Factors influencing rural and urban emergency clinicians' participation in an online knowledge ex... more Factors influencing rural and urban emergency clinicians' participation in an online knowledge exchange intervention
Recurrent abdominal pain (RAP) affects 10% to 18% of school-age children and is caused by obvious... more Recurrent abdominal pain (RAP) affects 10% to 18% of school-age children and is caused by obvious organic pathology in fewer than 10% of cases. Two recent studies do not support previous beliefs that most RAP is psychogenic. Studies have shown disorders of bowel motility in children with RAP similar to those of adult irritable bowel syndrome (IBS); controlled trials of additional dietary fiber in adult IBS have shown beneficial results. We did a randomized, double-blind, placebo-controlled study in 52 children with RAP and demonstrated a clinically and statistically significant decrease in pain attacks (at least 50% fewer) in almost twice as many children who were given additional fiber as placebo. Compliance was excellent in both groups and side effects were few. Although the cause of RAP is poorly understood, it is hypothesized that the beneficial effect of added fiber is due to its effect on shortening transit time, as in IBS.
Although evidence suggests that adolescents with chronic illness are at a greater risk for psycho... more Although evidence suggests that adolescents with chronic illness are at a greater risk for psychosocial disability, little is known about the adolescent's perception of the impact of the disease on his or her day-to-day life. Standardized measures of coping strategies, mastery, self-efficacy, social support, depression, and a semistructured interview on everyday difficulties were administered to matched groups (sex and age) of 31 adolescents with cystic fibrosis, 31 adolescents with diabetes, and 31 healthy controls. No differences were found between control and adolescents with a chronic disease responses on the standardized measures. The semistructured interview, however, revealed that the adolescent's perception of his or her physical health and the reaction of other family members to the illness were important sources of stress. These findings suggest that, in general, adolescents with a chronic illness cope effectively with their disability but that parents and clinicians must be sensitive to the adolescents' feelings and concerns regarding their health and its impact on the family.
The Oxford Textbook of Paediatric Pain brings together an international team of experts to provid... more The Oxford Textbook of Paediatric Pain brings together an international team of experts to provide an authoritative and comprehensive textbook on all aspects of pain in infants, children and youth. Divided into nine sections, this resource analyses pain as a multifactorial problem and gives the reader a comprehensive understanding of this challenging subject. Topics covered include the biological, social, and psychological basis of pain, pain in specific populations, pain measurement, pharmacology, psychosocial and physical interventions, complementary therapies, education, and ethics of pain control in youths, children, and infants. Evidence-based chapters look in depth at areas ranging from the long-term effects of the pain in children, to sociodemographic differences in paediatric pain management. Case examples and online materials including scales, worksheets, and videos are provided to aid learning and illustrate the application of knowledge.
The implementation of the comprehensive plan for the care, management, and treatment of HIV and A... more The implementation of the comprehensive plan for the care, management, and treatment of HIV and AIDS in South Africa [1] needs to be supported by all. It is encouraging to note that Wilson and Blower [2] used South Africa to develop a novel method to determine the optimal strategy for allocating antiretroviral treatment (ART) sites among healthcare facilities (HCFs) in KwaZulu-Natal. An equitable allocation of HCFs is necessary to ensure that each individual with HIV will have an equal chance of receiving antiretroviral drugs (ARVs). We have applied their method to determine the number of ART HCFs per district in KwaZulu-Natal. We fi rst set out to assemble basic details about the KwaZulu-Natal health districts, namely, population and number of hospitals and fi xed and mobile clinics. Secondly, by using population data as reported in the KwaZulu-Natal Department of Health 2004 annual report [3], and based on a 10% HIV prevalence, we determined the HIV population per district and also as a percentage of the total HIV population in the province. Finally, we calculated the number of ART HCFs, based on the premise that 54 ART HCFs will serve 100% of the HIV population in the province. By contrasting the estimated number of ART HCFs with the current ART HCFs, we calculated the number of ART HCFs that still need to be established. The national target for access to HCFs is 10,000 habitants per one fi xed primary health-care (PHC) facility [2]. A PHC facility could be a clinic, a community health center, or a hospital. At present, there is one fi xed PHC facility for 17,215 inhabitants in KwaZulu-Natal [3]. With regard to ART, the 54 HCFs proposed by Wilson and Blower translate to 18,076 people with HIV per facility (Table 1). This number is close to the actual fi gure of 17,215 inhabitants per facility in the province. In terms of equity, it could be argued, for instance, that the two facilities in the eThekwini district cannot be expected to provide ARVs to the estimated 319,994 individuals with HIV. In comparison, the Umziyathi, Amajuba, Umkhanyakude, Uthungulu, and Ugu districts currently have the same number of ART HCFs as eThekwini, but serve smaller populations (Table 1). This refl ects the fact that the choice of the current facilities was guided more by practical considerations, such as availability of staff and infrastructure, than by the principle of equity as suggested by the World Health Organization [4]. From our calculations, it seems that in order to achieve treatment equity for individuals with HIV in KwaZulu-Natal, more ARV HCFs should be established as follows: 15 in eThekwini, four each in Umgungundlovu and Zululand, three each in Uthukela and Uthungulu, two each in Ugu and iLembe, and one each in Amajuba, Sisonke, Umzinyathi, and Umkhanyakude. As a recommendation, future rollout of ART should take into consideration the principle of equity. This will ensure that all people with HIV have equal access to ARVs from their nearest HCF. We show that by applying the Wilson-Blower method, it is possible to determine the number of health-care facilities where ARVs would be equitably provided.
Migraine headaches are frequent in adolescents. Although many adolescents are adequately treated ... more Migraine headaches are frequent in adolescents. Although many adolescents are adequately treated palliatively with analgesics, an important subgroup requires prophylactic treatment. Medical treatments for adolescents with frequent severe headaches is often problematic. Prophylactic pharmacological treatments are often shunned by adolescents and their parents because of concern over drug usage. Moreover, propranolol, the most widely used prophylactic drug with adults, is frequently not effective. Psychological interventions are effective but are costly and often not available. A randomized controlled trial was undertaken to evaluate the efficacy and efficiency of a predominantly self-administered treatment that could be delivered in a very cost-efficient format. Eighty seven adolescents (63 females and 24 males) ranging in age from 11 to 18 years were randomly assigned to receive a self-administered treatment, the same treatment delivered by a therapist or a control treatment. Self-administered and clinic treatment were equally effective and superior to the control treatment. However, the self-administered treatment was substantially more efficient. Both active treatments were durable at l-year follow-up.
ABSTRACT Current methods for evaluating pain in children with chronic arthritis suffer from metho... more ABSTRACT Current methods for evaluating pain in children with chronic arthritis suffer from methodological problems. A real-time data capture (RTDC) approach using electronic diaries has been proposed as a new standard for pain measurement. A descriptive study design with repeated measures was used to explore pain in adolescents with juvenile idiopathic arthritis (JIA) using a RTDC approach with the newly developed e-Ouch multidimensional electronic pain diary. A convenience sample of adolescents (n=76) with active JIA were recruited from a large metropolitan rheumatology clinic in a university affiliated paediatric tertiary care centre in Canada. Adolescents were signalled electronically and asked to record their pain three times a day for two-weeks using the e-Ouch electronic pain diary. On average, adolescents reported mild levels of pain intensity, unpleasantness, and interference as well as stiffness and mild to moderate levels of fatigue. Pain interfered most with walking and least with relationships with friends/family. On average, participants perceived that they could effectively control their pain. Adolescents reported significantly higher levels of pain interference and stiffness in the morning compared to the afternoon and evenings, and significantly higher levels of fatigue in the morning and evening compared to the afternoon. 17.7% of adolescents missed school due to pain. The duration of morning stiffness lasted from a few minutes to all day for two-thirds of the adolescents. Adolescents had an average of 3 painful joints per diary entry with the most common joints being the ankles, knees, and fingers. Participants typically used two word descriptors to describe their pain, with the most frequently used words being uncomfortable, hurting, and throbbing. In conclusion, use of RTDC approaches should be considered in future studies of chronic arthritis to better understand the nature of pain and other symptoms in adolescents with JIA. Supported by a University of Toronto AstraZeneca Pain Award.
This systematic review examined group based injury prevention interventions that targeted young c... more This systematic review examined group based injury prevention interventions that targeted young children to determine the effectiveness of such strategies in enhancing children's safety behaviors. Methods: A comprehensive (manual and electronic) search of the literature was performed using the following study selection criteria: (1) intervention engaged children under the age of 6 years; (2) included a control group; (3) used a group intervention approach; (4) study written in English language; (5) addressed unintentional injuries; and (6) outcomes included injuries, knowledge, or safety behaviors. Data abstraction was performed independently by two researchers using a standardized approach. Results: Nine studies met the criteria that included safety interventions of road crossing (4), car restraint (2), spinal cord safety (1), poison safety (1), and 911/stranger danger/street crossing (1). The types of interventions included videos, interactive activities, cartoons, stories, puppets, singing, coloring, games, simulation games, demonstrations, modeling/role playing, and rehearsal practice using seat belts, models, and real street crossing. The intensity and duration of interventions varied substantially and only two studies randomly assigned participants. The review revealed a positive effect (knowledge, behaviour, and/or attitude) for five of the studies, three had mixed effect, and one reported no effect. Conclusions: Although no clear conclusions can be drawn from the limited number of studies of diverse design and rigor, researchers should attempt to minimize shortcomings occurring in community based research. Engaging community partners including teachers and parents who influence relationships and outcomes could provide opportunity for more rigorous, comprehensive, and integrated approach to longitudinal research that could identify key factors of successful strategies.
Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 1990
One hundred sixty-one children between 9 and 17 years of age who had migraine headaches participa... more One hundred sixty-one children between 9 and 17 years of age who had migraine headaches participated in a behaviourally oriented treatment programme. Data were collected on factors related to staying in treatment and adherence to treatment instructions. The results revealed that older children were less likely to drop out during treatment. In addition, children with fewer headaches were more likely
Background: Borg developed scales for rating pain and perceived exertion in adults that have also... more Background: Borg developed scales for rating pain and perceived exertion in adults that have also been used in pediatric populations. Models describing functional relationships between perceived exertion and work capacity have not been studied in children. We compared different models and their fits to individual trajectories and assessed the variability in these trajectories. Methods: Ratings of perceived exertion (RPE) were collected from 79 children. Progressive cycle ergonometric testing was performed to maximal work capacity with test duration ranging from 6-12 minutes. Ratings were obtained during each 1-minute increment. Work was normalized to individual maximal work capacity (Wmax). A delay was defined as the fraction of Wmax at which point an increase in ratings of leg fatigue occurred. Such a delay term allows the characterization of trajectories for children whose ratings were initially constant with increasing work. Two models were considered, a delay model and a power model that is commonly used to analyze Borg ratings. Individual model fit was assessed with root mean squared error (RMSE). Functional clustering algorithms were used to identify patterns. Results: Leg tiredness developed quickly for some children while for others there was a delay before an increased ratings of leg exertion occurred with increasing work. Models for individual trajectories with the smallest RMSE included a delay and a quadratic term (quadratic-delay model), or a power function and a delay term (power-delay model) compared to a simple power function. The median delay was 40% Wmax (interquartile range (IQR): 26-49%) in a quadratic-delay model, while the median exponent was 1.03 (IQR: 0.83-1.78) in a power-delay model. Nine clusters were identified showing linear or quadratic patterns with or without a delay. Cluster membership did not depend on age, gender or diagnosis. Conclusion: Children and adolescents vary widely in their capacity to rate their perceptions and exhibit different functional relationships between ratings of perceived exertion and work capacity normalized across individuals. Models including a delay term, a linear component, or a power function can describe these individual trajectories of perceived leg exertion during incremental exercise to voluntary exhaustion.
Canadian family physician Médecin de famille canadien, 1988
THERE ARE SIX CHIEF CONTROVERSIES RELATING TO INFANT NUTRITION: breast- vs. bottle feeding; the a... more THERE ARE SIX CHIEF CONTROVERSIES RELATING TO INFANT NUTRITION: breast- vs. bottle feeding; the age to start solids; the need for supplemental iron, fluorides, or vitamins; sterilization of formulas; food allergies; and the relationship of infant feeding to subsequent coronary heart disease. This article discusses these controversies and reviews the evidence on both sides of each question.
Factors influencing rural and urban emergency clinicians' participation in an online knowledge ex... more Factors influencing rural and urban emergency clinicians' participation in an online knowledge exchange intervention
Recurrent abdominal pain (RAP) affects 10% to 18% of school-age children and is caused by obvious... more Recurrent abdominal pain (RAP) affects 10% to 18% of school-age children and is caused by obvious organic pathology in fewer than 10% of cases. Two recent studies do not support previous beliefs that most RAP is psychogenic. Studies have shown disorders of bowel motility in children with RAP similar to those of adult irritable bowel syndrome (IBS); controlled trials of additional dietary fiber in adult IBS have shown beneficial results. We did a randomized, double-blind, placebo-controlled study in 52 children with RAP and demonstrated a clinically and statistically significant decrease in pain attacks (at least 50% fewer) in almost twice as many children who were given additional fiber as placebo. Compliance was excellent in both groups and side effects were few. Although the cause of RAP is poorly understood, it is hypothesized that the beneficial effect of added fiber is due to its effect on shortening transit time, as in IBS.
Although evidence suggests that adolescents with chronic illness are at a greater risk for psycho... more Although evidence suggests that adolescents with chronic illness are at a greater risk for psychosocial disability, little is known about the adolescent's perception of the impact of the disease on his or her day-to-day life. Standardized measures of coping strategies, mastery, self-efficacy, social support, depression, and a semistructured interview on everyday difficulties were administered to matched groups (sex and age) of 31 adolescents with cystic fibrosis, 31 adolescents with diabetes, and 31 healthy controls. No differences were found between control and adolescents with a chronic disease responses on the standardized measures. The semistructured interview, however, revealed that the adolescent's perception of his or her physical health and the reaction of other family members to the illness were important sources of stress. These findings suggest that, in general, adolescents with a chronic illness cope effectively with their disability but that parents and clinicians must be sensitive to the adolescents' feelings and concerns regarding their health and its impact on the family.
The Oxford Textbook of Paediatric Pain brings together an international team of experts to provid... more The Oxford Textbook of Paediatric Pain brings together an international team of experts to provide an authoritative and comprehensive textbook on all aspects of pain in infants, children and youth. Divided into nine sections, this resource analyses pain as a multifactorial problem and gives the reader a comprehensive understanding of this challenging subject. Topics covered include the biological, social, and psychological basis of pain, pain in specific populations, pain measurement, pharmacology, psychosocial and physical interventions, complementary therapies, education, and ethics of pain control in youths, children, and infants. Evidence-based chapters look in depth at areas ranging from the long-term effects of the pain in children, to sociodemographic differences in paediatric pain management. Case examples and online materials including scales, worksheets, and videos are provided to aid learning and illustrate the application of knowledge.
The implementation of the comprehensive plan for the care, management, and treatment of HIV and A... more The implementation of the comprehensive plan for the care, management, and treatment of HIV and AIDS in South Africa [1] needs to be supported by all. It is encouraging to note that Wilson and Blower [2] used South Africa to develop a novel method to determine the optimal strategy for allocating antiretroviral treatment (ART) sites among healthcare facilities (HCFs) in KwaZulu-Natal. An equitable allocation of HCFs is necessary to ensure that each individual with HIV will have an equal chance of receiving antiretroviral drugs (ARVs). We have applied their method to determine the number of ART HCFs per district in KwaZulu-Natal. We fi rst set out to assemble basic details about the KwaZulu-Natal health districts, namely, population and number of hospitals and fi xed and mobile clinics. Secondly, by using population data as reported in the KwaZulu-Natal Department of Health 2004 annual report [3], and based on a 10% HIV prevalence, we determined the HIV population per district and also as a percentage of the total HIV population in the province. Finally, we calculated the number of ART HCFs, based on the premise that 54 ART HCFs will serve 100% of the HIV population in the province. By contrasting the estimated number of ART HCFs with the current ART HCFs, we calculated the number of ART HCFs that still need to be established. The national target for access to HCFs is 10,000 habitants per one fi xed primary health-care (PHC) facility [2]. A PHC facility could be a clinic, a community health center, or a hospital. At present, there is one fi xed PHC facility for 17,215 inhabitants in KwaZulu-Natal [3]. With regard to ART, the 54 HCFs proposed by Wilson and Blower translate to 18,076 people with HIV per facility (Table 1). This number is close to the actual fi gure of 17,215 inhabitants per facility in the province. In terms of equity, it could be argued, for instance, that the two facilities in the eThekwini district cannot be expected to provide ARVs to the estimated 319,994 individuals with HIV. In comparison, the Umziyathi, Amajuba, Umkhanyakude, Uthungulu, and Ugu districts currently have the same number of ART HCFs as eThekwini, but serve smaller populations (Table 1). This refl ects the fact that the choice of the current facilities was guided more by practical considerations, such as availability of staff and infrastructure, than by the principle of equity as suggested by the World Health Organization [4]. From our calculations, it seems that in order to achieve treatment equity for individuals with HIV in KwaZulu-Natal, more ARV HCFs should be established as follows: 15 in eThekwini, four each in Umgungundlovu and Zululand, three each in Uthukela and Uthungulu, two each in Ugu and iLembe, and one each in Amajuba, Sisonke, Umzinyathi, and Umkhanyakude. As a recommendation, future rollout of ART should take into consideration the principle of equity. This will ensure that all people with HIV have equal access to ARVs from their nearest HCF. We show that by applying the Wilson-Blower method, it is possible to determine the number of health-care facilities where ARVs would be equitably provided.
Migraine headaches are frequent in adolescents. Although many adolescents are adequately treated ... more Migraine headaches are frequent in adolescents. Although many adolescents are adequately treated palliatively with analgesics, an important subgroup requires prophylactic treatment. Medical treatments for adolescents with frequent severe headaches is often problematic. Prophylactic pharmacological treatments are often shunned by adolescents and their parents because of concern over drug usage. Moreover, propranolol, the most widely used prophylactic drug with adults, is frequently not effective. Psychological interventions are effective but are costly and often not available. A randomized controlled trial was undertaken to evaluate the efficacy and efficiency of a predominantly self-administered treatment that could be delivered in a very cost-efficient format. Eighty seven adolescents (63 females and 24 males) ranging in age from 11 to 18 years were randomly assigned to receive a self-administered treatment, the same treatment delivered by a therapist or a control treatment. Self-administered and clinic treatment were equally effective and superior to the control treatment. However, the self-administered treatment was substantially more efficient. Both active treatments were durable at l-year follow-up.
ABSTRACT Current methods for evaluating pain in children with chronic arthritis suffer from metho... more ABSTRACT Current methods for evaluating pain in children with chronic arthritis suffer from methodological problems. A real-time data capture (RTDC) approach using electronic diaries has been proposed as a new standard for pain measurement. A descriptive study design with repeated measures was used to explore pain in adolescents with juvenile idiopathic arthritis (JIA) using a RTDC approach with the newly developed e-Ouch multidimensional electronic pain diary. A convenience sample of adolescents (n=76) with active JIA were recruited from a large metropolitan rheumatology clinic in a university affiliated paediatric tertiary care centre in Canada. Adolescents were signalled electronically and asked to record their pain three times a day for two-weeks using the e-Ouch electronic pain diary. On average, adolescents reported mild levels of pain intensity, unpleasantness, and interference as well as stiffness and mild to moderate levels of fatigue. Pain interfered most with walking and least with relationships with friends/family. On average, participants perceived that they could effectively control their pain. Adolescents reported significantly higher levels of pain interference and stiffness in the morning compared to the afternoon and evenings, and significantly higher levels of fatigue in the morning and evening compared to the afternoon. 17.7% of adolescents missed school due to pain. The duration of morning stiffness lasted from a few minutes to all day for two-thirds of the adolescents. Adolescents had an average of 3 painful joints per diary entry with the most common joints being the ankles, knees, and fingers. Participants typically used two word descriptors to describe their pain, with the most frequently used words being uncomfortable, hurting, and throbbing. In conclusion, use of RTDC approaches should be considered in future studies of chronic arthritis to better understand the nature of pain and other symptoms in adolescents with JIA. Supported by a University of Toronto AstraZeneca Pain Award.
This systematic review examined group based injury prevention interventions that targeted young c... more This systematic review examined group based injury prevention interventions that targeted young children to determine the effectiveness of such strategies in enhancing children's safety behaviors. Methods: A comprehensive (manual and electronic) search of the literature was performed using the following study selection criteria: (1) intervention engaged children under the age of 6 years; (2) included a control group; (3) used a group intervention approach; (4) study written in English language; (5) addressed unintentional injuries; and (6) outcomes included injuries, knowledge, or safety behaviors. Data abstraction was performed independently by two researchers using a standardized approach. Results: Nine studies met the criteria that included safety interventions of road crossing (4), car restraint (2), spinal cord safety (1), poison safety (1), and 911/stranger danger/street crossing (1). The types of interventions included videos, interactive activities, cartoons, stories, puppets, singing, coloring, games, simulation games, demonstrations, modeling/role playing, and rehearsal practice using seat belts, models, and real street crossing. The intensity and duration of interventions varied substantially and only two studies randomly assigned participants. The review revealed a positive effect (knowledge, behaviour, and/or attitude) for five of the studies, three had mixed effect, and one reported no effect. Conclusions: Although no clear conclusions can be drawn from the limited number of studies of diverse design and rigor, researchers should attempt to minimize shortcomings occurring in community based research. Engaging community partners including teachers and parents who influence relationships and outcomes could provide opportunity for more rigorous, comprehensive, and integrated approach to longitudinal research that could identify key factors of successful strategies.
Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 1990
One hundred sixty-one children between 9 and 17 years of age who had migraine headaches participa... more One hundred sixty-one children between 9 and 17 years of age who had migraine headaches participated in a behaviourally oriented treatment programme. Data were collected on factors related to staying in treatment and adherence to treatment instructions. The results revealed that older children were less likely to drop out during treatment. In addition, children with fewer headaches were more likely
Background: Borg developed scales for rating pain and perceived exertion in adults that have also... more Background: Borg developed scales for rating pain and perceived exertion in adults that have also been used in pediatric populations. Models describing functional relationships between perceived exertion and work capacity have not been studied in children. We compared different models and their fits to individual trajectories and assessed the variability in these trajectories. Methods: Ratings of perceived exertion (RPE) were collected from 79 children. Progressive cycle ergonometric testing was performed to maximal work capacity with test duration ranging from 6-12 minutes. Ratings were obtained during each 1-minute increment. Work was normalized to individual maximal work capacity (Wmax). A delay was defined as the fraction of Wmax at which point an increase in ratings of leg fatigue occurred. Such a delay term allows the characterization of trajectories for children whose ratings were initially constant with increasing work. Two models were considered, a delay model and a power model that is commonly used to analyze Borg ratings. Individual model fit was assessed with root mean squared error (RMSE). Functional clustering algorithms were used to identify patterns. Results: Leg tiredness developed quickly for some children while for others there was a delay before an increased ratings of leg exertion occurred with increasing work. Models for individual trajectories with the smallest RMSE included a delay and a quadratic term (quadratic-delay model), or a power function and a delay term (power-delay model) compared to a simple power function. The median delay was 40% Wmax (interquartile range (IQR): 26-49%) in a quadratic-delay model, while the median exponent was 1.03 (IQR: 0.83-1.78) in a power-delay model. Nine clusters were identified showing linear or quadratic patterns with or without a delay. Cluster membership did not depend on age, gender or diagnosis. Conclusion: Children and adolescents vary widely in their capacity to rate their perceptions and exhibit different functional relationships between ratings of perceived exertion and work capacity normalized across individuals. Models including a delay term, a linear component, or a power function can describe these individual trajectories of perceived leg exertion during incremental exercise to voluntary exhaustion.
Canadian family physician Médecin de famille canadien, 1988
THERE ARE SIX CHIEF CONTROVERSIES RELATING TO INFANT NUTRITION: breast- vs. bottle feeding; the a... more THERE ARE SIX CHIEF CONTROVERSIES RELATING TO INFANT NUTRITION: breast- vs. bottle feeding; the age to start solids; the need for supplemental iron, fluorides, or vitamins; sterilization of formulas; food allergies; and the relationship of infant feeding to subsequent coronary heart disease. This article discusses these controversies and reviews the evidence on both sides of each question.
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