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Childhood maltreatment and neglect are associated with a host of negative outcomes. Yet, some children show resilience despite their exposure to these traumatic events. Several protective factors have been documented in the literature, but few studies focus on protective factors in the child’s community that can promote resilience. The purpose of this review was to provide a comprehensive portrait of the impact of community protective factors on the resilience of abused and neglected children. The databases PsycNet and PubMed were used to screen the literature relying on the following inclusion criteria: (1) published in English or in French; (2) report empirical and quantitative data; (3) include a minimum sample size of 30 participants; (4) rely on a sample of maltreated children or adolescents under the age of 24; (5) examine the associations between community protective factors and indicators of psychological adaptation; and (6) include outcome measures that assessed either positive adaptation or the absence of symptomatology in participants. Of the 9,553 articles identified, 44 studies met the eligibility criteria for inclusion in this review. Although many protective factors show significant results, several methodological limitations remain to be examined to affirm that these community variables have a significant impact on the level of resilience of maltreated children. Since child maltreatment is a systemic issue, it remains important to fully understand how community protective factors operate on the resilience of these children as it can greatly inform practitioners and community institutions on how to intervene with populations at risk of maltreatment.

This study sought to test a serial mediation model in which depressive symptoms and hostile attributions mediate the relationship between post-traumatic stress symptoms and peer victimization in a sample of child victims of sexual abuse. Participants included 771 children aged 6 to 12 years old, consulting specialized intervention settings following disclosure of sexual abuse. Children completed questionnaires assessing their levels of post-traumatic stress symptoms, depressive symptoms and experiences of peer victimization in the school context. Vignettes were used to assess hostile attributions for instrumental and relational provocations. Results of the path analysis revealed that post-traumatic stress symptoms were associated with depressive symptoms, which were linked to greater hostile attributions for relational provocations, which were in turn associated to a greater likelihood of reporting peer victimization. Hostile attributions for instrumental provocations were not related to peer victimization.

Sexual abuse and peer victimization often co-occur and generate similar repercussions. The current study aimed to determine the extent to which child sexual abuse is associated to peer victimizatio...

Background Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR). Methods This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date. Results 87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41). Conclusions AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.

BACKGROUND A few studies suggest that children who suffered maltreatment are more at risk for victimization by peers. However, there is little knowledge about factors that may influence the risk of re-victimization by peers for sexually abused (SA) children. OBJECTIVES Identify if self-blame and post-traumatic stress symptoms (PTSS) are risk factors for SA children victimization by peers. DESIGN/METHODS 376 children (248 girls and 128 boys) between 5 to 14 years of age were recruited within five centers for child and youth SA evaluation. Victimization by peers was measured with the Report Victimization Scale answered by the child, his parent and his teacher. PTSS were measured with the subscale of the Children’s Impact of Traumatic Events Scale (CITES II) and self-blame was measured with three items from the subscale guilt/blame of ​CITES II. Characteristics of the abuse were abstracted from the medical chart. Description of SA was done according to Russell’s classification: less severe (physical contact over clothing), severe (physical contact without penetration, and without using of force), very severe (attempted or actual penetration). Statistical analysis was done through logistic regression. RESULTS Abuse was very severe in 61% of cases and chronic in 37.4% of cases. Aggressors were family members in 53.3% of cases. Clinical level of peer victimization was reported for 19.2% of children by their own score, 9.2% by parental score and 3.6% by teacher’s score. PTSS were at the clinical level for 53.3% of children Around 60% of the sample reported feelings of blame, as indicated by at least one score of “somewhat true”on one of the three items. The dichotomized analysis (clinical vs subclinical score of victimization by peers) showed that PTSS were positively associated with the child’s peer victimization score (Exp (B) = 1.05, p CONCLUSION These results suggest that PTSS and self-blame are key targets for intervention in order to diminish the risk of victimization by peers in SA children.

Objective The objective of this study was to assess the accuracy of gadoxetic acid hepatic enhancement indices in predicting posthepatectomy liver failure (PHLF) and other major complications (OMCs). Methods Sixty-five patients underwent prehepatectomy gadoxetic acid-enhanced magnetic resonance imaging. Enhancement indices were calculated by obtaining regions of interest on magnetic resonance images and segmented volumes of the liver and spleen. Multivariate regression analysis was performed to predict PHLF and OMC as a function of the indices, and areas under the receiver operator characteristic (AUROC) curves were calculated. Results Areas under the receiver operator characteristic values varied from 0.412 to 0.681 and 0.462 to 0.738 in predicting PHLF and OMC, respectively. The most accurate indices in predicting PHLF were the region of interest-based, fat-normalized relative liver enhancement and liver enhancement index (AUROC, 0.681). The most accurate index in predicting OMC was the volumetric least-squares regression slope of a pharmacokinetic model (Khep_V, AUROC, 0.738). Conclusions Indices of gadoxetic acid liver enhancement demonstrate variable performance in predicting PHLF and OMC.

Background Clinical pathways (CPW) are considered safe and effective at decreasing postoperative length of stay (LoS), but the effect on economic costs is uncertain. This study sought to elucidate the effect of a CPW on direct hospitalization costs for patients undergoing pancreaticoduodenectomy (PD). Methods A CPW for PD patients at a single Canadian institution was implemented. Outcomes included LoS, 30-day readmissions, and direct costs of hospital care. A retrospective cost minimization analysis compared patients undergoing PD prior to and following CPW implementation, using a bootstrapped t test and deviation-based cost modeling. Results 121 patients undergoing PD after CPW implementation were compared to 74 controls. Index LoS was decreased following CPW implementation (9 vs. 11 days, p = 0.005), as was total LoS (10 vs. 11 days, p = 0.003). The mean total cost of postoperative hospitalization per patient decreased in the CPW group ($15,678.45 CAD vs. $25,732.85 CAD, p = 0.024), as was the mean 30-day cost including readmissions ($16,627.15 CAD vs. $29,872.72 CAD, p = 0.016). Areas of significant cost savings included laboratory tests and imaging investigations. Conclusions CPWs may generate cost savings by reducing unnecessary investigations, and improve quality of care through process standardization and decreasing practice variation.

Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW.We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development.122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03).Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.

To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group).Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χTechnical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P.001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P.001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE.PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.

Pancreatic cancer is the fifth leading cause of cancer death in Canada with slowly rising incidence and projections to become the second cause of cancer death by 2020. Diagnosis is based on history and physical examination, laboratory and imaging studies including computed tomography (CT). Tissue diagnosis is needed only to offer chemotherapy in unresectable cases and when neoadjuvant chemotherapy is considered. Stage at diagnosis is the most important prognostic factor and depends on careful evaluation of the CT to assess resectability. Overall survival of patients with resectable disease is ~30 % at 5 years. However, only 15–20 % of cases are resectable at diagnosis. Commonly observed metastatic sites include liver, peritoneum, and lung. Treatment of pancreatic cancer depends on the stage of disease. Surgery is the only curative treatment for localized disease. Completeness of resection (R0) is prognostically important. Adjuvant chemotherapy is currently recommended as standard of care.

362 Background: Stage 3 pancreas ductal adenocarcinoma (PDAC) is defined by arterial involvement, and its resection remains controversial. The objective of this study was to evaluate clinical and oncologic outcomes for patients with stage 3 PDAC who entered a treatment program of neoadjuvant therapy (NAT) and pancreatic resection, with comparison between those who underwent arterial (AR) vs. standard resection (SR). Methods: This cohort study included patients from 2009-2016 in a single academic institution, with biopsy-proven potentially resectable stage 3 PDAC who entered a treatment program of NAT followed by surgical exploration if non-progressive disease on imaging. AR was performed if required to achieve R0 resection. Oncological outcomes were analyzed as intention to treat from diagnosis date. Results: Eighty-nine patients met inclusion criteria, of whom 87 (97.8%) received chemotherapy and 50 (56.2%) received radiotherapy. 46/89 (51.7%) underwent surgical exploration; 31 underwent pancreas resection (AR n = 20, SR n = 11), and 15 were found to have metastatic or unresectable disease. The AR group had a longer operative time (681 vs. 563 minutes, p = 0.0059) and more blood loss (1600 vs. 575 mL, p = 0.0004) compared with SR, with no difference between groups for blood transfusion, overall complications, pancreatic fistula, length of stay, reoperation, readmission or mortality. R0 rate was 100% for resected patients. Post-operative 90-day mortality was 1.1%. Median overall survival of resected patients was longer than in non-resected patients (25.9 vs. 14.8 months, p = 0.01), while AR had comparable overall survival to SR (19.7 vs. 28.4 months, p = 0.41). Conclusions: Patients with non-progressive stage 3 PDAC after NAT should be considered for pancreas resection. AR had comparable clinical and oncologic outcomes to SR. Resection may offer a survival advantage over non-surgical therapy alone, and AR should be considered if required to obtain a negative resection margin.

Amélie Tremblay-Martin addresses the issue of developing leadership through sharing and reflecting on a series of multiple activities that occurred on an expedition in the Norwegian Arctic. This expedition was a seen as a wonderful opportunity that challenged the author’s leadership skills. By sharing her stories, she hopes that her experiences will resonate with others and help them to become better leaders themselves.

447 Background: Involvement of a major artery with PDAC is a criteria of unresectability. Although major vein resection/reconstruction is now accepted in PDAC resection, the feasibility of arterial resection requires investigation. The response to neoadjuvant therapy (NAT) may be a useful tool for identifying appropriate candidates for extended resection. Methods: We retrospectively reviewed the UHN experience of multimodality therapy in patients (pts) with histologically confirmed PDAC and single vessel arterial involvement (superior mesenteric, celiac or hepatic artery) on CT from Jan 2009 to Dec 2013. These pts received NAT prior to being re-assessed for surgery; pts whose disease was either stable or improved were considered for surgery. Baseline imaging was reviewed independently. Postoperative complications were assessed and oncologic outcomes were analysed with Kaplan-Meier method. Results: We identified a cohort of 57 pts of whom 56 received NAT. On reassessment, 26 (46%) had no evidence of disease progression and were considered operable, while 31 had local or distant progression and were deemed inoperable. Of 26 pts proceeding to surgery, 21 (81%) underwent resection and 5 had a palliative procedure. In the resection group, 10 pts required arterial resection/reconstruction to achieve R0. The post-operative mortality at 90-days was 0% and morbidity was 86% with 33% major complications (Clavien-Dindo III-IV). With a median follow-up of 12,1 months, the median survival for the resection group was 18.7 months (95% CI: 11.2-NA) vs. 13.6 months (95% CI: 11.9-18.1) for the non-resection group, P=0.0246. Conclusions: Our results suggest that a multimodal approach including NAT +/- segmental arterial resection/reconstruction, can be considered but with high post-operative morbidity. The encouraging survival rates of pts after extended resection must be balanced with the morbidity of this surgery. Given the poor prognosis of pts with locally advanced PDAC, there is a rationale for prospective evaluation of this approach to identify pts who are most likely to benefit from this aggressive strategy.