What are the views of Quebec and Ontario citizens on the tiebreaker criteria for prioritizing access to adult critical care in the extreme context of a COVID-19 pandemic?

BACKGROUND: The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario's protocols were presented to the public in a democratic deliberation during the summer of 2022. OBJECTIVES: (1) To explore the perspectives of Quebec and Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. METHODS: This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. RESULTS: A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value - a less acceptable tiebreaker. CONCLUSION: Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria.

Drivers that decrease hospital-delivered care in children with medical complexity: Parental perspectives.

Background and objective: Children with medical complexity (CMC) have chronic and severe conditions leading to medical fragility. CMC represent less than 1% of children but account for one-third of paediatric healthcare expenditures. Enrollment to a complex care program (CCP) decreases health care resource utilization while improving parental satisfaction. An in-depth understanding of how these changes operate in real-world setting is needed to further support CMC and their families. This study aimed at assessing the possible reasons for a decrease in emergency department (ED) visits and hospitalization length of stay related to enrollment to a CCP, based on parental perspectives. Study design: Using a qualitative approach, data were collected using in-depth, semi-structured interviews with parents of CMC enrolled in a CCP from a university hospital centre in Montreal, Canada. The interview guide was co-constructed by an interdisciplinary team, including a parent partner and a clinical nurse coordinator. Themes have been identified inductively, using thematic analysis. Results: Parents identified personalized care, family empowerment and guidance as enablers arising from the CCP that contributed to the decrease in hospital-delivered care utilization. Improvement in medical baseline condition was also identified as a contributing factor, while not necessarily related to program's support. Conclusions: In this study, we identified personalized care, parental empowerment, and guidance as three strategies for a CCP to potentially decrease ED visits and hospital length of stay, from the parents' perspective. Parents identified the clinical nurse coordinator as playing a central role in supporting the implementation of these strategies.

Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. METHODS: We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods. RESULTS: The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). INTERPRETATION: The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Care of suspected long bone fractures in the emergency department: Families' perspectives and priorities.

OBJECTIVE: Despite growing interests in patient-reported outcomes, youth and families are rarely involved in designing quality improvement measures. Few quality indicators exist for the care of children with injuries in the Emergency Department (ED) and extremity fractures are among the most common injuries in children. This study's aim was to identify both parents' and youth's perspectives about ED care in the context of a suspected long-bone fracture. METHODS: Youth (10-18 years old) and their parents were surveyed prospectively during their ED visit. Participants were asked: 1) to identify their main concerns, 2) to identify quality measures that were most important to them, and 3) to evaluate the ED care they received. Descriptive analyses present participants' responses. Continuous data was analyzed using a Student t-test and categorical data using a Chi-square test. RESULTS: Over 15 months, 350 families met eligibility criteria and were approached to participate, of which 300 participants consented and 249 surveys were completed (71% response rate): 148 parents and 101 youth (median age: 12) completed their respective surveys. Participants placed a high importance on several themes: pain management, short length of stay, and quality interactions with ED clinicians. Youth as a group prioritized their overall wellbeing and the ED environment (e.g., waiting room comfort, signage), while parents focused on accurate diagnoses and treatments. The following items were less prioritized: that radiology be close to the ED, to see the radiograph, to have access to a wheelchair, to know the identities of clinicians on the team, and to have access to entertainment. Parents and youth within the same family often did not share the same priorities. Ninety-two percent of parents reported their child's pain was treated, while 81% and 63% of youth reported their pain was treated sufficiently and quickly, respectively. CONCLUSIONS: Parents and youth can identify their priorities for ED care and should be engaged in efforts to improve and report on the quality of care in the ED. Youths' and parents' perspectives are complimentary and may not align, even within families. The priorities identified in this study can help inform quality improvement initiatives and personalized patient care.

Parents' perspectives, information needs and healthcare preferences when consulting for their children with bronchiolitis: A qualitative study.

AIM: Bronchiolitis is the leading cause of hospitalisation in infants, but parental experiences have not been well described. This study explored parents' experiences and asked them how they wanted to receive information. METHODS: A qualitative study was conducted in a tertiary paediatric hospital in Québec, Canada. It consisted of semi-structured interviews with 15 parents of 13 children with bronchiolitis. The interview guide was constructed by a multidisciplinary team that included a parent. The interviews, which were transcribed verbatim, were conducted until no new themes emerged. RESULTS: We interviewed eight mothers, three fathers and two couples for 22-70 minutes: six were carried out in person during the bronchiolitis episode, and seven were phone interviews after a median interval time of 107 days. Parents were very worried about their child's health and their lack of knowledge about bronchiolitis contributed to their anxiety. They found education resources informative, but expressed a strong need for support and reassurance from healthcare teams. The two groups provided similar feedback, regardless of when they were interviewed or whether their child was admitted. CONCLUSION: Although bronchiolitis is common in infancy, parental knowledge was low. Standardised educational tools were useful, but insufficient to meet all their needs.

Effect on Pain of an Oral Sucrose Solution vs. Placebo in Children 1 to 3 Months Old Needing Nasopharyngeal Aspiration: A Randomized Controlled Trial.

BACKGROUND: Oral sweet solutions have been proposed as effective pain-reducing agents for procedures. OBJECTIVES: To compare the efficacy of an oral sucrose solution vs. placebo in alleviating pain in children (1-3 months) during nasopharyngeal aspiration (NPA). METHODS: A randomized, double-blind, controlled clinical trial was conducted in a pediatric hospital emergency department. Participants (aged 1-3 months) requiring NPA were randomly allocated to receive 2 mL of 88% sucrose (SUC) or 2 mL of a placebo (PLA) 2 min prior to the procedure. The primary outcome was the mean difference in pain scores at 1 min post NPA as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale. RESULTS: Seventy-two participants completed the study, 37 receiving SUC and 35 PLA. The mean difference in FLACC scores compared with baseline was 3.3 (2.5-4.1) for SUC vs. 3.2 (2.3-4.1) for PLA (p = .094) at 1 min and -1.2 (-1.7-0.7) for SUC vs. -0.8 (-1.5 to -0.1) for PLA (p = 0.66) at 3 min after NPA. For the Neonatal Infant Pain Scale scores, it was 2.3 (1.6-3.0) (SUC) vs. 2.5 (1.8-3.2) (PLA) (p = .086) at 1 min and -1.2 (-1.6 to -0.8) (SUC) vs. -0.8 (-1.3 to 0.2) (PLA) (p = 0.59) 3 min after NPA. There was no difference in the mean crying time, 114 (98-130) s, SUC vs. 109 (92-126) s, PLA (p = 0.81). No significant difference was found in participants' heart rate at 1 min 174 (154-194) beats/min in SUC vs. 179 (160-198) beats/min in PLA (p = 0.32). CONCLUSIONS: In infants (1-3 months) undergoing NPA, administration of an oral sweet solution did not statistically decrease pain scores.

What Do We Know About Pediatric Palliative Care Patients Consulting to the Pediatric Emergency Department?

OBJECTIVES: The objective of this study was to describe the characteristics of pediatric palliative care (PPC) patients presenting to a pediatric emergency department (ED) and these patients' ED visits. METHODS: This retrospective chart review was conducted from April 1, 2007, to March 31, 2012, in a tertiary care pediatric university-affiliated hospital. Eligible patients had initial PPC consultations during the study period; all ED visits by these patients were included. Data were drawn from the ED's electronic data system and patient's medical chart. RESULTS: A total of 290 new patients were followed by the PPC team, and 94 (32.4%) consulted the ED. Pediatric palliative care patients who consulted the ED had a median age of 7 years and baseline diagnoses of cancer (39.4%) or encephalopathy (27.7%). No patients died in the ED, but 36 (38.3%) died in hospital after an ED visit and 18 (19.1%) within 72 hours of admission. Pediatric palliative care patients consulted 219 times, with a median number of visits per patient of 2 (range, 1-8). They presented acutely ill as per triage scales. Reasons for consultation included respiratory distress/dyspnea (30.6%), pain (12.8%), seizure (11.4%), and fever (9.1%). Patients were often admitted to wards (61.2%) and the pediatric intensive care unit (7.3%). Two thirds (65.7%) of patients had signed an advanced care directive at the time of their visit. Discussions about goals of care occurred in 37.4% of visits. CONCLUSIONS: Pediatric palliative care patients present to the ED acutely ill, often at their end of life, and goals of care are not always discussed. This is a first step toward understanding how to improve PPC patients' ED care.

Management and outcomes of paediatric ileocolic intussusception at a paediatric tertiary care hospital: A retrospective cohort study.

BACKGROUND: Rapid reduction of ileocolic intussusception is important to minimize the compromise in blood flow to the affected bowel segment. This study aimed to quantify the potentially modifiable time between diagnosis and initiation of pneumatic reduction, identify factors associated with delays, and characterize the outcomes of pneumatic reduction in a recent cohort. METHODS: This retrospective observational study occurred at a tertiary care paediatric hospital with a consecutive sample of all children with ileocolic intussusception September 2015 through September 2018. The primary outcome was the time between ultrasound diagnosis of intussusception and the beginning of pneumatic reduction. Independent variables were age of the patient, time of day of arrival, transfer from another facility, and intravenous access prior to ultrasound. Outcomes of pneumatic reduction were expressed as proportions. RESULTS: There were 103 cases of ileocolic intussusception (among 257,282 visits) during the study period. The median time between diagnostic confirmation and initiation of reduction was 36 minutes. This was shorter for transferred patients and children with intravenous access prior to ultrasound. One perforation was identified at the beginning of reduction, without hemodynamic instability. Six children (5.8%) underwent either open (n=4) or laparoscopic surgery (n=2) for reduction failure. CONCLUSION: The median delay between diagnosis and initiation of reduction at this paediatric hospital was short, especially among patients transferred with a suspicion of intussusception and children with intravenous access prior to diagnosis. Complications from pneumatic reduction were infrequent.

Paediatric palliative care in practice: Perspectives between acute and long-term healthcare teams.

AIM: To explore and compare acute and long-term care professionals' perspectives about paediatric palliative care. METHODS: Focus group interviews were conducted in 2016-2017 with professionals from acute (Emergency Department, Intensive Care Unit) and long-term care (Complex Care Service, Palliative Care) teams. RESULTS: Fifty-eight participants were enrolled. Palliative care definitions were similar throughout groups: to provide active care early in the illness, focusing on the child as a whole and supporting families. Each group perceived a different role in the patient's illness trajectory, reflecting their own culture of care. They demonstrated important differences in their approach to palliative care. Disagreements regarding when or how to discuss goals of care were expressed. Acute care professionals reported discomfort when having to introduce these discussions for the first time, while long-term care professionals perceived negative judgements about their patients' quality of life by acute care teams during health events. Personalised care, communication with families and continuity of care were thought to be key elements to improve care. CONCLUSION: Paediatric palliative care is well recognised throughout specialties, yet continuity of care is challenged by groups' roles and interventions in a patient's illness. A reflective and mutual clinical approach is needed to improve quality of care and professionals' satisfaction.

Palliative Care in the Pediatric Emergency Department: Findings From a Qualitative Study.

STUDY OBJECTIVE: Children with medical complexity represent a fragile population and account for the majority of patients followed in pediatric palliative care. Little is known in regard to the role of the emergency department (ED) in caring for the families of children with medical complexity. METHODS: Semistructured focus groups were held with health care professionals from pediatric emergency medicine, palliative care, complex care, and intensive care to explore their perspective on pediatric palliative care in the ED. Data were transcribed and analyzed with NVivo software, and thematic analysis and theoretic sampling were performed. RESULTS: From January to October 2016, 58 participants were interviewed. Difficulties providing pediatric palliative care in the ED are related on the one hand to characteristics specific to the ED, such as its culture and its health care professionals' strong emotional responses when caring for children with medical complexity, and on the other hand to factors extrinsic to the ED; mainly, lack of continuity of care. For critically ill children with unknown goals of care and potential for end of life, professionals in the ED should evaluate the clinical situation, contact known health care teams, remain open to families' preferences, alleviate distressing symptoms, and create a caring environment. Communication between teams is targeted by health care professionals to facilitate and improve patient flow and care. CONCLUSION: Although perspectives differ in regard to how to provide care for pediatric palliative care patients in the ED, several barriers to providing high-quality emergency pediatric palliative care can be overcome.

Pre-exchange training - Developing ethical and cultural competencies in medical students.

Background: The International Federation of Medical Students' Associations (IFMSA) organizes over 15,000 international medical exchanges per year in over 100 countries. In the past, there was no standardized Pre-Departure Training (PDT) for participants. A PDT is important to protect patient safety and prepare students for their exchange.Objective: To determine whether a two-hour case-based Pre-Departure Training can increase self-reported level of comfort on competencies in basic medical ethics, cultural competence, research ethics, and recognizing the limits of one's level of skill in medical students.Methods: In 2017, the PDT was implemented in nine countries for medical students prior to their IFMSA exchange. Participants self-evaluated their competencies in an online questionnaire before and after the PDT.Results: 234 students from 32 countries completed the pre-PDT evaluation and 104 completed both evaluations. Participants demonstrated statistically significant improvements in self-reported competencies in 16 out of 18 items including voicing lack of skill to a supervisor (p < 0.001) and recognizing personal cultural biases (p < 0.001).Conclusions: A case-based PDT can improve participants' self-reported comfort in treating patients from different cultural backgrounds and help maintain high ethical standards abroad. The PDT was implemented at large within IFMSA in 2018.

A Randomized Double-Blind Trial Comparing the Effect on Pain of an Oral Sucrose Solution vs. Placebo in Children 1 to 3 Months Old Undergoing Simple Venipuncture.

BACKGROUND: Few clinical trials evaluating the efficacy of oral sweet solutions for procedures in the emergency department (ED) have been published. OBJECTIVES: To compare the efficacy of an oral sucrose solution vs. a placebo in reducing pain in infants undergoing venipuncture without cannulation. METHODS: A randomized, double-blinded clinical trial was conducted in a pediatric ED. Infants 1 to 3 months old were randomly allocated to receive 2 mL of 88% sucrose or 2 mL of placebo, 2 min prior to venipuncture. The outcome measures were the difference in pain levels as assessed by the Face, Legs, Activity, Cry and Consolability Pain Scale (FLACC) and Neonatal Infant Pain Scale (NIPS) scores, crying time, and variations in heart rate. RESULTS: Eighty-two participants were recruited. Data were analyzed for 38 patients from each group (excluding protocol deviations). The mean difference in FLACC scores 1 min post venipuncture compared with baseline was 2.84 ± .64 (sucrose) vs. 2.71 ± .62 (placebo) (p = 0.98). For the NIPS score, it was 2.32 ± .47 (sucrose) vs. 1.63 ± .49 (placebo) (p = 0.60). The difference in the median crying time was not statistically significant between the two groups: 63.0 ± 3 (sucrose) vs. 48.5 ± 5 s (placebo) (p = 0.17). No significant difference was found in participants' heart rates 1 min post venipuncture compared with baseline: 33 ± 6 (sucrose) vs. 24 ± 5 beats per minute (placebo) (p = 0.44). CONCLUSIONS: In infants 1 to 3 months of age undergoing simple venipuncture, administration of an oral sweet solution did not statistically decrease pain scores, and participants' heart rate variations and crying time were not significantly changed.

Measuring Anxiety in the Pediatric Emergency Department.

OBJECTIVES: The objective of this study was to evaluate the agreement between the State Trait Anxiety Inventory (STAI) and other anxiety scales to determine whether these shorter to administer scales could replace the STAI. METHODS: This was a prospective cohort study on a convenience sample of children, aged 9 to 17 years, presenting to a pediatric emergency department. Patients were divided into 2 groups: preteens (PT) (aged 9-12 years) completed the pediatric STAI and teens (T) (aged 13-17 years) completed the adult STAI. Participants also completed a visual analog scale (0-100 mm), a Likert scale (1-5), and a short version of the STAI. Intraclass correlation (2-way mixed model, average measures) was used to evaluate agreement between the STAI and the other scales. A sample size of 100 patients per group was estimated as sufficient. RESULTS: The median (interquartile range) STAI state anxiety scores were 33 (28.25-36.75) and 37.5 (32-44), in the PT (n = 100) and T (n = 100) groups, respectively. The median (interquartile range) STAI trait anxiety scores were 33.5 (28-38.75) and 36 (31-44), in the PT and T groups, respectively. Agreements between the STAI and the other scales were poor for all scales. At best, the intraclass correlation was 0.71 for the agreement between the STAI and the short version of the STAI. CONCLUSIONS: There appears to be poor agreement between the STAI and the other scales designed to measure anxiety in children 9 to 17 years presenting to the pediatric emergency department.

Focusing on relationships, not information, respects autonomy during antenatal consultations.

Policy statements regarding antenatal consultations for preterm labour are guided by physicians' concerns for upholding the legal doctrine of informed consent, through the provision of standardised homogeneous medical information. This approach, led by classical in-control conceptions of patient autonomy, conceives moral agents as rational, independent, self-sufficient decision-makers. Recent studies on these antenatal consultations have explored patients' perspectives, and these differ from guidelines' suggestions. Relational autonomy - which understands moral agents as rational, emotional, creative and interdependent - resonates impressively with these new data. CONCLUSION: A model for antenatal consultations is proposed. This approach encourages clinicians to explore individual patients' lived experiences and engage in trusting empowering relationships. Moreover, it calls on physicians to enhance patients' relational autonomy by becoming advocates for their patients within healthcare institutions and professional organisations, while calling for broadscale policy changes to encourage further funding and support in investigations of the patient's voice.

Personalized Antenatal Consultations for Preterm Labor: Responding to Mothers' Expectations.

OBJECTIVE: To explore prospective mothers' perspectives regarding antenatal consultations by neonatology teams for threatened preterm delivery. STUDY DESIGN: In a prospective multicenter study, women at risk of preterm delivery between 26 and 32 weeks of gestational age were surveyed during the 72 hours following their antenatal consultation. The questionnaire used was developed and validated during a single-center study. RESULTS: Over 18 months, 229 mothers completed the survey (73% response rate), at a median gestational age of 30 weeks. Spouses/partners were present for 49% of consultations. Most women (90%) reported a positive experience. They found it important to discuss the outcomes of prematurity (96%), but 39% of them reported receiving too much information. Women wanted their spouse/partner to be present (71%) and wished to discuss parental concerns: their roles as mother of a premature baby (82%), their integration in their baby's care (83%), and a better understanding of the neonatal intensive care unit (NICU) environment, including antenatal NICU visits (69%). The majority (56%) wanted a follow-up consultation: this was less likely if a NICU visit had been offered (P < .001), if their role as decision-maker had been discussed (P < .05), or if the consultation had lasted longer (P = .001). CONCLUSION: Policy statements recommend a standardized approach to providing parents with child-centered information. Although clinicians follow these guidelines, mothers want personalized information focusing on their individual concerns and questions, such as what they can do for their baby, how NICUs work, and the integration of their family.

Parental Preferences and Shared Decision-Making for the Management of Febrile Young Infants.

OBJECTIVE: To inform shared decision-making by identifying parental preferences for the management of their febrile young infant. METHODS: This was a sequential explanatory mixed-methods study using a cross-sectional questionnaire (May 2020-May 2022) followed by qualitative focus groups (September-December 2022) with parents of infants aged ≤60 days evaluated for fever at a tertiary pediatric hospital. Parental expectations, stressors, and desired level of decisional involvement were assessed using multiple-choice and 6-point-Likert scales. Questionnaire results informed the qualitative naturalistic inquiry into parents' decision-making experiences and preferences regarding the need for lumbar puncture (LP) and hospitalization. RESULTS: Among 432 parents (64.9% response), few anticipated the need for LP (10.2%) or hospitalization (20.8%), and these were selected as the most stressful aspects of management. No parent identified lack of decisional involvement as the most important stressor, although nearly all (97.5%) wanted to be involved in management decisions. Six focus groups with a subset of 17 parents revealed 4 main themes: (1) varying preferences for decisional involvement depending on the strength of the medical recommendation; (2) importance of involving parents in their infant's medical care; (3) need for tailored information; and (4) importance of supportive relationships. Parents reported feeling involved in discussions about their infant's care but that decisions regarding LP and hospitalization were usually made by the medical team. CONCLUSIONS: Parents of febrile young infants identified LP and hospitalization as the most unexpected and stressful aspects of care. Understanding individual family expectations and tailoring information based on the strength of medical recommendation is necessary to guide shared decision-making.

Antireflux Procedures in Children With Neurologic Impairment: A National Survey of Physician Perspectives.

OBJECTIVE: Decision-making about antireflux procedures (ARPs) to treat gastroesophageal reflux disease in children with neurologic impairment and gastrostomy tubes is challenging and likely influenced by physicians' experience and perspectives. This study will explore physician attitudes about ARPs and determine if there are relationships to clinical practice and personal characteristics. METHODS: This is a national observational cross-sectional study that used an electronic questionnaire addressing reported practice, attitudes regarding the ARPs, and responses to clinical vignettes. Participants were physicians in Canadian tertiary-care pediatric settings. Descriptive statistics were used to analyze physician attitudes. Multivariable logistic regression modeling was used to determine associations between physician and practice characteristics and likelihood to consider ARP. RESULTS: Eighty three respondents represented 12 institutions, with a majority from general or complex care pediatrics. There was a wide disparity between likelihood to consider ARP in each clinical scenario. Likelihood to consider ARP ranged from to 19% to 78% depending on the scenario. Two scenarios were equally split in whether the respondent would offer an ARP. None of the demographic characteristics were significantly associated with likelihood to consider ARP. Often, gastrojejunostomy tubes alone were considered (56% to 68%). CONCLUSIONS: There is considerable variability in physician attitudes toward and recommendations regarding ARPs to treat gastroesophageal reflux disease. We did not find a significant association with clinical experience or location of practice. More research is needed to define indications and outcomes for ARPs. This is a scenario where shared decision-making, bringing together physician and family knowledge and expertise, is likely the best course of action.

Use of Invasive Brain-Computer Interfaces in Pediatric Neurosurgery: Technical and Ethical Considerations.

Invasive brain-computer interfaces hold promise to alleviate disabilities in individuals with neurologic injury, with fully implantable brain-computer interface systems expected to reach the clinic in the upcoming decade. Children with severe neurologic disabilities, like quadriplegic cerebral palsy or cervical spine trauma, could benefit from this technology. However, they have been excluded from clinical trials of intracortical brain-computer interface to date. In this manuscript, we discuss the ethical considerations related to the use of invasive brain-computer interface in children with severe neurologic disabilities. We first review the technical hardware and software considerations for the application of intracortical brain-computer interface in children. We then discuss ethical issues related to motor brain-computer interface use in pediatric neurosurgery. Finally, based on the input of a multidisciplinary panel of experts in fields related to brain-computer interface (functional and restorative neurosurgery, pediatric neurosurgery, mathematics and artificial intelligence research, neuroengineering, pediatric ethics, and pragmatic ethics), we then formulate initial recommendations regarding the clinical use of invasive brain-computer interfaces in children.

Impact of physicians' characteristics on the admission risk among children visiting a pediatric emergency department.

OBJECTIVE: This study aimed to assess the impact of physicians' gender, work experience, and training on hospitalization among children visiting a pediatric emergency department (ED). METHODS: This retrospective cohort study used the computerized database of a tertiary care pediatric ED staffed by pediatric emergency physicians, general pediatricians, and general emergency physicians. Participants were all children evaluated in the ED between April 1, 2008, and March 31, 2009. The primary outcome was hospitalization, and secondary outcome was unscheduled return in the 48 hours after discharge from the ED. Determinants of outcomes were physician's gender, experience, and specialty training. Multivariate logistic regression was used to evaluate associations between physicians' characteristics and the risk of admission, adjusting for referral status, triage level, chief complaints, and other potential risk factors. RESULTS: Forty-five physicians evaluated 49,146 patients during the study period. Physicians' individual admission and return rates varied from 1% to 24% and 0% to 11%, respectively. On multiple logistic regression, physician's gender was not a predictor of admission but the physician's years of experience was slightly associated with both admission rates and unscheduled return visits. As a group, pediatric emergency physicians demonstrated a lower admission rate than physicians trained in general pediatric or general emergency medicine. CONCLUSIONS: Individual physician's admissions proportions vary widely. Providers' experience and specialization in pediatric emergency medicine are weak predictors of admission, whereas gender was not associated.