 miljoner barn hade 2018 ett palliativt vårdbehov i världen och varje år dör uppemot 170 000 barn av sin obotliga sjukdom i Europa. Grunden för pediatrisk palliativ vård är en helhetssyn utifrån barnets kropp, själ och ande och vården behöver anpassas utifrån familjernas behov. Den palliativa vården kan innebära en stor livsomställning utifrån flera aspekter för de drabbade familjerna. Den pediatriska palliativa vården är komplex och behöver därför belysa föräldrars erfarenheter för att kunna bidra med kunskap till vårdpersonal.  Syfte: Syftet med litteraturstudien var att undersöka föräldrars erfarenheter av att ha ett barn som får palliativ vård.  Metod: En kvalitativ litteraturstudie med nio artiklar. Databassökningen genomfördes i Cinahl och PubMed. Analys enligt Fribergs femstegsmodell.  Resultat: Ur analysen erhölls fyra kategorier; “Kompetens och bemötande”, “Organisation av vården”, “Behov av stöd och information” och “Livets vändpunkter”.  Konklusion: Pediatrisk palliativ vård kan innebära ett tungt vårdansvar samt ekonomiska och sociala konsekvenser för föräldrar. Litteraturstudiens resultat och tidigare forskning tyder på ojämlik vård, bristande samordning och stöd till föräldrar. Vårdpersonal behöver därför utbildning och kunskap förankrat i föräldrars erfarenheter för att förbättra den pediatriska palliativa vården. / Background: In 2018, 21 million children had a palliative care need worldwide, and every year, up to 170 000 children die from their incurable disease in Europe. The foundation of pediatric palliative care is a holistic view of the child’s body, mind and spirit, and the care needs to be tailored to the families’ needs. Palliative care can entail a significant life adjustment in various aspects for the affected family. The pediatric palliative care is complex and therefore needs to highlight parents’ experiences to contribute knowledge to healthcare professionals.  Aim: The aim of the literature study was to explore parents’ experiences of having a child receiving palliative care.  Methods: A qualitative literature study with nine articles. The database search was conducted in PubMed and Cinahl, using Friberg’s five-step model for analysis.  Results: Four categories were identified in the analysis; “Competence and interaction”, “Organization of the care”, “Support needs and information” and “Turning point in life”.  Conclusion: Pediatric palliative care can entail a heavy caregiving responsibility, as well as economic and social consequences for parents. The findings of the literature study and previous research indicate unequal care, lack of coordination and support for parents. Therefore, healthcare professionals need education and knowledge anchored in parents’ experiences to improve pediatric palliative care.

Bakgrund: Barn i alla åldrar kan känna smärta vid nålstick vilket är starkt sammankopplat med rädsla. Det kan generera stress och negativa minnen inför framtida vårdtillfällen, med risk för individ, vård och ökade samhällskostnader. Adekvat smärtlindring är en mänsklig rättighet för individen, men även sett från ett medicinskt, etiskt och juridiskt perspektiv. Trots detta är icke-farmakologisk smärtlindring, som avledning, underutnyttjade i den pediatriska vården. Eftersom barnvaccinationsprogrammet innebär flera nålstick under barnets uppväxt är kunskap om avledning av stor vikt.  Syfte: Syftet med denna litteraturstudie var att beskriva effekter av avledning som icke-farmakologisk metod för reducerad smärtupplevelse hos barn vid nålstick. Metod: En litteraturstudie utfördes med deskriptiv design och kvantitativ ansats. Studiens resultat har baserats på 16 randomiserade originalartiklar som hämtades från databaserna Cinahl och PubMed. Artiklarna kvalitetsgranskades enligt Caldwell et al. (2011) och resultatanalysen utfördes enligt Popenoe et al. (2021). Huvudresultat: Avledning men hjälp av virtual reality, avledningskort, verbal interaktion med vårdnadshavare, träleksak, leksaksarmband och kalejdoskop hade smärtreducerande effekter för barn vid nålstick. Avledning med såpbubblor visade endast en smärtreducerande effekt hos mindre barn (3–6 år). Vibrerande instrument med kylkudde hade ingen smärtreducerande effekt hos barn som redan var smärtpåverkade. Studien fann motstridiga resultat för effekten av surfplatta och inga signifikanta effekter för leksaksrobot och aromaterapi.  Slutsats: Resultatets påvisande av avledningsmetoders smärtreducerande effekter på barn vid nålstick, föranleder en rekommendation om att dessa implementeras inom hälso- och sjukvård (primärvård, slutenvård, barnhälsovård och elevhälsovård). / Background: Children of all ages feel pain during needlesticks, which is strongly linked to fear. Associated stress and negative memories could affect future healthcare visits. This could imply an increased risk and cost for society. Adequate pain management is, from a medical, ethical and judicial standpoint, a human right. Despite this, pain management, such as distraction, remains underutilized in paediatric care. The childhood vaccination programme involves several needlesticks during the child’s upbringing, understanding the impact of distraction is of great importance. Aim: The aim of this literature review was to describe the effects of distraction as a non-pharmacological method for reducing the pain experience in children during needlesticks. Methods: This literature review was carried out using a descriptive design and a quantitative approach. The results have been based on 16 randomized original studies which were found through the Cinahl and PubMed databases. Article quality was assessed in accordance with Caldwell et al. (2011) and the data analysis was carried out in accordance with Popenoe et al. (2021). Main results: Virtual reality, distraction cards, verbal parent interaction, wooden toy, toy bracelet and kaleidoscope were found to have pain reducing effects for children during needlesticks. Distraction using soap bubbles showed effect only on younger children (3-6 years). Vibrating tool with cold patch showed no effect on children already in pain. There were contradictory results regarding the pain reducing effects of a smart tablet and no significant pain reducing effects of a toy robot and aromatherapy. Conclusion: The demonstrated pain reducing effect of distraction in children warrants a recommendation of implementation of these distraction methods in primary care, inpatient care, child health care and student healthcare.

Världen över drabbas barn av cancer. Till följd av barnets cancerdiagnos påverkas barnets föräldrar och föräldrarollen förändras drastiskt. Livet tar en ny vändning där hälsa och lidande dominerar vardagen. Sjuksköterskans uppgift blir att stödja och stärka i mötet med barnet och föräldrarna trots att sjuksköterskan upplever det utmanande att arbeta med barn som har cancer. Föreliggande studie syftar till att belysa upplevelsen av att vara förälder till ett barn som har cancer. För att svara på syftet valdes metoden litteraturöversikt med grund i tio kvalitativa artiklar för att sammanställa befintlig forskning. Artiklarna söktes fram i CINAHL och Medline för att sedan granskas och analyseras. Utifrån färgkodning identifierades fyra teman med nio underteman. De fyra teman är: när barnet får cancer ändras hela livssituationen; föräldrarnas relationer förändras; känslorna pendlar som i en berg- och dalbana; upplevelsen av vården. Till följd av barnets cancerdiagnos upplever föräldrarna känslor som oro, hopp och förtvivlan. Mindre saker blir mer viktiga när livet nu fått en ny betydelse. Upplevelsen av isolering från omvärlden och ekonomi påverkar föräldrarnas liv mycket och en oro och rädsla för framtiden är påtaglig. När vårdpersonalen inkluderar föräldrarna uppkommer känslan av delaktighet. Föräldrarnas hälsa kan påverkas till följd av barnets sjukdom och ekonomins påverkan ger stora avtryck i vardagen vilket äventyrar den hållbara utvecklingen. Sjuksköterskan har en viktig uppgift i att fånga upp föräldrarnas mående vilket kan bidra till att barnet kan få bättre stöd och hjälp från sina föräldrar vilket på sikt också kan leda till en hållbar utveckling. / Across the world, children are affected by cancer, which has a drastic impact on their parents and alters the parental role significantly. Life takes a new turn where health and suffering dominate everyday life. The nurse's task is to support and strengthen parents in their encounter with the child, despite the nurse experiencing it challenging to work with children who have cancer. The purpose of this study is to shed light on the experience of being a parent to a child with cancer. To answer the purpose, a literature review method was chosen based on ten qualitative articles to compile existing research. The articles were searched in CINAHL and Medline and then reviewed and analyzed. Based on color-coding, four themes with nine subthemes were identified. The four themes are: when the child gets cancer, the entire life situation changes; the parents' relationships are alter; emotions fluctuate like a rollercoaster; the experience of care. As a result of the child's cancer diagnosis, parents experience feelings of worry, hope, and despair. Small things become more important when life has taken on new meaning. The experience of isolation from the world and the impact on finances greatly affects parents' lives, and there is a tangible fear and anxiety about the future. When healthcare professionals include parents, a sense of involvement arises. The parents' health may be affected due to the child's illness, and the impact on finances leaves a significant mark on daily life, which jeopardizes sustainable development. The nurse has an essential task in capturing parents' well-being, which can contribute to the child receiving better support and help from their parents, leading to sustainable development in the long run.

Bakgrund: Mötet mellan föräldrar och vårdpersonal spelar en stor roll vid omvårdnad av barn. För att säkerställa att detta sker på ett bra sätt tillämpas metoder som familjecentrerad omvårdnad. När sjuksköterskor tillfrågas om vikten av familjecentrerad omvårdnad och hur det appliceras framgår det att familjecentrerad omvårdnad inte tillämpas på ett bra sätt trots att det anses viktigt. Genom att bättre förstå hur föräldrar upplever mötet kan förbättringsområden identifieras. Syfte: Syftet var att beskriva föräldrars upplevelser av mötet med vårdpersonal vid pediatriska besök på akutmottagning. Metod: Allmän litteraturstudie enligt niostegsmodellen av Polit och Beck (2021) med sökningar i CINAHL och PubMed samt reflexiv tematisk analys enligt Braun och Clarke (2021). Resultat: Fyra teman och tolv subteman identifierades. Dessa teman var Kommunikation och bemötande, Känslor och upplevelser, Effektiv hälso- och sjukvård och resurser samt Miljö och närhet på mottagningen. Slutsats: Föräldrar beskrev överväldigande känslor i samband med besök på akutmottagningen. Vikten av stöd och bemötande ansågs vara viktiga för föräldrarna samt att de blir bemötta med respekt och empati från vårdpersonal. De önskar att möten ska ske på ett barnanpassat sätt. Föräldrarna upplever även att vårdpersonalen har tidsbrist vilket hindrar den familjecentrerade omvårdnaden. / Background: Parents’ encounter with healthcare workers plays a big part in the care of children. To promote good care and treatment methods like family-centred care are used. However, nurses asked about family-centred care explained it is not used well despite being considered important. By improving our understanding of parents’ perceptions, we can identify areas of improvement. Purpose: This study aimed to describe parents’ experiences of encounters with healthcare workers during paediatric visits to the emergency department. Method: Literature study following the nine-step model by Polit and Beck (2021), searching CINAHL and PubMed, and using reflexive thematic analysis according to Braun and Clarke (2021). Results: Four themes and twelve subthemes were identified. The themes were Communication and treatment,Emotions and experiences, Effective healthcare and resources, and Environment and proximity. Conclusions: Parents described overwhelming feelings when visiting the emergency department. They emphasised the importance of support and treatment from healthcare workers and to be greeted with respect and empathy. They wish for encounters to be child-appropriate. Parents noted that healthcare workers seemed to experience a lack of time, preventing them from applying family-centred care.

Neuroblastoma is a childhood cancer of the peripheral sympathetic nervous system, emerging from cells of the neural crest. In Sweden, neuroblastoma accounts for 20 cases out of all, 300-350, pediatric cancer cases each year (Barncancerfonden 2019, Turup on behalf of Cancer Centrum 2019). This cancer often appears in the sympathetic ganglia and/or the adrenal gland and has a high rate of metastasis that often results in morbidity (Matthay et al. 2016). Recent findings implicating a mutation in the Rho/Rac signaling pathway, a pathway involved in neural crest differentiation and migration, were found in every fourth neuroblastoma patient (Dyberg et al. 2017) These mutations tend to shift Rho to a more active state which is believed to lead to more downstream Rho-associated Kinase (ROCK) activation. While inhibition of ROCK has been seen to promote MYCN protein degradation, induce neuroblastoma cell differentiation and repress neuroblastoma growth in vitro and in vivo (Dyberg et al. 2017). Rho/ROCK signaling pathway effects on cytoskeletal arrangement and cell shape have also been suggested to be involved in tumor promoted changes of the TME (Johan and Samuel, 2018). In this master’s thesis project, we explore the effects of the Rho/ROCK pathway on the tumor microenvironment (TME) and immune response (IR) in neuroblastoma. More specifically we are focusing on populations of T cells, macrophages and fibroblasts in tumors, and looking into tumor vascular structure (such as blood vessel) and extracellular matrix (ECM) formation after ROCK inhibitor treatment within neuroblastoma tumors from transgenic mice model TH-MYCN and multi-cellular tumor spheroids (MCTS), a three-dimensional (3D) in vitro model simulating TME in neuroblastoma cell lines. Through our studies we hope to find insights into the Rho/ROCK signaling pathway and involvement of the tumor microenvironment in cancer therapy, while elucidating potential new drugs and drug targets for improving outcomes in neuroblastoma treatment.