Browsing by Subject "Pediatric"

Friendship has consistently been found to act as a buffer against psychological maladjustment for healthy youth and youth experiencing difficulties including parental divorce and natural disasters. Less known is the role of friendship may have for females coping with a chronic health problem. Therefore, the objective of the current study was to evaluate the health factors and friendship precursors that may influence friendship, and in turn, how those friendships may predict psychosocial adjustment. A sample of chronically ill females (N = 30) was compared to a control group of healthy females (N = 45) on measures of opportunities for social interaction, similarity to their best friend, social capability, friendship quality, and psychological adjustment. Results revealed that health condition and friendship precursors were not associated with friendship quality. However, higher friendship quality was predictive of fewer externalizing symptoms for healthy girls. Additionally, positive parent relationships predicted fewer internalizing symptoms for both groups of females. Notably, chronically ill girls noted their friendships were higher in punishment and lower in companionship than healthy girls. Further assessment, including objective measures, will elucidate the beneficial processes of friendships and parent-child relationships that buffer youth from maladjustment.

Background: The Cataldo Cancer Stigma Scale (CASS) was developed to measure patient experienced and perceived stigma and was further modified for use in the pediatric patient population. This study aimed to adapt and translate a Swahili version of the CASS for use in the Tanzanian pediatric patient population to measure cancer stigma and identify the types of stigma pediatric cancer patients face. Methods: Approximately 40 items were extracted from two prior developmental and validation studies of the CASS that assessed stigma in adult patients and non-patient cohorts. The survey items, developed initially in English, underwent translation into Swahili, back-translated, reconciled, and screened for duplications. The translated items were refined using concurrent cognitive interviewing. Results: After three rounds of cognitive interviews with 15 respondents, comprehension of the survey questions was assessed and improved with all items reaching at least 80% comprehension. Additional reviews included grammar and specific Swahili word selection changes to clarify the question’s meaning. Duplications or repetition of sentences were also considered to remove questions from the survey. The final survey comprised 25 survey items with 7 stigma sub-categories. Conclusions: This study sheds light on the complex nature of cancer-related stigma in pediatric patients. For future purposes, research is needed to validate the CASS survey with a larger sample of the population, including a comparison stigma assessment to establish validity.

Background: Nutrition is a key determinant of pediatric cancer patient outcomes in sub-Saharan Africa. Accurately identifying pediatric cancer patients at risk of malnutrition remains a challenge. There is a need for a standardized nutritional screening tool, developed and validated in sub-Saharan Africa. Study aims: The aims of this study were to: 1) select candidate variables in the development of a nutritional screening from predictors associated with malnutrition in pediatric cancer patients and, 2) conduct a secondary data analysis estimating the prevalence of pediatric cancer in Uganda from cases presented at the Uganda Cancer Institute between January 1, 2017 and December 31, 2019. Methods: This study is a longitudinal hospital-based study, carried out at the Bugando Medical Center in Tanzania and Uganda Cancer Institute in Uganda. The study enrolled clinically confirmed pediatric cancer patients (<18 years) at the study sites. Measures of interest include: nutritional status, symptom duration, abdominal distention, anthropometric measures such as height, weight, mid-upper arm circumference, abdominal circumference, triceps skinfold thickness, and clinical characteristics such as serum albumin, mean corpuscular volume, and protein. Logistic regression models examined predictors of nutritional status in pediatric cancer patients. Lastly, geospatial analysis estimated the prevalence and examined the country-wide distribution of the pediatric cancers presented at the Uganda Cancer Institute between 2017 and 2019. Results: The sample of 77 pediatric cancer patients enrolled at the two study sites ranged from 1 to 17 years old. Solid tumor malignancies like Wilms tumor comprise of 40% of all diagnoses. 60% of cancer patients were malnourished at baseline. The strongest predictors of nutritional status were mid-upper arm circumference (AOR 0.52, 95% CI: 0.31 – 0.87), abdominal circumference (AOR 1.38, 95% CI: 1.16 – 1.65) and serum albumin (AOR 0.73, 95% CI: 0.62 - 0.86). Secondary analysis of the Uganda Cancer Institute registry shows 11607 patients with confirmed cancer diagnosis between 2017 and 2019. Acute lymphoblastic leukemia (31.4%) is the most common cancer diagnosis, followed by Wilms tumor (19.1%), rhabdomyosarcoma (9.4%) and Burkitt’s lymphoma (6.9%). Blood cancers are most common cancer types, of them the most frequent cases being leukemia (37%). 2018 saw the highest number of cancer presentations within the study timeframe. Conclusions: The results show abdominal circumference, serum albumin, and muac are candidate variables in developing a nutritional screening tool for pediatric cancer patients in SSA. Blood and solid cancers are prevalent in Uganda; thus, a customized nutritional screening tool is much needed.

Project 1: Effects of High Volume MOSFET Usage on Dosimetry in Pediatric CT

Purpose

The objective of this study was to determine if using large numbers of Metal-Oxide-Semiconducting-Field-Effect Transistors, MOSFETs, effects the results of dosimetry studies done with pediatric phantoms due to the attenuation properties of the MOSFETs. The two primary focuses of the study were first to experimentally determine the degree to which high numbers of MOSFET detectors attenuate an X-ray beam of Computed Tomography (CT) quality and second, to experimentally verify the effect that the large number of MOSFETs have on dose in a pediatric phantom undergoing a routine CT examination.

Materials and Methods

A Precision X-Ray X-Rad 320 set to 120kVp with an effective half value layer of 7.30mm aluminum was used in concert with a tissue equivalent block phantom and several used MOSFET cables to determine the attenuation properties of the MOSFET cables by measuring the dose (via a 0.18cc ion chamber) given to a point in the center of the phantom in a 0.5 min exposure with a variety of MOSFET arrangements. After the attenuating properties of the cables were known, a GE Discovery 750 CT scanner was employed using a routine chest CT protocol in concert with a 10-year-old Atom Dosimetry Phantom and MOSFET dosimeters in 5 different locations in and on the phantom (upper left lung (ULL), upper right lung (URL), lower left lung (LLL), lower right lung (LRL), and the center of the chest to represent skin dose). Twenty-eight used MOSFET cables were arranged and taped on the chest of the phantom to cover 30% of the circumference of the phantom (19.2 cm). Scans using tube current modulation and not using tube current modulation were taken at 30, 20, 10, and 0% circumference coverage and 28 MOSFETs bundled and laid to the side of the phantom. The dose to the various MOSFET locations in and on the chest were calculated and the image quality was accessed in several of these situations by taking the standard deviation of a large regions of interest in both the lung and the soft tissue of the chest to measure the noise.

Results

The proof of concept experiment found that the main cable of the MOSET, not the ends closest to the reading tip, is the most attenuating part of the cable. The proof of concept also found that increasing the number of MOSFET layers to 1, 2, 3, and 4 layers decreased the dose to the center of the phantom by 17.92, 28.04, 39.98, 42.49% respectively. Increasing the percent of the block phantom covered to 10, 30, and 50% coverage decreased the dose to the center of the phantom by 17.92, 17.80, and 18.17% respectively.

Project 2: Pediatric Lens of the Eye Dose Reduction Using Siemens Care kV

Purpose

The Siemens Care kV is a software that recommends a tube potential (kV) setting for CT scans based on the thickness of the anatomy being scanned in order to reduce dose on a patient to patient basis. Pediatric cranial scans at Duke do not use this software nor do they use tube current modulation. Dose to the lens of the eye in pediatric patients can lead to lens opacity later in life [10]. The goal of this project was to determine if Care kV can be used in pediatric cranial scans to reduce the dose to the lens of the eye while maintaining adequate image quality.

Materials and Methods

A Siemens SOMATOM Force CT scanner performing a routine cranial scan protocol was used in concert with two Atom Dosimetry Phantoms (1-year-old and 5-year-old) and MOSFET dosimeters to determine the effect changing the reference tube potential of the Care kV software would have on dose and image quality (measured with CNR). The settings used with Care kV were off, and semi reference tube potential 120, 110, and 100 kV.

Results

Dose to the lens of the eye was reduced for the 1-year old phantom by 9.601, 17.572, and 19.724% by using Care kV with tube potential set to 120, 110 and 100 kV respectively. Dose to the lens of the eye was reduced for the 5-year old phantom by 1.060, 8.859, and17.854% by using Care kV with tube potential set to 120, 110 and 100 kV respectively. Soft tissue CNR was reduced for the 1-year old phantom by 8.812, 11.001, and 5.018% by using Care kV with tube potential set to 120, 110 and 100 kV respectively. Soft tissue CNR was reduced for the 5-year old phantom by 3.473, 5.517, and 3.248% by using Care kV with tube potential set to 120, 110 and 100 kV respectively. Bone CNR was reduced for the 1-year old phantom by 4.447, 8.175, and 10.046% by using Care kV with tube potential set to 120, 110 and 100 kV respectively. Bone CNR was reduced for the 5-year old phantom by 4.782, 7.966, and 11.715% by using Care kV with tube potential set to 120, 110 and 100 kV respectively.

Project 3: Designing Quality Assurance for Cesium Calibration Source

Purpose

North Caroline regulations state that survey meters must be traceable to NIST. The Cs-137 Calibration source used by Duke was installed in 2005 and has since not been measured except for routine calibration of survey meters. The goal of this project was to measure the geometry and dose rate of the source and make a recommendation as to how and how often quality assurance measurements should be made with a NIST traceable ion chamber.

Materials and Methods

Gafchromic XR QA2 radiochromic film was placed in the source beam to measure the angle of the source collimator. Two 0.18 cc and a 6 cc ion chamber were used in a variety of combinations of distance from source and attenuation to determine the exposure rate of the calibration source and compare it to the current calibration table in use.

Results

The collimator angles for the top, bottom, left, and right were calculated to be 12.13, 9.648, 11.58, and 11.58, respectively. The two 0.18 cc ion chambers deviated from the table values by more than 30% for every measurement. The 6 cc ion chamber deviated from the calibration table in use by 9.55, 8.13, 3.36, and 3.72% for 30 cm no attenuation, 30 cm 2x attenuation, 100 cm no attenuation, and 100 cm 2x attenuation measurements respectively.

Background: Cancer is grossly underreported and underdiagnosed in Africa, as only an estimated 57% of childhood cancers are diagnosed and survival rates for children with cancer are very low; an estimated 20% of children survive cancer in Africa. Several factors can lead to delays in treatment and discontinuing treatment such as lack of knowledge about cancer and negative beliefs or stigma about cancer. The research objective of this paper is to explore the types of stigmas faced by pediatric cancer patients and their families to inform interventions to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.Methods: The study took place at Bugando Medical Centre (BMC) in Mwanza, Tanzania. The study sample included more than 300 patients who had completed treatment for pediatric cancer at Bugando Cancer Centre. This qualitative study was conducted using structured focus group discussions (FGD) and in-depth interviews (IDI) with patients and caregivers. Data was transcribed and translated into English and NVivo12 was used for qualitative data analysis and coding through an inductive and deductive approach. Results: The main themes of stigma found in both the FGDs and IDIs were severity of condition, avoidance, financial discrimination, beliefs about causes of cancer and stigma due to physical changes. These themes were found among all age groups and were experienced by both caregivers and patients. Conclusions: The results and data gathered from this study illustrate that cancer stigma is still an issue faced by pediatric cancer patients and their families. It also illustrates that, although some aspects of stigma have been described and addressed in the literature through adult stigma studies, there are aspects of stigma for pediatric cancer patients specifically that should be addressed. The data gathered here can be used to develop interventions targeted towards cancer stigma for pediatric populations, to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.

Traumatic injuries are the leading cause of death to children between the ages of one to nineteen years in the United States. The primary source of these traumatic injuries is motor vehicle traffic, with the head being the primary region of the body to suffer injury. While the pediatric neck is also prone to injury, it is particularly notable since it governs head excursion and acceleration, thus influencing head impacts and injuries. Pediatric fatalities can be prevented through safety improvements to vehicle compartments and child restraints by way of advanced biofidelic pediatric anthropomorphic testing devices (ATDs) and a more complete understanding of pediatric biomechanics. Computer models of the pediatric head and neck provide a valuable tool to combine results from pediatric postmortem human specimen (PMHS), radiological, and human volunteer studies to investigate the dynamics of the pediatric head and neck. The current study produced the first validated computer model of the pediatric head and neck which were created using the framework of a validated adult model. Radiology studies were conducted to determine pediatric cervical muscle cross sectional areas, vertebral anthropometry, and vertebral inertial properties. The results of these studies were combined with available pediatric PMHS properties to create the six and ten year old models. The models were validated against pediatric volunteer low speed frontal impacts and were then used to simulate higher rate and injurious inducing loading scenarios. The six and ten year old flexion bending stiffnesses were found to be 36% and 45% of the adult bending stiffness, respectively. The pediatric tensile stiffnesses were found to be 67% and 76% of the adult tensile stiffness. The tensile failure tolerance of the six year old was between 1490 and 2300 N and of the ten year old between 2040 and 3170 N. The adult and pediatric Hybrid III ATDs were found to be on average 2.5 times stiffer in flexion bending than the computer models. Biofidelity corridors were created with the models to be used to guide future ATD designs. Overall, the pediatric models provide a general tool that can be used to assess the safety of children during motor vehicle crashes.

Background: In North America and Europe, SLE is more common and severe in people of African extraction than in Caucasians; however, the epidemiology of SLE in Africa is largely undetermined. Historically, the incidence of SLE in Africa was presumed to be low, but recent studies challenge this theory. In general, children present with higher disease activity, require more therapy, and accrue more organ damage than adult-onset patients. Although African children with SLE may be at high risk for poor outcomes, little research has investigated this population. We have initiated the first registry of this high risk pediatric SLE (pSLE) population in South Africa (SA). Here, we report the initial findings of the South African pSLE patients (PULSE cohort).

Methods: We conducted a cross sectional analysis (retrospective and prospective chart review) of pediatric and adult rheumatology and nephrology patients seen at 2 centers in Cape Town, South Africa from 1988-2014 meeting American College of Rheumatology criteria for pSLE. Patient age, gender, race, presenting features, clinical and serologic disease markers, and treatment were recorded for the PULSE cohort and compared to an established North American pSLE cohort.

Results: Initial review of patients yielded 72 patients (age 11.5; 83% female). The racial distribution was 68% colored, 26% black, 5% white, and 3% Asian/Indian. Most patients presented with severe lupus nephritis (LN) (renal biopsy performed in 58%)). Of patients with LN, 93% presented with ISN class III or higher. Within the SA cohort, 13% went on to develop ESRD, of which 9% required transplant, strikingly higher than NA peers. There were treatment differences between cohorts: patients in the North American cohort had increased use of MMF and biologic therapies. The SA cohort had severe disease at diagnosis (mean SLEDAI 20.6), compared to the NA pSLE cohort (SLEDAI 4.8). Also, the PULSE cohort had end organ damage with 63% of the cohort having a SLICC score >0 (mean SLICC 1.9), compared to only 23% in a previously reported US cohort of 221 pSLE patients.

Conclusions: The PULSE cohort is the largest registry of pSLE patients in Africa to date. These children present with high disease activity and progress to end organ damage at higher rates than pSLE cohorts in developed nations. Further research is required to determine the risk factors for poor outcomes in this high risk population.

Since its inception in the 1970's, computed tomography (CT) has revolutionized the practice of medicine and evolved into an essential tool for diagnosing numerous diseases not only in adults but also in children. The clinical utility of CT examinations has led to a rapid expansion in CT use and a corresponding increase in the radiation burden to patients. CT radiation is of particular concern to children, whose rapidly growing tissues are more susceptible to radiation-induced cancer and who have longer life spans during which cancerous changes might occur. In recent years, the increasing awareness of CT radiation risk to children has brought about growing efforts to reduce CT dose to the pediatric population. The key element of all dose reduction efforts is to reduce radiation dose while maintaining diagnostic accuracy. Substantiating the tradeoff between the two is the motivation behind this dissertation work.

The first part of this dissertation involved the development of an accurate method for estimating patient-specific radiation dose and potential cancer risk from CT examinations. A Monte Carlo program was developed and validated for dose simulation in a state-of-the-art CT system. Combined with realistic computer models of patients created from clinical CT data, the program was applied to estimate patient-specific dose from pediatric chest and abdomen-pelvic CT examinations and to investigate the dose variation across patients due to the variability of patient anatomy and body habitus. The Monte Carlo method was further employed to investigate the effects of patient size and scan parameters on dose and risk for the entire pediatric population.

The second part of this dissertation involved the development of tools needed to study the diagnostic accuracy of small lung nodules on pediatric CT images. A prior method for modeling two-dimensional symmetric liver/lung lesions was extended to create three-dimensional nodules with asymmetric shapes and diffused margins. A method was also developed to estimate quantum noise in the lung region of a CT image based on patient size.

The last part of this dissertation involved assessment of diagnostic accuracy using receiver operating characteristic (ROC) observer experiments. A pilot study of 13 pediatric patients (1-7 years old) was first conducted to evaluate the effect of tube current on diagnostic accuracy, as measured by the area under the ROC curve (Az). A study of 30 pediatric patients (0-15 years old) was then conducted to assess protocol- and scanner-independent relationships between image quality (nodule detectability and noise) and diagnostic accuracy. The relationships between diagnostic accuracy and nodule detectability, between noise and scan parameters, and between dose/risk and scan parameters were lastly combined to yield the relationship between diagnostic accuracy and dose/risk.

For pediatric patients in the same weight/protocol group, organ dose variation across patients was found to be generally small for large organs in the scan coverage (< 10%), larger for small organs in the scan coverage (1-18%), and the largest for organs partially or completely outside the scan coverage (6-77%). Across the entire pediatric population, dose and risk associated with a chest scan protocol decreased exponentially with increasing patient size. The average chest diameter was found to be a stronger predictor of dose and risk than weight and total scan length.

The effects of bowtie filter and beam collimation on dose and risk were small compared to the effects of helical pitch and tube potential. The effects of any scan parameter were patient size-dependent, which could not be reflected by the difference in volume-weighted CT dose index (CTDIvol).

Over a nodule detectability (product of nodule peak contrast and display diameter to noise ratio) range of approximately 52-374 mm with an average of 143 mm, tube current or dose had a weak effect on the diagnostic accuracy of lung nodules. The effect of 75% dose reduction was comparable to inter-observer variability, suggesting a potential for dose reduction.

Diagnostic accuracy increased with increasing nodule detectability over the range of 25-374 mm, but reached a plateau beyond a threshold of ~ 99 mm. The trend was analogous to the relationship between Az and signal-to-noise ratio and suggested that the performance of the radiologists saturates (or increases slowly) beyond a threshold nodule detectability level; further reducing noise or increasing contrast to improve nodule detectability beyond the threshold yields little gain in diagnostic accuracy.

For a typical product of nodule contrast and physical diameter (1400 HU·mm) and a set of most commonly used scan parameters (tube potential of 120 kVp, helical pitch of 1.375, slice thickness of 5 mm, gantry rotation period of 0.4 second, image pixel size of 0.48 mm), diagnostic accuracy increased with effective dose and effective risk for a given patient size, but reached a plateau beyond a threshold dose/risk level. At a given effective dose, Az increased with decreasing patient size, i.e., the dose needed to achieve the same noise and hence diagnostic accuracy increased with patient size. To achieve an Az of 0.90, the dose needed for a 22-cm diameter (male) patient was about quadruple of that for a 10-cm diameter patient. While the effective risk associated with achieving the same diagnostic accuracy also increased with patient size, the risk associated with an Az of 0.90 was only twice as high for a 22-cm diameter (male) patient than for a 10-cm diameter patient due to the older age of the larger patient.

The research in this dissertation has two important clinical implications. First, the quantitative relationships between patient dose/risk and patient size, between patient dose/risk and scan parameters, between diagnostic accuracy and image quality, and between diagnostic accuracy and radiation dose can guide the design of pediatric CT protocols to achieve the desired diagnostic accuracy at the minimum radiation dose. Second, patient-specific dose and risk information, when included in a patient's dosimetry and medical records, can inform healthcare providers of prior radiation exposure and aid in decisions for image utilization, including the situation where multiple examinations are being considered.

Child head injury is a very costly problem, both in terms of morbidity/mortality and direct medical costs. In fact, it is the leading cause of death and disability for those in the United States under age 18-years-old. Currently, head injury in children ages newborn to 19-years-old is responsible for 7500 deaths per year--30% of all childhood deaths in the United States. Given its importance and effect on the population, the study of pediatric head injury is greatly hindered by the lack of available pediatric post mortem human specimen (PMHS) data. As a substitute for PMHS testing, anthropometric test devices (ATDs) and finite element models (FEMs) have been developed to model the head. However, there is a dearth of data for the design and validation of these models.

The goal of this study was to use pediatric PMHSs to both advance the study of pediatric head injury and to provide validation data for ATD and finite element head models. 14 pediatric heads, 8 adult heads, and 6 ATD heads were studied to obtain geometrical, inertial, structural stiffness, and impact properties. The computational tomography (CT) method was used on pediatric heads to get inertial properties, and clinical CT scans were used to develop average head and skull contours for 12 different age groups. To obtain impact properties, the heads were dropped onto a rigid plate from 15cm and 30cm, and the acceleration-time pulses were analyzed to obtain acceleration HIC and other impact properties. The heads were then placed between two aluminum plates and compressed at four different rates to obtain structural stiffness values. Using the PMHS results, the ATD heads were compared against age-matched human heads, and the scaling rules used for ATD production were tested for accuracy.

The study found that between the ages of 5-months-old and 22-months-old, the human head was susceptible to fracture from drops as low as 15cm. The structural stiffness of the human head was shown to increase by three orders of magnitude from neonate to adult. For the impact properties, the human head's peak acceleration and head injury criteria increased with age, while the human head's pulse duration and coefficient of restitution decreased with age. The 50th percentile Hybrid III head was found to adequately model the response of the adult head for multiple head impact locations, while the 3-year-old Q3 child ATD was found to be too stiff during impact. Overall, this study provides novel data that can be directly applied to pediatric head injury curves, and pediatric ATD and finite element head models.

Pediatric cervical spinal injuries are associated with high morbidity and mortality. Cervical injuries observed in the pediatric population appear to be age dependent with younger children experiencing more upper cervical level injuries compared to increased lower level cervical injury patterns to older children. The majority of pediatric cervical spinal injuries are motor vehicle crash related. Current progress in child occupant protection, including increased and proper restraint usage continues to reduce serious injury and fatalities to child occupants. However, improper restraint usage and incorrect child seating location, especially with children transitioning from rear-facing child restraints to forward-facing restraints is still a concern. Continued reductions in serious injury and fatalities to child occupants in survivable motor vehicle crashes will be based on continued education and improvements in child anthropometric test devices, child computational injury models and child restraint system design. Improvements in all of these categories are dependent on an improved understanding of the developmental biomechanics of the human cervical spine. Currently, limited data exist on human child neck biomechanics and none of the current cadaveric work has evaluated the biomechanical response over the entire age spectrum from birth to young adulthood. Numerous surrogate studies exist and have formed the basis of child injury criteria and developmental biomechanics, but have not been assessed in relation to the response of the pediatric human cervical spine. The current work investigates the biomechanics of the osteoligamentous human cervical spine from birth to young adulthood under tensile and bending loading environments. Tensile low-load and load-to-failure stiffness, load-to-failure, and flexion-extension bending stiffness increased with age. Tensile normalized displacement at failure and total bending low-load range of motion decreased with age. Viscoelastic rate effects are present in the pediatric cervical spine and are modeled with quasi-linear viscoelasticity. Peak load and loading energy increases with increased loading rate, while hysteresis energy is rate insensitive at lower loading rates, but increases at higher rates of loading. These data establish structural response behavior and injury thresholds for the osteoligamentous cervical spine by age. Additionally, they provide human data to assess the appropriateness of current surrogate models and current scaling techniques associated with these models. Finally, these data provide human response by age useful in progressing the biofidelity of computational and physical models for child occupant protection.

Background: There is a significant disparity in survival rates for pediatric cancer in low and middle-income countries compared to high-income countries. A variety of factors contribute to this disparity including late stage disease at presentation, high rates of abandonment of care, and lack of supportive care. In Mwanza, Tanzania, a residential hostel was created to reduce these barriers among patients being treated for childhood cancer at Bugando Medical Centre (BMC). This study explores the potential benefit of the hostel in terms of event free survival and quality of life and examines the barriers and facilitators for completing care and the perceptions of the hostel. Methods: The study had three major components. A medical record review was conducted for 229 patients who presented to BMC in 2016-17, looking at survival outcomes. Surveys were collected from patients and caregivers who presented in 2018. In-depth interviews were conducted to explore patient/caregiver experiences. Data was collected at BMC and was analyzed with survival curves, hazard models, logistic regression, t-tests and applied thematic analysis. Results: One-year EFS was not significantly different for patients who presented to BMC before the hostel opened compared to those that presented after the hostel opened. However, a proportional hazard model showed a significantly lower hazard for patients that stayed at the hostel compared to patients that did not. Participants that stayed at the hostel also scored significantly higher in emotional functioning compared to patients that did not stay at the hostel. In-depth interview participants highlighted barriers and facilitators for completing care and described the benefits of the hostel including psychosocial support and reduced financial burden. Conclusions: Higher one-year event free survival and better scores in emotional wellbeing were observed for patients that stayed at the hostel. Caregivers and patients shared positive perceptions of the hostel as a facilitator for completing care. Key supportive care programs such as a hostel can be beneficial for improving pediatric cancer outcomes in LMICs.

Longitudinal studies have demonstrated that the white matter in adolescents is still developing well into young adulthood. However, these studies of the corpus callosum were anatomical and DTI studies involving manual region of interest measures, which have not proven to be as in depth of an analysis as the one proposed in this study. In addition, there have been relatively few studies that have looked at the effects of childhood maltreatment on brain structure.

The methodology presented here develops a technique that will perform an extensive analysis between a well characterized group of healthy adolescents with no trauma history and a group of maltreated adolescents with PTSD symptoms. It employs a voxelwise analysis to determine significant groups of voxels using cluster enhancement and permutation correction algorithms. It then uses these significant clusters to perform an in-depth ROI analysis to determine the correlations present in these clusters with several physical and neuropsychological measures. This technique has produced evidence that validates earlier studies showing that better executive function and task ability indicate stronger structural organization within the white matter of the brain. In addition, it has provided substantial evidence that maltreated children complete myelination within the corpus callosum of the brain earlier than healthy children, indicating that chronic stress during childhood may be associated with stress-induced premature ageing.