Tesis sobre el tema "Childhood cancers"
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Watkins, Sharon Minnich. "Increased Risk of Childhood Cancers Among Children With Congenital Anomalies: A Florida Birth Cohort Experience /". The Ohio State University, 1996. http://rave.ohiolink.edu/etdc/view?acc_num=osu1487933245536724.
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Kroll, Mary Eileen. "Time trends in childhood cancer : Britain 1966-2005". Thesis, University of Oxford, 2009. http://ora.ox.ac.uk/objects/uuid:8be887be-36e7-4b77-a7af-5887f3a1df8c.
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Increasing time trends in the recorded incidence of childhood cancer have been reported in many different settings. The extent to which these trends reflect real changes in incidence, rather than improvements in methods for diagnosis and registration, is controversial. Using data from the National Registry of Childhood Tumours (NRCT), this thesis investigates time trends in cancer diagnosed under age 15 in residents of Britain during 1966-2005 (54650 cases), and considers potential sources of artefact in detail. Several different methods are used to estimate completeness of NRCT registration. The history of methods for diagnosis and registration of childhood cancers in Britain is described, and predictions are made for effects on recorded incidence. For each of the 12 main diagnostic groups, Poisson regression is used to fit continuous time trends and ‘step’ models to the annual age-sex-standardised rates by year of birth and year of diagnosis. Age-specific rates by period, and quinquennial standardised rates for diagnostic subgroups, are shown graphically. For three broad groups (leukaemia, CNS tumours and other cancer), geographical variation is compared by period of diagnosis. The results of these analyses are discussed in relation to the predicted artefacts. The evidence for a positive association between affluence and recorded incidence of childhood leukaemia is briefly reviewed. A special form of diagnostic artefact, the ‘fatal infection’ hypothesis, is proposed as an explanation of both this association and the leukaemia time trend. This hypothesis is examined in a novel test based on clinical data. The recorded incidence of childhood cancer in Britain increased in each of 12 diagnostic groups during 1966-2005 (from 0.5% per year for bone cancer to 2.5% for hepatic cancer, with 0.7% for leukaemia). Evidence presented here suggests that these increases are probably artefacts of diagnosis and registration. The potential implications for epidemiological studies of childhood cancer should be considered.
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Grèze, Victoria. "Cancers dans l'enfance et fertilité à l'âge adulte". Thesis, Université Clermont Auvergne (2017-2020), 2019. http://www.theses.fr/2019CLFAS011.
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Les progrès dans le traitement des cancers de l’enfant et de l’adolescent ont permis de réelles améliorations puisque la survie à long terme est maintenant de plus de 80%. De ce fait, la qualité de vie de ces futurs adultes est une préoccupation majeure des professionnels impliqués dans la prise en charge de ces patients. Notre travail se focalise en particulier sur le développement pubertaire et la fertilité, au travers de la recherche épidémiologique et de la recherche de transfert, chez les enfants et adolescents guéris d’un cancer.Sur le versant « recherche épidémiologique », le développement pubertaire et la fertilité chez la fille ont été étudiés à partir de la cohorte L.E.A. (Leucémies de l’Enfant et Adolescent), qui recueille des données concernant le devenir des patients traités pour une leucémie au cours de leur enfance. Bien qu’elle soit plus importante chez les femmes ayant bénéficié d’une greffe de cellules souches hématopoïétiques et/ou ayant rechuté, la gonadotoxicité atteint également celles n’ayant reçu que de la chimiothérapie en première ligne.En parallèle, l’accès à la préservation de la fertilité des adolescents et jeunes adultes pris en charge pour des pathologies malignes en Auvergne a été analysé. Les garçons bénéficient davantage de consultations au CECOS et d’une préservation de leur fertilité. Des progrès devraient se faire grâce à la création de plateformes clinico-biologiques telles que PREFERA (PREservation FERtilité Auvergne) qui assurent une meilleure coordination entre les différentes équipes prenant en charge ces patients. Sur le versant « recherche de transfert », nous nous sommes intéressés à la cryoconservation des tissus gonadiques, seule option envisageable chez les enfants prépubères notamment, mais comportant un risque potentiel de réintroduction de cellules néoplasiques en cas d’utilisation ultérieure. Nous avons mis au point des techniques sensibles et spécifiques de détection de la maladie résiduelle pour deux tumeurs solides pédiatriques dont les traitements actuels sont potentiellement stérilisants : le neuroblastome et la tumeur d’Ewing. L’intérêt étant de disposer d’un test diagnostic utilisable pour les adultes guéris de ces cancers, dont la fertilité a été compromise par les traitements et qui ont bénéficié d’une cryoconservation de tissu ovarien ou testiculaireAdvances in the treatment of childhood and adolescent cancers have led to real improvements as long-term survival is now over 80%. As a result, quality of life of these future adults is a major concern for the professionals involved in the care of these patients. Our work focuses on pubertal development and fertility, through epidemiological research and transfer research, in childhood cancer survivor.Concerning the "epidemiological research", female pubertal development and fertility were studied using the L.E.A cohort (Childhood and Adolescent Leukemias), which collects data about the outcome of patients treated for childhood leukemia. Although it is more important in women who received hematopoietic stem cell transplantation and/or relapsed, gonadotoxicity also affects those who received only first-line chemotherapy.In parallel, access to fertility preservation for adolescents and young adults treated for malignant diseases in Auvergne was analyzed. Boys benefit more from fertility consultation and preservation of their fertility. Progress should be made thanks the creation of clinico-biological platforms such as PREFERA (PREservation FERtilité Auvergne), which ensure better coordination between the different teams that support these patients.Concerning the "transfer research", we addressed the cryopreservation of gonadal tissues, only option for prepubertal children in particular, but with a potential risk of neoplastic cells reintroduction in case of future use. We developed sensitive and specific techniques of residual disease detection for two solid pediatric tumors whose current treatments are potentially sterilizing: neuroblastoma and Ewing's tumor. The interest is to have a diagnostic test usable for adults cured of these cancers, whose fertility has been compromised by the treatments and who have benefited from ovarian or testicular tissue cryopreservation
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Vangile, Kirsten M. "Childhood cancer survivorship patient characteristics /". restricted, 2008. http://etd.gsu.edu/theses/available/etd-12042008-133347/.
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Thesis (M.P.H.)--Georgia State University, 2008.Title from file title page. Russ Toal, committee chair; Karen Wasilewski-Masker, committee member. Description based on contents viewed July 7, 2009. Includes bibliographical references (p. 68-72).
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Vangile, Kirsten M. "Childhood Cancer Survivors: Patient Characteristics". Digital Archive @ GSU, 2008. http://digitalarchive.gsu.edu/iph_theses/51.
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Survivors of childhood cancer are a relatively new phenomenon in the medical world. The introduction of treatment protocols in the 1970s started a trend in curing children of cancer that historically had been a death sentence. Under these treatment protocols children were given different treatment regimens based on past research that helped remove cancerous cells from their bodies, but were later found to be the cause of treatment related morbidities years into the future; for most survivors roughly ten to 20 years post treatment. These morbidities, commonly called late-effects, are the prime reason that survivors of childhood cancer need to participate in survivorship care. Survivors of childhood cancer are particularly vulnerable to late-effects because the majority of them receive their treatment at a time when their bodies are still growing and developing. Survivorship care services vary by site, but all maintain the common goals of providing long-term follow up for the survivor and education about the ways in which treatments may affect a survivors’ health as they age. Similar to many other facets of healthcare and medicine, there are many populations who do not participate in survivorship care. The purpose of this research is to identify possible barriers to care, assess the level of impact these barriers have upon the survivor’s potential for participation and provide suggestions as to how these barriers can be mitigated. Additionally, this research highlights areas that need further research and analysis.
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Janson, Christopher M. "Marriage and Divorce in Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study". Yale University, 2008. http://ymtdl.med.yale.edu/theses/available/etd-08092007-145913/.
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In this report from the Childhood Cancer Survivor Study (CCSS), we described marriage and divorce rates in survivors of childhood cancer, as compared to a sibling control group and the general U.S. population. We also sought to identify patient and treatment characteristics that were associated with survivor marital status. This study included 8,930 five-year survivors of childhood malignancy and 2,855 sibling controls participating in the CCSS. Data on marital status, sociodemographic factors, and current health status were obtained from questionnaires; detailed disease and treatment histories were available from medical records. Marital status of the U.S. population was obtained from the 2002 Current Population Survey of the U.S. Census. We found that survivors were more likely to have never married than both sibling (odds ratio [OR] = 1.79; 95 % CI = 1.65-1.94; p < 0.0001) and population controls (OR = 2.29; 95 % CI = 2.19-2.38; p < 0.0001), with persistence of trends across age and gender strata. Once married, survivors divorced at rates equivalent to controls. In adjusted analysis, we found that several survivor characteristics predicted never-married status, including treatment involving cranial radiation (OR = 2.41; p < 0.0001), CNS tumor diagnosis (OR = 2.05; p < 0.0001), history of growth hormone deficiency (OR = 2.02; p < 0.0001), and unemployment secondary to disability (OR = 1.78; p = 0.0001). Survivor characteristics predictive of divorce included unemployment (OR = 1.91; p < 0.0001, for unemployed or disabled), lower educational achievement (OR = 1.74; p < 0.0001, for non-college graduates), and psychological distress (OR = 1.60; p < 0.0001). This study confirms prior reports of lower marriage rates in survivors of childhood cancer, providing further evidence that this population struggles with psychosocial adjustment to adult life.
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Mutalima, Nora. "Infections and childhood cancer in Malawi". Thesis, University of Oxford, 2007. http://ora.ox.ac.uk/objects/uuid:9d0c9045-34eb-426c-acec-9c1ffa269417.
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The causes of childhood cancers are not well understood. That infections are believed to play an important role in childhood cancer development is of particular interest in sub-Saharan Africa, where infectious diseases are common. The objectives of this thesis were to identify childhood cancers associated with HIV, malaria, EBV and HHV-8, and to investigate child and maternal factors associated with Burkitt lymphoma and Kaposi sarcoma. In Blantyre, Malawi, 305 children diagnosed with cancer and 212 of their mothers, were recruited. Risk factor data were collected using a brief questionnaire and blood samples tested for infections. Case-control analyses were conducted to compare 148 Burkitt lymphoma cases and 22 Kaposi sarcoma case with a control group comprising 104 children with cancers other than those known to be associated with HIV. The prevalence of HIV was 6% among children with Burkitt lymphoma and 2% in controls (OR=12.4, 95% CI 1.3 to 116.2). Tumour risk increased with increasing litres of antibodies against EBV and malaria. In comparison with those who had low titres against both EBV and malaria, the highest risk of Burkitt lymphoma was among those with high titres against both infections (OR=13.2, 95% CI 3.8 to 46.6). Reported use of mosquito nets was protective against Burkitt lymphoma. The prevalence of HIV was 81% among children with Kaposi sarcoma (OR=762.7, 95% CI 44 to 13376), and risk increased with increasing HHV-8 antibodies. Prevalence of infections was also examined among children with other cancer types and no associations were identified, although the number of cases was small. Few maternal factors were found to be associated with cancer in children. This research demonstrates that infections play a particularly important role in increasing the risk of Burkitt lymphoma and Kaposi sarcoma in children in sub- Saharan Africa. Prevention or early treatment of these infections may be vital in the control of childhood cancer.
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Sylvester, Dianne. "Genes underpinning predisposition to childhood cancer". Thesis, The University of Sydney, 2020. https://hdl.handle.net/2123/22458.
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The genetic changes underpinning cancer predisposition in children are not clearly defined and warrant further research, as identification of a genetic contribution to a patient’s disease can be beneficial for patients and their families. With technological advances, it is now possible to discover a broad spectrum of genetic changes implicated in cancer predisposition by sequencing the genome. An analytical review of six publications utilising germline genome sequencing in paediatric oncology found that these studies differed in the selected childhood cancer diagnoses and the genes considered for interpretation, resulting in differences in the proportions of childhood cancer patients that were reported to carry clinically relevant pathogenic germline variants. In this study, childhood cancer patients that presented with phenotypes indicative of a genetic susceptibility to cancer, such as multiple cancer diagnoses, a family history of cancer and/or a genetic diagnosis, underwent germline exome sequencing. Sequencing data were analysed for rare germline variants in over 1000 cancer predisposition, cancer associated and DNA repair genes, that were predicted to cause a loss of function or to be deleterious. Almost one quarter of childhood cancer patients with features suggestive of a genetic predisposition to cancer were found to carry pathogenic or likely pathogenic germline variant/s in 12 known cancer predisposition genes. A rare variant burden analysis of 31 autosomal dominant cancer predisposition genes found that deleterious germline variants were significantly enriched in a cohort of 63 childhood cancer patients compared to a cohort of 1107 genetically matched healthy aged controls. Novel germline variants not previously associated with cancer predisposition were also detected in 10 genes in 16 childhood cancer patients. This study has expanded our understanding of cancer predisposition in children, by discovering the diagnostic potential of sequencing patients with defined phenotypic features, and by linking pathogenic or likely pathogenic germline variants in known predisposition genes with new cancer diagnoses. Ultimately, by combining the analysis of family pedigrees with functional gene studies and data-sharing, the significance of novel germline variants associated with the onset of cancer in childhood will be established. As more childhood cancer predisposition genes are identified and characterised, screening processes may be more routinely incorporated into paediatric clinical care.
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Luk, Yin-ching y 陸燕青. "Evidence-based psychosocial intervention for families with childhood cancer patients". Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2010. http://hub.hku.hk/bib/B44625698.
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Prouty, Diana Frances Ward-Smith Peggy. "The lived experience of adult survivors of childhood cancer". Diss., UMK access, 2005.
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Thesis (Ph. D.)--School of Nursing. University of Missouri--Kansas City, 2005."A dissertation in nursing." Advisor: Peggy Ward-Smith. Typescript. Vita. Title from "catalog record" of the print edition Description based on contents viewed June 26, 2006. Includes bibliographical references (leaves 142-147). Online version of the print edition.
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Villeneuve, Paul. "Population based survival analysis of childhood cancer". Thesis, University of Ottawa (Canada), 1995. http://hdl.handle.net/10393/10442.
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Purpose: To assess the survival of children diagnosed with cancer between 1982 and 1988 using population based data. Subjects: 4715 cancer patients diagnosed with cancer prior to age twenty, between 1982-1988, as reported population based cancer registries. Mortality status (up to December 31, 1991) was ascertained by linking subjects to the Canadian mortality database. Actuarial survival rates and assessment of the role of covariates (ie. gender, age at diagnosis, year of diagnosis) on survival using the proportional hazards model. The five year survival rate of children diagnosed with a primary malignancy between 1982 and 1988 was 69%. Among those cancers examined, age at diagnosis was a significant prognostic factor for children diagnosed with leukaemia, neuroblastoma, astrocytoma, ependymoma, and rhabdomyosarcoma ($\rm p0.05$). Infants with leukaemia had a substantially poorer prognosis when compared to children diagnosed after age one. Conversely, those diagnosed with neuroblastoma prior to age one had a considerably improved chance of survival. After adjusting for age and year of diagnosis, females were found to have a markedly higher survival for acute lymphocytic leukaemia, and ependymomas ($\rm p0.05$). Improved survival was observed for children diagnosed more recently with acute lymphocytic leukaemia, acute non-lymphocytic leukaemia and Non-Hodgkin's lymphoma ($\rm p0.02$). There was evidence to suggest that survival also improved by year of diagnosis among children with fibrosarcoma ($\rm p=0.05$), Wilms' tumour ($\rm p=0.07$) and ovarian germ cell malignancies ($\rm p=0.06$). No significant trends in survival were observed for the other forms of childhood cancer examined. Geographical variations in survival were assessed for children diagnosed with either acute lymphocytic leukaemia, an astrocytoma or Hodgkin's disease. The survival rates among children diagnosed with acute lymphocytic leukaemia or astrocytoma in British Columbia between 1987 and 1988, were found to be significantly higher when compared to the remainder of the cohort ($\rm p0.05$).
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Thomson, Angela B. "Male fertility in survivors of childhood cancer". Thesis, University of Edinburgh, 2003. http://hdl.handle.net/1842/27532.
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The successful treatment of childhood cancer with chemotherapy and radiotherapy may be associated with testicular damage resulting in impaired spermatogenesis and temporary or permanent infertility in adulthood. In this study testicular function and semen quality was investigated in 33 survivors of childhood cancer. Treatment of childhood cancer was associated with a significant risk of impaired spermatogenesis, with 30.3% of this population being azoospermic and 18.2% being oligozoospermic. Moreover, in those men who do have surviving spermatogenesis after treatment, it is commonly compromised, with reductions being observed in ejaculate volume, sperm concentration, sperm motility and the proportion of morphologically normal sperm. Only 33.3% of this group of 33 male childhood cancer survivors had completely normal semen quality by conventional criteria. However, the sperm produced do not appear to carry a greater burden of damaged DNA compared with the healthy population, suggesting that assisted conception treatment is a safe option for these men. Detection of gonadal damage in the prepubertal male is hampered by lack of a sensitive marker. The role of inhibin B as a marker of early gonadotoxic effects of chemotherapy in prepubertal children treated for cancer was investigated. In prepubertal boys, chemotherapy had little immediate effect on Sertoli cell production of inhibin B during and immediately after treatment stopped, although one boy showed a delayed deleterious effect. Inhibin B changed earlier and appeared to be a more sensitive marker of gonadal damage than FSH or LH. Prospective studies are underway combining inhibin B with FSH, LH and sex hormone measurements, to assess the impact of cancer therapy on gonadal function in children, particularly as they approach and progress through puberty. For prepubertal boys fertility preservation through semen cryopreservation is not an option and consequently, attention is focusing on the development of techniques that might preserve or restore fertility potential in boys being subjected to gonadotoxic cancer therapy. In rats, it has been shown that some germ cells survive cytotoxic therapy and that the resulting azoospermia is a consequence of the inability of those spermatogonia that are present to proliferate and differentiate. Suppression of the hypothalamic-pituitary-gonadal (H-P-G) axis facilitates recovery of spermatogenesis following such cytotoxic treatment. Investigation of whether suppression of the H-PG axis in men rendered azoospermic by treatment for childhood cancer might restore spermatogenesis was undertaken, using both semen analysis and testicular biopsy as end points. In men treated with sterilising radiotherapy and chemotherapy for childhood cancer, effective gonadotrophin suppression with medroxyprogesterone acetate for at least 3 months did not result in restoration of spermatogenesis. The absence of histological evidence of spermatogonial stem cells in testicular biopsies from these men before and after suppression suggests complete ablation of the germinal epithelium and irreversible infertility. Understanding the vulnerability of the prepubertal human testis to cytotoxic damage is compounded by the dearth of data describing normal testicular development in the prepubertal human. Based on immunohistochemical studies in marmosets, a primate that exhibits a similar developmental profile to the human male, it has been shown that significant testicular development occurs during childhood long before the clinical onset of puberty. If we can establish that cell activity does occur in the 'quiescent' testis in boys and is comparable to changes shown in the marmoset, it will validate use of the marmoset as a model for the human in this instance and give encouragement to the possibility of using this primate model to develop a method of protecting spermatogenesis in boys undergoing cancer therapy prior to puberty. Preliminary studies to investigate the development of the prepubertal human testis confirmed testicular cell activity in the foetal and neonatal periods and infancy comparable to that shown in the marmoset. However, to date development during mid childhood and early puberty has proved to be somewhat discordant with the marmoset studies. It is too premature to definitively conclude that marmoset and human testicular development are dissimilar, as a number of explanations have been proffered to explain the discrepancies, including suboptimal tissue fixation and antigen preservation in the human tissues.
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Cornman, Barbara Jane. "Impact of childhood cancer on the family /". Thesis, Connect to this title online; UW restricted, 1988. http://hdl.handle.net/1773/7827.
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Absolom, Kate L. "Follow-up for survivors of childhood cancer". Thesis, University of Sheffield, 2005. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.425627.
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Wong, Kwok Fai. "Epidemiological analysis of survivorship after childhood cancer". Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6629/.
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This thesis investigates the adverse outcomes amongst survivors of childhood cancer using the British Childhood Cancer Survivor Study (BCCSS) and the Pancare Childhood and Adolescent Cancer Survivor Care and Follow-up studies (PCSF). The specific aims were to investigate (1) adverse outcomes up to 50 years of follow-up in survivors of Wilms’ tumour; (2) risks of hospitalisations due to renal morbidities in childhood cancer survivors; (3) risk of subsequent primary neoplasms arising in the digestive system in survivors of childhood cancer; and (4) adverse outcomes beyond 50 years of follow-up in survivors of heritable retinoblastoma. This thesis demonstrated that survivors of Wilms’ tumour are at substantial risk of premature mortality, particularly for those who have survived 30 years from original diagnosis. This particular group of survivors have the highest risk of hospitalisations due to renal morbidities, such as chronic renal failure, and subsequent primary neoplasms in specific organs in the lower digestive system. Survivors of heritable retinoblastoma who received external beam radiotherapy experienced an increased risk of subsequent primary neoplasms developing above the shoulder, whereas those who received brachytherapy were similar to those who did not receive any radiotherapy and did not experience an increased risk of subsequent primary neoplasms.
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Hartman, J. E. M. "Motor performance following chemotherapy for childhood cancer". [S.l.] : Rotterdam : [The Author] ; Erasmus University [Host], 2009. http://hdl.handle.net/1765/14636.
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Leary, Alison. "Emotion regulation in childhood cancer survivors : the coping after cancer study /". Thesis, Connect to this title online; UW restricted, 2007. http://hdl.handle.net/1773/9159.
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Russell, Claire C. "LONGITUDINAL PREDICTORS OF QUALITY OF LIFE IN ADOLESCENT SURVIVORS OF CHILDHOOD CANCER: A REPORT FROM THE CHILDHOOD CANCER SURVIVOR STUDY". VCU Scholars Compass, 2013. http://scholarscompass.vcu.edu/etd/3160.
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Objective: The impact of childhood cancer on future quality of life (QoL) in survivors is unclear. Current studies focus on comparing outcomes to healthy peers and identifying related treatment and demographic variables, but a shift in our approach is necessary. This study is guided by the Wilson and Cleary Model (WMC) and seeks to identify longitudinal predictors of QoL in adolescent survivors of cancer that explain variance in QoL beyond the impact of treatment and demographic variables. Methods: The Childhood Cancer Survivor Study (CCSS) is a multi-institutional longitudinal study following a cohort of childhood cancer survivors. This study focuses on the CCSS cohort (N = 305) who completed the baseline survey in 1994 and the Teen survey in 2001. The baseline survey assessed parent-report of child’s psychological and physical symptoms, functional status, and health perceptions. The Teen survey utilized the Child Health and Illness Profile – Adolescent Edition (CHIP-AE), a self-report measure assessing QoL in six domains: achievement, resilience, satisfaction, discomfort, disorders, and risk. The primary hypothesis was that psychological and physical symptoms, functional status impairment, and health perceptions as rated by parents at baseline would predict variance in quality of life as rated by adolescents at follow-up after adjusting for demographic and treatment-related variables. Six separate hierarchical regressions were analyzed for each of the QoL domains. Results: The main hypothesis was supported. For each QoL outcome, a significant amount of variance was predicted: achievement, F (6, 259) = 8.90, p < .001, adjusted R2 = .152, resilience, F (12, 209) = 3.47, p < .001, adjusted R2 = .118, satisfaction, F (6, 265) = 8.73, p < .001, adjusted R2 = .146, discomfort, F (7, 273) = 6.75, p < .001, adjusted R2 = .126, disorders, F (9, 212) = 6.47, p < .0001, adjusted R2 = .182, and risk, F (7, 238) = 4.81, p < .001, adjusted R2 = .098. Furthermore, for all outcomes, psychological and physical symptoms, functional status impairment, and health perceptions predicted variance above and beyond the impact of demographic and treatment variables. These factors accounted for an additional 9.5% of the variance in the achievement domain, 6.2% for resilience, 10.8% for satisfaction, 6.5% for discomfort, 12.4% for disorders, and 6.1% for risk. Conclusions: Results suggest that psychological and physical symptoms, functional status and health perceptions should be assessed and targeted in interventions for childhood cancer survivors to promote future positive QoL. Future studies need to continue identifying factors related to positive long-term functioning in diverse samples of childhood cancer survivors.
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Langeveld, Neeltje Elisabeth. "Cured of cancer from childhood to adulthood quality of survival /". [Amsterdam] : Amsterdam University Press, 2003. http://www.netlibrary.com/urlapi.asp?action=summary&v=1&bookid=259079.
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Academisch proefschrift--Universiteit van Amsterdam, 2003."Academisch proefschrift ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. mr. P.F. van der Heijden ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Aula der Universiteit op donderdag 15 mei 2003, te 12.00 uur." Description based on print version record. Includes bibliographical references.
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McMillan, Amy. "Educational late effects among survivors of childhood cancer". Thesis, University of British Columbia, 2007. http://hdl.handle.net/2429/31601.
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Increased survival rates of childhood cancer have meant a growing population of survivors within the education system. Although research suggests that survivors face educational difficulties, methodological shortcomings and lack of consensus have contributed to difficulties interpreting this literature. Moreover, there exists a paucity of literature objectively measuring survivors' educational outcomes, particularly achievement. In this population-based research, 782 survivors of childhood cancer from the BC cancer registry, and BC school system from 1995-2004, were age and gender-matched with a randomly selected control group of 8386 BC schoolchildren. Objective educational measures including Foundation Skills Assessments (FSAs), Provincial examinations, and special education designations from the BC Ministry of Education were compared between the survivor and control cohorts; potential disease-related risks among survivors were assessed. Survivors were significantly more likely than controls to have special education or physical disability designations and performed significantly more poorly on several FSAs. Notably, once survivors of central nervous system (CNS) tumours and leukemia were excluded from the analysis, there were no significant achievement differences. Survivors younger at diagnosis (<2 years) had higher educational achievement, despite having more hearing and visual impairments than survivors older at diagnosis ([Greater Than or Equal to] 5 years). Childhood cancer survivors appear at increased risk for special education utilization. In particular, survivors of leukemia and CNS tumours may be at increased risk for poor educational achievement and special education designations. It is important that potential adverse educational outcomes and associated risk factors be identified such that surveillance and appropriate interventions be provided to ensure survivors a successful educational experience.Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
Graduate
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Behera, Malabika. "Long term endocrine sequelae of childhood cancer survivors". Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2014. http://hdl.handle.net/10722/206611.
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Background:
Newer multimodality therapeutic interventions have resulted in dramatic survival rates in childhood cancers. However diverse treatment related morbidities affect the long term survivors. An Endocrine complication comprises 20-40% of these morbidities and affects the hypothalamic pituitary axis, growth, pubertal progression, fertility, bone health and glucose homeostasis.
Objectives:
The aim of our study was to enumerate and evaluate the frequency of endocrine complications arising as a late effect of treatment in childhood cancer survivors. Risk factors likely to be associated with these complications were also evaluated.
Methodology:
Retrospective analysis of medical records from the Long Term Endocrine Follow up clinic in the Department of Paediatrics and Adolescent Medicine of Queen Mary Hospital was done. Patients with a primary diagnosis of Cancer and Langerhans cell histiocytosis with endocrine sequelae arising from various treatment modalities who have survived 5 years after diagnosis were included in the study. Those who had endocrine complications arising from various treatment modalities for Thalassemia’s, Immunodeficiency’s were excluded from the study
Results:
135 cases were included in the study and 27 were excluded. Leukemia and Brain tumor survivors were the majority accounting for 40% and 26.67% respectively. ALL formed majority of leukemia survivors, Medulloblastoma survivors accounted for 50% of brain tumor survivors. Most common endocrine problem was Hypogonadism in 51.1% of cases, followed by growth disturbances in 40%, Thyroid dysfunction in 23% and Hyperlipidemias in 18.5%. Pubertal problems, Central Diabetes Insipidus, Adrenal insufficiency, Obesity, Altered glucose homeostasis were rest of the problems in small frequencies. PHGN (Primary Hypogonadism) was present in 91.3% and mostly in prepubertal males. PHGN was statistically associated with Leukemia survivors with OR-2.06 (1.02- 4.15), p value 0.04. The risk factors associated were exposure to alkylating agents, radiotherapy, TBI prior to transplant. SHGN (Secondary HGN) was statistically associated with Brain tumor survivor OR - 15.8 (1.7-140.5), p value 0.013. Cranial irradiation was the major risk for SHGN. PGV (Poor growth velocity) was the major growth problem.GHD (Growth Hormone Deficiency) had a highly significant association with Brain tumors (p value ˂ 0.0001), and significantly associated when all 3 modalities of treatment given together (p value 0.01). Risk factors for GHD were cranial radiotherapy, exposure to cyclophosphamide and TBI. PH (Primary Hypothyroidism) had highly significant association with craniospinal radiotherapy (p value ˂ 0.0001), and significantly associated with brain tumors. Similar results were observed in patients of CH (Central Hypothyroidism).
Hyperlipidemias were present in 18% with no statistical correlation with the type of cancer. Brain tumor survivors had a significant association of GHD, PH, CH, SHGN and CDI. Leukemia survivors had significant association with GHD and PHGN.
Conclusions:
Endocrine problems are frequent manifestations of late effects of cancer related treatments. Early detection and intervention of these potentially treatable problems could be done through structured long term surveillance. Increasing awareness among health care professionals to anticipate problems in suspected patients and education of patients would optimize health care and quality of life.published_or_final_version
Paediatrics and Adolescent Medicine
Master
Master of Medical Sciences
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Raji, Olaide Yaqeen. "Parental occupational exposure and risk of childhood cancer". Thesis, University of Leeds, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.491636.
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The risk of childhood cancer has been inconsistently linked with parental exposure to occupational agents, partly because of poor exposure assessment. Data from the UK Childhood Cancer Study,. a nationwide population based case-control study, was used to extend previous analyses ofparental occupational exposures assessed via job and industry titles. Eight specific work related exposures were examined as possible risk factors for childhood leukaemia and lymphoma for three exposure time windows (preconception, pregnancy, postnatal). Personal interview data from parents of cases and matched controls included a full occupational history; for each job where exposure had been indicated, detailed information was gathered on each reported exposure agent. A new exposure assessment method was designed, which scrutinised five exposure determinants to provide semi-quantitative indices on exposure probability, level of exposure, frequency of contact, and degree of protection. These were combined to derive a final 'reviewed' exposure status. The method was externally validated against an independent expert assessment. Multivariable unconditional logistic regression estimated odds ratios and 95% confidence intervals for 'self-reported' and 'reviewed' exposures. Mothers had a lower prevalence of exposure (18%) compared· to fathers (44%). The 'reviewed' exposure status reclassified 33% of 4833 mothers' and 50% of 19,326 fathers' reported job exposures as 'exposed'. Many statistically significant risks for 'self-reported' exposure disappeared when applying the reclassified exposure. Only maternal exposure to solvents during pregnancy remained statistically significantly associated with acute lymphoblastic leukaemia (ALL) (OR=2.7, C.I=1.6-4.6) with evidence of a dose-response relationship. Paternal exposure to fertilisers during pregnancy and postnatally also remained statistically significantly associated with ALL and Hodgkin Lymphoma but without evidence of dose-response relationships. The designed exposure assessment method represents a novel approach for evaluating parental occupational exposure for use in future studies. The findings for mothers for the generic group of solvents warrants further independent research. Overall, findings must invoke caution in the interpretation of risk estimates reliant on 'selfreported' occupational exposure in epidemiological investigations.
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Maynard, Maria. "Diet in childhood and risk of adult cancer". Thesis, University of Bristol, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.325909.
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Reulen, Raoul. "Adverse health outcomes in survivors of childhood cancer". Thesis, University of Birmingham, 2009. http://etheses.bham.ac.uk//id/eprint/265/.
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This thesis concerns investigations into adverse health outcomes among survivors of childhood cancer using the British Childhood Cancer Survivor Study (BCCSS). The BCCSS is a large-scale population-based cohort of 17,981 survivors of childhood cancer who were diagnosed with childhood cancer (age 0-14 years) between 1940 and 1991, in Britain, and had survived for at least five years. The specific aims were to investigate, within the BCCSS cohort; (1) the psychometric properties of the SF-36 health-status questionnaire, (2) the self-reported health-status by using the SF-36, (3) the effect of therapeutic radiation on the offspring sex ratio, (4) the risks of adverse pregnancy outcomes, and (5) the risks of second primary breast cancer. This thesis demonstrates that the SF-36 questionnaire exhibits good validity and reliability when used in long-term survivors of childhood cancer. Survivors rate their physical and mental health similarly to those in the general population, apart from bone and central nervous system tumour survivors who rate their physical health below population norms. Therapeutic irradiation does not alter the sex ratio of offspring. Female survivors exposed to abdominal irradiation are at a three-fold risk of delivering premature and two-fold risk of producing low birth-weight offspring. Lastly, the risk of breast cancer among female survivors is two-fold that of the general population, but is not sustained into ages at which the risk of breast cancer in the general population becomes substantial.
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WIERMAA, JACQUELYN DAWN. "HEALTH BEHAVIORS IN ADULT SURVIVORS OF CHILDHOOD CANCER". University of Cincinnati / OhioLINK, 2002. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1021032822.
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Kamonchaiwanich, Jinda. "Dental late effects in survivors of childhood cancer". Thesis, Faculty of Dentistry, 1994. http://hdl.handle.net/2123/4580.
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Sköldenberg, Erik. "Angiogenesis in childhood malignancies /". Uppsala : Institutionen för kirurgiska vetenskaper, Uppsala universitet, 2003. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-3481.
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Chiarelli, Anna Maria. "Reproductive outcomes in females following treatment for childhood cancer". Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1997. http://www.collectionscanada.ca/obj/s4/f2/dsk2/ftp02/NQ27791.pdf.
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Larcombe, Isobel. "Lifestyle behaviours of young adult survivors of childhood cancer". Thesis, University of Bristol, 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.364928.
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Eastaugh, Rachel Kathryn. "The experiences of volunteers in a childhood cancer charity". Thesis, University of Leeds, 2018. http://etheses.whiterose.ac.uk/21559/.
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Introduction: Serious childhood illness has a significant impact on the child and their family, but it is known that strong supportive relationships can act as a buffer. Due to limited NHS resources, volunteers are becoming integral to the support of such families. Despite this, little is known about the experiences of volunteers in such roles, and more specifically, those choosing to volunteer in emotionally challenging areas such as childhood cancer. Method: A sample of seven volunteers working for Candlelighters childhood cancer charity were interviewed using semi structured interviews; transcripts were analysed using interpretative phenomenological analysis. Results: Volunteer’s experiences of working in a childhood cancer charity were described in terms of five superordinate themes: ‘Motivation’, ‘Identity and Roles’, ‘Coping’, ‘Community’, and ‘Family’. Overall, the themes captured what motivates individuals to volunteer and in particular why they chose the area of childhood cancer. The themes also reflected the impact that the role has on their sense of identity and self, and how the participants seemed to cope with that role. It is speculated that this is in part due to the protective experience of belonging to a community as described by the participants, with frequent allusions to an even deeper link in terms of feeling part of a family. Discussion: The findings of this study are related to the wider literature with consideration of role identity theory and the significance of community and relationships. The strengths and limitations are discussed to assess the quality of the study. Implications for our current understanding of volunteers and suggestions for future research are proposed.
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Lowis, Stephen. "The optimization of etoposide therapy in childhood malignancy". Thesis, University of Newcastle Upon Tyne, 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.336815.
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Kelly, Paula Jean. "Competing vulnerabilities in childhood cancer : the everyday lives of British Bangladeshi children with cancer". Thesis, Queen Mary, University of London, 2008. http://qmro.qmul.ac.uk/xmlui/handle/123456789/1468.
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This thesis presents a social study of childhood cancer treatment in a group of British Bangladeshi children living in one city in the United Kingdom. It draws on theoretical perspectives that see childhood as a social construction and children as active contributors to the social world, whilst acknowledging that their contributions are mediated by their dependence on adults. British Bangladeshi children represent a significant minority group whose cultural heritage may challenge the underlying assumptions of biomedical paediatric cancer care. An ethnographic study was undertaken to develop a detailed description of the social and cultural needs of this group of children. Fieldwork was conducted in home and clinical settings to provide an account of how day to day social relations for children, families and health care professionals are experienced. The analysis indicates that cancer service organisation, the dual language of families and clinical implications of the disease simultaneously contributed to the social impact of childhood cancer treatment on the daily lives of children. The data themes on childhood, cancer treatment and culture: language and power reveal that children, parents and professionals differentially constituted vulnerability in childhood cancer. Central to this thesis is the role of relationships between children, parents and professionals in the production of childhood cancer treatment including their ambiguous and borderline nature. I conclude that this produced a day to day reality of diminished power and agency for participants and led to children in particular occupying positions of liminality. This work challenges the assumption that membership of the social category of childhood has equivalent meaning to all social actors. It calls for further exploration of the taken for granted ideas of childhood during illness that professionals employ in their clinical practice from a perspective that acknowledges the structures that frame adult child relations and the context of care delivery.
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Waldon, Eric G. "School attendance following cancer diagnosis: A report based on the childhood cancer survivor study". Scholarly Commons, 2007. https://scholarlycommons.pacific.edu/uop_etds/2621.
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Medical advances in the area of pediatric oncology have resulted in significantly increased rates of survivorship among children diagnosed with cancer. Accordingly, there has been increasing emphasis placed on long-term, quality-of-life issues for this population. Many agree that maintaining a typical or normalized lifestyle following diagnosis is important for positive adaptation and functioning during adulthood: many agree that, for children, school attendance is seen as an especially important developmental task. However, little attention has been paid to which variables are related to school absence and attendance following a cancer diagnosis. This study explored the extent to which illness-related and personal/environmental factors affect absence rates among a cohort of long-term survivors of pediatric cancer. Two samples ( n = 3039; n = 307) from the Childhood Cancer Survivor Study, a multi-institutional longitudinal investigation, were subjected to analysis. Findings suggest that: (1) The hypothesized set of illness-related factors do predict membership in either a high or low absence group; (2) Additional medical problems account for a significant proportion of the variance explaining school absence; (3) Several personal/environmental factors predict absence beyond that which is explained by the presence of additional medical problems; and (4) Self-esteem serves as a protective factor in terms of school absence, especially for those children receiving central nervous system treatment. Findings are discussed with regard to future research and recommendations aimed towards supporting school reentry for pediatric cancer patients.
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Bath, Louise E. "The reproductive health of women treated for cancer in childhood". Thesis, University of Edinburgh, 2005. http://hdl.handle.net/1842/24986.
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This thesis addresses aspects of hypothalamic, pituitary, ovarian and uterine function in post pubertal women following treatment for cancer in childhood. The effect of low dose cranial irradiation (18-24 Gray) on gonadal function was evaluated in long-term survivors of childhood leukaemia. Tracking of urine luteinising hormone (LH), oestrone and pregnandiol demonstrated reduced LH secretion throughout the cycle and particularly during the LH surge, short luteal phases and decreased oestrone production. These data indicate that treatment for childhood leukaemia results in a subtle ovulatory disorder in some patients, probably related to cranial irradiation. Women treated for childhood cancer, who have progressed spontaneously through puberty and have regular menstrual cycles, may still be at risk of an early menopause. Ovarian reserve was assessed in women with regular menstrual cycles and women with a history of regular cycles who were using the oral contraceptive pill (OCP), for contraception. They were investigated before and 24 hours after an injection of follicle stimulating hormone (FSH). Women with regular cycles had significantly higher basal FSH, and lower anti-Mullerian hormone levels, and reduced ovarian volume. Women on the OCP had a reduced inhibin B response to FSH and lower antral follicle counts. Therefore, both groups showed hormonal and biophysical evidence of partial loss of ovarian reserve. Radiotherapy to the abdomen carries a high risk of ovarian failure. The effect on the uterus is less well documented. Ovarian and uterine function were evaluated in women who had received total body irradiation in childhood (14.4 Gray). In women with ovarian failure, uterine function was evaluated before and after 3 months of physiological sex steroid replacement (pSSR). At baseline, uterine artery blood flow and thickening of the endometrial were not detectable. After 3 months of pSSR neither blood flow or endometrial thickness were different from controls. Uterine volume remained smaller, and there was a correlation with age at irradiation. Endometrial samples were obtained and the histology and histochemistry of the endometrium were normal compared with controls. Hormone replacement therapy and achieves physiological sex steroid concentrations improves uterine size, blood flow and endometrial development. For those young women that have ovarian failure there is no good evidence as to the optical method of pubertal induction and subsequent cyclical hormone replacement therapy. UK practice was evaluated by postal questionnaire sent to all British Endocrinologists who were members of the European Society for Paediatric Endocrinology.
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Weston, Claire Louise. "Applications of non-mixture cure models in childhood cancer studies". Thesis, University of Leicester, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.492826.
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The United Kingdom Children's Cancer Study Group (UKCCSG) was formed in 1977 with the aims of improving the management and advancing knowledge and Ludy of childhood cancers. UKCCSG studies are usually analysed using Cox models to assess whether certain prognostic factors may have an influence on survival. Cox models assume that proportional hazards exist and that all individuals will eventually experience the event of interest resulting in a long-term survival of zero. In childhood cancer, this may not be the case, as survival rates in excess of 70% are often observed. Parametric cure models have been proposed as an alternative method for analysing long term outcome aata m cases such as these.
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Yuen, Nga-yee Ada y 袁雅儀. "The role of hope and rumination in childhood cancer adjustment". Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2013. http://hdl.handle.net/10722/209670.
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In support of Snyder’s cognitive theory, hope has been found to be a positive factor in psychological adjustment among adult cancer patients and non-cancer paediatric patients with various illnesses. Nonetheless, Snyder’s cognitive theory of hope has not been specifically examined among childhood cancer patients and survivors. Unlike adult cancer patients, childhood cancer patients and survivors are characterized by early onset age in their cancer diagnosis which may mean that they face different psychological and physiological challenges. The identification of positive factors that attenuate negative psychological adjustment outcomes may be crucial in the development of effective therapeutic interventions.
Despite that previous studies support the correlation between hope and positive adjustment outcomes, the exact cognitive mechanism that underpins the cognitive theory of hope remains underexplored. Although Snyder postulated that hope is goal-directed thinking which comprises willpower and waypower, he failed to establish any association between hope and rumination. The role of rumination in predicting the onset of mood symptoms and maintaining psychopathology has been well-researched, but it is conceptually meaningful to investigate the potential association between hope and rumination and their respective roles in affecting psychological adjustments in cancer experiences.
The current thesis improves on the understanding of relationships between hope, rumination and cancer adjustment, and expands on studies of cancer adjustment by tapping into both positive and negative psychological outcomes, and examines how these two juxtaposed outcomes are associated with hope as mediated by positive and negative ruminations respectively.
Eighty-nine childhood cancer survivors from the Children’s Cancer Foundation in Hong Kong took part in questionnaires that measured their levels of hope, rumination, mood symptoms and self-perceived positive changes or post-traumatic growth (PTG). The findings suggest that hope is negatively correlated with depression and anxiety, which are specifically mediated by negative cancer-related rumination. Hope is also positively correlated with PTG, which is specifically mediated by positive cancer-related rumination. These results provide empirical evidence to support the postulation by Snyder that low hope individuals adjust poorly because they are more likely to have negative rumination. High hope individuals adjust better as they are more likely to engage in positive rumination which is associated with PTG. The overall findings provide a possible explanation for the cognitive mechanism that underlies hope.
A supplementary pilot study conducted measuring 20 childhood cancer patients’ hope level and mood symptoms over a period of nine months post-acute treatment also suggests patients have fewer prospective depressive symptoms have higher hope level in early measurement.
The findings of the current thesis have important clinical implications. The understanding of hope and its association with rumination and cancer adjustment may inform the specific development of hope-based therapeutic interventions for childhood cancer patients and survivors, such as the hope-based storybook developed in this study with the aim to increase the hope levels of childhood cancer patients.published_or_final_version
Clinical Psychology
Doctoral
Doctor of Psychology
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MICELI, ANA VALÉRIA PARANHOS. "CHILDHOOD AND JUVENILE CANCER: SIBLINGS, THE CHILDREN NO ONE SEES". PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO, 2013. http://www.maxwell.vrac.puc-rio.br/Busca_etds.php?strSecao=resultado&nrSeq=34381@1.
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PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIROEste trabalho vem refletir sobre as repercussões do câncer infanto-juvenil nos irmãos das crianças doentes. O câncer é apresentado como doença grave que abala a estrutura familiar afetando a todos os membros da família. Como no imaginário social o câncer é sempre associado à morte, a família reproduz a conspiração do silêncio em torno da morte, impedindo a livre circulação das informações sobre a doença e os tratamentos, deixando as crianças entregues às suas próprias fantasias sobre o adoecimento e o tratamento do irmão. Em virtude de longos períodos de hospitalização para acompanhamento do filho doente, os pais, sobretudo a mãe, marcam os demais filhos com sua ausência e demandam mudanças importantes na rotina familiar e uma equivocada exigência de súbita maturidade. Realizamos pesquisa de campo qualitativa com sete irmãos, com idades variando entre 8 e 16 anos, utilizando entrevistas semiestruturadas cujos conteúdos foram analisados em quatro categorias: representações sobre a doença e a morte; sobre afetos relacionados ao irmão doente; sobre perdas; e sobre ambiente e mudanças. Os resultados apontam para sentimentos também observados em outras pesquisas (tristeza, solidão, rejeição, ciúmes, raiva, culpa, ressentimento; insatisfação com a informação recebida; medo da morte; sentimentos de perda e de abandono; queixa da ausência física e emocional dos pais; rivalidade entre os irmãos; ruptura da normalidade e da segurança dentro da família; mudanças nos papéis e relacionamentos familiares; diminuição da vida social ou isolamento social; dificuldades escolares; empobrecimento da qualidade de vida; queixas somáticas ou preocupação com a própria saúde; sentimentos de compaixão, de amadurecimento, de maior responsabilidade, de independência; percepção, compromisso ou desejo de maior coesão familiar) e, ainda, para a vergonha, a inveja, o altruismo, o heroismo e a expectativa que as crianças têm de verem seus esforços reconhecidos. Interpretamos e discutimos os resultados à luz da psicanálise e concluimos que o câncer irrompe com força traumática na família não só pelas particularidades da doença e sua associação à morte, mas, sobretudo, pela sensação de desamparo e exclusão vivenciada pelos irmãos ditos saudáveis . A doença e os desdobramentos que ela provoca trazem algo inesperado e incompreensível para a criança que se encontrava despreparada para o evento e ainda não era capaz de uma reação madura ao mesmo. Esta falha ambiental, uma falha no cuidado, pode ser vivenciada como traumática, com efeitos em curto, médio ou longo prazo, demandando maior atenção e cuidado para com estes irmãos. Entretanto, eles não recebem o devido suporte familiar, nem social, nem escolar, nem da equipe de saúde, pois são as crianças que ninguém vê.
This paper contemplates the repercussions of childhood and juvenile cancer on the patients siblings. Cancer is presented as a serious illness that threatens the family s structure affecting all of its members. Since cancer is always related to death in social imagination, the family reproduces the silent conspiracy around the theme, creating obstacles to the free circulation of information about the disease and its treatment, leaving children subject to their own fantasies about the illness and treatment of their sibling. The parents, specially the mother, are frequently absent due to prolonged hospitalizations, affecting the other children who suffer important changes in their routine and are equivocally demanded to mature more rapidly. Qualitative field research was done with seven siblings, ages between 8 and 16, using semi-structured interviews whose content was analyzed in four categories: representations about illness and death; about emotions concerning the sick brother/sister; about loss and about the environment and its changes. The results point towards feelings also observed in other studies (sadness, loneliness, rejection, jealousy, rage, guilt, resentment, dissatisfaction with the information received, fear of death, feelings of loss and abandonment, complaints about the physical and emotional absence of parents, rivalry with other siblings, rupture in normality and safety in the family, changes in roles and family relationships; diminution of social life and even social isolation; scholastic difficulties; impoverishment of life’s quality; somatic complaints and preoccupation with one s own health; feelings of compassion; of maturity, of more responsibility, and of independence; increased perceptiveness and commitment; desire of more family cohesion) and also to shame, envy, altruism, heroism, and the kids expectation of having their own efforts recognized. We have interpreted and discussed the results in the light of psychoanalytic viewpoints and concluded that cancer disrupts the family with traumatic force not only due to its characteristics and association with death, but moreover, due to the sensation of helplessness and the exclusion felt by the healthy siblings. The disease and its developments bring out something incomprehensible to the child that was unprepared for the event and still was not capable of a mature reaction to the fact. This environmental failure, a flaw in the caring of the child can be lived as traumatic with short, medium and long term effects, demanding more attention and care of these siblings. However, they get neither familiar, social, scholastic or support of the health team, because these are the children no one sees.
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Martinez, Mariel y Mariel Martinez. "Assessing Nurse Practitioner Preparedness When Caring for Childhood Cancer Survivors". Diss., The University of Arizona, 2016. http://hdl.handle.net/10150/622904.
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Background: The rate of childhood cancer survivors has grown to nearly 80% in the past few decades. Current evidence reveals that primary care providers report feeling unprepared with inadequate knowledge about the variable types of late effects and diagnostic screenings recommended for childhood cancer survivors (Dulko et al., 2013; Potosky et al., 2011). However, the current evidence reflects data mainly from physicians. None of the current literature addresses the specific preparedness of primary care nurse practitioners. Such data would be helpful in better understanding how education and current resources affect nurse practitioner preparedness for such a narrow, but growingly prevalent, patient population.Purpose: To assess primary care nurse practitioner preparedness when caring for childhood cancer survivors.Methods: This descriptive study obtained data using a survey disseminated to primary care nurse practitioner members of the Puget Sound Nurse Practitioner Association in Seattle, WA. Analysis was conducted by calculating the means and modes for each survey item. Results: This sample (n=5) revealed that 50% of nurse practitioners identify as feeling adequately trained to care for childhood cancer survivors. Time and insurance coverage were not found to be barriers to care. Less than 50% of nurse practitioners utilized guidelines from the Children’s Oncology Group. The most wanted resources included the Children’s Oncology Group guidelines, survivor care plans, and electronic health record prompts. Discussion: According to the results of this study imply that nurse practitioners in the Seattle area feel adequately prepared to care for childhood cancer survivors. In addition, nurse practitioners identify that clinical practice guidelines may be beneficial in guiding their care. However, certain limitations, including small sample size, may affect the trustworthiness of the results. Thus, more research is warranted to gather more comprehensive knowledge and understanding regarding nurse practitioner preparedness when caring for childhood cancer survivors in the primary care setting.
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Mansouri, Imène. "Long-Term Kidney and Cardiac Disease Following Childhood Cancer Treatment". Thesis, Université Paris-Saclay (ComUE), 2019. http://www.theses.fr/2019SACLS579.
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Les progrès thérapeutiques ont conduit à une augmentation de la survie à 5 ans des enfants traités pour un un cancer et qui dépasse actuellement 80%. En France il a été estimé que 50 000 adultes guéris d’un cancer pédiatrique, mais la prévalence des complications à long terme causées par la maladie et par ses traitement dépasse 60% après un suivi de 30 ans. L’objectif général de cette thèse était de faire avancer les connaissances actuelles sur la mortalité et la morbidité à long terme liées aux cancers pédiatriques.Avec les données de la cohorte FCCSS (French Childhood Cancer Survivor Study) qui inclut des sujets ayant été traités pour entre 1946 et 2000 pour un cancer pédiatrique solide, nous avons observé que le risque de mortalité chez ces patients demeure plus élevé que la population générale même à plus de 40 ans après le diagnostic de leur premier cancer. D’autre part, la mortalité liée plus aux effets à long terme des traitements anticancéreux, plus spécifiquement les seconds cancers et maladies circulatoires, a significativement baissé parmi les sujets traités plus récemment.Par ailleurs, nous avons aussi confirmé le rôle des anthracyclines dans la survenue de l’insuffisance cardiaque et montré que la fraction du volume médian du cœur ayant reçu 30 Gray était beaucoup plus élevés chez les sujets ayant développé une insuffisance cardiaque par rapport aux autres. Nous avons aussi observé que des faibles volumes du cœur (10% du volume du ventricule gauche) ayant reçus ≥30 Gy sont associés à un risque élevé de développer une insuffisance cardiaque. Cette étude est la première à rapporter une relation dose-effet basée sur des indicateurs dose-volume et ces résultats peuvent être utilisés dans la pratique clinique couranteNos travaux ont aussi montré que les patients ayant subi une néphrectomie unilatérale étaient à risque de développer une maladie rénale chronique à très long terme. L’effet de la dose de radiation reçue aux reins différait selon si les patients ayant subi une néphrectomie unilatérale ou non . En effet, une dose au seul rein même <5Gy était associée à un risque élevé de dysfonctionnement rénal. Par ailleurs, grâce aux données du registre REIN, nous avons pu montrer que l’incidence de l’insuffisance rénale terminale liée aux anticancéreux était en train d’augmenter au fil des années. Cependant ces patients étaient moins inscrits en liste d'attente comparés à d’autres malades rénaux et avaient par conséquent un accès très limité à la transplantation rénale.En conclusion, le travail effectué courant cette thèse pourrait aider à identifier les patients à risque accru de complications tardives majeures liées aux traitements anticancéreux. Nos résultats pourraient être utilisés dans la pratique clinique courante pour l’adaptation de la prise en charge thérapeutique des enfants atteints de cancer et pour les recommandations de leurs suivi à long termeAdvances in treatment have increased the overall 5-year survival rate for childhood cancers to approximately 80%. In France, it estimated that about 50,000 adults have survived childhood cancer. However, previous studies have demonstrated that by the second decade of life, more than 60% of survivor of childhood malignancies (CCS) will suffer from at least one chronic disease related to the treatment they have received.The general objective of this thesis was to advance knowledge about the very long morbidity associated with childhood cancer, with the ultimate target to improve both the long term outcome and quality of life of survivors.Using data from the French Childhood Cancer Survivor Study (FCCSS) cohort, which includes patients treated for a solid pediatric malignancy between 1942 and 2000, we found that that mortality among CCS remained higher than the general population even after more than 40 years of the primary cancer diagnosis. A major finding of this study was that mortality attributed to adverse effects of cancer treatments (secondary primary neoplasm and circulatory disease) declined among patients treated in more recent treatment periods. We also conducted a case control study nested in the FCCSS cohort and further affirmed the role of anthracycline in the occurrence of heart failure. We demonstrated that the median heart volume that received at least 30Gy was higher among heart failure cases and that exposing small volumes of the heart (10% of the volume of the left ventricle) to at least 30Gy was associated with an elevated risk of cardiac failure. This study was the first to derive a dose response relationship based on dose-volume metrics which can be used in current clinical practice.Our results also showed that unilateral nephrectomy was associated with a high risk of renal impairment. The effect of radiation dose to the kidneys was also different among nephrectomized patients for whom any exposure to radiation was associated with an elevated risk of chronic kidney disease even at doses less than 5 Gy.Furthermore, data from the renal epidemiology and information network (REIN) registry allowed us to investigated ESKD (end stage kidney disease) related to nephrotoxic chemotherapy and/or radiation. Our registry-based study showed that ESKD related to nephrotoxic cancer treatment has been steadily increasing over the past decade in the French population. These patients experienced a much lower rate of wait-listing than matched controls with other causes of ESKD, despite similar survival on dialysis.To conclude the results of this thesis are useful to identify survivors of childhood malignancies who are at risk of developing severe long term adverse effects related to the treatment of their primary cancer. Our results could be applied in current clinical practice to help adapt current treatment strategies and improve the long-term follow-up recommendations of childhood cancer survivors
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Carrière, Natalie. "It Still Isn't Over: A Mother's Experiences of Healing After Childhood Cancer". Thesis, Université d'Ottawa / University of Ottawa, 2015. http://hdl.handle.net/10393/32862.
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This autoethnographic account explores my experiences of healing with my daughter and two sons after childhood cancer. My goal was to understand the disconnect between my experiences of persisting fear, grief and trauma and the contradictory messages we encountered during treatment that urged us to resume our ‘normal lives’ at the end of treatment. In analyzing my story, juxtaposed with other anthropologists’ narratives of their journey through cancer and beyond, I realized that my experiences were mediated by prevalent war metaphors in illness; the pervasive social and medical messages and expectations of restitution; as well as narrow biomedical un- derstandings of illness and healing. I offer up my story with the intention of bridging the divide between patients, their family, and medical professionals.
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Tweddle, Deborah Anne. "The role of p53 and p53 regulated proteins in neuroblastoma". Thesis, University of Newcastle Upon Tyne, 2002. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.246680.
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Ward, Mary Whitney. "Psychotropic Medication Use in the Pediatric Cancer Population". Scholarly Repository, 2010. http://scholarlyrepository.miami.edu/oa_dissertations/487.
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Psychotropic medications commonly used with children have been associated with side effects significant enough to warrant warnings from the Food and Drug Administration. The risks of these side effects are potentially increased in children who are long-term survivors of childhood cancer because of damage to the heart and central nervous system (CNS) due to chemotherapy and radiation therapy. There are few empirical studies addressing whether children treated for cancer have greater exposure to psychotropic medications than the general population, the reasons for use of psychotropic medications in cancer survivors, or whether risks associated with cancer treatment are considered when psychotropic medications are used. The specific aims of this study were: (1) to examine the prevalence of psychotropic medication use among children treated for cancer, (2) to obtain descriptive data regarding variables associated with medication usage, and (3) to develop a model to predict which children are likely to be prescribed psychotropic medication. A cross-sectional sample of 69 children, ages two to 17 years, who were undergoing treatment or had successfully completed treatment for leukemia/lymphoma, central nervous system (CNS) tumors, or other non-CNS related cancers were recruited. Caregivers completed measures of psychosocial functioning, medication use, and developmental history. Medical history was also obtained. Results indicated that 15% of subjects were taking psychotropic medication, specifically stimulants and antidepressants. The Classification and Regression Trees (CART) algorithm was used to develop a predictive model. Results indicated gender, age, and presence of school difficulty explained a total of 46% of the variance in psychotropic medication use in the pediatric cancer population; children treated for cancer who were male, age 10 or older and had reported school difficulty were more likely to be prescribed psychotropic medication. No cancer variables were found to influence psychotropic medication use. Several limitations likely influenced results including limited sample size, inclusion of multiple diseases in the non-CNS involved solid tumor diagnosis group, and recruitment limited to three sites. Results indicate a need for continuous examination of psychotropic medication use and possible side effects in the childhood cancer population.
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McKinney, P. "An examination of antenatal factors in the aetiology of childhood malignancies". Thesis, University of Leeds, 1986. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.378056.
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Simon, Coma Marina. "Comprehensive Molecular Characterization of Childhood Liver Cancer: Identification of Prognostic Biomarkers". Doctoral thesis, Universitat de Barcelona, 2017. http://hdl.handle.net/10803/664344.
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Malignant tumors in children and adolescents are one of the leading causes of death from disease in this population despite being rare events. The main liver tumor in children is Hepatoblastoma (HB) representing two thirds of the total while pediatric Hepatocellular Carcinoma (pHCC) is rarer than HB and is usually diagnosed in older patients. Patient survival at 5 years is higher than 75% for HB and less than 30% for pHCC. At molecular level, 2 different subclasses of HBs have been described based on a 16-gene signature, C1 and C2, being the latest more aggressive. Nowadays patient stratification is based only in clinical and pathological parameters. For this reason, the identification of prognostic markers easy to apply at the clinical practice is mandatory in order to better stratify patients and diminish the side effects of chemotherapy treatment, moving towards a more personalized medicine.
The proteomic profile of 16HBs and 8 paired normal liver (NL) tissue was obtained by 2 different techniques, two-dimensional gel electrophoresis and label-free LC-MS. The differential expressed proteins were validated by western blot (WB) in the same patients and the final protein signature was validated by immunohistochemistry in additional 144 patients. Furthermore, RNA sequencing and copy number variation analysis were performed in 31 HB samples, 11 patient-derived xenografts (PDXs) and 5 pHCC. Results were validated by Sanger sequencing, droplet digital PCR or real time PCR and correlated with clinical features.
Two hundred and thirty proteins were identified as deregulated in aggressive C2 tumors and 8 of them were selected and validated by WB considering also their expression in NL. After WB, 2 proteins were found significantly upregulated in C2 tumors while 1 was downregulated. A score was calculated for each protein and biomarkers 1 and 2 were considered altered when their staining was at least 2-fold higher than the NL while the biomarker 3 was considered as altered when no staining was observed. The 3-protein signature was defined by the number of altered biomarkers in each tumor and was highly correlated with patient survival and complementary to the current clinical stratification.
RNA-sequencing data revealed that fusion proteins are rare events in HB as they were found in only 2% of patients. Mutational analysis allowed us to identify mutations in CTNNB1 (30%), NFE2L2 (7%) and EPHB4 (7%). Interestingly we identified a downregulation of the RNA editing which is correlated with patient outcome. The copy number variation analysis showed that gains are more frequent than losses in HB tumors and that PDXs maintain 78% of the aberrations, being a good model for the study of HB. In contrast, pHCC are characterized by more aberrations than HB and mainly losses. Thus, we stablished a molecular classification that includes 3 HB types: stable (no big CNVs), gains-enriched and losses-enriched classes. This classification is correlated with event-free survival, CTNNB1 mutations and the expression of stem cell markers.
As a result of this thesis, we stablished a 3-protein signature that could be easily applied at the clinical practice and increased the molecular knowledge of childhood liver tumors.Els tumors malignes en nens i adolescents són una de les principals causes de mort per malaltia en aquesta població malgrat ser poc freqüents. El principal tumor de fetge en la infància és l’Hepatoblastoma (HB) mentre que el Carcinoma Hepatocel·lular pediàtric (pHCC) és menys freqüent i normalment es diagnostica en pacients més grans. La supervivència als 5 anys és superior al 75% per l’HB i menor del 30% pel pHCC. A nivell molecular, s’han descrit 2 subclasses d’HB en base a una signatura de 16 gens, C1 i C2, essent la segona més agressiva. Actualment l’estratificació dels pacients es basa només en paràmetres clínics i patològics. Per aquesta raó, la identificació de marcadors pronòstic que siguin fàcilment aplicables a la pràctica clínica és imprescindible per a una millor estratificació els pacients per tal de disminuir els efectes secundaris de la quimioteràpia, avançant cap a una medicina personalitzada. Es va estudiar el perfil proteòmic de 16 HBs i 8 teixits no tumorals (NL) mitjançant 2 tècniques, l’electroforesi bidimensional amb fluorescència i una tècnica sense marcatge LC-MS. Les proteïnes amb expressió diferencial es van validar per western blot (WB) en els mateixos pacients i la signatura final es va validar per immunohistoquímica en 144 pacients. A més, es va realitzar seqüenciació de RNA i un array genòmic en 31HBs, 11 xenògrafts derivats de pacients (PDXs) i 5 pHCC. Els resultats es van validar per seqüenciació Sanger, droplet digital PCR o PCR a temps real i correlacionar amb característiques clíniques. Es van identificar 230 proteïnes desregulades en els tumors agressius C2 i 8 d’aquestes es van seleccionar per ser validades per WB considerant també la seva expressió en NL. Els resultats del WB van confirmar que 2 de les proteïnes estaven sobreexpressades en els tumors C2 mentre que una d’elles estava infraexpressada. Es va calcular una puntuació per cada proteïna, de manera que els biomarcadors 1 i 2 es consideren desregulats si la seva expressió és superior a 2 vegades l’expressió del NL mentre que BM3 es considera alterat si no es detecta expressió. La firma de 3 proteïnes, que es va definir com el número de biomarcadors alterats, estava fortament correlacionada amb la supervivència i era complementària a l’actual estratificació clínica. Les dades de seqüenciació de RNA van revelar que les proteïnes de fusió són poc freqüents en HB i l’anàlisi de mutacions ens va permetre identificar mutacions en CTNNB1 (30%), NFE2L2 (7%) i EPHB4 (7%). A més, vam identificar una infra-regulació del mecanisme d’edició del RNA correlacionat amb el pronòstic. L’anàlisi genòmic va mostrar que els guanys cromosòmics són més freqüents que les pèrdues en l’HB i que els PDXs mantenen un 78% de les alteracions, representant un bon model per a l’estudi del HB. Per contra, el pHCC presenta més alteracions que l’HB i majoritàriament pèrdues. Finalment, vam establir una classificació molecular que inclou 3 classes d’HB: estable, enriquida en guanys i enriquida en pèrdues. Aquesta classificació està correlacionada amb la supervivència, mutacions de CTNNB1 i expressió de marcadors de cèl·lules progenitores. Amb aquesta tesi, hem establert una signatura de 3 proteïnes fàcilment aplicable a la pràctica clínica i augmentat el coneixement molecular dels tumors hepàtics pediàtrics.
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Tsanos, Andrea P. "Childhood cancer patients : an examination of their coping and adaptive behavior". Thesis, McGill University, 1994. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=26346.
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The existing literature on adaptation to childhood cancer is integrated within the stress and coping paradigm (Lazarus & Folkman, 1984) to demonstrate its functional utility. The coping resources (i.e. psychological and social resources) and coping efforts of 21 children (9 male, 12 female) diagnosed with cancer were assessed and compared with standardized norms. Within-group differences were explored as the cancer sample was subdivided by stage of therapy (i) newly diagnosed, (ii) currently in treatment, and (iii) off treatment. Results suggest that children with cancer differed significantly from typical children on measures of coping effort (Coping Inventory) in that they demonstrated relatively more adaptive and efficient coping behavior as compared to their normative peers. Children with cancer differed slightly from typical children on measures of psychological resources (Assessment of Coping Style) such that they utilized a slightly more restrictive style of coping. Children with cancer did not differ significantly from normative children on measures of social resources (Social Support Scale for Children). The data are analyzed and discussed with reference to mediating factors including developmental stage, gender, and stage of illness.
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Clarke, Sally Ann. "Parental communication about childhood cancer and the child's quality of life". Thesis, University of Sheffield, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.490322.
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Lopez, Alana Delores. "Transition Experiences of Adolescent Survivors of Childhood Cancer: A Qualitative Investigation". Scholar Commons, 2011. http://scholarcommons.usf.edu/etd/3213.
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Adolescent survivors of childhood cancer are a growing population with unique needs as they face a combination of challenges associated with normal development and returning to life after treatment completion (Wakefield et al., 2010). One specific need identified in the research literature includes the effective delivery of transitional care and planning (Hewitt, Greenfield, & Stovall, 2005). It has been suggested that the provision of transition care and planning can help facilitate the shift from one phase of care to another and promote positive transition experiences (National Cancer Institute, 2008). The shift from off-treatment to post-treatment and school reintegration have been identified in the literature as significant transitions for adolescent survivors of childhood cancer (Cabat & Shafer, 2002; MacLean, Foley, Ruccione, & Sklar, 1996). However, limited research has been conducted to explore these transitions from the perspectives of adolescent survivors of childhood cancer.
An exploratory, qualitative study was conducted with eight adolescent survivors of childhood cancer between the ages of 14 and 17. A multiple case study research design was used to explore adolescent cancer survivors' perceptions of these transition processes, challenges associated with these transitions, and their beliefs about what supports/services were or would be beneficial during these transitions. Data collected for analysis included questionnaires, transcribed interviews and follow-up meetings, direct observation, documents, and parent feedback. These data were analyzed using a combination of a template organizing style, immersion/crystallization (I/C) approach, and multiple case study strategies (Borkan, 1999; Crabtree & Miller, 1999, Stake, 2005; Yin, 2008).
Results indicated that adolescents perceived that change was occurring on some level during the shift from off-treatment to post-treatment and school reintegration but did not necessarily define this time as a "transition." They defined these times in personalized terms that reflected more subtle changes in their lives. The focus was placed on returning to a sense of "normalcy" and capitalizing on opportunities to regain some control over one's life. The improvement and/or absence of treatment residuals along with re-engagement in activities and roles served as signs, or indicators, that life was returning back to "normal" and provided feedback to the adolescent on their transition progress. Conversely, the presence of these signs continued to impact their lives as they restricted participation in desired activities and served as reminders that the effects of cancer and treatment extended beyond treatment completion. In addition to the presence of treatment residuals, fear of relapse also was a concern associated with the transition from off to post-treatment. However, adolescents tended not to let this be the focus of their lives. School reintegration challenges included disruption of school life and routines as well as academic and social concerns. Academic challenges included falling behind/catching up with work, maintaining motivation to do work, and readjusting to school demands and routines. Social challenges included answering peer questions, adjusting to peer awkwardness/discomfort, and managing peer reactions to their physical side effects. These challenges were not perceived by adolescents as sources of significant distress and, often times, they adapted and employed coping strategies to address these concerns in the school setting.
Adolescents also varied in their perceived need for transitional care and support during these transitions. Support received during the shift from off-treatment to post-treatment included advice from health care team members as well as relationships with peer cancer survivors across school, community, hospital, and camp settings. They received a variety of academic and social support during school reintegration. Teachers, family members, and peers provided academic support across home, hospital, and school settings. Teachers were a particularly important source of academic assistance. Accommodations and modifications also were provided to these adolescents at school. Peers, teachers, and other school staff provided social support. Based on the findings of the study, suggestions for future research and practical implications are offered.
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Guha, Joyeeta. "Risks of adverse health and social outcomes among childhood cancer survivors". Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6612/.
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As a result of improvement in survival after childhood cancer, there are now increasing numbers of long-term survivors of childhood cancer living in the United Kingdom and across Europe. Specific groups of these childhood cancer survivors experience substantial excess risks of adverse health and social outcomes. Using the population-based British Childhood Cancer Survivor Study (BCCSS) the following areas were investigated: (I) The proportion of survivors on regular long-term hospital follow-up using risk stratification levels of care developed by the BCCSS in partnership with the National Cancer Survivorship Initiative. (2) The risks of adverse health and social outcomes using record-linkage and a self-reported questionnaire to assess which survivors of central nervous system tumours were at excess risk compared to the general population. (3) The risk of hospitalisation due to cerebrovascular conditions among childhood cancer survivors by electronic record linkage with Hospital Episode Statistics. Using the European PanCareSurFup cohort, the excess risks of genitourinary subsequent primary neoplasms were investigated among five-year survivors of childhood cancer. This thesis quantifies the risks experienced by childhood cancer survivors in four areas and provides an evidence-base for risk stratification by healthcare professionals caring for survivors.
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Patel, Aysha. "Development of T cell based therapeutic strategies for childhood cancer neuroblastoma". Thesis, University College London (University of London), 2017. http://discovery.ucl.ac.uk/10040429/.
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High risk neuroblastoma poses a significant clinical problem in paediatric oncology and new treatment strategies are needed. Antibody-derived bispecific T cell engagers (BiTEs) and chimeric antigen receptors (CARs) are novel treatment options that redirect a patient’s own T cells to recognise and eliminate tumour cells; both have demonstrated promise in clinical trials for haematological malignancies. In this study I explored an empirical approach to BiTE design in order to identify the optimal format for redirecting T cell cytotoxicity against neuroblastoma cells. GD2 was used as a target antigen, based on its high level of expression across neuroblastoma tumours and limited expression on healthy tissues. BiTEs were designed with different single chain variable fragments (scFv) to bind GD2 and CD3 (T cell) antigens. We demonstrated that a high affinity for GD2 was determinant of improved cytotoxicity of T cells against neuroblastoma cell lines and an optimal linker length between the two scFvs impacted tumour cell targeting. The secretion of interferon-γ and proliferation by activated T cells occurred in a CD3-specific and GD2-specific manner, confirming target specificity of the BiTEs. In a second strategy; as an attempt to reduce the on-target off-tumour toxicity of targeting GD2, novel antigen O-acetyl-GD2 was explored as an improved target antigen due to its restricted tumour expression pattern. The latter is a requirement when aiming to induce a persistent anti-tumour response with CAR T-cell therapy. An O-acetyl-GD2 specific CAR was generated which showed selective specificity to the O-acetylated form of GD2. Finally, as a pre-clinical approach to develop BiTE and CAR T cell therapy for neuroblastoma in vivo, pilot experiments were performed in a transgenic neuroblastoma mouse model which has co-expression of the ALKF1174L mutation and MYCN oncogene. This work indicated that this murine model appears suitable to develop T cell based immunotherapy into an effective therapeutic approach for neuroblastoma.
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Armstrong, Katherine B. "The Genetic Counseling Experience in a Multidisciplinary Childhood Cancer Survivor Center". University of Cincinnati / OhioLINK, 2012. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1337101530.
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