Surgical waitlist management: Perspectives from surgeons on surgical prioritization at a paediatric hospital.

Globally exacerbated surgical waitlists have provided the opportunity to reflect on prioritization and resource allocation decisions. The unique circumstances of paediatric surgery and consequences of surgical delay prompted the study reported in this paper. As part of a larger project to attend to prioritization in our surgical waitlists, we conducted a Quality Improvement study, the purpose of which is to understand surgeon's perspectives regarding the ethical and practical realities of surgical prioritization at our institution. The study comprises semi-structured interviews with nine full-time paediatric surgeons from a variety of subspecialties conducted at our institution, which is a tertiary paediatric hospital with ten surgical subspecialties in a publicly funded healthcare system. Participants articulated how they prioritize their waitlists, and how they understand ethical prioritization. These findings resonate with the growing public concern for ethical practice in healthcare delivery and transparency in prioritization and resource allocation practices. Specifically, more transparency, consistency, and support is required in prioritization practices. This work highlights the importance of institutional dialogue regarding surgical case prioritization. Because quality improvement work is necessarily site-specific, concrete generalizations cannot be offered. However, the insights gleaned from these interviews and the process by which they were gleaned are a valuable knowledge-sharing resource for any institution that is interested in ongoing quality improvement work. The objectives here were to clarify the goals of prioritization within the institution, improve prioritization practices, and make them more ethical and transparent.

Introduction of a Warming Bundle to Reduce Hypothermia in Neonatal Surgical Patients.

INTRODUCTION: Hypothermia in the neonatal surgical population has been linked with significant morbidity and mortality. Our goal was to decrease intra and postoperative hypothermia. INTERVENTION: In November 2021, a radiant warmer and hat were included along with standard warming methods prior to the start of General Surgery procedures to minimize episodes of hypothermia. PRIMARY OUTCOME: Core body temperature was measured pre, intra and post-operatively. METHODS: Data were prospectively collected from electronic medical records from July 2021 to March 2023. A retrospective analysis was performed. Hypothermia was defined as a temperature <36.5C. Control charts were created to analyze the effect of interventions. RESULTS: A total of 277 procedures were identified; 226 abdominal procedures, 31 thoracic, 14 skin/soft tissue and 6 anorectal. The median post-natal age was 36.1 weeks (IQR: 33.2-39.2), with a pre-surgical weight of 2.3 kg (IQR: 1.6-3.0) and operative duration of 181 min (IQR: 125-214). Hat and warmer data were unavailable for 59 procedures, both hat and warmer were used for 51 % procedures, hat alone for 29 %, warmer alone for 10 % and neither for 10 % of procedures. Over time there was a significant increase in hat utilization while warmer usage was unchanged. There was a significant increase in the mean lowest intra-operative temperature and decrease in proportion of hypothermic patients intra-operatively and post-operatively. CONCLUSIONS: The inclusion of a radiant warmer and hat decreased the proportion of hypothermic patients during and after surgery. Further studies are necessary to analyze the impact on surgical outcomes. LEVEL OF EVIDENCE: III.

Secondary impacts of the COVID-19 pandemic at a tertiary children's hospital in Canada: a mixed-methods study.

OBJECTIVES: Decisions to pause all non-essential paediatric hospital activities during the initial phase of the COVID-19 pandemic may have led to significant delays, deferrals and disruptions in medical care. This study explores clinical cases where the care of children was perceived by hospital clinicians to have been negatively impacted because of the changes in healthcare delivery attributing to the restrictions placed resulting from the COVID-19 pandemic. DESIGN AND SETTING: This study used a mixed-methods approach using the following: (1) a quantitative analysis of overall descriptive hospital activity between May and August 2020, and utilisation of data during the study period was performed, and (2) a qualitative multiple-case study design with descriptive thematic analysis of clinician-reported consequences of the COVID-19 pandemic on care provided at a tertiary children's hospital. RESULTS: Hospital-level utilisation and activity patterns revealed a substantial change to hospital activity including an initial reduction in emergency department attendance by 38% and an increase in ambulatory virtual care from 4% before COVID-19 to 67% between May and August 2020. Two hundred and twelve clinicians reported a total of 116 unique cases. Themes including (1) timeliness of care, (2) disruption of patient-centred care, (3) new pressures in the provision of safe and efficient care and (4) inequity in the experience of the COVID-19 pandemic emerged, each impacting patients, their families and healthcare providers. CONCLUSION: Being aware of the breadth of the impact of the COVID-19 pandemic across all of the identified themes is important to enable the delivery of timely, safe, high-quality, family-centred paediatric care moving forward.

The intersection of pediatric surgery, climate change, and equity.

Climate change is occurring at an unprecedented rate. Recent years have seen heatwaves, wildfires, floods, droughts, and re-emerging infectious diseases fueled by global warming. Global warming has also increased the frequency and severity of surgical disease, particularly for children, who bear an estimated 88% of the global burden of disease attributable to climate change. Health care delivery itself weighs heavily on the environment, accounting for nearly 5% of global greenhouse gas emissions. Within the health care sector, surgery and anesthesia are particularly carbon intensive. The surgical community must prioritize the intersection of climate change and pediatric surgery in order to address pediatric surgical disease on a global scale, while reducing the climate impact of surgical care delivery. This review defines the current state of climate change and its effects on pediatric surgical disease, discusses climate justice, and outlines actions to reduce the climate impact of surgical services. LEVEL OF EVIDENCE: Level V.

Development of a five point enhanced recovery protocol for pectus excavatum surgery.

PURPOSE: We implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation. METHODS: A 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test. RESULTS: A total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience. CONCLUSION: Our results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics. LEVEL OF EVIDENCE: III - Retrospective comparative study.

Findings in percutaneous trans-hepatic cholecysto-cholangiography in neonates and infants presenting with conjugated hyperbilirubinemia: emphasis on differential diagnosis and cholangiographic patterns.

BACKGROUND: Biliary atresia (BA) is one of the causes of conjugated hyperbilirubinemia in infants which if untreated leads to end-stage liver disease and death. Percutaneous Trans-hepatic Cholecysto-Cholangiography (PTCC) is a minimally invasive study which can be utilized in the diagnostic work-up of these patients. This study's purpose is to describe the experience with PTCC in neonates, the imaging findings encountered, and the abnormal patterns which warrant further investigation. METHODS: A 16-year single-center retrospective study of patients with persistent neonatal cholestasis (suspected BA) undergoing PTCC. Patient demographics, laboratory values, PTCC images, pathology and surgical reports were reviewed. RESULTS: 73 patients underwent PTCC (68% male, mean age 8.7 weeks, mean weight 4.0 Kg). The majority of studies were normal (55%). Abnormal patterns were identified in 33 cases, 79% were diagnosed with BA and 12% with Alagille syndrome. Non-opacification of the common hepatic duct with a narrowed common bile duct (42%) and isolated small gallbladder (38%) were the most common patterns in BA. CONCLUSION: PTCC is a minimally invasive study in the diagnostic work-up of infants presenting with conjugated hyperbilirubinemia (suspected BA). Further invasive investigations or surgery can be avoided when results are normal.

I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients.

BACKGROUND: I-PASS is a validated and standardized hand-off protocol shown to reduce medical error and improve hand-off efficiency in the pediatric medical population. Our aim was to evaluate the feasibility, effectiveness, accuracy and resident satisfaction of implementing I-PASS on a pediatric surgery service. METHODS: A prospective intervention Quality Improvement (QI approved) study was utilized to evaluate resident written and verbal hand-offs before and after implementation of I-PASS on a pediatric surgery service at a tertiary center. Anonymous surveys were completed by residents following each observation. Results were analyzed using T or Mann-Whitney U Tests and Chi Square. RESULTS: A total of 49 written tools and 50 verbal hand-offs were compared pre-and post I-PASS implementation. With I-PASS, increased written accuracy was observed in the documentation of the patient summary (p < 0.05). Accuracy in the verbal hand-off of illness severity, patient summary, contingency plan, action list and synthesis also improved (p < 0.05); but duration of hand-off increased (p < 0.01). Post implementation surveys of residents demonstrated an increased understanding of patient management (p < 0.05). CONCLUSION: Implementing I-PASS on a pediatric surgery service with modifications catered to surgical patients, improved the effectiveness and accuracy of written and verbal patient hand-offs and increased provider satisfaction and preparedness. LEVEL OF EVIDENCE: Level II.

Conflict resolution and negotiation in pediatric surgery.

Conflict is pervasive in pediatric surgery - it is experienced during patient care, in the operating room and between colleagues. The ethical principles of autonomy, beneficience, non-maleficience and justice are firmly anchored in any discourse regarding conflict in the setting of healthcare. The authors review key features of conflict in healthcare including the effect on patient outcomes as well as implications for the ability of the surgeon and the medical team to function appropriately and safely when conflicts arise. Although most pediatric surgery fellowship programs have no formal training in conflict management, much has been written about strategies to teach and utilize techniques of conflict mitigation and negotiation. In this article, the authors discuss common areas of conflict in the medical environment and suggest useful tools for the practicing pediatric surgeon to aid in the resolution of conflict.

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations.

BACKGROUND: Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery. METHODS: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process. RESULTS: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline. DISCUSSION: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

First national survey on opioids prescribing practices of Canadian pediatric surgeons.

PURPOSE: Prescription opioid misuse has become a public health concern globally. In Canada, little is known about the national prescription patterns in children. The purpose of the present study was to evaluate the opioid prescribing practices of pediatric surgeons in Canada. METHODS: Following ethical approval, an electronic questionnaire was administered to all pediatric surgeons currently practicing in Canada. Questions included surgeon practice information, patterns of opioid prescription at discharge based on the type of surgery, type of opioid prescribed, and availability of training for surgeons/families. RESULTS: Fifty-eight questionnaires were completed (response rate: 84%) by surgeons from 8 out of 8 Canadian provinces with pediatric surgery coverage. 33% of responders prescribed opioids (most commonly morphine) for day surgeries and 73% of Pediatric Surgeons prescribed opioids for major surgeries. Most responders (84%) declared that at their institution there was no formal training for residents/fellows in pain control and opioid prescribing. Similarly, 57% reported no education for families about opioids at discharge. CONCLUSION: This first national survey on opioid prescribing practices across Canada reveals that opioids were prescribed to pediatric patients following a broad range of minor and major surgical procedures. Moreover, there seems to be a lack of education for surgeons and families about opioid use. TYPE OF STUDY: Descriptive, cross-sectional, practice survey. LEVEL OF EVIDENCE: Level 5.

The role of sonography for depiction of a whirlpool sign unrelated to midgut malrotation in neonates.

BACKGROUND: The sonographic whirlpool sign of volvulus due to midgut malrotation is well recognized. However, variations of the whirlpool sign may be seen in other conditions, but this observation has received little attention in the literature. OBJECTIVE: This study presents a series of neonates with a variety of causes of congenital intestinal obstruction, all associated with a whirlpool sign (unrelated to midgut volvulus), which was correctly recognized preoperatively on sonography. We also emphasize the pivotal role of sonography in managing congenital obstruction of the intestinal tract in neonates. MATERIALS AND METHODS: This is a retrospective analysis of clinical, imaging and surgical findings in 11 neonates with congenital intestinal obstruction associated with a whirlpool sign (unrelated to midgut volvulus) that was recognized preoperatively on sonography and in whom the cause for the whirlpool was documented at surgery. RESULTS: Eleven neonates (eight male, three female) had clinical and radiographic evidence of intestinal obstruction in whom sonography depicted a whirlpool sign, which was recognized on the initial sonogram in nine and on a repeat sonogram in two. The whirlpool was located in the upper abdomen in only two, mid-abdomen in five and right lower quadrant in four. The whirlpool was only 1-2 cm in diameter. An upper gastrointestinal series in three neonates failed to depict the cause of obstruction. Contrast enema in three cases had findings suggesting the site of obstruction was in the ileum but none depicted the exact cause of the obstruction. At surgery, the whirlpool sign correlated with a segmental volvulus of the small intestine in eight neonates and with the coiled distal small intestine associated with apple-peel atresia in the other three. CONCLUSION: This study illustrates neonates in whom a whirlpool sign (unrelated to midgut volvulus) was correctly recognized on sonography before surgery. Sonography proved more useful than an upper gastrointestinal series or contrast enema in depicting the exact cause of the obstruction. Pediatric radiologists must make the effort to search throughout the entire abdomen and pelvis for a small whirlpool sign on sonography, even in the absence of midgut malrotation, in neonates with congenital intestinal obstruction. Its recognition preoperatively will facilitate a rapid diagnosis and will obviate the necessity for contrast examinations of the gastrointestinal tract, which require ionizing radiation.

Training surgeons and the informed consent discussion in paediatric patients: a qualitative study examining trainee participation disclosure.

BACKGROUND: The process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee's participation during the consent process has not been reported in the paediatric setting. METHODS: Nineteen face-to-face interviews were conducted with surgical trainees and staff surgeons at a tertiary-level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by three reviewers. RESULTS: Five main themes were identified from the interviews. (1) Surgeons do not consistently disclose the role of surgical trainees to parents. (2) Surgical trainees are purposefully vague in disclosing their role during the consent discussion without being misleading. (3) Surgeons and surgical trainees believe parents do not fully understand the specific role of surgical trainees. (4) Graduated responsibility is an important aspect of training surgeons. (5) Surgeons feel a responsibility towards both their patients and their trainees. Surgeons do not explicitly inform patients about trainees, believing there is a lack of understanding of the training process. Trainees believe families likely underestimate their role and keep information purposely vague to reduce anxiety. CONCLUSION: The majority of surgeons and surgical trainees do not voluntarily disclose the degree of trainee participation in surgery during the informed consent discussion with parents. An open and honest discussion should occur, allowing for parents to make an informed decision regarding their child's care. Further patient education regarding trainees' roles would help develop a more thorough and patient-centred informed consent process.

The experiences of parents and caregiver(s) whose child received an organ from a living anonymous liver donor.

BACKGROUND: Anonymous living donor transplantation is a potential strategy to address the shortage of available organs for transplant. A living anonymous donor (LAD) is a donor with no biological connection and whose identity is unknown to the recipient. This study captured the lived experiences of pediatric liver transplant recipient families whose child received an organ from a LAD. METHODS: Qualitative data collection and analysis were guided by a theoretical framework of phenomenology. Data analysis highlighted themes through an inductive process of reviewing transcript paragraphs to code for significant statements that represented key concepts and captured depth of experience. RESULTS: A total of nine interviews were conducted with 10 participants. Data analysis yielded themes of emotional turbulence through their transplant journey. Pre-transplant experiences were characterized by feelings of helplessness and desperation. Receiving a LAD transplant prompted shock, relief, and acceptance of the donation. Post-transplant experiences were characterized by altered life-perspectives and varied levels of connectedness to the donor, marked by gratitude and concern for donor well-being. CONCLUSION: Anonymous donation in liver transplantation is perceived by recipient families as a remarkable gift and a viable donor option. Our preliminary findings can be used to inform strategy development regarding future delivery of care.

Superior Outcomes and Reduced Wait Times in Pediatric Recipients of Living Donor Liver Transplantation.

BACKGROUND: Living donor liver transplantation (LDLT) is increasingly used to bridge the gap between the current supply and demand imbalance for deceased donor organs to provide lifesaving liver transplantation. METHODS: Outcomes of 135 children who underwent LDLT were compared with 158 recipients of deceased donor liver transplantation (DDLT) at the largest pediatric liver transplant program in Canada. RESULTS: Recipients of LDLT were significantly younger than deceased donor recipients (P ≤ 0.001), less likely to require dialysis pretransplant (P < 0.002) and had shorter wait time duration when the primary indication was cholestatic liver disease (P = 0.003). The LDLT donors were either related genetically or emotionally (79%), or unrelated (21%) to the pediatric recipients. One-, 5-, and 10-year patient survival rates were significantly higher in LDLT (97%, 94%, and 94%) compared with DDLT (92%, 87%, and 80%; log-rank P = 0.02) recipients, as were graft survival rates (96%, 93%, and 93% for LDLT versus 89%, 81.4%, and 70%, respectively, for DDLT; log-rank P = 0.001). Medical and surgical complications were not statistically different between groups. Graft failure was higher in recipients of DDLT (odds ratio, 2.60; 95% confidence interval, 1.02, 6.58) than in the LDLT group after adjustment for clinical characteristics and propensity score. CONCLUSIONS: Living donor liver transplantation provides superior outcomes for children and is an excellent and effective strategy to increase the chances of receiving a liver transplant.

Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference.

INTRODUCTION: Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown. METHODS: A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed. RESULTS: The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts. CONCLUSIONS: Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety. LEVEL OF EVIDENCE: V.

First Population-Based Report of Infants with Congenital Diaphragmatic Hernia: 30-Day Outcomes from the American College of Surgeons National Quality Improvement Program.

AIM: The American College of Surgeons has developed a registry, the National Quality Improvement Program Pediatric (NSQIP-P), that provides participating centers with high-quality surgical outcome data for children. Herein, we aimed to analyze for the first time the short-term outcomes of live-born infants with congenital diaphragmatic hernia (CDH) registered on this large North American database. METHODS: During 2015 to 2016, up to 101 participating centers uploaded 95 perioperative data points on the NSQIP-P database for patients that underwent surgical repair of CDH. The demographics, peri-, and post-operative data (up to 30 days following surgical repair) of infants with CDH were reviewed. Binary logistic regression was performed to test associations between risk factors and mortality. MAIN RESULTS: There were 432 (61% male) infants, who underwent CDH surgical repair during the study period. The prematurity rate (gestational age < 37 weeks) was 17%. The majority of infants (82%) had cardiac risk factors identified (72% were reported as major/severe). Extracorporeal membrane oxygenation (ECMO) was employed in 13% of patients prior to surgery. The majority of infants (83%) were ventilated preoperatively, and 34% received inotropes. Median age at surgery was 5 (0-74) days. CDH repair was attempted via thoracoscopy in 18% (n = 79) infants, but with a high rate of conversion to open surgery (n = 32, 41%). The postoperative 30-day mortality rate was 9%. At binary logistic regression, major cardiac risk factors (odds ratio [OR], 1.7 [0.9-3.2], p = 0.095), Appearance, Pulse, Grimace, Activity, and Respiration at 1 minute (OR, 0.7 per unit [0.5-0.8], p < 0.005), and birth weight (OR, 0.5 per kg [0.2-1.0], p < 0.05) were retained in the final model as significantly associated with mortality. CONCLUSION: This is the first report on CDH outcomes from the NSQIP-P database. Utilization of ECMO was low compared with single-center studies from North America. The early postoperative mortality rate of babies with CDH considered suitable for surgery remains high.

Microvascular Hepatic Artery Anastomosis in Pediatric Living Donor Liver Transplantation: 73 Consecutive Cases Performed by a Single Surgeon.

BACKGROUND: Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited. METHODS: A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up. RESULTS: Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years. CONCLUSIONS: Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Disordered Eating Behaviors Through the Lens of Self-Determination Theory.

This study aimed to verify a conceptual model of eating regulation based on the Self-Determination Theory. This model suggests that basic psychological needs satisfaction is related to general self-determined motivation and autonomous regulation toward eating, which in turn are associated with less disordered eating behaviors and attitudes and better satisfaction with life. Two hundred thirty-nine women without an eating disorder completed self-reported questionnaires. The hypothesized model was tested with a serial multiple mediation analysis using PROCESS macro. The overall indirect effect of basic psychological needs satisfaction on life satisfaction through the three mediators, i.e. general motivation, regulation of eating behaviors, and eating behaviors and attitudes, was significant. Results are coherent with the Self-Determination Theory and add to past research by suggesting that basic psychological needs satisfaction might be a key target when addressing women's disordered eating behaviors and attitudes.

Checklist to improve informed consent process in pediatric surgery: A pilot study.

PURPOSE: The purpose of this study was to develop and validate a checklist to standardize surgical informed consent process. METHODS: A checklist was created following a literature search. Consent processes were observed from general surgery (GS) and urology (US) in the pre- and post-intervention phases. Competent patients/guardians were asked to complete a satisfaction questionnaire. All trainees and staff surgeons were interviewed on the checklist's utility. RESULTS: 73 observations (GS=39, US=34) and 66 observations (GS=30, US=36) were made in the pre- and post-intervention phase, respectively. Our checklist increased the frequency with which surgeons explained alternative treatments (pre-intervention 23.3% vs. post-intervention 81.8%), the role of trainees (15.1% vs. 72.7%), and the potential outcomes of not pursuing surgery (60.3% vs. 87.9%). The patient/guardian average satisfaction score increased between phases within GS (mean[standard deviation] 3.55[0.58] vs. 3.85[0.24]); p=0.002), but not within US (3.53[0.61] vs. 3.52[0.54]); p=0.705) or the overall sample (3.54[0.59] vs. 3.67[0.46]); p=0.329). Interestingly, there was no significant improvement in patient/guardian average anxiety levels in GS (X2=0.069, p=0.793), US (X2=0, p=1) or the overall sample (X2=0.143, p=0.706) following the intervention. CONCLUSION: Our checklist aids in standardizing the informed consent process. However, it did not significantly change satisfaction or anxiety levels of patients and guardians. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III.

2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: resiliency, well-being, and burnout.

The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.