Ethical Considerations in Pediatric Surgery.

Pediatric surgeons need to learn to give as much importance to the ethical approach as they have been giving to the systemic methodology in their clinical approach all along. The law of the land and the governmental rules also need to be kept in mind before deciding the final solution. They need to always put medical problems in the background of ethical context, reach a few solutions keeping in mind the available resources, and apply the best solution in the interest of their pediatric patients.

Originalbeiträge (Originals). Der Zusammenhang zwischen der Strukturachse nach OPD-2 und dem statischen/dynamischen Risiko für das Begehen von sexuellem Kindesmissbrauch bei 30 Männern mit sexuellem Interesse an Minderjährigen aus dem Dunkelfeld ­ eine Pilotstudie.

The Relation between the OPD-2 Axis Structure and the Static/Dynamic Risk for Committing Child Sexual Abuse in a Sample of 30 Men with Sexual Interest in Minors from the Dark Field - A Pilot Study Objectives: The present pilot study examined the relation between the OPD-2 axis structure of 30 men with a sexual interest in minors from the dark field and their static and dynamic risk factors for committing child sexual abuse. METHODS: Two independent raters estimated the structural dimensions based on notes from outpatient psychotherapy sessions using the OPD-2 structure checklist.The interrater reliability of the structural data was moderate. Pearson/Spearman correlations between these structural data and the previously assessed static and dynamic risk were calculated. RESULTS: Attachment was the only structural dimension to correlate significantly positively moderately with the dynamic risk.The less integrated the structural dimension of attachment was, the more pronounced the dynamic risk was. CONCLUSIONS: The correlation between the structural dimension of attachment and the dynamic riskmay provide first indications of the potential of structure-oriented psychotherapeutic interventions formodifying dynamic risk in individuals with a sexual interest in minors from the dark field. The limitations of the methodological approach constrain the significance of the findings, prompting further research on the relation between structure and risk.

Mood disorders among adolescents in conflict with the law and in custody.

The high prevalence of psychiatric symptoms among juvenile delinquents is a well-replicated international finding. This study aimed to find the prevalence of mood disorders and their relationship with serious criminal acts in a population of adolescents in conflict with the law and in custody. A total of 123 male inmates aged 14 to 17 years were interviewed and assessed. Mood disorders were diagnosed in 15% of the sample for current episode and 31% for lifetime, making them third most prevalent after dependence disorders and disruptive disorders. The psychopathological profile of the adolescents who had committed violent crimes corroborates other studies reporting a high prevalence of mood disorders in this population. Several factors have been found to influence the formation of juvenile delinquency, including absence of family structure, social inequality, lack of quality school education, alcohol and drug abuse/addiction and disruptive disorders. The present results confirm mood disorders as another such factor.

Developing a Collaborative Approach to Support Access and Acceptability of Mental Health Care for Refugee Youth: An Exploratory Case Study with Young Afghan Refugees.

Despite an increased prevalence of psychiatric morbidity, minor refugees resettled in Western host societies are less likely to access mental health care services than their native peers. This study aims to explore how a collaborative approach can be implemented to promote access to specialized mental health care. Collaborative mental health care embeds specialized intervention in primary care settings and emphasizes the inclusion of minority cultural perspectives through an interdisciplinary, intersectoral network. In this study, we analyze how such a collaborative approach can support access to specialized mental health care for refugee youth. The study presents findings from a qualitative multiple-case study (n = 10 refugee patients), conducted in the setting of a psychiatric day program for young refugees that develops an intersectional, collaborative practice in supporting minor refugees' trajectory from referral to admission. Building on in-depth interviews, participant observation and case documents, within-case analysis and cross-case inductive thematic analysis identify the specific working mechanisms of a collaborative approach. The results indicate how this intersectoral approach addresses the interplay between traumatic suffering and both cultural and structural determinants of mental health. To conclude, a discussion identifies future research directions that may further strengthen the role of collaborative practice in promoting mental health care access for refugee youth.

[Health consequences of violence against women by the couple]. / Consecuencias para la salud de la violencia contra la mujer por la pareja.

Intimate partner violence against women (IPV) has devastating effects on the healthcare and well-being of women and their children. Physical, psychological, and social consequences, a worse perception of their own health, and loss of quality of life are well-documented, while aftereffects persist in time even after the end of abuse. Psychological consequences of abuse last longer and are more serious. IPV also affects sons and daughters, disabled people, family, and the attacker himself. Many health problems, both physical and mental, that lead women to go to healthcare services in search of help have an origin in the violence they experience. Treatment of the symptoms without awareness of its relation to such violence favours medicalization, iatrogenesis, and chronification. Psychological violence poses a threat that is invisible, subtle, cumulative, and difficult to detect; it is, however, the most destructive.

High incidence of HPV infection in minors with oral squamous cell carcinoma.

BACKGROUND: Oral squamous cell carcinoma in minors is considered to be a distinct entity from OSCC in older patients, with an uncertain etiology. Human papillomavirus (HPV) infection may trigger the initiation and promote the progression of OSCC, but these roles have not been firmly established.We aimed to explore the correlation between HPV infection and the development of oral squamous cell carcinoma in minors and know the characteristics of OSCC in young patients more thoroughly. METHOD: From January 2013 to December 2022,6 cases of OSCC aged < 15 years were selected from the Department of Oral Pathology, Peking University School of Stomatology, Beijing, China. All cases underwent testing for high-risk HPV mRNA infection using the RNA scope technique, and immunohistochemical staining was performed to investigate the expression of p16, pan-cytokeratin (CK), CK5/6, CK7, CK8/18, epidermal growth factor receptor (EGFR), p53, and Ki-67. Furthermore, we reviewed the literature on OSCC in patients aged < 21 years. CONCLUSIONS: Minors OSCC is associated with HPV infection, and that p16 can serve as an immunohistochemical marker of HPV positivity.

Access to Dental Care for Children and Young People in Care and Care Leavers: A Global Scoping Review.

AIMS: This scoping review aimed to explore three research questions: 1. What is the dental care access for children and young people (CYP) in care and care leavers? 2. What factors influence CYP in care and care leavers' access to dental care? 3. What pathways have been developed to improve access to oral health care for CYP in care and care leavers? METHODS: Five databases (Ovid MEDLINE, Ovid Embase, CINAHL, SocINDEX and Dentistry and Oral Sciences Source) and grey literature sources were systematically searched. Articles relating to CYP in care or care leavers aged 0-25 years old, published up to January 2023 were included. Abstracts, posters and publications not in the English language were excluded. The data relating to dental care access were analysed using thematic analysis. RESULTS: The search identified 942 articles, of which 247 were excluded as duplicates. A review of the titles and abstracts yielded 149 studies. Thirty-eight were eligible for inclusion in the review: thirty-three peer-reviewed articles, one PhD thesis and four grey literature sources. All papers were published from very high or medium Human Development Index countries. The studies indicate that despite having higher treatment needs, CYP in care and care leavers experience greater difficulty in accessing dental services than those not care-experienced. Organisational, psycho-social and logistical factors influence their access to dental care. Their experience of dental care may be impacted by adverse childhood events. Pathways to dental care have been developed, but little is known of their impact on access. There are very few studies that include care leavers. The voices of care-experienced CYP are missing from dental access research. CONCLUSIONS: care-experienced CYP are disadvantaged in their access to dental care, and there are significant barriers to their treatment needs being met.

A Scoping Review of the Oral Health Status, Oral Health Behaviours and Interventions to Improve the Oral Health of Children and Young People in Care and Care Leavers.

BACKGROUND: Children and young people (CYP) in care experience poorer physical health and overall wellbeing in comparison to their peers. Despite this, relatively little is known about what their oral health needs and behaviours are. The aim of this scoping review was to provide a global perspective on the oral health status and behaviours of CYP in care and care leavers. It also aimed to synthesise interventions that have been trialled in this population to improve oral health. METHODS: Five databases were searched, Ovid Embase, Ovid MEDLINE, CINAHL (EBSCOhost), SocINDEX (EBSCOhost) and Dentistry and Oral Sciences Source (EBSCOhost), alongside grey literature sources up to January 2023. Eligibility criteria were studies that (i) reported on children and adolescents aged 25 years or younger who are currently in formal/informal foster or residential care and care leavers, (ii) pertained to oral health profile, behaviours or oral health promotion interventions (iii) and were published in the English language. Thematic analysis was used to develop the domains for oral health behaviours and interventions. RESULTS: Seventy-one papers were included. Most papers were published from very high or medium Human Development Index countries. CYP in care were found to experience high levels of decay, dental trauma, periodontal disease and poorer oral health-related quality of life. Oral health behaviours included limited oral health self-care behaviours and a lack of oral health-based knowledge. The trialled interventions involved oral health education, supervised brushing and treatment or preventative dental care. CONCLUSIONS: This scoping review reveals that CYP in care experience poorer oral health in comparison to their peers. They are also less likely to carry out oral health self-care behaviours. This review highlights a scarcity of interventions to improve the oral health of this population and a paucity of evidence surrounding the oral health needs of care leavers.

[Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]. / Beyond NICE: Aktualisierte systematische Übersicht zur Evidenzlage der Pubertätsblockade und Hormongabe bei Minderjährigen mit Geschlechtsdysphorie.

Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.

Strict regulations on energy drinks to protect Minors' health in Europe - It is never too late to set things right at home.

The consumption of energy drinks poses significant risks to minors' health, and strict regulations are urgently needed to protect them. The high caffeine, high sugar, and high caloric content of energy drinks have drawn concern from health professionals. The consumption of energy drinks has been linked to unhealthy dietary behaviors, obesity, and mental health problems in adolescents. The psychoactive and stimulant effects of energy drinks are particularly worrisome, and the marketing of these drinks on social media platforms is also a cause for alarm. In light of these concerns, we strongly recommend policy measures, such as restrictions on the sale of energy drinks to minors, to prevent their health risks. The evidence clearly suggests that energy drinks pose significant risks to minors' health and well-being, and regulatory standards must be implemented without further delay.

The psychology, legality, ethics and medical aspects of organ donation by minors.

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

Knowledge Gaps and Bridges: The Relationship between the Awareness of General Patient Rights and the Awareness of Minors' Patient Rights in the Netherlands.

The major focus of this research is the level of awareness among Dutch parents of general patient rights in relation to minors' patient rights. Moreover, this study is intended to highlight the most effective strategies to increase the awareness of general and minor patient rights in the Netherlands. A survey was conducted among 1010 Dutch parents aged between 35 and 55 years who had at least one child. In this study, we described the relationship between the knowledge among parents of general patient rights and their understanding of the patient rights of minors. A significant connection was found between the knowledge levels of general patient rights and the knowledge levels of the patient rights of minors (p < 0.05 [95% CI: 0.019-0.183]). While age and sex (male/female) did not appear to be significant confounders in this association, the educational background of the participants may have played a role. This study provides comprehensive insights into the association between the knowledge of general patient rights and the patient rights of minors among Dutch parents. Furthermore, this study points out that there is a need for focused educational interventions to address specific areas of misunderstanding or uncertainty.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe.

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Culturally appropriate consent processes for community-driven indigenous child health research: a scoping review.

BACKGROUND: Current requirements for ethical research in Canada, specifically the standard of active or signed parental consent, can leave Indigenous children and youth with inequitable access to research opportunities or health screening. Our objective was to examine the literature to identify culturally safe research consent processes that respect the rights of Indigenous children, the rights and responsibilities of parents or caregivers, and community protocols. METHODS: We followed PRISMA guidelines and Arksey and O'Malley's approach for charting and synthesizing evidence. We searched MEDLINE, PsycINFO, ERIC, CINAHL, Google Scholar, Web of Science, Informit Indigenous Collection, Bibliography of Native North Americans, and Sociological Abstracts. We included peer-reviewed primary and theoretical research articles written in English from January 1, 2000, to March 31, 2022, examining Indigenous approaches for obtaining informed consent from parents, families, children, or youth. Eligible records were uploaded to Covidence for title and abstract screening. We appraised the findings using a Two-Eyed Seeing approach. These findings were inductively coded using NVivo 12 and analyzed thematically. RESULTS: We identified 2,984 records and 11 eligible studies were included after screening. Three key recommendations emerged: addressing tensions in the ethics of consent, embracing wise practices, and using relational approaches to consent. Tensions in consent concerned Research Ethics Board consent requirements that fall short of protecting Indigenous children and communities when culturally incongruent. Wise practices included allowing parents and children to consent together, land-based consenting, and involving communities in decision-making. Using relational approaches to consent embodied community engagement and relationship building while acknowledging consent for Indigenous children cannot be obtained in isolation from family and community. CONCLUSIONS: Very few studies discussed obtaining child consent in Indigenous communities. While Indigenous communities are not a monolith, the literature identified a need for community-driven, decolonized consent processes prioritizing Indigenous values and protocols. Further research is needed to examine nuances of Indigenized consent processes and determine how to operationalize them, enabling culturally appropriate, equitable access to research and services for all Indigenous children.

Protective factors associated with resilience among unaccompanied refugee minors after settling in Norway: a matched cross-sectional study.

This study aimed to examine protective factors associated with resilience among unaccompanied refugee minors in comparison to their Norwegian peers and to examine associations between resilience factors and characteristics related to positive outcomes among unaccompanied minors. Data stem from the Pathways to Independence study conducted in Bergen municipality, Norway in 2018-2019 where 81 unaccompanied minors aged 15-20 participated (83.3% male; 80% response rate). An age- and sex-matched control group of 324 adolescents was retrieved from the youth@hordaland study conducted in Norway in 2012. Resilience factors were assessed by the Resilience Scale for Adolescents. Unaccompanied minors reported lower scores on Goal Orientation (d = 0.4), Social Competence (d = 0.4), and Social Support (d = 0.7) compared to Norwegian adolescents. Being male was associated with lower scores on Goal Orientation (standardized mean difference [SMD] = - 0.9) and Social Support (SMD = - 0.9) among unaccompanied minors, while being in frequent contact with family in the home country was associated with higher scores on all resilience factors (SMD range = 0.6-1.1). The number of leisure activities was associated with Social Competence (SMD = 0.22). There were no significant associations between the resilience factors and amount of support in the living arrangements or contact with the child welfare services. Unaccompanied minors reported fewer resilience factors compared to Norwegian adolescents, indicating that they may have different needs compared to other adolescents. Our study also suggests that frequent contact with family in the home country may be important to bolster positive development for unaccompanied minors after settlement.

Coping strategies of unaccompanied refugee minors shortly after arrival in Belgium.

Unaccompanied refugee minors (URMs) are a group in an especially vulnerable situation with heightened psychological suffering due to both stressful life events and current daily stressors. Research has shown that certain coping strategies such as avoidance can be adaptive in the face of ongoing stress. We conceptualize social support as an essential coping resource that these strategies tap into. Since the interrelations between these factors are often not clear in the literature, this study strives to identify and link URMs' coping strategies, the respective coping resources and the various stressors they target, shortly after arrival in a high-income country. Seventy-nine URMs from various backgrounds were recruited in two first-phase reception centers in Belgium. In addition to self-report questionnaires to assess stressful life events and current daily stressors, we conducted semi-structured interviews, with cultural mediators if required. Thematic analysis was applied to the participants' accounts and resulted in the identification of four coping strategies: avoidance and distraction, continuity and coherence, selective reliance, and positive appraisal and acceptance. The relation between these coping strategies, the various coping resources used, and the specific stressors at which they aim are discussed. We conclude that avoidant coping and contact with the ethnic community, particularly the peer group, are fundamental strategies for successful coping. Practitioners need to support URMs in their coping efforts by providing and facilitating appropriate coping resources.

Gillick competence: an inadequate guide to the ethics of involving adolescents in decision-making.

Developmentally, adolescence sits in transition between childhood and adulthood. Involving adolescents in their medical decision-making prompts important and complex ethical questions. Originating in the UK, the concept of Gillick competence is a dominant framework for navigating adolescent medical decision-making from legal, ethical and clinical perspectives and is commonly treated as comprehensive. In this paper, we argue that its utility is far more limited, and hence over-reliance on Gillick risks undermining rather than promoting ethically appropriate adolescent involvement. We demonstrate that Gillick only provides guidance in the limited range of cases where legal decisional authority needs to be clarified. The range of cases where use of Gillick actually promotes adolescent involvement is narrower still, because several features must be present for Gillick to be enacted. Each of these features can, and do, act as barriers to adolescent involvement. Within these limited situations, we argue that Gillick is not specific or strong enough and is reliant on ethically contestable principles. Moreover, in most situations in adolescent healthcare, Gillick is silent on the ethical questions around involving adolescents. This is because it focuses on decisional authority-having the final say in decision-making-which is one small subset of the many ways adolescents could be involved in decision-making. The implication of our analysis is that use of Gillick competence tends to limit or undermine adolescent involvement opportunities. We propose that those working with adolescents should be judicious in seeking Gillick's guidance, instead drawing on and developing alternative frameworks that provide a comprehensive model for adolescent involvement.

Culturally sensitive stepped care for adolescent refugees: efficacy and cost-utility of a multicentric randomized controlled trial.

Adolescent refugees and asylum seekers (ARAS) are highly vulnerable to mental health problems. Stepped care models (SCM) and culturally sensitive therapies offer promising treatment approaches to effectively provide necessary medical and psychological support. To our knowledge, we were the first to investigate whether a culturally sensitive SCM will reduce symptoms of depression and PTSD in ARAS more effectively and efficiently than treatment as usual (TAU). We conducted a multicentric, randomized, controlled and rater-blinded trial across Germany with ARAS between the ages of 14 to 21 years. Participants (N = 158) were stratified by their level of depressive symptom severity and then equally randomized to either SCM or TAU. Depending on their severity level, SCM participants were allocated to tailored interventions. Symptom changes were assessed for depression (PHQ) and PTSD (CATS) at four time points, with the primary end point at post-intervention after 12 weeks. Based on an intention-to-treat sample, we used a linear mixed model approach for the main statistical analyses. Further evaluations included cost-utility analyses, sensitivity analyses, follow-up-analyses, response and remission rates and subgroup analysis. We found a significant reduction of PHQ (d = 0.52) and CATS (d = 0.27) scores in both groups. However, there was no significant difference between SCM and TAU. Cost-utility analyses indicated that SCM generated greater cost-utility when measured as quality-adjusted life years compared to TAU. Subgroup analysis revealed different effects for the SCM interventions depending on the outcome measure. Although culturally sensitive, SCMs did not prove to be more effective in symptom change and represent a more cost-effective treatment alternative for mentally burdened ARAS. Our research contributes to the optimization of clinical productivity and the improvement of therapeutic care for ARAS. Disorder-specific interventions should be further investigated.

Are autopsies on minors a taboo?: The experience of Milan in a 19-year retrospective study.

Forensic autopsy is an important tool for the proper management of non-natural deaths in minors. However, it seems that autopsy in minors is a practice which may not be performed routinely. In this framework, we conducted a study analyzing autopsies of minors (under 18 years of age in Italy) performed at the Institute of Forensic Medicine in Milan in the period 2001-2019. For the period 2015-2019, we extrapolated all deaths due to non-natural causes in minors to investigate how many and which of these deaths were not subjected to forensic autopsy. Of the total, 344 minors (235 males and 109 females) underwent autopsies, with an overall downward trend of about 80% since 2004. Most autopsies occurred between the ages of 0 and 1 year, and the fewest between the ages of 5 and 9 years. The place of death was home in most cases, and accidental death was most common, followed by natural death, suicide, and homicide, with prevalence varying by age group. Blunt force trauma predominated among accidental death in all age groups, followed by asphyxia. Similar findings were observed for suicides, although there was a more differentiated pattern for suicides between the ages of 15 and 17 years. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups. Between 2015 and 2019, a total of 86 minors died of a non-natural cause, and a forensic autopsy was performed in only 33 cases (38%). Our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of forensic investigation of children and adolescent deaths, with enormous implications for prevention of child abuse.