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Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

Objective: Identify risk factors for central line-associated bloodstream infections (CLABSI) in pediatric intensive care settings in an era with high focus on prevention measures., Design: Matched, case-control study., Setting: Quaternary children's hospital., Patients: Cases had a CLABSI during an intensive care unit (ICU) stay between January 1, 2015 and December 31, 2020. Controls were matched 4:1 by ICU and admission date and did not develop a CLABSI., Methods: Multivariable, mixed-effects logistic regression., Results: 129 cases were matched to 516 controls. Central venous catheter (CVC) maintenance bundle compliance was >70%. Independent CLABSI risk factors included administration of continuous non-opioid sedative (adjusted odds ratio (aOR) 2.96, 95% CI [1.16, 7.52], P = 0.023), number of days with one or more CVC in place (aOR 1.42 per 10 days [1.16, 1.74], P = 0.001), and the combination of a chronic CVC with administration of parenteral nutrition (aOR 4.82 [1.38, 16.9], P = 0.014). Variables independently associated with lower odds of CLABSI included CVC location in an upper extremity (aOR 0.16 [0.05, 0.55], P = 0.004); non-tunneled CVC (aOR 0.17 [0.04, 0.63], P = 0.008); presence of an endotracheal tube (aOR 0.21 [0.08, 0.6], P = 0.004), Foley catheter (aOR 0.3 [0.13, 0.68], P = 0.004); transport to radiology (aOR 0.31 [0.1, 0.94], P = 0.039); continuous neuromuscular blockade (aOR 0.29 [0.1, 0.86], P = 0.025); and administration of histamine H2 blocking medications (aOR 0.17 [0.06, 0.48], P = 0.001)., Conclusions: Pediatric intensive care patients with chronic CVCs receiving parenteral nutrition, those on non-opioid sedative infusions, and those with more central line days are at increased risk for CLABSI despite current prevention measures.

Objectives: Generative language models (LMs) are being evaluated in a variety of tasks in healthcare, but pediatric critical care studies are scant. Our objective was to evaluate the utility of generative LMs in the pediatric critical care setting and to determine whether domain-adapted LMs can outperform much larger general-domain LMs in generating a differential diagnosis from the admission notes of PICU patients., Design: Single-center retrospective cohort study., Setting: Quaternary 40-bed PICU., Patients: Notes from all patients admitted to the PICU between January 2012 and April 2023 were used for model development. One hundred thirty randomly selected admission notes were used for evaluation., Interventions: None., Measurements and Main Results: Five experts in critical care used a 5-point Likert scale to independently evaluate the overall quality of differential diagnoses: 1) written by the clinician in the original notes, 2) generated by two general LMs (BioGPT-Large and LLaMa-65B), and 3) generated by two fine-tuned models (fine-tuned BioGPT-Large and fine-tuned LLaMa-7B). Differences among differential diagnoses were compared using mixed methods regression models. We used 1,916,538 notes from 32,454 unique patients for model development and validation. The mean quality scores of the differential diagnoses generated by the clinicians and fine-tuned LLaMa-7B, the best-performing LM, were 3.43 and 2.88, respectively (absolute difference 0.54 units [95% CI, 0.37-0.72], p < 0.001). Fine-tuned LLaMa-7B performed better than LLaMa-65B (absolute difference 0.23 unit [95% CI, 0.06-0.41], p = 0.009) and BioGPT-Large (absolute difference 0.86 unit [95% CI, 0.69-1.0], p < 0.001). The differential diagnosis generated by clinicians and fine-tuned LLaMa-7B were ranked as the highest quality in 144 (55%) and 74 cases (29%), respectively., Conclusions: A smaller LM fine-tuned using notes of PICU patients outperformed much larger models trained on general-domain data. Currently, LMs remain inferior but may serve as an adjunct to human clinicians in real-world tasks using real-world data., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: The pediatric Sequential Organ Failure Assessment (pSOFA) score was designed to track illness severity and predict mortality in critically ill children. Most commonly, pSOFA at a point in time is used to assess a static patient condition. However, this approach has a significant drawback because it fails to consider any changes in a patients' condition during their PICU stay and, especially, their response to initial critical care treatment. We aimed to evaluate the performance of longitudinal pSOFA scores for predicting mortality., Design: Single-center, retrospective cohort study., Setting: Quaternary 40-bed PICU., Patients: All patients admitted to the PICU between 2015 and 2021 with at least 24 hours of ICU stay., Interventions: None., Measurements and Main Results: We calculated daily pSOFA scores up to 30 days, or until death or discharge from the PICU, if earlier. We used the joint longitudinal and time-to-event data model for the dynamic prediction of 30-day in-hospital mortality. The dataset, which included 9146 patients with a 30-day in-hospital mortality of 2.6%, was divided randomly into training (75%) and validation (25%) subsets, and subjected to 40 repeated stratified cross-validations. We used dynamic area under the curve (AUC) to evaluate the discriminative performance of the model. Compared with the admission-day pSOFA score, AUC for predicting mortality between days 5 and 30 was improved on average by 6.4% (95% CI, 6.3-6.6%) using longitudinal pSOFA scores from the first 3 days and 9.2% (95% CI, 9.0-9.5%) using scores from the first 5 days., Conclusions: Compared with admission-day pSOFA score, longitudinal pSOFA scores improved the accuracy of mortality prediction in PICU patients at a single center. The pSOFA score has the potential to be used dynamically for the evaluation of patient conditions., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: To describe trends in critical illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children over the course of the COVID-19 pandemic. We hypothesized that PICU admission rates were higher in the Omicron period compared with the original outbreak but that fewer patients needed endotracheal intubation., Design: Retrospective cohort study., Setting: This study took place in nine U.S. PICUs over 3 weeks in January 2022 (Omicron period) compared with 3 weeks in March 2020 (original period)., Patients: Patients less than or equal to 21 years old who screened positive for SARS-CoV-2 infection by polymerase chain reaction or hospital-based rapid antigen test and were admitted to a PICU or intermediate care unit were included., Interventions: None., Measurements and Main Results: A total of 267 patients (239 Omicron and 28 original) were reviewed. Forty-five patients in the Omicron cohort had incidental SARS-CoV-2 and were excluded from analysis. The Omicron cohort patients were younger compared with the original cohort patients (median [interquartile range], 6 yr [1.3-13.3 yr] vs 14 yr [8.3-17.3 yr]; p = 0.001). The Omicron period, compared with the original period, was associated with an average increase in COVID-19-related PICU admissions of 13 patients per institution (95% CI, 6-36; p = 0.008), which represents a seven-fold increase in the absolute number admissions. We failed to identify an association between cohort period (Omicron vs original) and odds of intubation (odds ratio, 0.7; 95% CI, 0.3-1.7). However, we cannot exclude the possibility of up to 70% reduction in intubation., Conclusions: COVID-19-related PICU admissions were seven times higher in the Omicron wave compared with the original outbreak. We could not exclude the possibility of up to 70% reduction in use of intubation in the Omicron versus original epoch, which may represent differences in PICU/hospital admission policy in the later period, or pattern of disease, or possibly the impact of vaccination., Competing Interests: Dr. Ross’ institution received funding from the National Heart, Lung, and Blood Institute (K23HL148312). Drs. Ross and Kleinman received support for article research from the National Institutes of Health (NIH). Drs. Hall’s and Kleinman’s institutions received funding from the NIH. Dr. Hall received funding from AbbVie and Kiadis. Dr. Kleinman’s institution received funding from the U.S. Health Resources Services Administration (HRSA); he disclosed that he is the owner of Quality Matters is a board member of Dartnet Institute of Principal and owns stock in Regeneron, Sanofi, and Amegen; he received support for article research from HRSA (U3DMC32755); and his work is supported in part by National Institute of Child Health and Human Development (1R61HD105619). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting., Design: Single-center, retrospective cohort study., Setting: Registry data from a regional, pediatric burn center in the United States., Patients: Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020., Interventions: None., Measurements and Main Results: Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge., Conclusions: The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

This article focuses on the possibilities through which curriculum on the other side of the Covid-19 pandemic might contribute more proactively to future social and political crises that are multifarious yet interconnected in nature. The Covid-19 pandemic is a global crisis that touches every aspect of social life, including politics, the economy, healthcare systems, poverty, forced human migration, climate change, and importantly, education. To potentially address future crises through curriculum, the article first problematizes the present in education and society-specifically, the 50-year neoliberal project that has transformed society and education. It connects the crisis in education to a transformed social, political, and economic system that has introduced what Gordon Lafer has called a revolution of falling expectations through a hollowing-out of public institutions. The article then returns to the crisis of curriculum, contextualized in Joseph Schwab's The Practical: A Language for Curriculum , which presaged the reconceptualization of the curriculum field. It dialogues with Schwab's advocacy for an eclectic, deliberative, and practical curricular ethic as a form of post-reconceptualization curriculum study to contribute to understanding and managing future disruptions, such as those inevitably associated with the climate crisis. Finally, the article connects to the concept of liquidity in curriculum, through which to embody curricular eclecticism and provoke teachers and students to author a vision for a more just future that will not reinscribe the pathologies of the past., (© UNESCO IBE 2021.)

Purpose: The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents., Methods: This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity., Results: A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon., Conclusions: Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objectives: Residents are often assigned online learning materials as part of blended learning models, superimposed on other patient care and learning demands. Data that describe the time patterns of when residents interact with online learning materials during the ICU rotation are lacking. We describe resident engagement with assigned online curricula related to time of day and ICU clinical schedules, using website activity data., Design: Prospective cohort study examining curriculum completion data and cross-referencing timestamps for pre- and posttest attempts with resident schedules to determine the hours that they accessed the curriculum and whether or not they were scheduled for clinical duty. Residents at each site were cohorted based on two differing clinical schedules-extended duration (>24 hr) versus shorter (maximum 16 hr) shifts., Setting: Two large academic children's hospitals., Subjects: Pediatric residents rotating in the PICU from July 2013 to June 2017., Interventions: None., Measurements and Main Results: One-hundred and fifty-seven pediatric residents participated in the study. The majority of residents (106/157; 68%) completed the curriculum, with no statistically significant association between overall curriculum completion and schedule cohort at either site. Residents made more test attempts at nighttime between 6 PM and 6 AM (1,824/2,828; 64%) regardless of whether they were scheduled for clinical duty. Approximately two thirds of test attempts (1,785/2,828; 63%) occurred when residents were not scheduled to work, regardless of time of day. Forty-two percent of all test attempts (1,199/2,828) occurred between 6 PM and 6 AM while off-duty, with 12% (342/2,828) occurring between midnight and 6 AM., Conclusions: Residents rotating in the ICU completed online learning materials mainly during nighttime and off-duty hours, including usage between midnight and 6 AM while off-duty. Increasing nighttime and off-duty workload may have implications for educational design and trainee wellness, particularly during busy, acute clinical rotations, and warrants further examination.

Importance: The recent and ongoing coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented toll on adults critically ill with COVID-19 infection. While there is evidence that the burden of COVID-19 infection in hospitalized children is lesser than in their adult counterparts, to date, there are only limited reports describing COVID-19 in pediatric intensive care units (PICUs)., Objective: To provide an early description and characterization of COVID-19 infection in North American PICUs, focusing on mode of presentation, presence of comorbidities, severity of disease, therapeutic interventions, clinical trajectory, and early outcomes., Design, Setting, and Participants: This cross-sectional study included children positive for COVID-19 admitted to 46 North American PICUs between March 14 and April 3, 2020. with follow-up to April 10, 2020., Main Outcomes and Measures: Prehospital characteristics, clinical trajectory, and hospital outcomes of children admitted to PICUs with confirmed COVID-19 infection., Results: Of the 48 children with COVID-19 admitted to participating PICUs, 25 (52%) were male, and the median (range) age was 13 (4.2-16.6) years. Forty patients (83%) had significant preexisting comorbidities; 35 (73%) presented with respiratory symptoms and 18 (38%) required invasive ventilation. Eleven patients (23%) had failure of 2 or more organ systems. Extracorporeal membrane oxygenation was required for 1 patient (2%). Targeted therapies were used in 28 patients (61%), with hydroxychloroquine being the most commonly used agent either alone (11 patients) or in combination (10 patients). At the completion of the follow-up period, 2 patients (4%) had died and 15 (31%) were still hospitalized, with 3 still requiring ventilatory support and 1 receiving extracorporeal membrane oxygenation. The median (range) PICU and hospital lengths of stay for those who had been discharged were 5 (3-9) days and 7 (4-13) days, respectively., Conclusions and Relevance: This early report describes the burden of COVID-19 infection in North American PICUs and confirms that severe illness in children is significant but far less frequent than in adults. Prehospital comorbidities appear to be an important factor in children. These preliminary observations provide an important platform for larger and more extensive studies of children with COVID-19 infection.

Objectives: The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists., Data Sources: An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists., Study Selection: Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models., Data Extraction: Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review., Data Synthesis: Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records., Conclusions: Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

Objective: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains., Design: A prospective, interventional crossover study conducted from October 2015 to December 2017., Setting: Multicenter study conducted in 33 PICUs across eight countries., Subjects: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation., Interventions: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions., Measurements and Main Results: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008)., Conclusions: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Purpose: Data on childhood intensive care unit (ICU) deaths are needed to identify changing patterns of intensive care resource utilization. We sought to determine the epidemiology and mode of pediatric ICU deaths in Australia and New Zealand (ANZ)., Methods: This was a retrospective, descriptive study of multicenter data from pediatric and mixed ICUs reported to the ANZ Pediatric Intensive Care Registry and binational Government census. All patients < 16 years admitted to an ICU between 1 January 2006 and 31 December 2016 were included. Primary outcome was ICU mortality. Subject characteristics and trends over time were evaluated., Results: Of 103,367 ICU admissions, there were 2672 (2.6%) deaths, with 87.6% of deaths occurring in specialized pediatric ICUs. The proportion of ANZ childhood deaths occurring in ICU was 12%, increasing by 43% over the study period. Unadjusted (0.1% per year, 95% CI 0.096-0.104; p < 0.001) and risk-adjusted (0.1%/year, 95% CI 0.07-0.13; p < 0.001) ICU mortality rates fell. Across all admission sources and diagnostic groups, mortality declined except following pre-ICU cardiopulmonary arrest where increased mortality was observed. Half of the deaths followed withdrawal of life-sustaining therapy (51%), remaining constant throughout the study. Deaths despite maximal resuscitation declined (0.92%/year, 95% CI 0.89-0.95%; p < 0.001) and brain death diagnoses increased (0.72%/year, 95% CI 0.69-0.75%; p = 0.001)., Conclusions: Unadjusted and risk-adjusted mortality for children admitted to ANZ ICUs is declining. Half of pediatric ICU deaths follow withdrawal of life-sustaining therapy. Epidemiology and mode of pediatric ICU death are changing. Further investigation at an international level will inform benchmarking, resource allocation and training requirements for pediatric critical care.

Objectives: We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016., Design: Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey., Setting: PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU., Subjects: Physician medical directors and nurse managers., Interventions: None., Measurements and Main Results: PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital., Conclusions: U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.

Importance: Measuring and improving performance is an essential component of any high-risk industry, including intensive care medicine. We undertook this systematic review to describe the current state of quality improvement efforts in pediatric intensive care medicine., Objective: To evaluate the quality and rigor of all published literature on quality improvement efforts in the pediatric intensive care unit in the current era., Methods: We conducted a literature search on MEDLINE, Embase, and Cochrane for studies that met two broad inclusion criteria: 1) the terms "pediatric critical care" and "quality improvement" and 2) they were completed in the past ten years. In the initial search, we also included academic and professional societies or organizations devoted to providing resources on quality improvement in intensive care medicine. We excluded studies that examined quality improvement processes exclusively for neonatal or adult patients receiving intensive care., Results: Forty-nine of 332 identified articles were selected for final review by two reviewers who independently rated the quality of the methodology and rigor of the evidence reported for each study. Of these, 23 studies targeted structural issues, 14 studies targeted process issues, and 12 targeted an outcome as the focus of the intensive care quality improvement effort., Interpretation: Our review of the published literature on quality improvement efforts in the pediatric intensive care unit in the current era found that 85% of studies were limited in methodology or analysis. Fifteen high-quality studies are reported here and serve as helpful examples of rigorous research methodology in this domain going forward., Competing Interests: The authors report no conflict of interests related to the material presented in this article., (© 2019 Chinese Medical Association. Pediatric Investigation published by John Wiley & Sons Australia, Ltd on behalf of Futang Research Center of Pediatric Development.)

Quality improvement programs focused on improving care in intensive care units have become standard at pediatric hospitals around the world over the past several decades. However, the methodology or framework by which these programs assess quality is not standard. This review describes the varying quality improvement frameworks that have been promoted by prominent pediatric and critical care societies and the strengths and limitations of these frameworks, as well as several notable international collaboratives in this domain., Competing Interests: The authors report no conflict of interests related to the material presented in this article., (© 2019 Chinese Medical Association. Pediatric Investigation published by John Wiley & Sons Australia, Ltd on behalf of Futang Research Center of Pediatric Development.)

Introduction:: The number of websites for the critical care provider is rapidly growing, including websites that are part of the Free Open Access Med(ical ed)ucation (FOAM) movement. With this rapidly expanding number of websites, critical appraisal is needed to identify quality websites. The last major review of critical care websites was published in 2011, and thus a new review of the websites relevant to the critical care clinician is necessary., Methods:: A new assessment tool for evaluating critical care medicine education websites, the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET), was modified from existing tools. A PubMed and Startpage search from 2007 to 2017 was conducted to identify websites relevant to critical care medicine education. These websites were scored based on the CCMEWQET., Results:: Ninety-seven websites relevant for critical care medicine education were identified and scored, and the top ten websites were described in detail. Common types of resources available on these websites included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes. Almost one quarter of websites (n = 22) classified themselves as FOAM websites. The top ten websites most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning., Conclusion:: Many excellent online resources for critical care medicine education currently exist, and the number is likely to continue to increase. Opportunities for improvement in many websites include more active engagement of learners, upgrading navigation abilities, incorporating an editorial process, and providing appropriate attribution for graphics and media.

Background: The purpose was to assess the minimum 2-year patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears., Methods: From 2008-2014, patients who underwent revision rotator cuff repair augmented with AHDM with greater than 2 years' follow-up by a single surgeon were retrospectively reviewed. Data regarding surgical history, demographic characteristics, and medical comorbidities were collected. Outcome data included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, as well as rotator cuff healing on magnetic resonance imaging or ultrasound. Retears and subsequent surgical procedures were characterized., Results: A total of 28 patients met our inclusion criteria, and 23 (82%) were available for follow-up at 2 years. The mean age was 60.1 ± 9.3 years (range, 43-79 years), with a mean follow-up period of 48 ± 23 months. All patients had at least 1 prior rotator cuff repair. Of the 23 patients, 13 (56%) underwent postoperative imaging, and 4 of these 13 (31%) had a retear. A reoperation was performed in 3 of 23 patients (13%). Among the 6 patients with both preoperative and postoperative outcome scores, we saw improvement in the ASES score from 56 to 85 (P = .03) and in the SANE score from 42 to 76 (P = .03). The full cohort's mean postoperative ASES and SANE scores were 77 and 69, respectively., Conclusion: AHDM allograft augmentation is a safe and effective treatment method for patients with full-thickness rotator cuff retears. Further research is needed with larger studies to confirm these findings from our small cohort of patients., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study., Design: Descriptive study., Settings: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education., Patients: None., Interventions: None., Measurements and Main Results: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education-accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match., Conclusions: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine.

Problem: Health care professionals are familiar with engaging in local communities of practice (CoPs) within their hospital, region, and/or country, but despite the availability of online technologies that facilitate online global collaboration, the health care sector has yet to fully embrace these tools., Approach: In 2013, OPENPediatrics (an online social learning platform) launched the World Shared Practices video (WSP) series to engage and coalesce the global community of critical care clinicians. Each month, a 30- to 45-minute video featuring a pediatric critical care medicine expert, interspersed with questions for the audience, is released. Viewers contribute to the community discussion by leaving comments that display alongside the video. Clinicians are encouraged to asynchronously host an educational conference so they can watch the videos and participate in the discussion together., Outcomes: From March 2013-November 2015, 28 WSPs were launched on a variety of topics. They were viewed over 18,414 times by 1,864 viewers in 132 countries and 760 hospitals; 1,155 comments were submitted. Attending physicians/consultants were the largest audience (36% [671/1,864]), and 37% (30/81) of responding viewers that commented in WSPs watched in small groups. The WSP series was reported to add value to respondents' learning or teaching and to have had a positive impact on their knowledge or practice., Next Steps: Future research will focus on further describing the context and structure of the CoP and on more deeply investigating its higher-level outcomes and impact. More work is needed to identify barriers and strategies that improve online community engagement.

Purpose: To compare patient-reported outcomes and healing rates after open subpectoral and all-arthroscopic suprapectoral biceps tenodesis without the use of interference screws in patients with more than 2 years of follow-up., Methods: Patients with at least 2 years of follow-up who underwent open subpectoral biceps tenodesis or all-arthroscopic suprapectoral biceps tenodesis without concomitant rotator cuff repair, labral repair, or Mumford procedure were considered for enrollment in the study. They were evaluated for visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and satisfaction with function and biceps contour. Ultrasonography was performed to evaluate the integrity of the tenodesis site and measure biceps muscle diameters on each arm., Results: Forty-nine patients were eligible for our study and of these, 38 were able to participate. Twenty-three patients had open subpectoral biceps tenodesis and 15 received all-arthroscopic suprapectoral biceps tenodesis. The average follow-up time was 4.5 years (range 2-9.1 years). There were no significant differences in anterior shoulder pain VAS, ASES scores, or satisfaction rates. The average anterior shoulder VAS was 0.7 ± 1.1 for the open group and 0.9 ± 1.8 for the arthroscopic group (P = .74). The mean ASES score for the open group was 90.6 ± 11.4 and 91.4 ± 13.9 for the arthroscopic group (P = .69). All patients had an intact tenodesis site on ultrasonography and the ratio of operative to nonoperative biceps diameters was 100.2% ± 12.8% for the open group and 99.1% ± 10.8% for the arthroscopic group (P = .66). There were no infections and no brachial plexus injuries in either group., Conclusions: Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. Tenodesis can be performed in either location without interference screw fixation with durable, reliable results., Level of Evidence: Level III, retrospective comparative trial., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The optimal design of pedagogical strategies for e-learning in graduate and postgraduate medical education remains to be determined. Video-based e-learning use is increasing, with initial research suggesting that taking short breaks while watching videos (independent of answering test questions) may improve learning by focusing attention on the content presented. Interspersed test questions may also improve knowledge acquisition and retention., Objective: To examine the effect of interspersed test questions and periodic breaks on immediate knowledge acquisition and retention at 6 months by pediatric residents engaged in video-based e-learning., Methods: First- and second-year pediatric residents were randomized to 1 of the following 3 groups: viewing the complete video uninterrupted (full video), viewing the video interrupted with unrelated logic puzzles (logic puzzles), or viewing the video interrupted with brief comprehension test questions (short answer questions). Residents answered pre- and post-tests before and after video viewing, followed by a retention test at 6 months. Primary outcome included comparison of the change in test scores between groups., Results: A total of 49 residents completed the initial testing session. All 3 learning groups had comparable mean increases in immediate knowledge gain, but with no significant differences between groups (F 2,46 =0.35, P=.71). Thirty-five residents completed retention testing with comparable degrees of knowledge retention in the full video and short answer test questions groups (P<.001), but no significant change in the logic puzzles group (F 1,32 =2.44, P=.13)., Conclusions: Improved knowledge gain was not demonstrated among residents answering interspersed questions or completing logic puzzles during interrupted online video viewing when compared with residents viewing uninterrupted video content. However, residents who either participated in uninterrupted video viewing or answered interspersed questions during interrupted video viewing demonstrated significant knowledge retention at 6 months., Competing Interests: Conflicts of Interest: None declared., (©Lisa A DelSignore, Traci A Wolbrink, David Zurakowski, Jeffrey P Burns. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.11.2016.)

Failed arthroscopic soft-tissue stabilization and anterior glenoid bone loss have been shown to have high failure rates after standard arthroscopic stabilization techniques. For patients with recurrent glenohumeral instability, the Bristow-Latarjet procedure is currently the standard of care. It is predominantly performed through an open deltopectoral approach but has recently been described arthroscopically. Although providing excellent clinical outcomes, the Bristow-Latarjet procedure violates the subscapularis muscle, has a steep learning curve with a high complication rate, and permanently changes the anterior shoulder anatomy, making any future revision surgery more challenging. We describe a technique for arthroscopic anterior glenoid augmentation using iliac crest bone graft that does not violate the subscapularis, by creating a far anterior-medial portal that traverses superior to the subscapularis and lateral to the conjoint tendon. The graft is passed through this portal and secured with rigid fixation. An arthroscopic Bankart capsulolabral repair is then performed, making the graft extra-articular. A remplissage can easily be added as indicated, allowing this procedure to arthroscopically address all 3 major components of structural instability: glenoid bone loss, capsulolabral tearing, and humeral bone loss.

We conducted a study to evaluate in vivo tension applied to the rotator cuff tendon positioned at the medial versus lateral footprint during arthroscopic rotator cuff repair. We evaluated 20 consecutive patients who underwent arthroscopic rotator cuff repair. During repair, a grasper was inserted through a lateral portal, and a digital weigh scale was attached. The tendon was grasped and translated to the medial footprint, and tension recorded. After a relaxation period, the tendon edge was translated to the lateral footprint, and tension recorded. Mean (SD) tension was 0.41 (0.33) pound when tendons were positioned at the medial footprint and 2.21 (1.20) pounds when they were positioned at the lateral footprint, representing a 5.4-fold difference (P < .0001). For smaller tears (≤ 20 mm anterior-posterior), 7.6 times less tension was applied to the tendons when pulled to the medial versus lateral footprint. For larger tears, 4.1 times less tension was applied to the tendons when pulled to the medial versus lateral footprint. This study demonstrated a significant, 5.4-fold increase in tension when the tendon edge was reduced to the lateral as opposed to the medial footprint in vivo.

Restoration of glenoid bony integrity is critical to minimizing the risk of recurrence and re-creating normal kinematics in the setting of anterior glenohumeral instability. We present an arthroscopic suture anchor-based technique for treating large bony Bankart fractures in which the fragment is secured to the intact glenoid using mattress sutures placed through the bony fragment and augmented with soft-tissue repair proximal and distal to the bony lesion. This straightforward technique has led to excellent fragment reduction and good outcomes in our experience.

Objective: To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States., Design: Prospective case series., Setting: Five U.S. teaching hospitals., Subjects: We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures., Interventions: None., Measurements and Main Results: The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death., Conclusions: The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

Objectives: Advances in Internet technology now enable unprecedented global collaboration and collective knowledge exchange. Up to this time, there have been limited efforts to use these technologies to actively promote knowledge exchange across the global pediatric critical care community. To develop an open-access, peer-reviewed, not-for-profit Internet-based learning application, OPENPediatrics, a collaborative effort with the World Federation of Pediatric Intensive and Critical Care Societies, was designed to promote postgraduate educational knowledge exchange for physicians, nurses, and others caring for critically ill children worldwide., Design: Description of program development., Setting: International multicenter tertiary pediatric critical care units across six continents., Subjects: Multidisciplinary pediatric critical care providers., Interventions: A software application, providing information on demand, curricular pathways, and videoconferencing, downloaded to a local computer., Measurements and Main Results: In 2010, a survey assessing postgraduate educational needs was distributed through World Federation of Pediatric Intensive and Critical Care Societies to constituent societies. Four hundred and twenty-nine critical care providers from 49 countries responded to the single e-mail survey request. Respondents included 68% physicians and 28% nurses who care for critically ill children. Fifty-two percent of respondents reported accessing the Internet at least weekly to obtain professional educational information. The five highest requests were for educational content on respiratory care [mechanical ventilation] (48% [38%]), sepsis (28%), neurology (25%), cardiology (14%), extracorporeal membrane oxygenation (10%), and ethics (8%). Based on these findings, and in collaboration with researchers in adult learning and online courseware, an application was developed and is currently being used by 770 registered users in 60 countries., Conclusions: We describe here the development and implementation of an Internet-based application which is among the first efforts designed to promote global knowledge exchange for physicians and nurses caring for critically ill children. This application has the potential to evolve new methods in postgraduate education. Ongoing assessment of the efficacy of Internet-based learning platforms will be necessary.

Purpose: Recent changes in duty hour allowances and economic constraints are forcing a paradigm shift in graduate medical education in the United States. Internet-based learning is a rapidly growing component of postgraduate medical education, including the field of critical care medicine. Here, we define the key concepts of Internet-based learning, summarize the current literature, and describe how Internet-based learning may be uniquely suited for the critical care provider., Methods: A MEDLINE/PubMed search from January 2000 to July 2011 using the search terms: "e-learning," "Web-based learning," "computer-aided instruction," "adult learning," "knowledge retention," "intensive care," and "critical care.", Results: The growth of the Internet is marked by the development of new technologies, including more user-derived tools. Nonmedical fields have embraced Internet-based learning as a valuable teaching tool. A recent meta-analysis described Internet-based learning in the medical field as being more effective than no intervention and likely as efficacious as traditional teaching methods. Web sites containing interactive features are aptly suited for the adult learner, complementing the paradigm shift to more learner-centered education. Interactive cases, simulators, and games may allow for improvement in clinical care. The total time spent utilizing Internet-based resources, as well as the frequency of returning to those sites, may influence educational gains., Conclusion: Internet-based learning may provide an opportunity for assistance in the transformation of medical education. Many features of Web-based learning, including interactivity, make it advantageous for the adult medical learner, especially in the field of critical care medicine, and further work is necessary to develop a robust learning platform incorporating a variety of learning modalities for critical care providers.

Background: We report our use of portable head computed tomography (CT) and the diagnostic yield and radiation dose from head CT in the pediatric intensive care unit (PICU)., Methods: 204 PICU patients underwent head CT during 2008-2009. Therapeutic interventions and resource intensity during CT were categorized. Severity of illness was summarized using the pediatric risk of mortality (PRISM-III) model. Estimates of patient radiation dose were based on dose measurements made in four anthropomorphic head phantoms., Results: 242 (62%) out of 391 head CT studies were portable. New pathology was identified on 80 (40%) scans. CT findings prompted a change in management in 46 (23%) patients; 25 of these resulted in life-extending treatments and 21 had forgoing of life-sustaining treatments within 24 hours. 26 patients with PRISM score greater than 30% underwent CT; 23 (88%) of these were portable. More portable versus fixed examinations were performed in patients requiring extracorporeal membrane oxygenation, inhaled nitric oxide, high levels of positive end expiratory pressure, and those with high vasopressor scores (P < 0.05). Estimated patient dose from portable CT was 83 ± 6 mGy compared to 72 ± 5 mGy for patients imaged on a fixed scanner (P < 0.0001)., Conclusion: Two-thirds of CT scans obtained in the PICU were portable because of patients' intensity of therapy and illness severity. Portable CT showed major new pathology in greater than 1/3 and led to a change in management in 1/4 of higher acuity patients scanned. The estimated radiation dose from portable CT is within the current national guidelines.

Purpose: To prospectively evaluate the safety and effectiveness of arthroscopic acellular human dermal matrix augmentation of large rotator cuff tear repairs., Methods: A prospective, institutional review board-approved, multicenter series of patients undergoing arthroscopic repair of 2-tendon rotator cuff tears measuring greater than 3 cm were randomized by sealed envelopes opened at the time of surgery to arthroscopic single-row rotator cuff repair with GraftJacket acellular human dermal matrix (Wright Medical Technology, Arlington, TN) augmentation (group 1) or without augmentation (group 2). Preoperative and postoperative functional outcome assessments were obtained by use of the American Shoulder and Elbow Surgeons (ASES), Constant, and University of California, Los Angeles scales. Gadolinium-enhanced magnetic resonance imaging (MRI) evaluation of these repairs was obtained at a mean of 14.5 months (range, 12 to 24 months). Adverse events were recorded., Results: There were 22 patients in group 1 and 20 in group 2 with a mean age of 56 years. The mean follow-up was 24 months (range, 12 to 38 months). The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .035). The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .008). The University of California, Los Angeles score improved from 13.3 to 28.2 in group 1 and from 15.9 to 28.3 in group 2 (P = .43). Gadolinium-enhanced MRI scans showed intact cuffs in 85% of repairs in group 1 and 40% in group 2 (P < .01). No adverse events were attributed to the presence of the matrix grafts., Conclusions: Acellular human dermal matrix augmentation of large (>3 cm) cuff tears involving 2 tendons showed better ASES and Constant scores and more frequent intact cuffs as determined by gadolinium-enhanced MRI. Intact repairs were found in 85% of the augmented group and 40% of the nonaugmented group (P < .01). No adverse events related to the acellular human dermal matrix were observed., Level of Evidence: Level II, lesser-quality randomized controlled trial., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)