Background: The Canadian Association of Paediatric Surgeons launched a 10-year prospective assessment of the Canadian pediatric surgery workforce and training environment, beginning in 2013. The results of the first 5 years (2013-2017) were previously published. Here, we present the results of the last 5 years (2018-2022), and the cumulative results of the past decade. Methods: With IRB approval, a web-based survey was sent to all pediatric surgery division chiefs in Canada each year (2013-2022). The survey gathered workforce data on pediatric surgery practices, as well as data regarding fellowship graduates from Canadian training programs. Results: Complete responses were received from all 18 divisions (100% response rate). Over the decade studied, the number of pediatric surgeons and full-time equivalent positions increased from 73 to 81, and 65 to 82, respectively. Thirty positions were vacated (15 retirement, 6 new Canadian practice, 8 leaving Canada, 1 other), and 38 were filled (20 new Canadian fellowship graduates, 8 Canadian surgeons moving from other sites in Canada, 10 surgeons coming from outside Canada). Seventy-five fellows completed training eligible for North American certification, including 34 Canadians, 31 Americans, and 10 nonNorth American foreign nationals (9 of whom left North America after training). The proportion of Canadian graduates who desired, but could not find, a Canadian position improved from 44% in the first 5 years to 20% in the second 5 years. Conclusions: The Canadian pediatric surgery workforce has experienced a modest increase over a decade. A mismatch still exists between Canadian pediatric surgery graduates and attending staff positions, but the situation has improved during the last 5 years. Type of Study: Survey. Level of Evidence: 5. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

# 01. Near-peer tutoring: an effective adjunct for virtual anatomy learning {#article-title-2} The start of the COVID-19 pandemic caused a shift in medical education from the classroom to the virtual setting. This abrupt change led to an increase in stress among students. In response, McGill

Background: The 2014–2016 Ebola outbreak in West Africa recapitulated that nosocomial spread of Ebola virus could occur and that health care workers were at particular risk including notable cases in Europe and North America. These instances highlighted the need for centers to better prepare for potential Ebola virus cases; including understanding how the virus spreads and which interventions pose the greatest risk. Methods: We created a fully equipped intensive care unit (ICU), within a Biosafety Level 4 (BSL4) laboratory, and infected multiple sedated non-human primates (NHPs) with Ebola virus. While providing bedside care, we sampled blood, urine, and gastric residuals; as well as buccal, ocular, nasal, rectal, and skin swabs, to assess the risks associated with routine care. We also assessed the physical environment at end-point. Results: Although viral RNA was detectable in blood as early as three days post-infection, it was not detectable in the urine, gastric fluid, or swabs until late-stage disease. While droplet spread and fomite contamination were present on a few of the surfaces that were routinely touched while providing care in the ICU for the infected animal, these may have been abrogated through good routine hygiene practices. Conclusions: Overall this study has helped further our understanding of which procedures may pose the highest risk to healthcare providers and provides temporal evidence of this over the clinical course of disease.

Background: In 2014, a survey study of the Canadian pediatric surgery workforce predicted a need for 2 new pediatric surgeons/yr. in Canada. We sought to assess these predictions and evaluate the status of the workforce. Methods: With IRB approval, aweb-based survey was sent to pediatric surgery division chiefs in Canada each year (2013-2017). The survey data included: number of practicing pediatric surgeons, full time equivalent (FTE) positions, and fellowship graduates. Results: There was a 100% response rate (18 divisions). From 2013 to 2017, the number of practicing pediatric surgeons and FTE positions increased (73 to 78, and 64.6 to 67.5, respectively). Eleven positions were vacated (4 retirement, 7 new practice), and 18 were filled. Eight were filled by new Canadian graduates, 7 by Canadians previously working in Canada or abroad, and 3 by European surgeons. Thirty-eight fellows completed training in Canada, including 24 non-Canadians who all left Canada. Nine Canadians who started practicing immediately after fellowship took positions in Canada (5) and the US (4). Conclusions: Predictions made in 2014 were largely accurate. There has been modest growth in the Canadian pediatric surgery workforce over the last 5 years. A significant mismatch continues to exist between Canadian pediatric surgery graduates and attending staff positions. Type of study: Survey. (C) 2019 Elsevier Inc. All rights reserved.

Please note that four authors (Logan Banadyga, Alixandra Albietz, Brad Pickering, and Gary Wong) have been erroneously omitted from the author list in the published original article [1].

BACKGROUND:This investigation aims to assess the variability in practice patterns regarding management of children with cryptorchidism (UDT) among pediatric urologists (U) and pediatric surgeons (S) practicing in Canada. METHODS:All active members of Pediatric Urologists of Canada (PUC) and Canadian Association of Pediatric Surgery (CAPS) were invited to participate in an online multiple-choice type questionnaire with clinical scenarios in management of UDT. Responses were compared between U and S using Fisher's exact test. RESULTS:The response rates were 74% and 79% among CAPS members (54/73) and PUC members (27/34) respectively. CAPS members were more likely to order diagnostic ultrasounds prior to surgery (44.4% vs 18.5%, p = 0.027). For palpable testis, most (80%) CAPS members favored the classic inguinal approach, while most PUC members did not demonstrate a clear preference, and were flexible with their approach depending on the position of the palpated testes (55%; p < 0.001). There was no statistically significant difference in preferred approach to unilateral or bilateral nonpalpable testis. However, for both palpable and nonpalpable bilateral UDT, more CAPS members preferred metachronous correction, compared to PUC members who opted to approach them synchronously (p = 0.008, 0.002, respectively). CONCLUSION:Preferences with regard to use of diagnostic tools such as US, surgical approach for palpable testes and bilateral UDTs were not consistent between the two surgical specialties who perform orchidopexy across Canada. Both groups were compliant with guideline recommendations, with the exception of utilizing preoperative ultrasounds, which is uniformly not recommended by the most recent guidelines. LEVEL OF EVIDENCE:This is a level II evidence study.

Introduction: There are currently no licensed treatments for Ebola Virus Disease, making supportive care the only viable option. While there is anecdotal evidence that this is effective, the paucity of experimental data to demonstrate the role of supportive care in EVD has limited its use. We hypothesized that supportive care would enhance survival in a non-human primate (NHP) model of EVD.

Critical care needs have been rising in recent decades as populations age and comorbidities increase. Sepsis-related admissions to critical care contribute up to 50% of volume and septic shock carries a 35-54% fatality rate. Improvements in sepsis-related care and mortality would have a significant impact of a resource-intensive area of health care delivery. Unfortunately, research has been hampered by the lack of an animal model that replicates the complex care provided to humans in an intensive care unit (ICU). We developed a protocol to provide full ICU type supportive care to Rhesus macaques. This included mechanical ventilation, continuous sedation, fluid and electrolyte management and vasopressor support in response to Ebolavirus-induced septic shock. The animals accurately recapitulated human responses to a full range of ICU interventions (e.g. fluid resuscitation). This model can overcome current animal model limitations by accurately emulating the complexity of ICU care and thereby provide a platform for testing new interventions in critical care and sepsis without placing patients at risk.

The Canadian Surgery Forum Steering Committee acknowledges and thanks the following organizations for their support of the 2015 Forum: # 02 The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks {#article-title-2} Although

Background: There is significant lack of information regarding the Canadian pediatric surgery workforce.Methods: An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.Results: The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006-2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.Conclusions: The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada. (C) 2014 Elsevier Inc. All rights reserved.

Atypical teratoid/rhabdoid tumor (AT/RT) is an uncommon, high-grade pediatric malignancy of the central nervous system (CNS) that rarely metastasizes outside the CNS (Chang stage M4). We describe a child with the sole metastasis of an AT/RT to an axillary lymph node and no other site of extra-CNS disease at presentation. The tumor included areas of rhabdoid cells and failed to express the SMARCB1 gene product (INI1). The metastatic site in this patient is unusual for 3 reasons: (1) it is anatomically unexpected for a CNS tumor, (2) no other extra-CNS metastasis or primary tumor outside the CNS was found, and (3) no cardiac septal defect or vascular anomaly was identified. This site as the presenting lesion and sole metastasis of an intracranial AT/RT has not been previously reported. We attempt to explain this phenomenon.

BACKGROUND The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and improve patient outcomes. In 2006, The Trauma Association of Canada Pediatric Committee set out to create an evidence-based, national pediatric cervical spine (c-spine) clearance guideline based on the literature, existing algorithms from each pediatric trauma center and from expert opinion from across Canada. METHODS A review of the literature took place in September 2006 using the PubMed database. Search criteria were "cervical spine," "c-spine," "clearance," and "trauma." Limits that were applied were "Languages: English," "Humans," "Type of Article: Meta-Analysis, Practice Guidelines, Randomized Control Trial, Review," and "Ages: all child 0-18 years." These search criteria were repeated in December 2007, April 2009, and October 2009. A total of 248 articles were identified. Existing guidelines were identified and their practices examined as models of care. Two draft guidelines were created for discussion: one for the pediatric patient with a reliable clinical examination and the other for the pediatric patient with an unreliable clinical examination. Via email, telephone, and two national videoconferences, the content of the guidelines was reviewed, discussed, and amended. The final article was prepared and circulated for author input until consensus was reached. RESULTS A consensus was reached on two pathways to evaluate the pediatric cervical spine: a patient with a reliable clinical examination and a patient with an unreliable examination. CONCLUSION Presented herein are the consensus Trauma Association of Canada, National Pediatric Cervical Spine Evaluation Pathways for the patient with a reliable clinical examination, and the patient with and unreliable clinical examination.

Background: Educational programs dedicated to pediatric trauma are either not available or comprehensive. Pediatric trauma is thus managed by a range of specialists with training in a variety of related fields. Post-certification fellowships in pediatric medicine all mandate education in the assessment and management of the injured child. The purpose of this study was to develop a blueprint for a national pediatric trauma training curriculum. Methods: A team of four experts developed content for a national pediatric trauma curriculum and disseminated it to 11 pediatric trauma sites across Canada. The objectives contained both knowledge and skill sets related to the management of the pediatric trauma patients. A multi-tiered Delphi process was used to develop the final content. Results: All the 11 pediatric teaching centers across the country participated. A final list, representing a consensus of views, was developed in 10 domains through the iterative process of the Delphi technique. The domains for the curriculum included introduction to pediatric trauma and epidemiology, initial management, pediatric airway, shock, thoracic injuries, abdominal and pelvic injuries, spinal and neurological injuries, pediatric head injuries, burns and electrical injuries, and orthopedic injuries. Conclusion: The Delphi process is an invaluable tool in developing curricula. The pediatric trauma curriculum can be used in teaching hospitals for house staff education and meeting core competencies. The blueprint can be validated further in the future.

Objectives. The objectives of this study were to determine whether the administration of morphine to children with acute abdominal pain would impede the diagnosis of appendicitis and to determine the efficacy of morphine in relieving the pain. Methods. This was a double-blind, randomized, placebo-controlled trial involving 5- to 16-year-old children who presented to the emergency department of a children’s hospital with a chief complaint of acute abdominal pain that was thought by the pediatric emergency attending physician to require a surgical consultation. Subjects were randomized to receive intravenously administered morphine or normal saline solution. Clinical data and the emergency physician’s confidence in his or her clinical diagnosis (0–100%) were recorded systematically with a standardized form. This was repeated 15 minutes after administration of the study medication. The surgeon assessed the child within 1 hour and completed a similar data collection sheet. Pain was assessed, with a color analog scale, before and after study medication administration. Each subject was monitored for 2 weeks after enrollment. Results. One hundred eight children were enrolled; 52 received morphine and 56 received a placebo saline solution. There were no differences between groups in demographic variables or the degree of pain. There were no differences between groups in the diagnoses of appendicitis or perforated appendicitis or the number of children who were observed and then underwent laparotomy. The reduction in the mean pain score was significantly greater in the morphine group (2.2 vs 1.2 cm). The emergency physicians’ and surgeons’ confidence in their diagnoses was not affected by the administration of morphine. Conclusions. Our data show that morphine effectively reduces the intensity of pain among children with acute abdominal pain and morphine does not seem to impede the diagnosis of appendicitis.

Objectives: To review practice patterns in a Canadian pediatric centre and develop a safe and effective care plan for managing children with splenic injuries. Design: A chart review. Setting: Winnipeg Children's Hospital. Patients: All patients with splenic injuries under the age of 17 years admitted to the hospital between December 1994 and April 1999. Outcome measures: These included patient demographics, length of stay, location of care, grade of splenic injury (American Association for the Surgery of Trauma Organ Injury Scale), imaging tests performed in hospital and after discharge, follow-up care and time to return to full activity. Results: Forty-four patients received nonoperative management. The mean age of the patients was 10.4 years. The average grade of splenic injury was 2.8. Sixteen patients (36%) were admitted to the intensive care unit for ail average of 1.9 days. Mobilization was allowed after a mean of 5.2 days, Average length of hospital stay was 9.2 days. At the time of admission 98% of the patients underwent computed tomography, but at follow-up only 20% of patients underwent this investigation. None of the follow-up imaging studies altered the postdischarge management plan. The median time to full activity was 12 weeks (range from 0-17 wk). One patient had a delayed hemorrhage and required splenectomy. Conclusions: Reduced admissions to the intensive care unit, shorter overall stays, omission of follow-up imaging and an earlier return to full activity should be considered in the management of children with blunt splenic injuries. Standardization of nonoperative care tor Such children would result in safe and more efficient delivery of health care.

Background/Purpose: Traumatic injuries cause substantial morbidity and mortality in children. Trauma registries are essential to assess and improve standards of trauma care. An interprovincial study of pediatric trauma between 6 centers across Canada who use identical software components was completed. Methods: Data were collected from April 1, 1995 to December 31, 1998 for children aged 1 day to 17 years with an injury severity score of ≥12. Cause of injury, injury time and day, gender, age, injury scores, length of hospital stay, and outcomes were compared. Results: A total of 1,276 patients were included. Mean age was 10.3 ± 5.6 years. Motor vehicle collisions were the most common mechanism of injury (56%). Boys were more often injured (66%; P <.05). Injuries occurred mainly between 1600 and 2400 hours (P <.0001). Mean hospital stay was 11.5 ± 16.6 days. The longest stays in the hospital were among those who had an abdominal abbreviated injury score (AIS) of 1 (P ≤.03). Patients with similar injury severities remained twice as long in Winnipeg Children's Hospital (hospital 5), hospital 2, and hospital 6 as compared with patients in hospital 3 (P <.05). Differences existed in discharge placement between hospitals (P <.0001). Conclusions: This study was the first to compare pediatric patients in multiple Canadian centers using identical trauma registries. Variations in length of stay and discharge placements between hospitals were identified. Further analysis of data in the registries may clarify these differences and serve as a foundation for hospitals to improve the quality of patient care. J Pediatr Surg 36:685-689. Copyright © 2001 by W.B. Saunders Company.

Nine children (6 boys, 3 girls) were diagnosed with a primary endobronchial or pulmonary parenchymal neoplasm. The average age at diagnosis was 9 years. Presenting complaints included cough (7), fever (5), pulmonary infection (3), respiratory distress (3), weight loss (2), pain (2), and hemoptysis (1). Pulmonary x-rays showed persistent atelectasis, pneumonic infiltrates or mass lesions. A computed tomography scan was performed in 8. Five of six endobronchial tumors were diagnosed with bronchoscopy and biopsy. Treatment consisted of thoracotomy and pulmonary resection in 7 cases and laser resection in 2. The pathologic diagnoses were bronchial carcinoid (3), bronchial mucoepidermoid carcinoma (1), inflammatory pseudotumor (plasma cell granuloma) of the bronchus (2) and of the lung parenchyma (1), fibrosarcoma (1), and rhabdomyosarcoma (1). Postoperative chemotherapy was given only to the patient with pulmonary rhabdomyosarcoma; this child died. One child has developed a local recurrence while 7 children are alive and free of disease at an average of 2.4 years postresection. Pulmonary neoplasms are unusual in the pediatric age group and represent a wide spectrum of pathology. Including the present series, 383 tumors have been described. Seventy-six percent were malignant. Early investigation and surgical intervention are essential in children with persistent pulmonary symptoms or x-ray abnormalities. In most cases, the prognosis is excellent with complete surgical resection; however, malignancies other than bronchial adenoma are associated with significantly mortality.

A 2-year-old child was found to have mesenteric lymphadenopathy during investigation of a fever of unknown origin. The lymphadenopathy persisted at follow-up 2 months later. Workup for an infectious etiology was negative. A laparotomy and excisional biopsy was performed to eliminate lymphoma. Pathology showed enlarged lymph nodes containing granulomas with giant cells and central caseating necrosis. Warthin-Starry staining showed cat-scratch bacilli within the necrotic material. Cat-scratch disease is a well-recognized cause of regional adenopathy in children and usually resolves without treatment. Intraabdominal involvement, consisting of hepatic and splenic lesions, often associated with retroperitoneal adenopathy, has been reported. Isolated mesenteric adenopathy is an unusual presentation of this disease but should be included in the differential diagnosis of intraabdominal lymphadenopathy.