Journal articles on the topic 'Children's Audio - 4-8'

This study investigated the role of social interaction in the literacy learning of twenty-one 3- and 4-year-olds. Over a period of 8 months, data were collected at a classroom writing center using the ethnographic techniques of participant/observation, field notes, collection of written texts, audio and video tape. Patterns in the data indicated that author/audience conversation occurring as children completed self-selected literacy activities encouraged them to (a) activate, confirm/disconfirm, and revise their existing hypotheses about literacy; (b) form new literacy knowledge; (c) become audiences for their own texts; (d) internalize the audience's perspective and use this information to plan texts for absent audiences; (e) experience literacy activities beyond their independent abilities; and (f) with their teachers, build shared understandings about literacy. Overall, the findings indicate that children's self-selected literacy activities are rich contexts for literacy learning, and that social interaction, as part of these events, provides the predictable context and motivation for literacy learning, as well as influencing the kinds of literacy strategies children internalize and use independently.

Our study examines the acceptability and feasibility of Moshi, an audio-based mobile application, among children 3–8 years old using a parent–child dyadic approach. Our 10-day within-subject pre–post study design consisted of five nights of a normal bedtime routine and a subsequent five nights exposed to one story on the Moshi application during the intervention. Each five-night period spanned three weeknights and two weekend nights. The Short-Form Children’s Sleep Habits Questionnaire (SF-CSHQ) was used to measure children’s sleep at baseline and post-intervention. The PROMIS, Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index were used to assess parents’ sleep. Among the 25 child–parent dyads, the mean child age was 4 (SD = 1.23) and 63% were male (n = 15). Mean parent age was 35 (SD = 5.83), 84% were female (n = 21), and 48.0% were Black (n = 12). For child-only comparisons, mean post-SF-CSHQ measures were lower compared to baseline. A trend in parent sleep is reported. This study shows the potential of an audio-based mobile sleep aid to improve sleep health in a racially diverse parent and child dyad sample.

AbstractObjective:A quarter of Australian children are overweight or obese. Research conducted in 2010 found that fast-food children’s meals were energy-dense and nutrient-poor. Since then, menu labelling and self-regulation of marketing have been introduced in Australia. The present study aimed to: (i) investigate the nutrient composition of children’s meals offered at fast-food chains; (ii) compare these with children’s daily requirements and recommendations and the food industry’s own criteria for healthier children’s meals; and (iii) determine whether results have changed since last investigated in 2010.Design:An audit of nutrition information for fast-food children’s meals was conducted. Meals were compared with 30 % (recommended contribution for a meal) and 100 % of children’s daily recommendations and requirements. A comparative analysis was conducted to determine if the proportion of meals that exceeded meal requirements and recommendations, and compliance with the food industry’s own criteria, changed between 2010 and 2016.Setting:Large Australian fast-food chains.Participants:All possible children’s meal combinations.Results:Overall, 289 children’s meals were included. Most exceeded 30 % of daily recommendations and requirements for a 4-year-old’s energy, saturated fat, sugars and Na. Results were also substantial for 8- and 13-year-olds, particularly for Na. When compared with mean energy and nutrient contents from 2010, there were minimal changes overall.Conclusions:Children’s meals can provide excess energy, saturated fat, sugar and Na to children’s diets. Systematic reformulation of energy, saturated fat, sugars and Na would improve the nutrient composition of the meals.

IntroductionThere has been an increased emphasis on the nutritional care of children in hospital with the recognition that those admitted to hospital, particularly with chronic conditions, are at significant nutrition risk. However, although nutrition risk screening tools (NRST) are widely used in acute hospital settings compliance with their use is poorly reported.MethodsOne-day cross-sectional audit of anthropometry/NRST records, Southampton Children’s Hospital. Inclusion criteria were all in-patients present on the ward between 8 am and 4 pm. Comparison was made with previous data.ResultsOne hundred and thirteen records were reviewed. Anthropometric measures; weight recorded in 96.4% length/height recorded in 64% . This reflects a significant improvement on previous length/height data of 19%. Compliance with NRST was poor; only 17% of records were completed.ConclusionCompliance with basic anthropometry was high and better than previously reported although use of nutritional screening tools was poor. This raises questions about the usefulness of current tools in clinical practice and whether measurement of height, weight and assessment of intake and nutrition risk may be more appropriate.

Abstract Introduction Adequate sleep is essential for a child’s growth and development. However, a growing number of children are experiencing trouble falling asleep. Smartphone audio-based mobile applications with soothing melodies and calming nighttime stories may improve sleep onset. Our study examined the efficacy of Moshi Twilight, an app designed to improve sleep onset, among children ages 3-8 years old using a parent-child dyadic approach. Methods Our within-subjects pre-post study design focused on healthy children studied over 10 days, spanning 3 weeknights and 2 weekend nights. During the baseline (Days 1-5) and exposure (Days 6-10) conditions the Child Sleep Health Questionnaire was used to measure children’s sleep behavior. The PROMIS and Pittsburgh Sleep Quality Index were used to assess parents’ sleep quality. Parents exposed their child to 1 story per night (15-20 minutes) during the exposured condition. Statistical analysis was based on paired t-tests, independent t-tests, and correlations. Results On average, participating parents were 37 (SD +9.6) year-old mothers. The sample was: 60% Black; 20% White, 20% other race/ethnicity. On average, children were 4 (SD + 0.78) years old and 50% male. Paired t-tests showed significant differences in children’s sleep onset within 20 minutes (t=2.582, 95% CI 0.116, 2.634, p= 0.036). Significant correlations were noted for children’s bedtime consistency (r = -0.755, p = 0.030), falling asleep in own bed (r = 0.735, p=0.015) and sleep duration (r = -0.715, p=0.046,) Significant correlations and paired t-test in parents’ sleep onset were also found (r = 0.744, p = 0.014); (mean= -1.2, t= -3.674, 95% CI -1.939, -0.461, p=0.005) Conclusion Our results showed that the audio-based sleep app, Moshi Twilight, might be useful in improving sleep health among both children and parents. This could be included in enhance bedtime routine among preschool-aged children. Support Bezos Grant and Community Service Plan grant.

Objective: The purpose of this study was to assess the prevalence of dental caries, developmental defects of enamel, and related factors in children with clefts. Design: This cross-sectional prevalence study used standard dental indices for assessment. Setting: Children underwent a dental examination under standard conditions of seating and lighting in the outpatient department of a dental hospital as part of an ongoing audit to monitor clinical outcomes. Participants: Ninety-one children aged 4, 8, and 12 years were included in the study. Outcome Measurements Dental caries were assessed by use of the decayed, missing, and filled index for primary teeth (dmft); Decayed, Missing, and Filled index for permanent teeth (DMFT) according to the criteria as used in the national survey of children's dental health in the United Kingdom (O'Brien, 1994). Developmental defects were assessed using the modified Developmental Defects of Enamel Index (Clarkson and O'Mullane, 1989). Dental erosion was assessed using the criteria derived for the national survey of children's dental health (O'Brien, 1994). Results: Caries prevalence increased with age; 63% of patients at 4 years and 34% at 12 years were caries free. The mean dmft for the 4-year-olds was 1.3 with a mean DMFT for the 12-year-olds of 1.8. All the 4-year-olds had evidence of erosion of enamel in the primary teeth (incisors and first molars) and 56% of the 12-year-olds had erosion of permanent teeth (incisors and first permanent molars). Developmental defects of enamel became more prevalent with age, with at least one opacity in 56% of 4-year-olds and 100% of 12-year-olds. Hypoplasia was not found in the primary dentition but affected permanent teeth in 38% of 8-year-olds and 23% of the 12-year-olds. Conclusion: This study has shown that dental disease is prevalent in these patients. These assessments not only provide a baseline on oral health parameters in young people with clefts but underline the need for a more aggressive approach to prevention of oral disease to optimize clinical outcome.

Background Research on sibling death in a pediatric/neonatal intensive care unit is limited, despite many qualitative differences from deaths at home or in hospitals’ general care areas and has overlooked cultural differences. Objectives To describe parents’ reports of children’s responses to a sibling’s death in a neonatal or pediatric intensive care unit via qualitative interviews at 7 months after the death. Methods English-speaking (n = 19) and Spanish-speaking (n = 8) parents of 24 deceased infants/children described responses of their 44 surviving children: 10 preschool, 19 school-age, and 15 adolescent. Parents’ race/ethnicity was 48% black, 37% Hispanic, 15% white. Ten siblings died in the neonatal unit and 14 in the pediatric intensive care unit. Semistructured interviews in parents’ homes were audio recorded, transcribed verbatim, and analyzed with content analysis. Results Six themes about surviving children emerged. Changed behaviors were reported by parents of school-age children and adolescents. Not understand what was going on was reported primarily by parents of preschoolers. Numbers of comments in the 4 remaining themes are as follows: maintaining a connection (n = 9), not having enough time with their siblings before death and/or to say goodbye (n = 6), believing the sibling is in a good place (n = 6), not believing the sibling would die (n = 4). Comments about girls and boys were similar. White parents made few comments about their children compared with black and Hispanic parents. The pattern of comments differed by whether the sibling died in the neonatal or the pediatric intensive care unit. Conclusions Children’s responses following a sibling’s death vary with the child’s sex, parents’ race/ethnicity, and the unit where the sibling died. Children, regardless of age, recognized their parents’ grief and tried to comfort them.

Many studies have shown a link between being competent in early mathematics and achievement in school. Early math skills have the potential to be the best predictors of later performance in reading and mathematics. Movement and songs are activities that children like, making it easier for teachers to apply mathematical concepts through this method. This study aims to develop audio-visual learning media in the form of songs with a mixture of western and traditional musical idioms, accompanied by movements that represent some of the teaching of early mathematics concepts. The stages of developing the ADDIE model are the basis for launching new learning media products related to math and art, and also planting the nation's cultural arts from an early age. These instructional media products were analyzed by experts and tested for their effectiveness through experiments on five children aged 3-4 years. The qualitative data were analyzed using transcripts of field notes and observations and interpreted in a descriptive narrative. The quantitative data were analyzed using gain score statistics. The results showed that there was a significant increase in value for early mathematical understanding of the concepts of geometry, numbers and measurement through this learning medium. The results of the effectiveness test become the final basis of reference for revision and complement the shortcomings of this learning medium. Further research can be carried out to develop other mathematical concepts through motion and song learning media, and to create experiments with a wider sample. Keywords: Early Mathematical Skills, Movement and Song Idiom Traditional, Audio-visual Learning Media References An, S. A., & Tillman, D. A. (2015). Music activities as a meaningful context for teaching elementary students mathematics: a quasi-experiment time series design with random assigned control group. 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Introduction: Late preterm (LP) neonates (34 to 36 weeks gestation) are often managed like term neonates though current literature has identified them to have greater complications. The primary objective of our study was to evaluate and compare morbidity and resource utilisation in LPs especially in view of paucity of Asian studies in this regard. Materials and Methods: A retrospective audit was carried out on 12,459 neonates born in KK Women’s and Children’s Hospital (KKWCH). The chief outcome measures were hypoglycaemia, hypothermia, respiratory morbidity, feeding problems and neonatal jaundice. Resource utilisation included neonatal intensive care unit (NICU) admission, mechanical ventilation, parenteral nutrition and length of hospitalisation. Results: Of 12,459 deliveries, 1221 (10%) were LP deliveries with a significantly increasing trend of 8.6% to 10% from 2002 to 2008 (P = 0.001). Neonatal morbidity in the form of hypoglycaemia (34 weeks vs 35 to 36 weeks vs term: 26% vs 16% vs 1%); hypothermia (5% vs 1.7% vs 0.2%); feeding difficulties (30% vs 9% vs 1.4%); respiratory distress syndrome (RDS) (4% vs 1% vs 0.1%); transient tachypnea of the newborn (TTNB) (23% vs 8% vs 3%) and neonatal jaundice (NNJ) needing phototherapy (63% vs 24% vs 8%), were significantly different between the 3 groups, with highest incidence in 34-week-old infants. Resource utilisation including intermittent positive pressure ventilation (IPPV) (15% vs 3.5% vs 1%), total parenteral nutrition/intravenous (TPN/IV) (53% vs 17% vs 3%) and length of stay (14 ± 22 days vs 4 ± 4.7 days vs 2.6 ± 3.9 days) was also significantly higher (P <0.001) in LPs. Conclusion: LP neonates had significantly higher morbidity and resource utilisation compared to term infants. Among the LP group, 34-week-old infants had greater complications compared to infants born at 35 to 36 weeks. Key words: Morbidity, Mortality, Respiratory distress syndrome, Total parenteral nutrition

Naturalist intelligence of early childhood has a very big role in today's modern age as the basis for children to have environmental-loving behaviour. The purpose of this study was to determine the effect of Loose Parts learning media on the naturalist intelligence. This study uses a quasi-experimental method with data collection techniques through multiple intelligence tests of children's intelligence instruments. The subjects of this study were 17 children aged 5-6 years. The results showed that there was a significant effect of giving Loose Parts media to the naturalist intelligence of early childhood after seeing a difference between pre-test and post-test. The use of natural-based Loose Parts media can be a means for teachers to increase children's naturalist intelligence in kindergarten and be a development of conventional media made from manufacturers in the learning cycle so far. For further research, it is recommended to look at the influence of other factors on naturalist intelligence in early childhood. Keywords: Early Childhood, Loose Parts, Naturalist Intelligence References: Aljabreen, H. (2020). Montessori, Waldorf, and Reggio Emilia: A Comparative Analysis of Alternative Models of Early Childhood Education. International Journal of Early Childhood, 52(3), 337–353. https://doi.org/10.1007/s13158-020-00277-1 Anjari, T. Y., & Purwanta, E. (2019). Effectiveness of the Application of Discovery Learning to the Naturalist Intelligence of Children About the Natural Environment in Children Aged 5-6 Years. International Conference on Special and Inclusive Education (ICSIE 2018), 296, 356–359. https://doi.org/10.2991/icsie-18.2019.65 Armstrong, T. (2002). You’re Smarter Than You Think: A Kid’s Guide to Multiple Intelligences. Free Spirit Publishing Inc., 217 Fifth Ave., North, Suite 200, Minneapolis, MN 55401-1299. Asih, S., & Susanto, A. (2017). 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Contextual learning binds the content of the subjects in the classroom with the context of the children's daily lives. Learning in early childhood classes (0-8 years) is carried out using the thematic method, which combines several learning materials into one subject. Thematic teaching resources in early childhood classes are still limited in number and rely on textbooks provided by the government. This study aims to develop activity-based teaching materials to assess contextual thematic learning. This research method uses model development research by Borg and Gall with data collection techniques using panels and questionnaires on expert tests, one to one test, small-group test, and large-group test. The research data analysis technique used mixed methods, namely quantitative data tabulated in the form of percentages and described in the qualitative form. The expert test provides recommendations that the instrument can be used to assess student teaching materials and teacher guidance. Teaching materials and teacher guides are suitable for use, and further testing is carried out. Based on the results of the one-to-one test, small-group test, and large-group test, both teaching materials and teacher guides are readability and eligibility with an average of 85.00. The implication of this research, it is suggested that early childhood education institutions where the pilot can use teaching materials and teacher guides in developing and assessing activity-based contextual thematic learning for further research. Keywords: Early Childhood Education, Contextual Thematic, Classroom Activities References: Aini, Q., & Relmasira, S. C. (2018). Penerapan Pembelajaran Tematik Integratif Berbasis Kontekstual untuk Meningkatkan Keaktifan dan Hasil Belajar Siswa Kelas 1 SD. 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The preliminary study showed that the main problem, however, faced by kindergarten students are lack of mathematics skill, such arithmetic ability in kindergarten Galis. Therefore, the present study aims to investigate the effectiveness of a modified bottle cap as an educational game tool towards enhancement of arithmetic ability. Samples were prepared for the quasi-experiment research design involving 60 children, aged 4-5 years. A detailed comparison is made between the experimental condition, consisted of 30 students, received the educational game tool activities and the control condition which consisted of 30 students, received the instructional activities as usual. Before and after two weeks of the intervention with the game tool of a modified bottle cap, measures of arithmetic ability were administered to either experiment or control class. The results of the study indicated that in the experiment class, children’s arithmetic ability increased significantly compared to children in the control class. The differences may have been due to the intervention. To conclude, the modified bottle cap as an educational game tool effective to improve children’s mathematics skill, especially for arithmetic ability. However, the findings required the extended study on other research methods and the bigger size of the samples. Keywords: Early Childhood, Modified bottle cap, Early Arithmetic Ability. References: Aqib, Zainal. (2010). Belajar dan Pembelajaran di Taman Kanak-Kanak. Bandung: Yrama Widya. Arsyad, A. (2017). Media Pembelajaran. PT Raja Grafindo Pursada. Aunio, Pirjo; Tapola, Anna; Mononen; and Niemivirta, M. (2016). Early Mathematics Skill Development, Low Performance, and Parental Support in the Finnish Context. In Blevins-Knabe; A.M.B. Austin (Ed.), Early Childhood Mathematic Skill Development in the home environment. 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IntroductionClopidogrel is a medicine that prevents platelet adhesion and is therefore used to reduce the risk of blood clots. In children’s cardiology, clopidogrel is usually added in combination with aspirin for patients who have had operations and procedures that carry a higher risk of thrombosis.In children, there are two major studies that assessed the use of clopidogrel to inhibit platelet aggregation and reduce blood clots; PICOLO1 and CLARINET.2 PICOLO showed that a dose of 0.2mg/kg once a day is effective at inhibiting platelet aggregation. CLARINET showed aspirin and clopidogrel had no significant benefit over aspirin monotherapy at preventing blood clots. However, this was in a very specific cohort of patient with complex heart disease. Due to the significant morbidity and mortality associated with blood clots and lack of suitable alternatives, clopidogrel is still used within children’s cardiology for patients who have multiple risk factors for blood clots from platelet adhesion.The aim of this audit was to establish the nature of prescribing of clopidogrel within our specialist centre compared to the published data.MethodWe collected data retrospectively using the pharmacy dispensing system JAC® to identify patients who had received clopidogrel over a two year period from July 2019 to June 2021. Patients were then included if they continued clopidogrel at discharge. Patient characteristics such as weight, indication, dose and administration instructions were gathered from our electronic patient record and made anonymous prior to anaylsis using Microsoft Excel®.ResultsWe identified 8 patients who had been prescribed clopidogrel over the 2 year period. The median average age at the start of treatment was 5.4 years (range 1.1 to 10.7 years), the median average weight was 21.4kg (range 11.7 to 41.6kg) and the median average dose was 0.71mg/kg (range 0.23 to 1.8mg/kg). The indications included shunts (n=3), devices/stents (n=4) and aspirin allergy (n=1). A review of administration instructions for families at hospital discharge found three inappropriate manipulations. This was due to the use of tablets to provide a small dose that was deemed to carry a risk of inconsistent dosing and difficulty for families to administer.ConclusionThis project has shown that the use of clopidogrel in our centre was variable and in a non-standard fashion. This is demonstrated by the wide range of doses prescribed and the methods used to administer them. This is likely due to the lack of evidence to guide prescribing in unusual circumstances. As a result, we have written guidance based on this review to encourage safer prescribing, particularly to avoid unsafe and unnecessary manipulation of formulations to give small doses. We also now have an unlicensed liquid available for infants who require small doses. For older children, prescribing of fractions of a tablet (e.g. 18.75mg, 37.5mg) is encouraged.ReferencesLi JS, Yow E, Berezny KY, et al. Dosing of clopidogrel for platelet inhibition in infants and young children: primary results of the platelet Inhibition in children on clopidogrel trial. Circulation 2008;117:553-559.Wessel DL, Berger F, Li JS, et al. Clopidogrel in infants with systemic-to-pulmonary-artery shunts. New England Journal of Medicine 2013;368:2377-2384.

Abstract Background Antibiotic overuse in the neonatal intensive care unit (NICU) has been associated with adverse patient outcomes such as necrotizing enterocolitis (NEC), late-onset sepsis, invasive candidiasis, bronchopulmonary dysplasia, neurodevelopmental impairment, and death. On 11/2020 at Nationwide Children’s Hospital, Columbus, OH, the Neonatal Antimicrobial Stewardship Program Committee recommended 5 days of antibiotic therapy with a subsequent antibiotic “timeout” for uncomplicated UTI without bacteremia as part of ongoing efforts to reduce antibiotic exposure among high risk infants in 7 Level 2/3/4 NICUs. Methods Retrospective review of all infants who received antimicrobial therapy for UTI after implementation of a UTI Diagnosis and Management Protocol. Twice weekly NEO-ASP meetings provided prospective audit and feedback to neonatologists on appropriate antibiotic therapy and duration. Pertinent clinical, laboratory, and outcome data were obtained from the infants’ electronic health record. Safety measure evaluated include recurrence of infection with the same previously identified pathogen in the fourteen days after discontinuation of antibiotic therapy and mortality. Results Since implementation of the UTI protocol, 28 infants (median gestational age, 28 wk [IQR, 26-30 wk; median birth weight, 1203 g [IQR, 731-1801 g]) received antimicrobial therapy for treatment of a UTI at a median age of 50 days (IQR, 28-69 days). The most frequent pathogens were E. coli (n=8), K. pneumoniae (n=5), and Enterobacter spp. (n=4). Median duration of antibiotic therapy was 6 calendar days (IQR, 5-6 days). Only 1 (4%) infant had antibiotic therapy restarted within 14 days of discontinuation of initial therapy; infant had fever but blood, urine, and CSF cultures were sterile and antibiotic therapy was discontinued after 48 hours. One (4%) infant (23 wk gestational age) died at 6 weeks of age from NEC totalis not related to the previous UTI. 22 (81%) infants have been discharged home while 6 remain in the NICU. Conclusion Our preliminary data suggests that short course antibiotic therapy (with a timeout) &lt; ![if !supportAnnotations] &gt;[SP1]&lt; ![endif] &gt; for uncomplicated UTIs in the NICU is an effective and safe therapy that ultimately may lead to less antibiotic exposure among high risk infants. Disclosures All Authors: No reported disclosures

AimTo determine if the use of IVIG in neurology patients at a children’s hospital was appropriate according to local1 and national guidance2 3.MethodAll paediatric neurology patients supplied with IVIG from the hospital pharmacy from April 2017 to April 2019 were identified retrospectively using the pharmacy dispensing system. The standards were based on local and national guidelines from the Department of Health (DoH). Patients’ details, for example indication and dose, were recorded and analysed on Microsoft Excel.Standards100% of patients will have an IVIG request form completed.100% of patients will have IVIG prescribed for indications approved by the DoH.100% of patients will have panel approval before being supplied with IVIG.100% of patients will have the appropriate dose and duration of IVIG for the corresponding indication according to guidelines.ResultsA total of 20 patients were identified for this audit with 4 patients from 2017/18 and 16 from 2018/19. Standard 1 was met by 100% of patients. 8 patients (40%) were given IVIG for indications that do not have automatic approval from the DoH guidelines, i.e. for indications under ‘grey’ or ‘black’ categories. 2 patients (10%) did not have panel approval and both of these patients had acute flaccid myelitis, which is a ‘black’ indication. 16 (80%) patients were prescribed IVIG at a dose or duration advised by local and DoH guidelines.Conclusion and DiscussionDuring the study period the method for completing the IVIG request forms changed to a new electronic system. The two patients with acute flaccid myelitis were incorrectly approved by the IVIG panel due to an error in the new electronic request form. The approval system was updated to prevent this error from reoccurring. All other patients that did not have automatic approval from the DoH guideline were approved by the local IVIG panel before use. Overall cost and usage increased significantly from 2017/18 to 2018/19; approximately £9,300 and £57,000 respectively. One patient was given a higher dose over a shorter period but the total dose for each course was the same. The shortened regimen meant that doses were rounded to the nearest vial size, which reduced wastage. The demand for IVIG is increasing and due to its limited availability and high cost, it is important that IVIG is only given to patients that meet the specified requirements.RecommendationsEnsure patients are only supplied with IVIG if the above standards are metNeurology pharmacist to re-audit data annually to ensure that IVIG is being given according to guidelinesReferencesPharmacists in a children’s hospital. 2017. Clinical guideline: human intravenous immunoglobulin (Privigen 100 mg/ml).Department of Health. Clinical Guidelines for Immunoglobulin Use. 2011. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216671/dh_131107.pdfDepartment of Health. Updated Commissioning Criteria for the use of therapeutic immunoglobulin (Ig) in immunology, haematology, neurology and infectious diseases in England January 2019. Available from: http://igd.mdsas.com/wp-content/uploads/Ig-PWG-Guidance-for-the-use-of-Ig-V1.3-12022019.pdf

Abstract Background Electronic medical task management systems (ETMs) have been adopted in health care institutions to improve health care provider communication. ETMs allow for the requesting and resolution of nonurgent tasks between clinicians of all craft groups. Visibility, ability to provide close-loop feedback, and a digital trail of all decisions and responsible clinicians are key features of ETMs. An embedded ETM within an integrated electronic health record (EHR) was introduced to the Royal Children's Hospital Melbourne on April 30, 2016. The ETM is used hospital-wide for nonurgent tasks 24 hours a day. It facilitates communication of nonurgent tasks between clinical staff, with an associated designated timeframe in which the task needs to be completed (2, 4, and 8 hours). Objective This study aims to examine the usage of the ETM at our institution since its inception. Methods ETM usage data from the first 3 years of use (April 2016 to April 2019) were extracted from the EHR. Data collected included age of patient, date and time of task request, ward, unit, type of task, urgency of task, requestor role, and time to completion. Results A total of 136,481 tasks were placed via the ETM in the study period. There were approximately 125 tasks placed each day (24-hour period). The most common time of task placement was around 6:00 p.m. Task placement peaked at approximately 8 a.m., 2 p.m., and 9 p.m.—consistent with nursing shift change times. In total, 63.16% of tasks were placed outside business hours, indicating predominant usage for after-hours task communication. The ETM was most highly utilized by surgical units. The majority of tasks were ordered by nurses for medical staff to complete (97.01%). A significant proportion (98.79%) of tasks was marked as complete on the ETM, indicating closed-loop feedback after tasks were requested. Conclusion An ETM function embedded in our EHR has been highly utilized in our institution since its introduction. It has multiple benefits for the clinician in the form of efficiencies in workflow and improvement in communication and also workflow management. By allowing collection, tracking, audit, and prioritization of tasks, it also provides a stream of actionable data for quality-improvement activities.

Character education in early childhood is not new, and character education is also not just a transfer of knowledge, but something that needs to be built early on through various stimula- tions. This study aims to develop the character of early childhood through audio-visual media with traditional Javanese songs. Using educational design-based research to develop audio-visual media from traditional songs, this media was tested in the field with an experimental design with a control group. Respondents involved 71 kindergarten students from one experimental class in one control class. The data revealed that character education in children shows the average value of the experi- mental class is higher than the control group, this means character education in children can be built through traditional songs. Further research can be done to improve the character of early childhood through a variety of media that interests children. 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OBJECTIVES/SPECIFIC AIMS: (1) To assess the prevalence of mental health symptomatology (depressive symptoms, anxiety symptoms, PTSD symptoms, and problematic alcohol use) and psychosocial risk factors for mental health disorders (low social support, immigration stress, acculturation, and marital/partner discord), and their association with immigration status, health care access and contextual risk factors in Spanish-speaking parents of young children (ages 0–5) who attended a well-child visit. (2) To explore acceptability of screening for and discussing parental distress in the pediatric primary care setting, and parental acceptability of a group well-visit format to address both psychosocial risk factors and mental health symptoms in this population. METHODS/STUDY POPULATION: Latino immigrant parents (n=100) of children ages 0–5 attending well-child visits at Johns Hopkins Bayview Children’s Medical Practice were surveyed between October 2015 and February 2016. The verbally administered survey included the Woman Abuse Screening Tool (WAST), AUDIT-C, Primary Care Post-Traumatic Stress Disorder (PC-PTSD) Screener, California Health Interview Survey (CHIS), National Latino and Asian American Study (NLAAS), Appraisal Support Subscale from Interpersonal Support Evaluation List (ISEL), Personal Health Questionnaire Depression Scale (PHQ-8), and Generalized Anxiety Disorder Scale (GAD-2). These questionnaires have been used in large regional or national surveys and most have been validated with US Latino populations. Positive screens were defined as PHQ-8>5 (mild depression or greater), GAD-2>3, AUDIT-C>3 for women and >4 for men, and PC-PTSD>3. Descriptive information and comparisons were obtained by χ2 and Student t-test. Study protocol will allow review of childrens’ pediatric records (n=100). From this sample, parents were separately recruited to participate in in-depth interviews (n=11 of 20 planned have been completed) further exploring both sources of parental distress, acceptability of screening for parental mental health symptoms in the primary care pediatric setting, and acceptability of a potential group-based well-visit model in the pediatric setting. RESULTS/ANTICIPATED RESULTS: Survey participants were 93.0% women, and predominantly<35 years of age. The vast majority (94.0%) were undocumented, recently arrived (<15 years ago) and reported poor or very poor English proficiency (75.0%). Most (84.7%) reported living with a partner or spouse (84.7%), and 58% reported partner relationship strain. In all, 71% reported poor social support. The prevalence of “screen positive” mental health symptoms was highest for depression (55%) and PTSD (35%), followed by anxiety (29%) and alcohol risk use (25%). Having depression was significantly higher (68.4%) (p<0.02) in participants with less education (<6 grade). Partner relationship strain was associated with a higher prevalence of depressive symptoms (59.3%) (p<0.03). Immigration stress (feeling guilty for leaving family and friends) was also significantly associated with depressive symptoms (58.1%) and PTSD (43.5%) (p<0.03). More than half of the participants (60.0%) with depression were not covered by any health insurance and 56.3% of those with depression reported not having been seen by a health care provider in the past 12 months. A high prevalence of symptoms was found in those with poor appraised social support: alcohol risk use (76.0%), depression (69.1%), anxiety (69.0%), and PTSD (68.6%). Among participants, those aged<30 years old and those with more children reported poorer appraised social support. Data from child medical records (including BMI, presence of feeding problems, referrals for social work, or mental health services) has been extracted but not yet linked to parent survey or interview results. Preliminary review of In Depth Interviews suggests that the most common reported source of stress among participants was related to finances, followed by documentation/legal status difficulties, access to childcare, and limited English proficiency. Some mothers also mentioned interpersonal violence and lack of access to healthcare as stressors. All mothers expressed an interest in a pediatric primary care based parent focused the majority of which indicated that a group based intervention would be acceptable, some mothers indicated they preferred a one-to-one intervention if mental health were to be discussed. Mothers seem preferential to social worker-led interventions compared with pediatrician-led, but most mothers were indifferent. Finally, mothers expressed low support from the Latino community in Baltimore. DISCUSSION/SIGNIFICANCE OF IMPACT: Results from this study suggest that this population of parents is experiencing a relatively high rate of mental health symptoms, low perceived social support, and limited access to their own source of care. This suggests that an intervention delivered within a primary care pediatric setting would have the potential to reach parents who might not otherwise interact with their own providers, and that there are an array of problems that could be targeted. Intervening with parents of young children has the potential to affect multiple child outcomes. A group intervention may target poor social support, though this format is not universally preferred. Next steps for this project include assessing the acceptability of and preference for various content components (ie, depression, parenting stress, legal issues) and linking parent data with child data (including developmental screening results, weight, feeding problems, and behavior problems).

AimTo evaluate whether healthcare professionals within the local community are able to counsel paediatric patients on the essential steps required for drug delivery with multi-dose inhalers (MDI), MDIs with a spacer and turbohalers.MethodAn expert panel produced and piloted checklists for essential and good practice counselling steps. Eligible participants included healthcare professionals regularly counselling children on inhaler devices, including doctors, nurses and pharmacy team members. Participants were recruited through purposive sampling on a general paediatric ward in a major children's hospital over 2 months and local community pharmacies. Participants counselled on each technique through simulated paediatric scenarios and were assessed by a trained researcher.ResultsThe audit captured 92 healthcare professionals, comprising 43 nurses, 9 doctors, 13 hospital pharmacy staff and 27 community pharmacies team members.Overall 13% (12/92) of participants counselled on all the essential criteria for an MDI inhaler. Pharmacy teams within the hospital and community saw the highest competency levels with 31% (4/13) and 30% (8/27) of staff able to discuss the essential steps respectively, no doctors or nurses were able to indentify all steps.10% (9/92) of participants were able to counsel on all essential steps for a MDI with a spacer device, with no nurse nor doctor achieving all steps. Hospital pharmacy staff were most likely to discuss all the essential steps with 6/13 staff competent and 3/27 community pharmacy team members counselled on the required steps. Commonly omitted steps included shaking the inhaler and leaving sufficient time between doses.Competency levels for turbohaler counselling were low, only 5 participants were able to counsel on the essential steps required. Commonly omitted or incorrect descriptions surrounded the priming of the device and incorrect inhalation technique.ConclusionOur findings mirror those of previously published studies with an adult focused counselling set,these concluded that less than 10% of healthcare professionals were competent with an MDI.1 Though respiratory conditions represent a large proportion of paediatric consultants, healthcare staff are failing to equip patients and carers with the knowledge and skills to utilise even the most common inhaler devices. With the NHS spending £900 million on inhalers2 and hospital admissions increasing dramatically3 more needs to be done to improve inhaler literacy within the local healthcare community.A comprehensive review of training methods needs to be undertaken to ensure these meet the requirements of the local healthcare community. A renewed emphasis on asthma care is required including standard methods for counselling on inhalers.A competency document should be created to assess and validate healthcare professionals to ensure the delivery of accurate and high quality inhaler counselling.

Background Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%. Objectives We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback. Design and setting Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres. Participants The participants were children aged < 17 years. Methods We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups. Results Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity). Limitations Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in. Conclusions Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement. Future work National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment. Funding This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

Abstract Introduction Anthracyclines are chemotherapeutic agents used in the treatment of over 70% of childhood and adolescent malignancies and their use has significantly improved cancer survival rates (Lipshultz, Alvarez et al. 2008). However, a major side effect of this drug class is the potential to develop subclinical, irreversible and fatal cardiomyopathy with the risk of sudden cardiac death. Despite the high incidence of cardiotoxicity in paediatric and adolescent cancer survivors as well as the emerging evidence that alteration in the genes that control drug absorption, distribution, metabolism and excretion (ADME) may be predictive of a patient's sensitivity to this complication, there are no current standard approaches to identify the 'at risk' group (Visscher, Amstutz et al. 2011). Consequently, there is no way to tailor therapy according to a patient's individual risk. This study aims to create a functional assay that will assess patient sensitivity to anthracyclines using a cohort of paediatric cancer survivors, with and without, evidence of anthracycline cardiotoxicity (ACT). A novel, exciting approach will be used through the creation of patient specific cardiomyocytes from induced pluripotent stem cells (iPSC). Through the exposure of iPSC derived cardiomyocytes to anthracyclines, a series of functional assays will be performed to help determine the patient's sensitivity to this drug toxicity. The cardiomyocytes in both cases and controls will be assessed for variations in the genes involved in drug ADME. The genetic analysis will help to validate the results of our collaborators at the British Columbia (BC) Children's Hospital (Vancouver) and the Canada Pharmacogenomic Network for Drug Sensitivity (CPNDS). Methods: An audit of paediatric patients diagnosed across two tertiary institutes between 2000-2015 was performed. From this patients were deemed to be either cases (no evidence of cardiac damage) or controls (evidence of cardiac damage). The degree of cardiac damage was defined as severe (ejection fraction < 24 %), intermediate (ejection fraction 24 - 27 % or a decline of > 10 % ejection fraction from baseline). Patients were then enrolled to the study upon routine presentation to clinic. Upon enrolment peripheral blood mononuclear cells (PBMC) were collected for DNA/RNA storage and a cell pellet was cryopreserved for iPSC development. Following storage, the aims of the project are to 1) Establish a biobank from anthracycline treated childhood cancer survivors, including both sensitive and resistant patients (cases and controls). 2) To confirm the capacity of patient iPSC derived cardiomyocytes to predict ACT and to explore the mechanistic basis and functional responses of human cardiomyocytes to anthracyclines. 3) To perform detailed genomic profiling of the cohort and assess if genetic variation in ADME genes is predictive of ACT in the Australian paediatric population. 4) To document the diastolic changes evident on echocardiography and correlate these findings with long-term anthracycline cardiotoxicity in all enrolled patients. Results: To date 56 cases and 199 controls have enrolled onto the study and had their blood processed accordingly. The median age of the cases is 11.5 years and controls 8.0 years. Of the 56 cases, 52 % (n = 29) are female and 48 % (n = 27) are male. The predominant anthracycline exposure in the cases was doxorubicin alone (47.3 %), daunorubicin and doxorubicin (29.1 %) and daunorubicin alone (14.1 %). Overall 63 % of cases and controls had a diagnosis of Acute Lymphoblastic leukaemia. The median anthracycline dose exposure in the cases was 172 mg/m2 (range 22 - 438) versus 96 mg/m2 (range 18 - 389) in the controls. To date we have successfully been able to derive cardiomyocytes from 8 cases and 8 controls and have begun a range of viability assays to assess susceptibility to anthracycline exposure. Conclusions: We hope over the next 12 months to complete whole exome sequencing and microarray SNP analysis to further characterise the genetic basis of anthracycline cardiomyopathy. Furthermore, using human induced pluripotent stem cell derived cardiomyocytes as a functional platform we hope to further characterise the molecular basis of the disease and create a novel functional assay to stratify patients according to their risk of anthracycline induced cardiomyopathy. Disclosures No relevant conflicts of interest to declare.

AWARDSSome major international children’s literature awards have just been announced as I compile the news for this issue. Several of these have Canadian connections.2016 ALSC (Association for Library Service to Children) Book & Media Award WinnersJohn Newbery Medal"Last Stop on Market Street,” written by Matt de la Peña, illustrated by Christian Robinson and published by G. P. Putnam’s Sons, an imprint of Penguin Books (USA) LLC Newbery Honor Books"The War that Saved My Life," written by Kimberly Brubaker Bradley and published by Dial Books for Young Readers, an imprint of Penguin Books (USA) LLC“Roller Girl,” written and illustrated by Victoria Jamieson and published by Dial Books for Young Readers, an imprint of Penguin Books (USA) LLC“Echo,” written by Pam Muñoz Ryan and published by Scholastic Press, an imprint of Scholastic Inc.Randolph Caldecott Medal"Finding Winnie: The True Story of the World’s Most Famous Bear," illustrated by Sophie Blackall, written by Lindsay Mattick and published by Little, Brown and Company, a division of Hachette Book Group, Inc.Caldecott Honor Books"Trombone Shorty," illustrated by Bryan Collier, written by Troy Andrews and published by Abrams Books for Young Readers, an imprint of ABRAMS“Waiting,” illustrated and written by Kevin Henkes, published by Greenwillow Books, an imprint of HarperCollins Publishers“Voice of Freedom Fannie Lou Hamer Spirit of the Civil Rights Movement,” illustrated by Ekua Holmes, written by Carole Boston Weatherford and published by Candlewick Press“Last Stop on Market Street,” illustrated by Christian Robinson, written by Matt de le Peña and published by G. P. Putnam’s Sons, an imprint of Penguin Books (USA) LLC Laura Ingalls Wilder AwardJerry Pinkney -- His award-winning works include “The Lion and the Mouse,” recipient of the Caldecott Award in 2010. In addition, Pinkney has received five Caldecott Honor Awards, five Coretta Scott King Illustrator Awards, and four Coretta Scott King Illustrator Honors. 2017 May Hill Arbuthnot Honor Lecture AwardJacqueline Woodson will deliver the 2017 May Hill Arbuthnot Honor Lecture. Woodson is the 2014 National Book Award winner for her New York Times bestselling memoir, “Brown Girl Dreaming.” Mildred L. Batchelder Award“The Wonderful Fluffy Little Squishy,” published by Enchanted Lion Books, written and illustrated by Beatrice Alemagna, and translated from the French by Claudia Zoe BedrickBatchelder Honor Books“Adam and Thomas,” published by Seven Stories Press, written by Aharon Appelfeld, iIllustrated by Philippe Dumas and translated from the Hebrew by Jeffrey M. Green“Grandma Lives in a Perfume Village,” published by NorthSouth Books, an imprint of Nordsüd Verlag AG, written by Fang Suzhen, iIllustrated by Sonja Danowski and translated from the Chinese by Huang Xiumin“Written and Drawn by Henrietta,” published by TOON Books, an imprint of RAW Junior, LLC and written, illustrated, and translated from the Spanish by Liniers.Pura Belpre (Author) Award“Enchanted Air: Two Cultures, Two Wings: A Memoir," written by Margarita Engle and published by Atheneum Books for Young Readers, an imprint of Simon & Schuster Children’s Publishing DivisionBelpre (Author) Honor Books"The Smoking Mirror," written by David Bowles and published by IFWG Publishing, Inc."Mango, Abuela, and Me," written by Meg Medina, illustrated by Angela Dominguez and published by Candlewick PressPura Belpre (Illustrator) Award"The Drum Dream Girl," illustrated by Rafael López, written by Margarita Engle and published by Houghton Mifflin HarcourtBelpre (Illustrator) Honor Books"My Tata’s Remedies = Los remedios de mi tata,” iIllustrated by Antonio Castro L., written by Roni Capin Rivera-Ashford and published by Cinco Puntos Press“Mango, Abuela, and Me,” illustrated by Angela Dominguez, written by Meg Medina and published by Candlewick Press“Funny Bones: Posada and His Day of the Dead Calaveras,” illustrated and written by Duncan Tonatiuh and published by Abrams Books for Young Readers, an imprint of ABRAMSAndrew Carnegie Medal "That Is NOT a Good Idea," produced by Weston Woods Studios, Inc.Theodor Seuss Geisel Award"Don’t Throw It to Mo!" written by David A. Adler, illustrated by Sam Ricks and published by Penguin Young Readers, and imprint of Penguin Group (USA), LLCGeisel Honor Books "A Pig, a Fox, and a Box," written and illustrated by Jonathan Fenske and published by Penguin Young Readers, an Imprint of Penguin Group (USA) LLC"Supertruck," written and illustrated by Stephen Savage and published by A Neal Porter Book published by Roaring Brook Press, a division of Holtzbrinck Publishing Holdings Limited Partnership"Waiting," written and illustrated by Kevin Henkes and published by Greenwillow Books, an imprint of HarperCollins Publishers.Odyssey Award"The War that Saved My Life," produced by Listening Library, an imprint of the Penguin Random House Audio Publishing Group, written by Kimberly Brubaker Bradley and narrated by Jayne EntwistleOdyssey Honor Audiobook"Echo," produced by Scholastic Audio / Paul R. Gagne, written by Pam Munoz Ryan and narrated by Mark Bramhall, David De Vries, MacLeod Andrews and Rebecca SolerRobert F. Sibert Informational Book Medal"Funny Bones: Posada and His Day of the Dead Calaveras,” written and illustrated by Duncan Tonatiuh and published by Abrams Books for Young Readers, an imprint of ABRAMSSibert Honor Books"Drowned City: Hurricane Katrina and New Orleans," written and illustrated by Don Brown and published by Houghton Mifflin Harcourt"The Boys Who Challenged Hitler: Knud Pedersen and the Churchill Club," by Phillip Hoose and published by Farrar Straus Giroux Books for Young Readers"Turning 15 on the Road to Freedom: My Story of the 1965 Selma Voting Rights March," written by Lynda Blackmon Lowery as told to Elspeth Leacock and Susan Buckley, illustrated by PJ Loughran and published by Dial Books, an imprint of Penguin Group (USA) LLC"Voice of Freedom: Fannie Lou Hamer, Spirit of the Civil Rights Movement," written by Carole Boston Weatherford, illustrated by Ekua Holmes and published by Candlewick PressCONFERENCES & EVENTSThis 2016 is shaping up to be a busy year for those of us involved with Canadian children’s literature. To tantalize your appetite (and encourage you to get involved) here are some highlights:January:Vancouver Children’s Literature Roundtable event: A Celebration of BC’s Award Children’s Authors and Illustrators with special guests Rachel Hartman and the Children’s Literature Roundtables of Canada 2015 Information Book Award winners Margriet Ruurs & Katherine Gibson, January 27, 2016, 7 – 9 pm. Creekside Community Centre, 1 Athletes Way, Vancouver. Free to members and students.April:Wordpower programs from the Young Alberta Book Society feature teams of Albertan children’s literary artists touring to schools in rural areas. Thanks to the generous sponsorship of Cenovus Energy, schools unable to book artist visits due to prohibitive travel costs are able to participate.April 4-8: Wordpower South will send 8 artist teams to communities roughly between Drumheller and Medicine Hat. Artists include Karen Bass, Lorna Shultz-Nicholson, Bethany Ellis, Marty Chan, Mary Hays, Sigmund Brouwer, Carolyn Fisher, Natasha DeenApril 25-29: Wordpower North will have a team of 8 artists traveling among communities in north-eastern Alberta such as Fort MacKay, Conklin, Wabasca, Lac La Biche, Cold Lake, and Bonnyville. The artists include Kathy Jessup, Lois Donovan, Deborah Miller, David Poulsen, Gail de Vos, Karen Spafford-Fitz, Hazel Hutchins, Georgia Graham May: COMICS AND CONTEMPORARY LITERACY: May 2, 2016; 8:30am - 4:30pm at the Rozsa Centre, University of Calgary. This is a one day conference featuring presentations and a workshop by leading authors, scholars, and illustrators from the world of comics and graphic novels. This conference is the 5th in the annual 'Linguistic Diversity and Language Policy' series sponsored by the Chair, English as an Additional Language, Werklund School of Education, University of Calgary. Tom Ricento is the current Chair-holder. The conference is free and lunch is provided. Seating is limited, so register early. The four presenters are:Jillian Tamaki, illustrator for This One Summer, and winner of the Governor General's Award for children's illustration.Richard van Camp, best-selling author of The Lesser Blessed and Three Feathers, and member of the Dogrib Nation.Dr. Nick Sousanis, post-doctoral scholar, teacher and creator of the philosophical comic Unflattening.Dr. Bart Beaty, University of Calgary professor, acclaimed comics scholar and author of Comics vs. Art TD Canadian Children’s Book Week 2016. In 2016, the Canadian Children's Book Centre celebrates 40 years of bringing great Canadian children's books to young readers across the country and the annual TD Canadian Children’s Book Week will be occurring this May across Canada. The theme this year is the celebration of these 40 years of great books written, illustrated and published in Canada as well as stories that have been told over the years. The 2016 tour of storytellers, authors and illustrators and their area of travel are as follows:Alberta: Bob Graham, storyteller; Kate Jaimet, authorBritish Columbia (Interior region) Lisa Dalrymple, author; (Lower Mainland region) Graham Ross, illustrator; (Vancouver Island region) Wesley King, author; (Northern region, Rebecca Bender, author & illustrator.Manitoba: Angela Misri, author; Allison Van Diepen, authorNew Brunswick: Mary Ann Lippiatt, storytellerNewfoundland: Maureen Fergus, authorLabrador: Sharon Jennings, authorNorthwest Territories: Geneviève Després, illustratorNova Scotia: Judith Graves, authorNunavut: Gabrielle Grimard, illustratorOntario: Karen Autio, author; Marty Chan, author; Danika Dinsmore, author; Kallie George, author; Doretta Groenendyk, author & illustrator; Alison Hughes, author; Margriet Ruurs, author.Prince Edward Island: Wallace Edwards, author & illustratorQuebec (English-language tour): LM Falcone, author; Simon Rose, author; Kean Soo, author & illustrator; Robin Stevenson, author; and Tiffany Stone, author/poet.Saskatchewan: (Saskatoon and northern area) Donna Dudinsky, storyteller; (Moose Jaw/Regina and southern area) Sarah Ellis, authorYukon: Vicki Grant, author-----Gail de Vos is an adjunct professor who teaches courses on Canadian children's literature, young adult literature, and comic books & graphic novels at the School of Library and Information Studies (SLIS) at the University of Alberta. She is the author of nine books on storytelling and folklore. Gail is also a professional storyteller who has taught the storytelling course at SLIS for over two decades.

The current investigation examines children’s (N = 61; 4- to 8-year old) learning about a novel machine in a local history museum. Parent–child dyads were audio-recorded as they navigated an exhibit that contained a novel artifact: a coffee grinder from the turn of the 20th century. Prior to entering the exhibit, children were randomly assigned to receive an experimental “component” prompt that focused their attention on the machine’s internal mechanisms or a control “history” prompt. First, we audio-recorded children and their caregivers while they freely explored the exhibit, and then, we measured children’s learning by asking them two questions in a test phase. Children of all ages, regardless of the prompt given, discussed most aspects of the machine, including the whole machine, its parts, and, to a lesser extent, its mechanisms. In the test phase, older children recalled more information than younger children about all aspects of the machine and appeared more knowledgeable to adult coders. Overall, this suggests that children of all ages were motivated to discuss all aspects of a machine, but some scaffolding may be necessary to help the youngest children take full advantage of these learning opportunities. While the prompts did not significantly influence the number of children who discussed the machine’s mechanisms, children who received the component prompt were rated as more knowledgeable about the machine in the test phase, suggesting that this prompt influenced what they learned. Implications for visitor experience and exhibit design are discussed.

Background. Infants are entirely dependent on their caregivers, especially <6 months old when they are not yet mobile. While the epidemiology of injury among children in general has been described, the exact causes of infant injury have never been investigated in South Africa (SA). Objective. To describe causes of injury in infants aged <12 months, stratified for the four quarters of the first year of life, in order to identify opportunities for targeted prevention strategies based on local data. Methods. This retrospective audit study used data collected by ChildSafe SA from the Red Cross War Memorial Children’s Hospital in Cape Town, SA, over a 4-year period from January 2013 to December 2016. Infants <1 year of age presenting to the hospital’s trauma casualty department were included. Additionally, mortuary data on traumatic infant deaths in the hospital’s catchment area were collected. Results. A total of 2 279 injured infants were identified. More than half were male (55%; n=1 250) and the median age was 8 months (interquartile range 5 - 10 months). Leading causes of injury were falls (42%; n=957) and burns (32%; n=736). A significant association between the age group and the cause of injury (p<0.001) was found. From 2014 to 2016, an additional 27 infants were traumatically injured and died before arriving at the hospital. Conclusion. Falls and burns are a significant contributor to the burden of infant injuries in Cape Town. This underlines the urgent need for targeted prevention strategies to improve safety, taking poverty into account.

Background: Regular well-baby visits during the first three years of childhood are critical to identify health, behavioral and development problems that could have long-lasting effects into adulthood. WHO stresses the importance of child health, and states that ensuring the healthy growth and development of children should be the prime concern. Aim: To ensure that well-baby services provide clinical care according to children’s age as per well-baby service protocol within primary health care centers, to find gaps if any and to generate an action plan for further improvement. Methodology: A retrospective chart review (baseline audit) was conducted on 245 health records of children who attended well-baby clinic for three months (March 01, 2018 to May 31, 2018). Further to the implementation of the action plan, a re-audit with retrospective chart review of 477 health records for three months (June 01, 2019 to August 31, 2019) was conducted to evaluate the improvements in the practice. Results: Performance for criterion on relevant clinical history taking (feeding and bowel history) has slightly increased from the baseline for each of the following age groups: from 71% to 82% at 4 months, 77% to 80% at 18 months and, 76% to 81% at 30 months, however, a declination was shown at 2 months 88% to 80%. Assessment of developmental milestones at 2, 18 and 30 months of age increased by 5% (76% to 81%), 13% (70% to 83%) and 19% (50% to 69%) respectively and, at 4 months performance remained the same at 69%. Examination of congenital hip dislocation/abduction has demonstrated a significant improvement where its performance increased by 79% (8% to 87%) at 2 months, and 82% (2% to 84%) at 4 months of age. On the other hand, at ages 18 & 30 months which were not measured in the baseline audit in the re-audit, it was 68% and 45% respectively. Screening for vision at 2 months of age has increased by 13% (78% to 91%), but, there was a slight drop of 10% in the screening of hearing from 86% to 76% at 2 months. Screening of autism spectrum disorder using a tool in children 18 and 30 months of age dropped from 86% to 83% and from 86% to 75% respectively. Conversely, request laboratory investigation to rule out anemia has increased by 46% (47% to 93%) at 18 months and 61% (23% to 84%) at 30 months. Conclusions: Impactful audits with actionable recommendations make real difference in practice and compliance. In conclusion, action plans implemented further to the baseline audit are effective in increasing the compliance in most of the areas. Key Words: Well-baby services audit, primary health care, Qatar

ObjectivesPatients from ethnic minority groups and key workers are over-represented among adults hospitalised or dying from COVID-19. In this population-based retrospective cohort, we describe the association of ethnicity, socioeconomic and family key worker status with incidence and severity of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS).SettingEvelina London Children’s Hospital (ELCH), the tertiary paediatric hospital for the South Thames Retrieval Service (STRS) region.Participants70 children with PIMS-TS admitted 14 February 2020–2 June 2020.Outcome measuresIncidence and crude ORs are presented, comparing ethnicity and socioeconomic status of our cohort and the catchment population, using census data and Index of Multiple Deprivation (IMD). Regression is used to estimate the association of ethnicity and IMD with admission duration and requirement for intensive care, inotropes and ventilation.ResultsIncidence was significantly higher in children from black (25.0 cases per 100 000 population), Asian (6.4/100 000) and other (17.8/100 000) ethnic groups, compared with 1.6/100 000 in white ethnic groups (ORs 15.7, 4.0 and 11.2, respectively). Incidence was higher in the three most deprived quintiles compared with the least deprived quintile (eg, 8.1/100 000 in quintile 1 vs 1.6/100 000 in quintile 5, OR 5.2). Proportions of families with key workers (50%) exceeded catchment proportions. Admission length of stay was 38% longer in children from black ethnic groups than white (95% CI 4% to 82%; median 8 days vs 6 days). 9/10 children requiring ventilation were from black ethnic groups.ConclusionsChildren in ethnic minority groups, living in more deprived areas and in key worker families are over-represented. Children in black ethnic groups had longer admissions; ethnicity may be associated with ventilation requirement.This project was registered with the ELCH audit and service evaluation team, ref. no 11186.

Seixas, Ana. Tinybop. Me: A Kid’s Diary. 2016. Apple App Store, https://itunes.apple.com/app/apple-store/id1126531257?mt=8. Ages 3-7 (depending on parent assistance)Cost: $2.99 This app allows young children to create a digital diary filled with their own writings, photos, audio recordings, and drawings. The child creates an avatar from a varied array of options for skin colour, hair colour and style, facial features, and accessories. The app then encourages the child to respond to prompts, such as, “A song about me would be titled…,” “This is an interesting fact about my family,” and, “If I were an animal, I would look like this.” Some questions require a textual response, while others ask the child to draw, record, or take a snapshot of their response to the prompt, thereby taking advantage of the affordances offered by a tablet or phone. Other activities include the option to create a family tree, to create avatars of the child’s friends, and to answer all kinds of questions about the people in the child’s life. A child can draw, record, and photograph daily activities, such as their life at school. Children can use the app to explore their own ideas, experiences, and feelings through both serious and silly questions. A Kid’s Diary takes a simple process and makes it even more accessible to quite young children. Ana Seixas’ illustrations use eye-popping colours, with good use of contrast and negative space to make clicking easy. The language of the questions is simple and displayed in a large font. Younger children should be able to use this app with the help of caregivers reading the text for the children’s answers. Caregivers should know that the company foregrounds their privacy policy on the developer site, noting that the app does not collect information about the users through the application itself. It is highly recommended as a fun way for children and their caregivers to learn more about themselves and the world they observe around them. Highly recommended: 4 out of 4 starsReviewer: Allison Sivak Allison Sivak is the Public Services Librarian at the University of Alberta Libraries. She is currently pursuing her PhD in Library and Information Studies and Elementary Education, focusing on how the aesthetics of information design influence young people’s trust in the credibility of information content.

Abstract Background Environments within schools including the physical, social-cultural and policy/practice environments have the potential to influence children’s physical activity (PA) behaviours and weight status. This Australian first study comprehensively examined the association(s) of physical, social-cultural and policy/practice environments with PA, active transport (AT) and weight status among regional primary school children. Methods Data were from two childhood obesity monitoring systems in regional Victoria, Australia. Measured height and weight were collected from students in Year 2 (aged approx. 7–8 years), Year 4 (9–10 years), and Year 6 (11–12 years). Self–reported PA behaviour, including AT were collected from students in Year 4 and 6 and a sub-sample wore an ActiGraph (wGT3X-BT) accelerometer for 7-days. A school physical activity environment audit was completed by the school principal and responses were used to calculate school physical activity environment scores (PAES) and active transport environment scores (ATES). Mixed effects logistic regression was used to assess the relationship between the proportion of students meeting the PA guidelines (≥60mins/day of moderate-to-vigorous PA) and PAES tertiles (low, medium, high) and those using AT and school ATES tertiles, controlling for gender, school size/type and socioeconomic composition. Results The analysed sample included 54/146 (37%) schools and 3360/5376 (64%) students. In stratified analysis, girls in schools with a medium PAES score were more likely to meet the objectively measured PA guideline compared to low PAES score (OR 2.3, 95%CI 1.27, 4.16). Similarly, students in schools with a medium or high ATES score had higher odds of self-reported AT (medium OR 3.15, 95%CI 1.67, 5.94; high OR 3.71, 95%CI: 1.80, 7.64). No association between PAES or ATES and weight status were observed. Self-reported AT among boys (OR 1.59, 95%CI 1.19, 2.13) and girls (OR 1.56, 95%CI 1.08, 2.27) was associated with higher odds of meeting self-reported PA guidelines on all 7-days than those who did not report using AT. Conclusions In this study of regional Victorian primary schools, PA environments were only associated with girls’ adherence to PA guidelines. School AT environments were strongly associated with students’ AT behaviours and with increased likelihood of students being physically active.

Abstract Background Recognizing the level of glycemic control of a client is an important measure/tool to prevent acquiring complications and risk of death from diabetes. However, the other most important variable, which is the time that the patient stayed in that poor glycemic level before reaching optimal glycemic control, has not been studied so far. Therefore, this study aim to estimate time to first optimal glycemic control and identify predictors among type 1 diabetic children in Bahir Dar city public referral hospitals, Northwest, Ethiopia, 2021. Methods A Retrospective cohort study was conducted at Bahir Dar city public referral hospitals among a randomly selected sample of 385 patients with type 1 diabetes who were on follow up from January 1, 2016 to February30, 2021.Data were collected by using a data abstraction tool and then entered into Epi-data version 4.6 and exported into STATA 14.0 statistical software. Descriptive statistics, Kaplan Meier plots and median survival times, Log-rank test and Cox-proportional hazard regression were used for reporting the findings of this study. After performing Cox-proportional hazard regression, model goodness-of-fit and assumptions were checked. Finally, the association between independent variables and time to first optimal glycemic control in months was assessed using the multivariable Cox Proportional Hazard model and variables with a p-value < 0.05 were considered as statistically significant. Results Median survival time to first optimal glycemic control among type 1 diabetic clients was 8 months (95%CI: 6.9–8.9). The first optimal glycemic achievement rate was 8.2 (95%CI: 7.2–9.2) per 100 person/month observation. Factors that affect time to first optimal glycemic control were age > 10–14 years (AHR = 0.32;95%CI = 0.19–0.55), increased weight (AHR = 0.96;95%CI = 0.94–0.99), having primary care giver (AHR = 2.09;95%CI = 1.39–3.13), insulin dose (AHR = 1.05;95%CI = 1.03–1.08), duration of diabetes ≥4 years (AHR = 0.64;95%CI = 0.44–0.94), adherence to diabetic care (AHR = 9.72;95%CI = 6.09–15.51), carbohydrate counting (AHR = 2.43;95%CI = 1.12–5.26), and comorbidity (AHR = 0.72;95%CI = 0.53–0.98). Conclusion The median survival time to first optimal glycemic control in this study was long. Age, weight, primary care giver, insulin dose, duration of diabetes, adherence, and carbohydrate counting, including history of comorbidity were determinant factors. Giving attention for overweight and comorbid illness prevention, increasing either the dose or frequency of insulin during initial treatment; counseling parent (for both the mother and father) about adherence to diabetic care focusing on insulin drugs and how to audit their children’s diet as prescription helps to reduce the length of glycemic control.

Introduction Media and gender are intricately linked in our society. Every day we see representations of women and men on the screen, read about politicians in the press, watch influencers on YouTube or go to the cinema where we meet screen heroes. Our images and notions of gender draw on these media narratives and role models. Children and young people are socialised with these views and cultivate their own identity and gender roles accordingly. Ideas of gender are not static. They are produced discursively in an ongoing process. Gender is understood as a social category, and this perspective is interwoven with an observation of people’s social behaviour, their “doing gender” (West and Zimmerman). From a social constructivist, the focus lies on the production processes connected with the construction of gender representations through the media. The question of how masculinity and femininity, concepts of “being a man” or “being a woman”, represented on a platform such as YouTube become relevant. Our research interest lies exactly in this: How gender inclusive is the video platform YouTube? Are male and female representations equally visible—or do we find exclusion mechanisms that hinder this? Literature Review Europe-wide studies show that children and adolescents are online for an average of 2.4 hours a day (Hasebrink et al.). Eighty-seven per cent of young people report watching videos (e.g. on YouTube) at least once a week (ibid., 11). This applies for Germany as well (MPFS). Considering the relevance YouTube has for adolescents, the question arises as to which role models are portrayed through YouTube and how diverse the representations of gender are depicted there. Initial analyses, primarily for the English-language YouTube platform, see its potential to counteract gender stereotypes (Maloney et al.), but generally show an unequal visibility of the genders on YouTube. These studies find that women are underrepresented, receive more hostile feedback and present themselves in stereotypical forms (Wotanis and McMillan; Döring; Molyneaux et al.). Döring and Mohseni showed in their current nine-country comparative analysis that men dominate the popular YouTube across countries and women are more likely to give up after hostility. The existing research usually examined the English-language, mainly US YouTube, it analysed gender performance, stereotypes in selected genres such as advertising or gaming, the stigmatisation of obesity, the representation and experiences of black women on YouTube, and the staging of alternative images of masculinity (see Hussin et al.; Kataria and Pandey; Wotanis and McMillan; Casabianca; Maloney et al.; Sobande). Molyneaux et al. noted in their landmark study gender-specific differences: female YouTubers tend to focus on private matters and interact more frequently with their users. Male YouTubers, on the other hand, share opinions and information and avoid emotions (Pedersen and Macafee). In addition, female vloggers are more often criticised for their appearance than for the content of their videos (Molyneaux et al.). Even though YouTube is an international medium, its use remains limited to language and nation. For example, the most popular YouTube stars among German children and young people are predominantly German-speaking influencers or sportsmen and women. In 2019, girls between the ages of 6 and 13 most often name Bibi, Dagi Bee, Shirin David, Lisa & Lena, and Miley; boys at the same age Julien Bam, Gronkh, Die Lochis, LeFloid and Manuel Neuer (IZI). All these are German YouTube or sports stars. YouTube itself shows in its recommendations under the heading “most popular videos in Germany” exclusively German-language videos, music videos, or sporting events (YouTube). Therefore, YouTube also needs to be examined in national contexts, as well as in cross-national context. Our study will focus on the national German context to examine whether there are similar gender differences in the German-speaking YouTube as have been identified for the English-speaking YouTube. For German-speaking YouTube, few studies are available. Döring and Mohseni examined male and female operators of the top 100 YouTube channels in nine different countries. The results show that women make up 25 per cent of the top 100 German YouTube channel operators, a distribution which is similarly uneven in other countries. Usage data shows that the German-speaking YouTube appears to have a greater relevance among boys than girls. Boys (93%) use YouTube more often on a regular basis, than girls (86%), and rank it higher as their favourite app (MPFS). Other than for traditional media such as television or film, where intensive research has for decades shown a wide gender gap in the visibility of women (Prommer and Linke; Linke and Prommer), research on German-speaking YouTube is rare (Döring and Mohseni). Hypotheses In reflection of the research outlined above on representations of gender in media and the stereotypical portrayals of men and women in film and television, we assume that these gender role depictions are carried over into online videos on social media platforms. The fact that girls use YouTube somewhat less often, consider themselves less competent in the necessary Internet skills, and anticipate greater risks related to communicative aspects suggests that female operators might have been held back and that the female perspective might be marginalised in public (self-)portrayals. The following hypotheses will therefore guide our study: H1: Fewer women are channel operators of Germany’s most popular YouTube channels, and they are more limited in their choice of genres. H2: Women are less visible than men in popular YouTube videos. H3: Women portray themselves more often as connected to stereotypically female topics or are depicted as such in videos. H4: Men stage themselves as professionals. Methods and Sample Following these hypotheses, we conducted a two-step research. The first research step was to analyse to what extent women and men produce popular content. For this, we looked at the ratio of female to male YouTubers among the 1,000 most successful German channels. These YouTubers are called either creators or channel operators by the industry. Both terms are used synonymously here. To identify the most popular YouTube channels, we acquired the viewing and ranking data from the market research company Social Blade, which is one of the very few sources for these data. We measured the popularity of the channels by the number of subscribers to a channel. The success of individual videos was measured by individual views. We coded the 1,000 most successful German YouTube channels, with a standardised quantitative content analysis. This method is frequently applied in existing studies on gender representations in YouTube (Döring; Döring and Mohensi). Different to existing research, we looked at a larger number of channels. This quantified analysis was combined with a more qualitative, but still standardised analysis of visibility of gender and concrete content and presentation forms (Prommer and Linke). For the second step we used the Audio-Visual Character Analysis (ACIS) developed by Prommer and Linke as a method that is able to code any audio-visual content in order to describe visibility and diversity of the depicted people. Here, the analysis considered the individual video as the unit of analysis. For 20 videos from each of the top 100 YouTube creators, we chose the 10 of most recent videos plus the 10 videos with the most views to be analysed. In total, 2,000 videos were analysed. For the qualitative analysis, looking at the visibility of gender, we excluded channels operated by institutions, such as radio and TV broadcasters, music labels, and other commercial entities. These were not considered since there is no individual person responsible. We also excluded “Let’s Play” videos, since these often do not show the operator, but only show game play from video games. Results H1: Fewer women are operators of Germany’s most popular YouTube channels, and they are more limited in their choice of genres. As the analyses show, if the non-individual channel operators are included in the statistics, we see that 27 per cent of the top popular channels in Germany are hosted by institutions (270); this leaves 172 channels operated by women (17%), 525 channels by men (53%), and 25 (3%) by mixed-gender teams. Further on, we will only consider the top 1,000 channels produced by one or more individuals; of these, one quarter (24%) of channel operators are female (fig. 1). This shows that, for every channel in the list produced by a woman, three are produced by men. Only three per cent of the channels are produced by men and women together, constituting a mixed-gender team. The YouTube genres, according to the YouTube classification, also show significant gender differences. Women can be seen first and foremost in tutorial channels (women: 61; men: 9). However, because only 24 per cent of channels in which an individual operator could be identified are contributed by women, all other genres except for tutorial channels are produced disproportionally more often by men. Gaming videos are solid male territory, as almost all "Let’s Play" channels are operated by men (women: 6; men: 150). Here, there are 25 men for every one woman who operates a gaming channel. This is particularly remarkable, as women make up 46 per cent of gamers (ISFE), and their underrepresentation can generally not be explained by lack of interest. Men operate channels in a wide variety of other genres, such as music (women: 9; men: 80) and sports (women: 4; men: 20). The genres of comedy, film, and education show only one female operator each—outnumbered from 10 to 1 to as much as 20 to 1. Examining the statistics for men and women separately reveals that men do not only operate the majority of the top 1,000 channels, but they are also visible in a wider variety of genres. Female YouTubers have primarily limited themselves to entertainment channels (50% of all women) and how-to channels (35% of all women). Male channels are more diverse and include entertainment (38% of all men), games (29% of all men), and music (15% of all men), as well as all other genres. Only in tutorial channels men are rarely seen (2%). The genre definitions of the YouTube channels used here are derived from YouTube itself, and these definitions are not in line with other genre theories and are overly broad. Nevertheless, these results confirm the first hypothesis that fewer women are operators of popular YouTube channels, and that women are more limited in their genre diversity. Fig. 1: Gender distribution of the top 1,000 YouTube channel creators—individuals only (n=722) H2: Women are less visible than men in popular YouTube videos. From the list of the top 1,000 channels, the top 100 most successful channels produced by individuals were analysed in more depth. Of these top 100 channels we analysed 20 videos each, for a total of 2,000 videos, for the visibility and appearance of men, women, and non-binary persons. If we count the main protagonists appearing in these 2,000 videos, we see for every woman (979; 29%) more than two men (2,343; 69%). Only two per cent (54) of the people appearing in these videos had a non-binary gender (intersexual, transsexual, or other). Interestingly, this is a similar imbalance as we can detect in television as well (Prommer and Linke). In other categories, there is more diversity than in television: in total, 44 per cent of channel operators have a recognisable “migration background”, which is more commonly seen in men (49%) than in women (32%). “Migration background” is the official German definition of people with a foreign nationality, people not born in Germany, or having parents with these criteria. This confirms the second hypothesis, according to which women are visible in popular Web videos less often than men. H3: Women portray themselves more often in connection to stereotypically female topics or are depicted as such in videos. In the 2,000 videos from the top 100 channels, female YouTubers are primarily visible in service-oriented tutorial channels (on topics like beauty, food, and the household). Female YouTubers are predominantly represented in video blogs (vlogs: 17%), battles/challenges (16%), sketches/parodies (14%), and tutorials (11%). The haul/unboxing format, in which presenters unpack acquired products or gifts, is almost exclusively female. Men are visible in a wide array of formats such as battles/challenges (21%), sketches (17%), and vlogs (14%), including music (9%), opinions/positions (6%), interviews (2%), music parodies (3%), and question-answer formats (2%). The wide range of content produced by male YouTubers, compared to the limited range of female YouTubers, becomes even more obvious when we consider the topics of the individual videos. The results show that men engage with a variety of themes. Women’s topics, on the other hand, are limited: female YouTubers address beauty (30%), food (23%), relationships (23%), fashion and family, as well as household topics (15%). As fig. 2 shows, men present a bigger variety of topics such as music, relationships, family and fashion, and they also address politics (7%), gaming, and much more. The men’s list is significantly more comprehensive (21 topic areas instead of 15). The data thus confirm the third hypothesis, according to which female YouTubers are more often represented in popular videos with stereotypically female themes. It also becomes clear that their spectrum of topics is significantly more limited than that of male actors. Fig. 2: Topic and subject areas of main actors by gender (3,322), statistics for all women and all men; multiple answers possible H4: Men stage themselves as professionals The following results reveal selected characteristics of the staging with which the main female protagonists portray themselves in the 2,000 videos analysed, and which we understand as an expression of professional versus non-professional ability. Female YouTubers appear predominantly in private settings, and their relationships to (almost exclusively male) partners and to their families play a larger role in their appearances than with the male protagonists. Their activities in the videos are described more frequently by the women themselves as personal passions and hobbies, and they rarely discuss their activities as connected to a career. Women talk about their passions, while men thematise their professional abilities. While fewer than a quarter of female YouTubers (22%) address their careers, almost two thirds of men (61%) do so. When looking at hobbies and passions the reverse is true: while only a third of male YouTubers (32%) mention these themes, two thirds of women (64%) create this context in their videos. Also, public spaces and professional contexts are predominantly reserved for male protagonist on YouTube. This means that women shoot their videos in what appears to be their homes or other private environments, while men are also visible in offices or other professional environments (e.g. fitness studios). The settings in which most people are visible on YouTube are private houses and apartments, where most women (71%) and more than half of male actors (57%) are shown. Settings in the public sphere, in contrast, are chosen by male YouTubers twice as often (34%) as by females. This confirms the fourth hypothesis, which states that men communicate and stage themselves as professionals in their videos, measured by the choice of public settings, references to professional activity, and thematisation of emotions. Limitations This study represents a first step toward a quantified analysis of gender portrayals on YouTube. Although a large number of channels and videos were included in the analysis, it is not a comprehensive assessment of all of the most popular videos, nor a random sampling. Limiting the scope to the most popular content necessarily excludes videos that may show alternative content but receive fewer clicks and subscribers. The content analysis does not allow conclusions to be drawn regarding the videos’ actual reception among adolescents. Even though the data prove the platform’s popularity among children and young adults, the audience groups for the individual videos we analysed could not be broken down by sociodemographics. The gender-typical depictions can thus only be understood as an offering; no statements can be made as to their actual acceptance. Discussion The results show that Web videos favourited by children and young adults on the YouTube platform adopt and propagate similar role models to those that previously existed in television and film (Götz et al.). Female channel operators are significantly underrepresented in the most popular videos, they are more limited in their range of topics, and they appear predominantly in and with topics with a stereotypically female connotation. Further, most of women’s (self-)portrayals take place in private settings. Here, the new Web formats have not created a change from classical depictions on television, where women are also predominantly shown in their personal and private lives. Web videos emphasise this aspect, as female actors refer often to their hobbies rather than to their careers, thus characterising their actions as less socially legitimised. This shows that in their favourite new media, too, adolescents encounter traditional gender stereotypes that steer the engagement with gender onto traditional tracks. The actual variety of gender identities and gender roles in real life is not presented in the popular YouTube videos and therefore excluded from the mainstream audience. Clearly, the interplay of the structure of YouTube, the market, and audience demand does not lead to the inclusion and visibility of alternative role models. References Casabianca, Barbara. "YouTube as a Net'Work': A Media Analysis of the YouTube Beauty Community." CUNY Academic Works, 2016. <https://academicworks.cuny.edu/gc_etds/1300/>. Döring, Nicola. “Videoproduktion auf YouTube: Die Bedeutung von Geschlechterbildern.” Handbuch Medien und Geschlecht: Perspektiven und Befunde der Feministischen Kommunikations- und Medienforschung. Eds. Johanna Dorer et al. Wiesbaden: Springer Fachmedien, 2019. 1–11. Döring, Nicola, and M. Rohangis Mohseni. “Male Dominance and Sexism on YouTube: Results of Three Content Analyses.” Feminist Media Studies 19.4 (2019): 512–24. DOI: 10.1080/14680777.2018.1467945. Götz, Maya, et al. “Whose Story Is Being Told? Results of an Analysis of Children's TV in 8 Countries.” TelevIZIon 31 (2018): 61–65. Hasebrink, Uwe, et al. Ergebnisse der EU Kids Online-Befragung in Deutschland 2019: Online-Erfahrungen von 9- bis 17-Jährigen. Hamburg: Verlag Hans-Bredow-Institut, 5 Oct. 2020. <https://www.hans-bredow-institut.de/uploads/media/Publikationen/cms/media/s3lt3j7_EUKO_Bericht_DE_190917.pdf>. Hussin, Mallory, et al. “Fat Stigmatization on YouTube: A Content Analysis.” Body Image 8.1 (2011): 90–92. DOI: 10.1016/j.bodyim.2010.10.003. ISFE (Interactive Software Federation of Europe). Key Facts 2020. 17 Nov. 2020. <https://www.isfe.eu/wp-content/uploads/2020/08/ISFE-final-1.pdf>. IZI (Internationales Zentralinstitut für das Bildungsfernsehen). "BibisBeautyPalace wieder ganz vorne bei den Kindern: Neue Studie zu den beliebtesten Influencer*innen bei Kindern und Preteens." München: Bayrischer Rundfunk. 26 Nov. 2019 <https://www.br-online.de › Pressemitteilungen › PM_LieblingsYouTuber>. Kataria, Manju, and Bandana Pandey. “Representation of Women in Online Advertisements: A Content Analysis.” Research on Humanities and Social Sciences 22.4 (2014): 138–45. <https://www.iiste.org/Journals/index.php/RHSS/article/view/16823>. Linke, Christine, and Elizabeth Prommer. “From Fade-Out into Spotlight: An Audio-Visual Character Analysis (ACIS) on the Diversity of Media Representation and Production Culture.” Studies in Communication Sciences (SComS), forthcoming 2021. Maloney, Marcus, et al. “‘Mmm … I Love It, Bro!’: Performances of Masculinity in YouTube Gaming.” New Media & Society 20.5 (2018): 1697–714. DOI: 10.1177/1461444817703368. Medienpädagogischer Forschungsverbund Südwest (MPFS). JIM Studie 2018: Jugend, Information, Medien: Basisuntersuchung zum Medienumgang 12- bis 19-Jähriger. 1 Jan. 2019. 5 Oct. 2020 <https://www.mpfs.de/fileadmin/files/Studien/JIM/2018/Studie/JIM2018_Gesamt.pdfZ>. Molyneaux, Heather, et al. “Exploring the Gender Divide on YouTube: An Analysis of the Creation and Reception of Vlogs.” American Communication Journal 10.2 (2008). <https://www.it.uu.se/edu/course/homepage/avint/vt09/1.pdf>. Pedersen, Sarah, and Caroline Macafee. “Gender Differences in British Blogging.” Journal of Computer-Mediated Communication 12.4 (2007): 1472–92. DOI: 10.1111/j.1083-6101.2007.00382.x. Prommer, Elizabeth, and Christine Linke. Ausgeblendet: Frauen im deutschen Film und Fernsehen. Herbert von Halem Verlag, 2019. Sobande, Francesca. “Watching Me Watching You: Black Women in Britain on YouTube.” European Journal of Cultural Studies 20.6 (2017): 655–71. DOI: 10.1177/1367549417733001. West, Candice, and D. H. Zimmerman. “Doing Gender.” Gender and Society 1.2 (1987): 125–51. Wotanis, Lindsey, and Laurie McMillan. “Performing Gender on YouTube.” Feminist Media Studies 14.6 (2014): 912–28. DOI: 10.1080/14680777.2014.882373. YouTube. 23 Oct. 2019 <https://www.youtube.com/results?search_query=beliebteste+videos+deutschland>.

Photo by National Cancer Institute on Unsplash INTRODUCTION Gift-giving by patients or their families to physicians has happened since there were patients and physicians, and in many places, it’s still quite common. It’s also potentially problematic, and the why and how of it offer important insight into the physician-patient relationship and human relationships more broadly. Yet ethicists, regulators, and the public have not paid much systematic attention. In the United States, no federal or state legislation directly addresses it. Only in the past two decades did the American Medical Association (AMA) release guidance to physicians about it. That guidance, which permits physicians to accept certain gifts by certain patients under certain circumstances, namely, when it will not influence their medical judgment or cause hardship to the gift-giver, is vague and incomplete – indeed, it’s all of 200 words.[1] Other physician professional organizations have little to add.[2] A few academics and opinion columnists have studied or reflected on the psychology of gift-giving and -receiving and recommended everything from categorical rejection of patient gifts[3] to erring on the side of accepting them, provided they are of modest value, and the motivation behind them can be discerned.[4] However, insufficient attention has been paid to the when and where of those gifts or the significance of clinic-, hospital- or other systems-level ethical safeguards. ANALYSIS When deciding whether they will accept a gift from a patient or their family, physicians must balance the possibility that the gift could cloud medical judgment, lead to favoritism, exploitation, and slippery slopes, or pressure other patients to give, and perhaps even debase the meaning of medical treatment, against the prospect that gift-giving could increase patient trust and satisfaction, as well as empower patients and respect their autonomy and culture.[5] Performing this harm-benefit calculation case by case is challenging and time-consuming. Unsurprisingly, many physicians opt simply to tell would-be gift-giving patients that they appreciate the sentiment, but, as a rule, they accept no gifts. I submit many physicians do this also because they are unaware of how meaningful giving a gift can be for patients or anyone in a disadvantaged position with respect to the gift recipient. They may also not know that there are simple accountability mechanisms they can institute that may prevent many of the possible adverse consequences of gift-giving and -receiving in the context of the physician-patient or physician-patient-family relationship. Unfortunately, many instances in which accepting a gift would have led to net benefit are foregone. It is my belief a consensus could quickly be formed about which types of gifts would clearly be wrong to accept. Few would defend the physician who agrees to use a patient’s villa in the Bahamas or welcomes expensive jewelry or lewd photos. The timing and intent of a gift also matter. Few would forgive the physician who accepted even a modestly valuable voucher to eat at a patient’s restaurant while their eligibility for transplant was being debated or after they had run out of opioid painkillers and were denied a prescription renewal. On the other hand, I doubt even Charles Weijer or the College of Physicians and Surgeons of Prince Edward Island, which views accepting gifts from patients as “boundary crossing,”[6] would demand an orthopedic surgeon turn down the happy picture a pediatric patient drew after recovering from a hip injury and resuming sports. They are also unlikely to criticize an oncology team that graciously receives a fruitcake baked by the sister of an elderly cancer patient after the decision was made and agreed to, around Christmastime, not to initiate another round of chemotherapy. These unlikely refusals may be because rejecting those gifts, all things considered, would seem cruel. But it might also be because there is disagreement about what constitutes a gift: whether it must be a tangible object (are heartfelt thank-yous and hugs not also “gifts”?) or whether it must be something that requires the physician actively do something, e.g., get on a plane. These disagreements about definitions may also partially underlie disagreements about practice. Suppose a patient in a sparsely populated, heavily wooded part of Maine takes it upon himself to offer a sack of apples from his orchard to his internist, who regularly waives fees for those who cannot pay them or will make a house call at any time of the night. In that case, the internist may not consider the apples a gift. He may not think of them as payment or re-payment either. They may exist in some in-between category, much like the knitted slippers brought in by a patient in whose culture “thank you” is seldom said. But clearly, some things are widely perceived as gifts or to have substantial gift-like character. Should they, at least, be rejected? I don’t think so. The act of gift-giving and -receiving can be a sort of ritual and gradually lead to trust and closeness.[7] Perhaps a shy patient whose wife previously sent chocolates to his physician around Christmastime will come to see the physician as a part of his extended family. Perhaps he needs to do so to feel comfortable talking about his erectile dysfunction. Gifts can be expressions of caring.[8] Perhaps an elderly Texan patient imagines her younger physician, whom she has known for thirty years and often sees at the grocery store, as her son and asks to prepare a homecoming mum (traditionally a chrysanthemum flower corsage) for his children’s school dance. Perhaps doing so will give her purpose, make her feel useful, as all her own children have moved away. Giving gifts may also provide patients with a sense of control and help them feel as if less of a power imbalance exists between them and their physician. Perhaps a young judge, who is not used to not being in control, and was previously misdiagnosed with rheumatoid arthritis, is now struggling to come to terms with his Lupus. Perhaps giving the physician who made the correct diagnosis a moderately-priced bottle of scotch restores his confidence or sense of pride to. Gifts are also undoubtedly important to the recipient. When medical providers receive a gift, they may interpret it as a sign that they are valued. While it would be wrong to practice medicine to receive gifts or expect them, there are times, like when ERs and ICUs are overwhelmed because of a viral pandemic,[9] which threatens the will to continue working, and most anything (within reason) that bolsters resolve can be considered good. There is also no obvious distinction between the satisfaction physicians normally receive on seeing their patients recover or being thanked or smiled at and what they feel when they receive a small or “token” gift, like a plate of homemade cookies. The point is that the physician-patient relationship is a human one. Many advocate it should be personal, that physicians should be emotionally invested in their patients, care about and have compassion for them in ways that professional oaths do not fully capture.[10] This dynamic is particularly important in primary care or when the physician-patient relationship continues for long periods. According to one Israeli study, many patients even wish for a relationship with their physician akin to friendship. Those who felt they had such a relationship were more satisfied with their care than those who believed the relationship was business-like.[11] The precedent for this “friendship between unequals” goes back at least to the time of Erasmus, some five hundred years ago.[12] There may be good reasons for physicians to draw the line before friendship, but if accepting certain gifts builds intimacy, and that intimacy does not cross over into an inappropriate relationship, e.g., a sexual or romantic relationship, and if it has the chance to improve healthcare outcomes through improved mood or early disclosure of problems, I think it should be done. Physicians have a prima facie duty to do good for their patients.[13] Most physicians want to do good for their patients and respect their traditions and preferences. I suspect that accepting the gifts from the patients in the examples above would do a lot of good, or at least that rejecting them could do significant harm, including making them or their families feel estranged from the medical community, impeding future care. Physicians might be more comfortable accepting gifts if receiving gifts would not subject them to scrutiny or penalty. They also may feel better if they knew that receiving gifts would not harm their patients and that rejecting gifts might. They should document all gifts they receive.[14] This will enable them to detect if gifts from a particular patient are increasing in frequency or lavishness or changing markedly in character, which could warrant attention. I maintain this “Gift Log” should be maintained in common with everyone at the clinic or in the relevant hospital department and potentially made available to hospital administration for audit. Investigation might be necessary if a gift is given (and accepted) with no explicable context, e.g., not near holiday season or after a treatment milestone is achieved. When possible, gifts should be shared communally, such as placing fruit baskets or chocolates in the staff room. Other gifts, like artwork, can be displayed on the walls. Others should be encouraged to hold physicians accountable if they feel patients who have given gifts receive preferential treatment, including something as seemingly small as priority for appointment bookings. Appearances matter and even the appearance of impropriety can affect the public’s trust in medicine. The culture of medicine has already changed such that nurses now reproach physicians they feel violate the standard of care,[15] and this would be an extension of that trend. Depending on the set-up of the practice, a staff member can be designated for receiving gifts and politely declining those that ought to be declined. Staff members should tell patients, who give gifts in full view of other patients, that they cannot do so in the future. Physicians can politely rebuff patients who wish to give inappropriate gifts, or gifts at inappropriate times and suggest they donate to charity instead. Medical practices and hospitals should develop a gift policy in consultation with staff and patients to avoid needlessly rejecting gifts that benefit both doctor and patient and to avoid pressuring patients into giving gifts. The policy should be flexible to account for the crucial human element in any provider-patient relationship and the cultural nuances of any practice setting. Psychiatrists, who work with particularly vulnerable patients, may need to be more vigilant when accepting gifts.[16] CONCLUSION Though we tend to think health innovation occurs in urban medical centers and spreads outward, there may be something big-city physicians can learn from their rural colleagues about personalized patient-physician relationships. The value of gifts is only one example. Normalizing the acceptance of patient gifts in appropriate restricted circumstances has the added benefit of shining a spotlight on the acceptance of patient gifts in dubious ones. By bringing an already fairly common practice into the open and talking about it, we can create policies that respect patients as persons, prevent abuse, and deconstruct the stereotype of the austere and detached physician. While there is no reason to think that gift-giving would get out of control if appropriate safeguards are put in place, the medical community can always re-evaluate after a period, or an individual medical practice can re-evaluate based on the circumstances of their practice environment. Gift-giving, especially when gifts are of small monetary value, should be recognized as a culturally appropriate gesture with meaning far beyond that monetary value. It is best governed by reasonable gift-giving policies, not banned altogether. - [1] Council on Ethical and Judicial Affairs. “Ethics of Patient-Physician Relationships.” In AMA Code of Medical Ethics, 11. Chicago: American Medical Association, 2021. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-1.pdf. [2] Sulmasy, Lois Snyder, and Thomas A. Bledsoe. “American College of Physicians Ethics Manual.” Annals of Internal Medicine 170, no. 2_Supplement (January 15, 2019): S1–32. https://doi.org/10.7326/M18-2160; Committee on Bioethics. “Pediatrician-Family-Patient Relationships: Managing the Boundaries.” Pediatrics 124, no. 6 (December 1, 2009): 1685–88. https://doi.org/10.1542/peds.2009-2147. [3] Weijer, Charles. “No: Gifts Debase the True Value of Care.” Western Journal of Medicine 175, no. 2 (August 2001): 77. [4] Lyckholm, Laurie J. “Should Physicians Accept Gifts From Patients?” JAMA 280, no. 22 (December 9, 1998): 1944–46. https://doi.org/10.1001/jama.280.22.1944; Spence, Sean A. “Patients Bearing Gifts: Are There Strings Attached?” BMJ 331, no. 7531 (December 22, 2005): 1527–29. https://doi.org/10.1136/bmj.331.7531.1527; Gaufberg, Elizabeth. “Should Physicians Accept Gifts from Patients?” American Family Physician 76, no. 3 (August 1, 2007): 437; Caddell, Andrew, and Lara Hazelton. “Accepting Gifts from Patients.” Canadian Family Physician 59, no. 12 (December 2013): 1259–60. [5] See above commentators and Drew, Jennifer, John D. Stoeckle, and J. Andrew Billings. “Tips, Status and Sacrifice: Gift Giving in the Doctor-Patient Relationship.” Social Science & Medicine 17, no. 7 (January 1, 1983): 399–404. https://doi.org/10.1016/0277-9536(83)90343-X. [6] College of Physicians and Surgeons of Prince Edward Island. “Respecting Boundaries.” Accessed April 4, 2021. https://cpspei.ca/respecting-boundaries/. [7] The Atlantic’s Marketing Team. “What Gifting Rituals from Around the Globe Reveal About Human Nature.” The Atlantic, 2018. https://www.theatlantic.com/sponsored/hennessy-2018/what-gifting-rituals-around-globe-reveal-about-human-nature/2044/. [8] Parker-Pope, Tara. “A Gift That Gives Right Back? The Giving Itself.” The New York Times, December 11, 2007, sec. Health. https://www.nytimes.com/2007/12/11/health/11well.html. [9] Harlan, Chico, and Stefano Pitrelli. “As Coronavirus Cases Grow, Hospitals in Northern Italy Are Running out of Beds.” Washington Post. Accessed April 4, 2021. https://www.washingtonpost.com/world/europe/italy-coronavirus-patients-lombardy-hospitals/2020/03/12/36041dc6-63ce-11ea-8a8e-5c5336b32760_story.html. [10] Frankel, Richard M. “Emotion and the Physician-Patient Relationship.” Motivation and Emotion 19, no. 3 (September 1, 1995): 163–73. https://doi.org/10.1007/BF02250509. [11] Magnezi, Racheli, Lisa Carroll Bergman, and Sara Urowitz. “Would Your Patient Prefer to Be Considered Your Friend? Patient Preferences in Physician Relationships.” Health Education & Behavior 42, no. 2 (April 1, 2015): 210–19. https://doi.org/10.1177/1090198114547814. [12] Albury, W. R., and G. M. Weisz. “The Medical Ethics of Erasmus and the Physician-Patient Relationship.” Medical Humanities 27, no. 1 (June 2001): 35–41. https://doi.org/10.1136/mh.27.1.35. [13] Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th edition. New York: Oxford University Press, 2012. [14] Caddell and Hazelton, 2013. [15] See, e.g. Peplau, Hildegard E. “A Glance Back in Time: Nurse-Doctor Relationships.” Nursing Forum 34, no. 3 (1999): 31–35. https://doi.org/10.1111/j.1744-6198.1999.tb00991.x and Ahmad, Ahmir. “The Doctor-Nurse Relationship: Time for Change?” British Journal of Hospital Medicine (2005), September 27, 2013. https://doi.org/10.12968/hmed.2009.70.Sup4.41642. [16] Hundert, Edward M. “Looking a Gift Horse in the Mouth: The Ethics of Gift-Giving in Psychiatry.” Harvard Review of Psychiatry 6, no. 2 (January 1, 1998): 114–17. https://doi.org/10.3109/10673229809000319.

Introduction: Doctor Who's “Wilderness Years”1989 saw the cancellation of the BBC's long-running science fiction television series Doctor Who (1965 -). The 1990s were largely bereft of original Doctor Who television content, leading fans to characterise that decade as the “wilderness years” for the franchise (McNaughton 194). From another perspective, though, the 1990s was an unprecedented time of production for Doctor Who media. From 1991 to 1997, Virgin Publishing was licensed by the BBC's merchandising division to publish a series of original Doctor Who novels, which they produced and marketed as a continuation of the television series (Gulyas 46). This series of novels, Doctor Who: The New Adventures (commonly referred to as “the Virgin New Adventures” by fans) proved popular enough to support a monthly release schedule, and from 1994 onwards, a secondary "Missing Adventures" series.Despite their central role in the 1990s, however, many fans have argued that the Doctor Who novels format makes them either less "canonical" than the television series, or completely "apocryphal" (Gulyas 48). This fits with a general trend in transmedia properties, where print-based expansions or spin-offs are generally considered less official or authentic than those that are screen-based (Hills 223). This article argues that the openness of the series to contributions from fan writers – and also some of the techniques and approaches prioritised in fan fiction - resulted in the Virgin range of Doctor Who novels having an unusually significant impact on the development and evolution of the franchise as a whole when compared to the print-based transmedia extensions of other popular series’. The article also argues that the tonal and stylistic influence of the New Adventures novels on the revived Doctor Who television series offers an interesting counter-example to the usually strict hierarchies of content that are implied in Henry Jenkins's influential model of transmedia storytelling. Transmedia StorytellingJenkins uses the term “transmedia storytelling” to describe the ways in which media franchises frequently expand beyond the format they originate with, potentially encompassing television series, films, games, toys, comics and more (Jenkins “Transmedia 202”). In discussing this paradigm, Jenkins notes the ways in which contemporary productions increasingly prioritise “integration and coordination” between the different forms of media (Jenkins Convergence Culture 105). As Jenkins argues, “most discussions of transmedia place a high emphasis on continuity – assuming that transmedia requires a high level of coordination and creative control and that all of the pieces have to cohere into a consistent narrative or world” (Jenkins “Transmedia 202”). Due to this increased emphasis on continuity, the ability to decide which media will be considered as “canonical” within the story-world of the franchise becomes an important one. Where previously questions of canon had been largely confined to fan discussions, debates and interpretive readings of media texts (Jenkins Textual Poachers 102-104), the proprietors of franchises in a transmedia economy have an interest in proactively defining and policing the canon. Designating a particular piece of media as a “canonical” expansion or spinoff of its parent text can be a useful marketing tool, as it creates the expectation that it will provide an important contribution. Correspondingly, declaring that a particular set of media texts is no longer canonical can make the franchise more accessible and allow the authors of new material more creative freedom (Proctor and Freeman 238-9).While Jenkins argues that a reliance on “one single source or ur-text” (“Transmedia 101”) is counter to the spirit of transmedia storytelling, Pillai notes that his emphasis on cohesiveness across diverse media tends to implicitly prioritise the parent text over its various offshoots (103-4). As the parent text establishes continuity and canon, any transmedia supplements are obligated to remain consistent with it, but this is often a one-sided and hierarchical relationship. For example, in the Star Wars transmedia franchise, the film series is considered crucial in establishing the canon; and transmedia supplements are obliged to remain consistent with it in order to be recognised as authentic. The filmmakers, however, are largely free to ignore or contradict the contributions of spin-off books.Hills notes that the components of transmedia franchises are often arranged into “transmedial hierarchies” (223), where screen-based media like films, television series and video games are assigned dominance over print-based productions like comics and novels. This hierarchy means that print-based works typically have a less secure place within the canon of transmedia franchises, despite often contributing a disproportionately large quantity of narratives and concepts (Guynes 143). Using the Star Wars Expanded Universe as an example, he notes a tendency whereby “franchise novels” are generally considered as disposable, and are easily erased or decanonised despite significantly long, carefully interwoven and coordinated periods of storytelling (143-5). Doctor Who as a Transmedia FranchiseWhile questions of canon are frequently debated and discussed among Doctor Who fans, it is less easy to make absolutist distinctions between canonical and apocryphal texts in Doctor Who than it is in other popular transmedia franchises. Unlike comparable transmedia productions, Doctor Who has traditionally lacked a singular authority over questions of canon and consistency in the manner that Jenkins argues for in his implicitly hierarchical conception of transmedia storytelling (Convergence Culture 106). Where franchises like Star Wars, Star Trek or The X-Files have been guided by creator-figures who either exert direct control over their various iterations or oblige them to remain broadly consistent with their original vision, Doctor Who has generally avoided this focus; creative control has passed between various showrunners and production teams, who have been largely free to establish their own style and tone.Furthermore, the franchise has traditionally favoured a largely self-contained and episodic style of storytelling; and different storylines and periods from its long history often contradict one another. For these reasons, Booth suggests that the largely retroactive attempts on the part of fans and critics to read the entire series as the type of transmedia production that Jenkins advocates for (i.e. an internally consistent narrative of connected stories) are counter-productive. He argues that Doctor Who is perhaps best understood not as a continuing series but as a long-running anthology, where largely autonomous stories and serials can be grouped into distinct “periods” of resemblance in terms of style and subject matter (198-206).As Britton argues, when appreciating Doctor Who as franchise, there is no particular need to assign primary importance to the parent media. Since its first season in 1965, the Doctor Who television series has been regularly supplemented by other media in the form of comics, annuals, films, stage-plays, audio-dramas, and novelisations. Britton maintains that as the transmedia works follow the same loosely connected, episodic structure as the television series, they operate as equally valid or equally disposable components within its metanarrative (1-9). Doctor Who writer Paul Cornell argues that given the accommodating nature of the show’s time-travel premise (which can easily accommodate the inconsistencies that Jenkins argues should be avoided in transmedia storytelling), and in the absence of a singular revered creator-figure or authority, absolutist pronouncements on canon from any source are unnecessary and exclusionary, either delegitimising texts that the audience may value, or insisting on familiarity with a particular text in order for an experience of the media to be considered “legitimate”. The Transmedia Legacy of the Virgin New AdventuresAs the Virgin Doctor Who novels are not necessarily diminished by either their lack of a clear canonical status or their placement as a print work within a screen-focused property, they can arguably be understood as constituting their own distinct “period” of Doctor Who in the manner defined by Booth. This claim is supported by the ways in which the New Adventures distinguish themselves from the typically secondary or supplemental transmedia extensions of most other television franchises.In contrast with the one-sided and hierarchical relationship that typically exists between the parent text and its transmedia extensions (Pillai 103-4), the New Adventures range did not attempt to signal their authenticity through stylistic and narrative consistency with their source material. Virgin had already published a long series of novelisations of story serials from the original television series under its children’s imprint, Target, but from their inception the New Adventures were aimed at a more mature audience. The editor of the range, Peter Darvill-Evans, observed that by the 1990s, Doctor Who’s dedicated fan base largely consisted of adults who had grown up with the series in the 1970s and 1980s rather than the children that both the television series and the novelisations had traditionally targeted (Perryman 23). The New Adventures were initially marketed as being “too broad and deep for the small screen” (Gulyas 46), positioning them as an improvement or evolution rather than an attempt to imitate the parent media or to compensate for its absence.By comparison, most other 1990s print-based supplements to popular screen franchises tended to closely mimic the style, tone and storytelling structure of their source material. For example, the Star Wars "Expanded Universe" series of novels (which began in 1991) were subject to strict editorial oversight to ensure they remained consistent with the films and were initially marketed as "film-like events" as a way of emphasising their equivalence to the original media (Proctor and Freeman 226). The Virgin New Adventures were also distinctive due to their open submission policy (which actively encouraged submissions from fan writers who had not previously achieved conventional commercial publication) alongside work from "professional" authors (Perryman 24). This policy began because Darvill-Evans noted the ability, high motivation and deep understanding of Doctor Who possessed by fan writers (Bishop) and it proved essential in establishing the more mature approach that the series was aiming for. After three indifferently received novels from professional authors, the first work from a fan author, Paul Cornell’s Timewyrm: Revelation (1991) became highly popular, due to its more grounded, serious and complex exploration of the character of the Doctor and their human companion. Following the success of Cornell’s novel, the series began to establish its own distinctive tone, emphasising gritty urban settings, character development and interpersonal drama, and the exploration of moral ambiguities and social and political issues that would have not been permissible in the original television series (Gulyas 46-8).Works by previously unpublished fan authors came to dominate the range to such an extent that the New Adventures has been described as “licensing professionally produced fan fiction” (Perryman 23). This trajectory established the New Adventures as an unusual hybrid text, combining the sanction of an official license with the usually unofficial phenomenon of fan custodianship. The cancellation of a television series (as experienced by Doctor Who in 1989) often allows its fan community to take custodianship of it in a variety of ways (McNoughton 194). While a series is being broadcast, fans are often constructed as elite but essentially ”powerless” readers, whose interpretations and desires can easily be contradicted or ignored by the series creators (Tulloch and Jenkins 141). With cancellation and a diminishing mass audience, fans become the custodians of the series and its memory. Their interpretations can no longer be overwritten, and they become the principle market for official merchandise and transmedia extensions (McNoughton 194-6).Also, fans can explore and fulfil their desires for the narrative direction and tone of the series, through the “cottage industries” of fan-created merchandise (196) and “gift economies” of fan fiction (Flegal and Roth 258), without being impeded or overruled by official developments in the parent media. This movement towards fan custodianship and production became more visible during the 1990s, as digital technology allowed for rapid communication, connection and exchange (Coppa 53). The Virgin New Adventures range arguably operated as a meeting point between officially sanctioned commercial spin-off media and the fan-centric industries of production that work to prolong the life and memory of a cancelled television series. Indeed, the direct inclusion of fan authors and the techniques and approaches associated with fan fiction likely helped to establish the deeper, more mature interpretation of Doctor Who offered by the New Adventures.As Stein and Busse observe, a recurring feature of fan fiction has been a focus on exploring the inner lives of the characters from its source media, and adding depth and complexity to their relationships (196-8). Furthermore, the successful New Adventures fan authors tended to offer support and encouragement to each other via their informal networks, which affected the development of the series as a transmedia production (Perryman 24). Flegal and Roth note that in contrast to often solitary and individualistic forms of “professional” and “literary” writing, the composition of fan fiction emerges out of collegial, supportive and reciprocal communities (265-8). The meeting point that the Virgin New Adventures provided between professional writing practice and the attitudes and approaches common to the types of fan fiction that were becoming more prominent in the nineties (Coppa 53-5) helped to shape the evolution of Doctor Who as a franchise.Where previous Doctor Who stories (regardless of the media or medium) had been largely isolated from each other, the informal fan networks that connected the New Adventures authors allowed and encouraged them to collaborate more closely, ensuring consistency between the instalments and plotting out multi-volume story-arcs and character development. Where the Star Wars Expanded Universe series of novels ensured consistency through extensive and often intrusive top-down editorial control (Proctor and Freeman 226-7), the New Adventures developed this consistency through horizontal relationships between authors. While Doctor Who has always been a transmedia franchise, the Virgin New Adventures may be the first point where it began to fully engage with the possibilities of the coordinated and consistent transmedia storytelling discussed by Jenkins (Perryman 24-6). It is notable that this largely developed out of the collaborative and reciprocal relationships common to communities of fan-creators rather than through the singular and centralised control that Jenkins advocates.While the Virgin range of Doctor Who novels ended long before the revival of the television series in 2005, its influence on the style, tone and subject matter of the new series has been noted. As Perryman argues, the emphasis on more cohesive story-arcs and character development between episodes has been inherited from the New Adventures (24). The 2005 series also followed the Virgin novels in presenting the Doctor’s companions with detailed backgrounds and having their relationships shift and evolve, rather than remaining static like they did in the original series. The more distinctly urban focus of the new series was also likely shaped by the success of the New Adventures (Haslop 217); its well-publicised emphasis on inclusiveness and diversity was likewise prefigured by the Virgin novels, which were the first Doctor Who media to include non-Anglo and LGBQT companions (McKee "How to tell the difference" 181-2). It is highly unusual for a print-based transmedia extension to have this level of impact. Indeed, one of the most visible and profitable transmedia initiatives that began in the 1990s, the Star Wars Expanded Universe novels (which like the New Adventures was presented as an officially sanctioned continuation of the original media), was unceremoniously decanonised in 2014, and the interpretations of Star Wars characters and themes that it had developed over more than a decade of storytelling were almost entirely disregarded by the new films (Proctor and Freeman 235-7). The comparably large influence that the New Adventures had on the development of its franchise indicates the success of its fan-centric approach in developing a more relationship-driven and character-focused interpretation of its parent media.The influence of the New Adventures is also felt more directly through the continuing careers of its authors. A number of the fan writers who achieved their first commercial publication with the New Adventures (e.g. Paul Cornell, Gareth Roberts, Mark Gatiss) went on to write scripts for the new series. The first showrunner, Russell T. Davies, was the author of the later novels, Damaged Goods (1997), and the second, Steven Moffat, had been an active member of Doctor Who fan communities that discussed and promoted the Virgin books (Bishop). As the former New Adventures author Kate Orman notes, this movement from writing usually secondary franchise novels to working on and having authority over the parent media is almost unheard of (McKee “Interview with Kate Orman” 138), and speaks to the success of the combination of fan authorship and official licensing and support found in the New Adventures. As Hadas notes, the chief difference between the new series of Doctor Who and its classic version is that former and long-term fans of the series are now directly involved in its production, thus complicating Tullouch and Jenkin’s assessment of Doctor Who fans as a “powerless elite” (141). ConclusionThe continuing influence of the nineties New Adventures novels can still be detected in the contemporary series. These novels operate with regard to the themes, preoccupations and styles of storytelling that this range pioneered within the Doctor Who franchise, and which developed directly out of its innovative and unusual strategy of giving official sanction and editorial support to typically obscured and subcultural modes of fan writing. The reductive and exclusionary question of canon can be avoided when considering the above novels. These transmedia productions are important to the evolution and development of the media franchise as a whole. 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