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IntroductionsSickle cell disease (SCD) is the most commonly inherited blood disorder in the United States, and it predominately affects the Black community. SCD is characterized by a number of symptoms, including unpredictable pain, which can lead to hospitalizations. Data indicate that people with SCD experience racism and ample data indicate that racism predicts depressive symptoms and impaired health-related quality of life (HRQOL). In contrast, research suggests that social support might buffer the impact of racism on depression. The aim of this study was to explore associations among perceived racism, depressive symptoms, and HRQOL in adolescents with SCD. Consistent with the literature, it was predicted that perceived racism would predict HRQOL through depression, and social support would moderate the negative impact of racism on depression.MethodsIn a cross-sectional design, 75 inpatient adolescents with SCD completed measures of perceived racism, depressive symptoms, HRQOL, and social support.ResultsThis results indicated a moderated mediation model with greater perceived racism predicting more depressive symptoms, which in turn related to poorer HRQOL; greater access to social support from individuals with SCD strengthened the perceived racism—depressive symptom association.ConclusionsFindings suggest a model for how racism, depressive symptoms, HRQOL, and social support might interact in hospitalized adolescents with SCD. Longitudinal or experimental designs are needed to substantiate directionality among these variables. Results highlight several areas for future research and clinical avenues to improve the welfare of youth with SCD.

Introduction: Limited access to SARS-CoV-2 testing has been identified as a potential source of anxiety among healthcare workers (HCWs), but the impact of repeated testing on pandemic-related anxiety in pediatric HCWs has not been examined. We sought to understand the impact of repeated SARS-CoV-2 antibody testing on pediatric HCWs COVID-19 anxiety. Methods: This longitudinal cohort study was conducted between April and July 2020. Participants, 362 pediatric HCWs, underwent rapid SARS-CoV-2 antibody testing either every 96 hours or weekly and were asked to rate their COVID-19 anxiety on a visual analog scale. Change in anxiety from baseline was calculated for each testing day response. Bivariate analyses, repeated measures, and logistic regression analyses were performed to examine demographics associated with change in anxiety.Results: Baseline COVID-19 anxiety was significantly higher in HCWs with less than 10 years of experience (Z=-2.63, p=.009), females compared to males (Z=-3.66 pF (3,302)=6.04, p =.003). After excluding participants that received a positive test result, repeated measures analyses indicated that anxiety decreased over time (F (5,835)=3.14, p=.008). Of those HCWs that reported decreased anxiety, 57 (29.8%) had a clinically significant decrease (> 30%) and ED HCWs were 1.97 times more likely to report a clinically significant decrease in anxiety (X2(1) = 5.05, p = .025).Conclusion: Results suggest that repeated SARS-CoV-2 antibody serology testing is associated with decreased COVID-19 anxiety in HCWs. Routine screening for disease may be a helpful strategy to attenuate pandemic-related anxiety in pediatric HCWs.

Previous studies have demonstrated associations between patient experience scores and physician's demographic characteristics such as gender and race. There is a paucity of data, however, on the effect of broader pediatrician characteristics on caregivers' experience of their children's care. This study assessed pediatric caregiver experience of care ratings within a children's hospital and examined the effects of pediatricians' interpersonal and personality traits on caregiver experience ratings.This cross-sectional study included caregivers of children under 18 years old (n = 26,703) and physicians within children's hospital system (n = 65). Caregivers of children who received care from 2017 to 2019 provided their rating (0-10) of care experience via the standardized National Research Corporation Health Survey. Top box provider ratings were used for analyses. Physician's interpersonal and personality data were collected. Multilevel logistic regression analyses were used to examine the effects of physician interpersonal characteristics (empathy, compassion) and personality (perfectionism, Big Five personality traits [openness, conscientiousness, extraversion, agreeableness, neuroticism]) on experience of care rating.The odds of caregivers of Spanish-speaking children to provide a high physician rating were 75% higher than the odds for non-Spanish-speaking patients. At the physician level, lower agreeableness (odds ratio [OR] = 0.63, P = .002), and lower narcissistic perfectionism (OR = 0.98, P = .016) were associated with an increased likelihood of a high care experience rating. The odds of nonemergency medicine pediatricians receiving high ratings were approximately 4.17 times higher than that of EM pediatricians.Current results may inform future interventions that address pediatrician personality characteristics associated with caregivers of children experience outcomes.

Purpose: The aims of the current study were to better understand, from the perspective of adolescents and young adults (AYAs) with sarcoma, parents, and providers, the friendship support needs of AYAs with bone and soft tissue sarcoma and the role of social media in facilitating social support for AYAs with sarcoma. Methods: Semistructured interviews were conducted with 21 participants. AYA (n = 10) ranged in age from 14 to 23 years (mean 19.3, standard deviation 3.4 years; 50% female). All AYAs reported a current or past diagnosis of sarcoma, except for one patient who had another cancer diagnosis but was receiving treatment through the sarcoma clinic. Five parents of the adolescent participants were interviewed, as well as six health care providers. Data analysis was conducted using theory-driven immersion/crystallization, incorporating the Resilience in Illness Model as a framework to guide interpretation of the data. Results: Four main themes associated with social support from friends and social media were identified: (1) Social media provides a way to feel normal and connected to friends; (2) Social media accentuates the frustration of being left behind; (3) Social media facilitates the need to be understood by peers who have experienced sarcoma, and (4) Social media can lead to despair, and also provide hope for the future. Conclusions: Connecting with peers through social media can play an important role in providing support for AYAs with sarcoma, but it may also amplify feelings of frustration and anxiety. Future work is needed to determine intervention components that can maximize the benefits of social media for social support of AYAs with sarcoma. Clinical Trial Registration number: NCT03130751.

Author(s): Heyming, Theodore W; Fortier, Michelle A; Martin, Sarah R; Lara, Bryan; Bacon, Kellie; Kain, Zeev N | Abstract: Background and objectiveThe goal of the present study was to determine the incidence of new onset maladaptive behaviours in paediatric emergency department (PED) patients during the COVID-19 pandemic and to examine whether child and parent anxiety and parental health status were predictors for the new-onset of maladaptive behaviours.MethodsParticipants included child-parent dyads seen in a PED following the state's issuance of mandatory stay-at-home orders on 19 March 2020. A total of 351 children age 0-25 years and 335 parents enrolled in the study. Parents provided baseline demographic data and completed standardised surveys that assessed aspects of parental and child anxiety and parental health, as well as child new-onset maladaptive behaviours. Children ≥8 years of age completed surveys that assessed child anxiety.FindingsParents reported the new onset of maladaptive behaviours in children during the pandemic with frequencies up to 43%. Bivariate analysis identified predictors such as child anxiety (t(96)n=n-2.04, Pn= 0.044) as well as parental variables such as state anxiety (t(190)n=n-4.91, Pnl 0.001) and parental sensitivity to anxiety (t(243)n=n-3.19, Pn= 0.002). A logistic regression model identified parent mental health and COVID-19 anxiety as predictors of new onset maladaptive behaviours in children (X2 (6)n=n42.514, Pnl 0.001). Specifically, every unit change in parental anxiety of COVID-19 was associated with a unit increase in maladaptive behaviours in children.ConclusionsWe identified distinct parent and child-related factors that predicted new onset child maladaptive behaviours during the COVID-19 pandemic. The identification of such predictors may help clinicians to prevent maladaptive responses to the pandemic quarantine.

Objective Pediatric chronic pain evaluation includes self-reports and/or caregiver proxy-reports across biopsychosocial domains. Limited data exist on the effects of caregiver–child discrepancies in pediatric pain assessment. In children with chronic pain, we examined associations among discrepancies in caregiver–child reports of child anxiety and depressive symptoms and child functional impairment. Methods Participants were 202 children (Mage=14.49 ± 2.38 years; 68.8% female) with chronic pain and their caregivers (95.5% female). Children and caregivers completed the Revised Child Anxiety and Depression Scale (RCADS) and RCADS-Parent, respectively. Children also completed the Functional Disability Inventory. Mean difference tests examined caregiver–child discrepancies. Moderation analyses examined whether associations between child self-reported anxiety and depressive symptoms and functional impairment varied as a function of caregiver proxy-report. Results Children reported more anxiety and depressive symptoms compared with their caregivers’ proxy-reports (Z = −4.83, p < .001). Both informants’ reports of child anxiety and depressive symptoms were associated with child functional impairment (rs = .44, rs = .30, p < .001). Caregiver proxy-report moderated associations between child-reported anxiety and depressive symptoms and functional impairment (B = −0.007, p = .003). When caregiver proxy-report was low, child self-reported anxiety and depressive symptoms were positively related to functional impairment (B = 0.28, SE = 0.07, 95% CI [0.15, 0.41], p < .001). Conclusions Discrepant caregiver–child perceptions of child anxiety and depressive symptoms may be associated with functioning in children with chronic pain, especially when caregivers report less child internalizing symptoms. These findings highlight the need for further examination of the effects of caregiver–child discrepancies on pediatric chronic pain outcomes and may indicate targets for intervention.

Objective To conduct a single-arm pilot study assessing the feasibility and acceptability of a 30-day parent-focused mindfulness and psychosocial support mobile app intervention for parents of children with chronic pain. Methods Thirty parents completed the intervention, which included a mindfulness curriculum, peer support videos, and written psychoeducational content. Twelve healthcare providers also assessed the app and provided feedback. Feasibility was assessed by server-side documented usage on ≥50% of the days in the intervention period and completion of ≥70% of the mindfulness content. Parent and provider acceptance were assessed by ≥70% of participants rating each acceptance test question as ≥5 on a 7-point Likert scale. Parents completed measures of solicitousness, stress, mindful parenting, and resilience prior to and following the intervention. Results Feasibility results were mixed: parents completed mindfulness content on an average of 11.2 days during the intervention period, slightly under the pre-established criterion. However, parents completed an average of 72.1% of the content, which met feasibility criterion. Acceptance criteria were met for the majority of parent acceptance test questions and all of the provider acceptance test questions. Exploratory analyses of the psychosocial measures revealed significant decreases in parental solicitous behavior and perceived stress, and a significant increase in mindful parenting. Conclusions The current study extends the emerging body of research on mindfulness-based interventions for parents of children with chronic illness and suggests that it may be acceptable to deliver this content through a mobile device. Future research is needed to assess the intervention’s efficacy compared to standard of care.

Recurrent or chronic pain affects 11–38% of children and adolescents. Pediatric pain research typically focuses on risk factors, such as anxiety and parent functional disability, but resilience-building, protective factors also play an important role in the pain experience. New methods to incorporate resilience-enhancing factors into pain research are needed. Photovoice is a highly participatory research method, where participants take photos to address a common question, caption their photos, and discuss the meaning of the photos in a group. The main objective of this study was to determine whether photovoice is an acceptable method to young people living with chronic pain for identifying and sharing sources of joy. Another objective was to explore sources of joy. Sixteen adolescents and young adults participated, which involved meeting in a group to discuss the goal of the study, taking photographs of self-identified sources of joy over a two-week period, and meeting as a group again to discuss the photographs and participate in a focus group about the experience. Results suggest that photovoice is an acceptable method, as all participants took photographs and attended both meetings, and three themes from the focus group data suggested the participants considered photovoice to be appropriate: 1.) Relief associated with meeting peers, 2.) Potential to benefit young people living with pain, and 3.) Potential to raise awareness. Three themes emerged from the discussion of the photographs to describe sources of joy: 1.) Gratitude for everyday pleasures and accomplishments, 2.) Support from pets, and 3.) Journey of acceptance. Results add to the strengths-based literature on pediatric pain by identifying an acceptable method that could be further explored for use as an intervention to enhance protective factors such as positive affect, gratitude, and social support and to compare the experiences of different populations of youth living with pain.

Objectives To describe the impact of the opioid epidemic on pain management practices in pediatric sickle cell disease and propose a conceptual framework for navigating ethical decision-making in pediatric sickle cell pain management. Methods A review of the literature on ethical challenges in the management of sickle cell pain was conducted and considered in the context of the opioid epidemic and psychosocial factors affecting youth with sickle cell disease. The Integrated Ethical Framework for Pain Management was applied to pediatric sickle cell pain management using a clinical case example. Results Implicit bias, health-related stigma, and potential neurocognitive impairment all present unique challenges in ethical decision-making for youth with sickle cell disease. National guidelines for prescribing opioid medication may complicate providers' clinical decision-making and affect their sickle cell pain management practices. The Integrated Ethical Framework for Pain Management was found to be applicable to ethical decision-making for pediatric sickle cell pain and captures both patient- and provider-related aspects of clinical pain management. Discussion The opioid epidemic has exacerbated existing ethical challenges for pain management among youth with sickle cell disease. The Integrated Ethical Framework for Pain Management provides a conceptual model that can be integrated into health care settings to facilitate ethical decision-making and promote greater health equity in the clinical management of pediatric sickle cell pain.

This chapter focus on distraction as an intervention for children’s acute medical pain. We start by highlighting the consequences of untreated procedural pain for children. Next, we discuss the theoretical rationale for distraction and its anesthetic qualities. Subsequently, we present the literature examining the effectiveness of distraction for lowering children’s distress associated with immunizations, venous access, burn debridement, and cancer treatments. Then we synthesize the distraction for procedural pain literature, and we highlight some of the issues to consider when conducting research or applying distraction in clinical settings. We conclude the chapter with a vignette, which illustrates some of the nuances to consider when applying and personalizing distraction for a child undergoing an acute painful procedure.

There is increasing pediatric use of complementary therapies, especially for pediatric pain. This chapter reviews the key literature on studies that pertain to the use of complementary therapy in pediatric pain management. Though limited evidence exists for many complementary therapy modalities, initial evidence is promising. Currently, the strongest evidence supports the use of hypnotherapy, which will have its own chapter, and biofeedback for headaches. Acupuncture research is growing, but there are few well-designed studies in children. Most data indicate that complementary therapy use is safe in children when administered by a trained practitioner using good clinical judgment (e.g., avoiding massage in children aversive to touch).

Objectives Sickle cell disease (SCD) pain and hospitalizations increase during adolescence and adolescents with SCD may be at-risk for experiencing health-related stigma, which may result in poor health outcomes. This study examined relations among health-related stigma, pain interference, social support, quality of life (QOL), and hospital outcomes (ie, loneliness, pain reduction, and length of stay [LOS]) in adolescents hospitalized with SCD pain. Materials and methods Twelve- to 18-year-old adolescents (N=92) hospitalized with SCD pain completed measures of stigma, pain interference, social support, QOL, and state loneliness. Reduction of pain intensity during hospitalization and LOS were collected from medical chart review. Results Higher stigma was associated with higher pain interference, lower QOL, more loneliness, and less pain reduction in the hospital. Pain interference was positively associated with LOS. Discussion These preliminary findings highlight the importance of assessing and addressing SCD-related stigma and pain interference in adolescents hospitalized for SCD pain as these factors may influence treatment outcomes.

Objective The goal of the study was to describe the experiences of adolescents with irritable bowel syndrome (IBS) from the perspective of adolescents, their parents, and health care providers who treat adolescents who have IBS. Design The study consisted of semistructured interviews. Setting Participants were recruited from multidisciplinary pain clinics. Subjects Thirty-six people participated in the study: 12 adolescents, 12 parents, and 12 health care providers. Results Two main themes associated with the impact of IBS on adolescents' social functioning emerged from the qualitative interview data: 1) disconnection from peers and 2) strain on family relationships, with subthemes reflecting the perspectives of adolescents, parents, and health care providers. Conclusions Participants in our study described that adolescents with IBS encounter significant peer- and family-related social stress. Helpful interventions may be those that focus on social support from other adolescents with similar conditions, as well as family-based therapeutic interventions.

This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group.Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy.Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma.Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

Pain and vaso-occlusive crises (VOC) are hallmark complications of sickle cell disease (SCD) and result in significant physical and psychosocial impairment. The variability in SCD pain frequency and triggers for the transition from steady state to VOC are not well understood. This paper summarizes the harmful physiological effects of pain and emotional stressors on autonomically-mediated vascular function in individuals with SCD and the effects of a cognitive, neuromodulatory intervention (i.e. hypnosis) on microvascular blood flow. We reviewed recent studies from the authors’ vascular physiology laboratory that assessed microvascular responses to laboratory stressors in individuals with SCD. Results indicate that participants with SCD exhibit marked neurally mediated vascular reactivity in response to pain, pain-related fear, and mental stress. Further, pilot study results show that engagement in hypnosis may attenuate harmful microvascular responses to pain. The collective results demonstrate that autonomically-mediated vascular responses to pain and mental stress represent an important SCD intervention target. This ongoing work provides physiological justification for the inclusion of cognitive, neuromodulatory and complementary treatments in SCD disease management and may inform the development of targeted, integrative interventions that prevent the enhancement of autonomic vascular dysfunction in SCD.

BACKGROUND Approximately 70,000 adolescents and young adults (AYA) are diagnosed with cancer each year in the United States. Sarcomas carry a particularly high symptom burden and are some of the most common cancers among AYA. Recent work has documented significant levels of unmet needs among AYA with cancer, particularly the need for psychosocial support. Mobile technology may be a cost-effective and efficient way to deliver a psychosocial intervention to AYA with cancer and cancer survivors. OBJECTIVE The two aims of this study were to (1) develop a pilot version of a mobile-based mindfulness and social support program and (2) evaluate program usage and acceptability. An exploratory aim was to examine change in psychosocial outcomes. METHODS Thirty-seven AYA with sarcoma or sarcoma survivors, parents, and health care providers participated in the study. Semistructured interviews were conducted with 10 AYA, parents of five of the adolescents, and six health care providers. Themes from the interviews helped to inform the development of a mobile-based mindfulness pilot program and a companion Facebook-based social support group. Twenty AYA consented to participate in a single-arm pre-post evaluation of the program; 17 downloaded the app and joined the Facebook group. Seven of these participants had participated in the semistructured interviews. Six additional health care providers consented to participate in the evaluation stage. RESULTS On average, participants completed 16.9 of the 28 unique sessions and used the mindfulness app for a mean 10.2 (SD 8.2) days during the 28-day evaluation period. The majority of participants (16/17) engaged in the social group and posted at least one reply to the moderator’s prompts. The mean number of responses per person to the moderator of the social group was 15.2 of 31 (49%, range 0%-97%). Both AYA and health care providers responded positively to the Mindfulness for Resilience in Illness program and offered useful recommendations for improvements. Exploratory psychosocial analyses indicated there were no significant differences from pretest to posttest on measures of perceived social support, mindfulness, body image, or psychological functioning. CONCLUSIONS This study offers preliminary support for the feasibility and acceptability of a mobile-based mindfulness and Facebook-based social support program for AYA with sarcoma. The feedback from AYA and health care providers will assist in creating a fully developed intervention. CLINICALTRIAL ClinicalTrials.gov NCT03130751; https://clinicaltrials.gov/ct2/show/NCT03130751

Ravi R Bhatt,1 Sarah R Martin,1 Subhadra Evans,2 Kirsten Lung,1 Thomas D Coates,3,4 Lonnie K Zeltzer,1 Jennie C Tsao1 1UCLA Pediatric Pain and Palliative Care Program, Division of Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; 2School of Psychology, Deakin University, Geelong, VIC, Australia; 3Department of Pediatrics, Keck School of Medicine, University of Southern California, 4Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA, USA Background: Vaso-occlusive pain crises (VOCs) are the “hallmark” of sickle-cell disease (SCD) and can lead to sympathetic nervous system dysfunction. Increased sympathetic nervous system activation during VOCs and/or pain can result in vasoconstriction, which may increase the risk for subsequent VOCs and pain. Hypnosis is a neuromodulatory intervention that may attenuate vascular and pain responsiveness. Due to the lack of laboratory-controlled pain studies in patients with SCD and healthy controls, the specific effects of hypnosis on acute pain-associated vascular responses are unknown. The current study assessed the effects of hypnosis on peripheral blood flow, pain threshold, tolerance, and intensity in adults with and without SCD. Subjects and methods: Fourteen patients with SCD and 14 healthy controls were included. Participants underwent three laboratory pain tasks before and during a 30-minute hypnosis session. Peripheral blood flow, pain threshold, tolerance, and intensity before and during hypnosis were examined. Results: A single 30-minute hypnosis session decreased pain intensity by a moderate amount in patients with SCD. Pain threshold and tolerance increased following hypnosis in the control group, but not in patients with SCD. Patients with SCD exhibited lower baseline peripheral blood flow and a greater increase in blood flow following hypnosis than controls. Conclusion: Given that peripheral vasoconstriction plays a role in the development of VOC, current findings provide support for further laboratory and clinical investigations of the effects of cognitive–behavioral neuromodulatory interventions on pain responses and peripheral vascular flow in patients with SCD. Current results suggest that hypnosis may increase peripheral vasodilation during both the anticipation and experience of pain in patients with SCD. These findings indicate a need for further examination of the effects of hypnosis on pain and vascular responses utilizing a randomized controlled trial design. Further evidence may help determine unique effects of hypnosis and potential benefits of integrating cognitive–behavioral neuromodulatory interventions into SCD treatment. Keywords: sickle-cell disease, pain, hypnosis, blood

Objective To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Accurate assessment is critical in pediatric pain, and often adults gauge pain via children’s behavior. To measure adults’ gender biases in regard to children’s pain, 183 adults completed measures and rated the pain of a videotaped child receiving a finger stick blood test. Half of the participants were told the child was male and half female. Participants rated the “male” patient as having greater pain. Similarly, participants’ indicated beliefs that girls are more sensitive and reactive to pain than boys. Results suggest adults hold explicit and implicit biases that girls are more sensitive and reactive to pain than boys.

BackgroundApproximately 70,000 adolescents and young adults (AYA) are diagnosed with cancer each year in the United States. Sarcomas carry a particularly high symptom burden and are some of the most common cancers among AYA. Recent work has documented significant levels of unmet needs among AYA with cancer, particularly the need for psychosocial support. Mobile technology may be a cost-effective and efficient way to deliver a psychosocial intervention to AYA with cancer and cancer survivors. ObjectiveThe two aims of this study were to (1) develop a pilot version of a mobile-based mindfulness and social support program and (2) evaluate program usage and acceptability. An exploratory aim was to examine change in psychosocial outcomes. MethodsThirty-seven AYA with sarcoma or sarcoma survivors, parents, and health care providers participated in the study. Semistructured interviews were conducted with 10 AYA, parents of five of the adolescents, and six health care providers. Themes from the interviews helped to inform the development of a mobile-based mindfulness pilot program and a companion Facebook-based social support group. Twenty AYA consented to participate in a single-arm pre-post evaluation of the program; 17 downloaded the app and joined the Facebook group. Seven of these participants had participated in the semistructured interviews. Six additional health care providers consented to participate in the evaluation stage. ResultsOn average, participants completed 16.9 of the 28 unique sessions and used the mindfulness app for a mean 10.2 (SD 8.2) days during the 28-day evaluation period. The majority of participants (16/17) engaged in the social group and posted at least one reply to the moderator’s prompts. The mean number of responses per person to the moderator of the social group was 15.2 of 31 (49%, range 0%-97%). Both AYA and health care providers responded positively to the Mindfulness for Resilience in Illness program and offered useful recommendations for improvements. Exploratory psychosocial analyses indicated there were no significant differences from pretest to posttest on measures of perceived social support, mindfulness, body image, or psychological functioning. ConclusionsThis study offers preliminary support for the feasibility and acceptability of a mobile-based mindfulness and Facebook-based social support program for AYA with sarcoma. The feedback from AYA and health care providers will assist in creating a fully developed intervention. Trial RegistrationClinicalTrials.gov NCT03130751; https://clinicaltrials.gov/ct2/show/NCT03130751

Objective Children experience distress after surgery. Associations exist between parent reassurance (e.g., ‘‘It’s OK’’) and child distress, but little is known about the causal direction of these interactions. This study examined sequential relations between mothers’ and fathers’ reassurance and children’s distress. Methods 146 families with 2- to 11-year-olds undergoing elective surgery participated. Timeevent coding and time-window sequential analysis examined whether reassurance preceded or followed child distress. Secondary analyses examined the relation of child sex and parent anxiety with the reassurance/distress contingency. Results Reassurance was positively correlated with distress; however, nonverbal distress was less likely to start following reassurance and was also more likely to continue following reassurance. Mothers were more likely to reassure following boys’ verbal distress, and mothers with higher anxiety were more likely to reassure following nonverbal distress. Conclusions Whereas parental reassurance may prevent the start of child distress, it might maintain ongoing child distress.

Summary Objectives: To examine the role of ethnicity, language, and socioeconomic variables in parental desire for information regarding children’s surgery. Aim: To compare anesthetic and surgical information desired between English- and Spanish-speaking White and Hispanic mothers of children undergoing outpatient surgery. Background: Parents report wanting to receive detailed information regarding children’s preoperative care; however, variables such as parent ethnicity and language spoken have not been accounted for in understanding desire for information. Methods/Materials: One hundred and eighty-one mothers of children undergoing outpatient surgery, elective surgery, and general anesthesia were recruited and categorized into one of three groups: English-speaking White (ESW, n = 79), English-speaking Hispanic (ESH, n = 63), and Spanish-speaking Hispanic (SSH, n = 39). In addition to providing demographic questionnaire, mothers completed the Parental Desire for Information (PDI) questionnaire, a 14-item measure of surgery and anesthesia-related statements. Results: Overall, mothers desired receiving information about the majority of the items on the PDI. As compared to ESW mothers, SSH mothers and ESH mothers were overrepresented in the ‘have a right to know’ response option, with significant differences existing in items concerning alternative methods of anesthesia, details of needles used, and location of PACU and OR. Conclusions: Anesthesiologists should tailor the provision of preoperative information based on ethnicity and language of mothers involved. Ethnic and language differences shown in this study may exist in other populations as well.

Summary Objectives: The purpose of this study was to conduct a prospective assessment of preoperative anxiety in adolescents undergoing surgery. Aim: To systematically conduct a multimodal evaluation of preoperative anxiety in adolescents undergoing surgery. Background: The existing literature on preoperative anxiety in children has overwhelmingly ignored adolescents in the surgical setting, yet adolescents may be at risk for under treatment of preoperative anxiety. Methods: A total of 59 adolescents aged 11–18 were recruited. Behavioral and physiological manifestations of anxiety were assessed with a visual analog scale and an ambulatory physiological data recorder that collected heart rate (HR), skin conductance level (SCL), and blood pressure data. Baseline emotional and behavioral functioning (child behavior checklist [CBCL]) as well as temperament (early adolescent temperament questionnaire-revised – parent version) and other potential risk factors were also assessed. Results: Over 80% of adolescents reported significant anxiety at the time of induction. Self-reported anxiety increased significantly at each time point (holding, separation from parents, and mask introduction), P = 0.001. Significant increases in both HR (P = 0.02) and SCL (P

Summary Objectives & Aim: The purpose of this investigation was to examine children’s anxiety across the perioperative setting. Background: Although several studies have examined preoperative anxiety in children, few researchers have illustrated perioperative anxiety; that is, anxiety in children throughout the pre and postoperative continuum. Methods: Participants were 261 children ages 2–12. Anxiety was rated prior to surgery, immediately after surgery, and for 2 weeks at home following surgery. Results: Low child sociability and high parent anxiety predicted perioperative anxiety. Perioperative anxiety was related to postoperative pain and negative postoperative behavioral change. Conclusions: Identification and prevention of anxiety in children can help prevent negative outcomes following surgery.

The goal of this randomized controlled trial was to examine the effect of intraoperative positive therapeutic suggestion on postoperative nausea and vomiting (PONV) in children undergoing general anesthesia and otolaryngological surgery.Because of the high incidence of PONV following otolaryngological surgery and its negative impact on recovery, researchers have examined various nonpharmacological interventions to target this phenomenon. To date, the effectiveness of therapeutic suggestion has not been studied in children.Participants were 67 children undergoing tonsillectomy and adenoidectomy and their mothers. Children received a standardized anesthetic procedure and were randomly assigned to one of three interventions administered under general anesthesia: therapeutic suggestion, story (prosody control), or standard operating room noise. Children, parents, and healthcare personnel were blinded to group assignment. Nausea and vomiting were recorded in the postanesthesia care unit (PACU) and for the first 3 days at home.Results demonstrated a decrease in nausea severity across the first 3 days, F(2,49) = 10.37, P0.001, but no group differences in nausea severity in the PACU (F(2,49) = 0.87, P = 0.43) or at home (F(2,49) = 0.80, P = 0.46). There were also no group differences in vomiting episodes in the PACU (chi(2) (2) = 1.25, P0.05) or at home (F(2,49) = 1.59, P = 0.21).In this blinded controlled trial, therapeutic suggestion delivered intraoperatively did not impact children's PONV. However, because this is the first study of this kind, replication may be needed.

OBJECTIVE: The purpose of this controlled study was to provide a description of children's postoperative pain, including pain intensity and analgesic consumption. METHODS: Participants included 261 children, 2 to 12 years of age, undergoing routine tonsillectomy and adenoidectomy surgery. Baseline and demographic data were collected before surgery, and a standardized approach to anesthesia and surgical procedures was used. Pain and analgesic consumption were recorded for 2 weeks at home. RESULTS: On the first day at home, although parents rated 86% of children as experiencing significant overall pain, 24% of children received 0 or just 1 medication dose throughout the entire day. On day 3 after surgery, although 67% of children were rated by parents as experiencing significant overall pain, 41% received 0 or 1 medication dose throughout the entire day. CONCLUSIONS: We conclude that a large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Objective Tympanostomy tube insertion is the most common pediatric surgery, but it typically requires general anesthesia. To facilitate in-office tube placement without general anesthesia, two complementary technologies have recently been developed comprising an iontophoresis system for delivering local anesthesia and an integrated tube delivery system. The purpose of this study was to evaluate behavioral support techniques used during a clinical study of the new technology for pediatric in-office tube placement without general anesthesia or physical restraints. Methods As part of an IRB-approved, prospective, nine-center clinical study, pediatric patients requiring tube insertion underwent in-office treatment using the new procedure. The behavior management techniques included preparation, distraction, coaching, and reinforcement for cooperation. The entire procedure was videotaped and two independent coders used the validated FLACC (Face, Legs, Activity, Cry, Consolability) scale to code behavioral distress across five procedural phases. Results Seventy pediatric patients aged 8 months to 17 years ( M = 7.0 years; 51% female) were enrolled in the study and 68 had video recordings available for analysis. Of the 68 recordings analyzed, 63 patients completed the procedure and had tubes placed without sedation. Mean FLACC scores ranged from 0.05 to 2.38 ( M = 1.25, SD = 0.82) and median FLACC scores ranged from 0 to 1 (Mdn = 0, IQR = 0.05), which indicate “mild” distress. During iontophoresis, eardrum tap (anesthesia assessment), and tube delivery, older children displayed lower distress and girls had higher FLACC scores during the eardrum tap procedural phase. Conclusion When combined with the evidence-based behavioral techniques, office-based local anesthesia and tube delivery resulted in minimal distress, suggesting that the new procedure may be a viable method of conducting tympanostomy tube placement in children without having to use general anesthesia. Clinicaltrials.gov identifier: NCT01496287 .

OBJECTIVE: The role of constitutive nitric oxide (NO) production in the regulation of beta-adrenergic and muscarinic responses remains controversial. Conflicting data in left ventricular (LV) myocytes from eNOS knockout mice (eNOS-/-) have been ascribed to inconsistent experimental conditions (i.e., differences in the choice of controls, age of the mice, myocytes' stimulation frequency, and in the level of beta-adrenergic stimulation); however, the recent identification of a neuronal-like NO synthase (nNOS) in the LV myocardium has raised the possibility that this isoform may be involved in the modulation of beta-adrenergic and muscarinic responses. METHODS: To address these issues we recorded sarcomere shortening at 35 degrees C under basal conditions, in the presence of isoproterenol (ISO, 10-100 nmol/L) and of ISO plus carbamylcholine (CCh, 1 micromol/L) in LV myocytes isolated from eNOS-/- and nNOS-/- mice, their wild type littermates (eNOS+/+ and nNOS+/+) or C57BL/6J mice. eNOS-/- and control myocytes were studied at 1 and 3 Hz, in the presence of 10 and 100 nmol/L ISO, and responses were compared between young (3 months) and old (> or =12 months) mice. RESULTS: Contraction did not differ between young eNOS-/- and eNOS+/+ mice at all stages of the experimental protocol, either at 1 or 3 Hz or in response to 10 or 100 nmol/L ISO. However, myocytes from old eNOS-/- mice showed a reduced inotropic response to ISO compared with age-matched eNOS+/+ mice (P = 0.02). Similarly, there was a significant difference in the ISO response between eNOS+/+ and C57BL/6J myocytes (P < 0.01), suggesting that experimental variables such as age and the choice of control animals may have contributed to the inconsistency in the results reported in the literature. In contrast, nNOS-/- myocytes showed greater contraction and slower relaxation at all stages of the experimental protocol (P = 0.0003 and P = 0.01 vs. nNOS+/+ myocytes). CONCLUSIONS: Constitutive eNOS expression in murine LV myocytes is not essential for the muscarinic-mediated inhibition of beta-adrenergic signalling and does not appear to play a significant role in the regulation of basal and beta-adrenergic myocardial contraction. Our data suggest that nNOS is the myocardial constitutive isoform responsible for the NO-mediated autocrine regulation of myocardial inotropy and relaxation.

Full-length human (hFMO2.1) and monkey (mFMO2) flavin-containing monooxygenase proteins, which share 97% sequence identity, were produced by baculovirus-mediated expression in insect cells and assayed for S-oxygenation under conditions known to affect FMO activity. Both enzymes demonstrated maximal activity at pH 9.5; but hFMO2.1 retained significantly more activity than mFMO2 did at pH 9.0 and higher. hFMO2.1 also retained significantly more activity than mFMO2 did in the presence of magnesium and all detergents tested. Although hFMO2.1 had more residual activity after heating at 45 degrees C than mFMO2, under some conditions, both had less than 10% of control activity, whereas expressed rabbit FMO2 retained over 50% activity. Screening for NADPH-oxygenation by hFMO2.1, indicated that substituted thioureas with a small cross-sectional area (2.4-4.3 A) are good substrates, whereas 1,3-diphenylthiourea (11.2 A) was not oxygenated. We confirmed the presence of hFMO2.1 in lung tissue from a heterozygous individual (hFMO2*1/hFMO2*2A) by Western analysis and confirmed activity by S-oxygenation. These microsomes also demonstrated a heat-associated loss of activity similar to expressed hFMO2.1. The heat sensitivity of hFMO2.1 may partially explain why activity in post mortem human lung samples has previously been unreported. Individuals that have the FMO2*1 allele-encoding full-length hFMO2.1 may exhibit altered drug metabolism in the lung.

Background: There is an emerging interest in identifying and meeting the unique needs of adolescents and young adults (AYA) with cancer. Roughly 700,000 AYA are diagnosed with cancer each year in the United States, and the incidence in this cohort has increased steadily over the past 30 years. Nevertheless, improvements in cancer outcomes for AYA lag far behind the advances that have been made for young children and older adults. Recent work has documented significant levels of unmet needs among AYA with cancer, particularly psychosocial challenges during the transition to adulthood—e.g., abrupt disruption to school and social life, fears for an uncertain future, and body image concerns. A mobile-based intervention for youth is an ideal way to complement treatment by delivering a psychosocial intervention which is developmentally appropriate and derived from evidence-based approaches to fostering resilience through mindfulness-based coping strategies and social support. Objective: To use a patient-centered approach to design, and evaluate the feasibility of a mobile-based psychosocial intervention for adolescent and young adult cancer patients. Methods: Formative research involved three steps: (1) In-depth interviews were conducted with ten AYA with sarcoma, with parents of the five adolescents, and six healthcare providers (N=21). Families were recruited from UCLA Pediatric Bone and Soft Tissue Sarcoma Program. Interview guides were based on the Resilience in Illness Model (RIM), which describes four health protective factors for resilience (social integration, family environment, courageous coping and derived meaning), and two risk factors (illness-related distress and defensive coping). Interview guides also included questions about preferences for a mobile intervention. Coding and analysis was inductive, also based on the RIM theory. (2) Adaptations were made to an existing mindfulness app (Whil Concepts, Inc.), which offers a program for youth called “Grow,” with over 500 audio relaxations. Modifications included creating a 4-week “Mindfulness for Resilience in Illness” program, with 28 relaxation exercises, and the addition of videos featuring two sarcoma survivors as program hosts. A patient advisory board was created to review drafts of content. (3) A one-month pilot study was conducted with 20 AYA cancer patients, which included using the app and engaging in a private Facebook usability group to (a) elicit beliefs about the mindfulness app and potential future enhancements, and (b) promote social support. Pre- and post-measures of mindfulness, social support, body image and quality of life were collected as well as post-intervention satisfaction data. Results: Themes derived from the in-depth interviews were incorporated into a demonstration version of the mobile app specifically for AYA cancer patients. Quantitative and qualitative evaluation data will be presented. Conclusions: A patient-centered approach may be a useful way to inform development of a mobile-based intervention for AYA with cancer. The intervention may be a feasible complement of medical and psychological treatment. [iproc 2017;3(1):e25]

This chapter provides a brief overview of paediatric procedural pain, highlighting some of the negative repercussions of untreated pain. The behavioural approach of distraction is covered in depth, starting with the theoretical underpinnings of this pain management intervention and then summarizing the distraction literature across children’s pain during immunizations, venous access, burn debridement and treatment, and cancer treatments. The chapter concludes with a discussion of some of the other reviews of this literature as well as clinical and research considerations when examining distraction for paediatric pain management.

When you consider submitting your research for a conference presentation, it is wise to weigh the costs and benefits of the endeavor. The benefits include disseminating information to appreciative audiences, such as professors, students, clinicians, teachers, and other professionals interested in new ideas to assist them in their own work. As a personal gain, your audience may provide feedback on your research findings which may be invaluable to you in the development of your research program. Presenting research at conferences also allows for the opportunity to meet potential future advisors, employers, collaborators, and/or colleagues. Conferences are ideal settings for networking and, in fact, many conferences have forums organized for this exact purpose (e.g., job openings listed on a bulletin board and networking luncheons). The costs include the time commitment of writing and constructing the presentation, the potential for rejection from the reviewers, the cost of attending the conference, the anxiety inherent in formal presentations, and the time and expenses of traveling to the meeting. Although we do believe that the benefits of presenting at conferences outweigh the costs, you should consider the specific pros and cons for you, your research, the specific meeting, and your particular situation before embarking on this experience.

Objective To develop and validate a behavioral coding measure, the Children's Behavior Coding System-PACU (CBCS-P), for children's distress and nondistress behaviors while in the postanesthesia recovery unit. Methods A multidisciplinary team examined videotapes of children in the PACU and developed a coding scheme that subsequently underwent a refinement process (CBCS-P). To examine the reliability and validity of the coding system, 121 children and their parents were videotaped during their stay in the PACU. Participants were healthy children undergoing elective, outpatient surgery and general anesthesia. The CBCS-P was utilized and objective data from medical charts (analgesic consumption and pain scores) were extracted to establish validity. Results Kappa values indicated good-to-excellent (κ's > .65) interrater reliability of the individual codes. The CBCS-P had good criterion validity when compared to children's analgesic consumption and pain scores. Conclusions The CBCS-P is a reliable, observational coding method that captures children's distress and nondistress postoperative behaviors. These findings highlight the importance of considering context in both the development and application of observational coding schemes.

Purpose The aim of this study was to identify the impact of ethnicity and language on parental attitudes regarding analgesic use to treat children's pain. Methods A total of 206 parents of children undergoing outpatient surgery were recruited to complete the Medication Attitudes Questionnaire, a measure of parental beliefs about using analgesic medications to treat children's pain. Parents were grouped into one of 3 categories according to ethnicity and primary language spoken: English-speaking white, English-speaking Hispanic, and Spanish-speaking Hispanic. Group differences in pain medication attitudes were examined. Results After controlling for socioeconomic status, English-speaking Hispanic parents endorsed higher levels of misconceptions about pain medication use, including a tendency to avoid analgesic use for children, compared with English-speaking white and Spanish-speaking Hispanic parents. Conclusions This study highlights parental characteristics, including ethnicity and language, which may place children at higher risk for undertreatment of acute pain based on misconceptions about analgesic use for children. Specifically, English-speaking Hispanic parents may be most likely to undertreat children's pain at home. Future studies are needed to identify the most appropriate means of providing education to counter parental misconceptions and support optimal pain management of children's pain in the home setting.

Epitope-specific CD8+ T lymphocytes may play an important role in controlling human immunodeficiency virus (HIV)/simian immunodeficiency virus replication. Unfortunately, standard cellular assays do not measure the antiviral efficacy (the ability to suppress virus replication) of CD8+ T lymphocytes. Certain epitope-specific CD8+ T lymphocytes may be better than others at suppressing viral replication. We compared the antiviral efficacy of two immunodominant CD8+ T lymphocyte responses--Tat(28-35)SL8 and Gag(181-189)CM9--by using a functional in vitro assay. Viral suppression by Tat-specific CD8+ T lymphocytes was consistently greater than that of Gag-specific CD8+ T lymphocytes. Such differences in antigen-specific CD8+-T-lymphocyte efficacy may be important for selecting CD8+ T lymphocyte epitopes for inclusion in future HIV vaccines.

A polymorphism for the phase I drug-metabolizing enzyme, flavin-containing monooxygenase isoform 2 (FMO2), encoding either truncated inactive protein, FMO2X472 (FMO2.2A), or full-length active enzyme, FMO2Q472 (FMO2.1), is known and exhibits significant interethnic differences in allelic frequency. FMO2 is the major or sole FMO isoform expressed in the lung of most mammals, including nonhuman primates. To date, FMO2.1 has been found only in African-American and Hispanic populations, rendering individuals with this allele subject to drug metabolism that is potentially different from that of the general population. Approximately 26% of African-Americans (n = 180) possess the FMO2*1 allele. In preliminary studies, we initially estimated that 5% of Hispanics (n = 40) have the FMO2*1 allele, but access to large cohorts of individuals of defined national origin has allowed us to determine the occurrence among Mexican-American and Puerto Rican-American groups. We used allele-specific genotyping to detect FMO2*1 from 632 Hispanic individuals, including 280 individuals of Mexican origin and 327 individuals of Puerto Rican origin. Statistical analysis indicated that results from Mexican (five sample sources) and Puerto Rican (three sample sources) samples were consistent with the hypothesis of homogeneity within each group from different sources. Data were subsequently pooled across sources to test for evidence of a difference in occurrence of FMO2*1 between ethnic groups. There was strong evidence (p = 0.0066) that FMO2*1 is more common among Puerto Ricans (7%) than among individuals of Mexican descent (2%). The overall occurrence of FMO2*1 among Hispanics of all origins is estimated to be between 2 and 7%.

Mammalian flavin-containing monooxygenase (FMO) exists as six gene families and metabolizes a plethora of drugs and xenobiotics. The major FMO in adult human liver, FMO3, is responsible for trimethylamine (TMA) N-oxygenation. A number of FMO3 mutant alleles have been described and associated with a disease termed trimethylaminuria (TMAU). The TMAU patient excretes large amounts of TMA in urine and sweat. A more recent ethnically related polymorphism in expression of the major FMO in lung, FMO2, has been described. All Caucasians and Asians genotyped to date are homozygous for a CAG --> TAG amber mutation resulting in a premature stop codon and a nonfunctional protein truncated at AA 472 (wildtype FMO2 is 535 AA). This allele has been designated hFMO2*2A. Twenty-six percent of individuals of African descent and 5% of Hispanics genotyped to date carry at least one allele coding for full-length FMO2 (hFMO2*1 allele). Preliminary evidence indicates that FMO2.1 is very active toward the S-oxygenation of low MW thioureas, including the lung toxicant ethylene thiourea. Polymorphic expression of functional FMO2 in the individuals of African and Hispanic descent may markedly influence drug metabolism and/or xenobiotic toxicity in the lung.

Summary Objectives: The purpose of this study was to conduct a prospective assessment of preoperative anxiety in adolescents undergoing surgery. Aim: To systematically conduct a multimodal evaluation of preoperative anxiety in adolescents undergoing surgery. Background: The existing literature on preoperative anxiety in children has overwhelmingly ignored adolescents in the surgical setting, yet adolescents may be at risk for under treatment of preoperative anxiety. Methods: A total of 59 adolescents aged 11–18 were recruited. Behavioral and physiological manifestations of anxiety were assessed with a visual analog scale and an ambulatory physiological data recorder that collected heart rate (HR), skin conductance level (SCL), and blood pressure data. Baseline emotional and behavioral functioning (child behavior checklist [CBCL]) as well as temperament (early adolescent temperament questionnaire-revised – parent version) and other potential risk factors were also assessed. Results: Over 80% of adolescents reported significant anxiety at the time of induction. Self-reported anxiety increased significantly at each time point (holding, separation from parents, and mask introduction), P = 0.001. Significant increases in both HR (P = 0.02) and SCL (P