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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.)

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.

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.

Calculation of a blood alcohol concentration (BAC) at the time of an offence by forward or back-extrapolation, using population average values for ethanol pharmacokinetic parameters or a single estimate of individual specific parameters, ignores the possibility of inter- and intra-subject variability. In order to estimate inter- and intra-subject variability in the elimination rate and absorption rate, BAC was measured over time in 12 male volunteers on 4 occasions. Subjects received 0.44 g kg(-1) body weight of ethanol on the first study day, and 0.70 g kg(-1) body weight on subsequent study days 1, 11 and 12 weeks later, to enable comparisons in variability over short and long time periods and when the same or different doses were administered. Evidence of both inter- and intra-subject variability was found, with inter-subject variability substantially smaller than intra-subject variability when the dose varied. Forensically important differences in pharmacokinetic parameters were observed within individuals between occasions. These findings could have an important impact on medico-legal issues related to ethanol pharmacokinetics.

Purpose: Document the biomechanics of the pitching motion to help provide insight about the etiology of common injuries seen in adolescent baseball pitchers., Methods: Kinematic and kinetic data for the upper and lower extremities, thorax, and pelvis were collected from 24 adolescent pitchers, using modern three-dimensional computerized motion-analysis techniques., Results: Original information regarding forearm and wrist motion was reported in this study and were consistent with expected motions for the fastball pitch. Average excursion of motion was: pronation/supination 63 +/- 15 degrees, wrist flexion/extension 44 +/- 14 degrees, and ulnar/radial deviation 12 +/- 4 degrees. Explosive forearm motion occurred between ball release (BR) and maximal glenohumeral internal rotation (GH-MIR) with a peak pronation velocity of 2051 +/- 646 degrees.s(-1). The majority of internal/external and abduction/adduction shoulder motion was attributed to the glenohumeral motion. Internal glenohumeral rotation range of motion was 125 +/- 13 degrees and mean peak internal glenohumeral rotation velocity was 3343 +/- 453 degrees.s(-1). Thorax and pelvic motion peak velocities and accelerations occurred before the peak elbow varus moment, which occurred at 59% of the pitch cycle (PC). The peak shoulder, elbow, and wrist velocities and accelerations occurred after the peak elbow varus moment. The pelvis squared to the plate at 51 +/- 10% PC and the thorax at 59 +/- 7% PC with maximal glenohumeral external rotation (GH-MER) at 65% PC and BR at 78 +/- 3% PC. The data collected in this study were consistent with the literature, with the exception of joint velocities and moments, which were lower than those in one published study., Conclusion: We have established the kinematic and kinetic parameters of the adolescent baseball pitch. These measured parameters and the differences between adolescent pitchers and their adult counterparts can be used to examine and help determine the causes of the rapid increase in adolescent pitching injuries.

Lampbrush chromosomes of growing amphibian oocytes carry thousands of lateral loops each of which consists of a chromatin fiber heavily encrusted with nascent ribonucleoprotein fibrils. These are believed to be responsible for the accumulation and maintenance of RNA transcripts found stored in the egg. In the case of mammalian oocytes, lampbrush chromosomes are most likely to occur during the major growth phase and also possibly during pachytene-early diplotene stages of meiosis. We have examined pachytene and early diplotene mouse oocyte chromosomes through the light microscope using sections of plastic-embedded material and air dried spreads stained with either silver nitrate or methyl green pyronin. Our results indicates that the projections radiating from the chromosomal axis are bundles of chromatin fibers rather than single fibers covered with an ribonucleoprotein matrix. These bundles may represent partially unfolded chromomeres. The axis itself could be partially dispersed revealing threads surrounding a fine linear element. -- Little is known about chromosome structure in growing mammalian oocytes, the stage when transcriptional activity is likely to be most rapid. In our preparations chromosomes at this stage appear as partially condensed fuzzy threads of relatively uniform width. In some cases, the fuzzy thread is seen to contain a dense linear core in the center. Thus, during the growth phase, the chromosomes retain a relatively condensed axis, a characteristic of meiotic chromosomes in general. RNA-containing material is found diffusely spread within the nucleus but not specifically associated with the chromosomes. Electron microscopic analysis of spread chromatin from growing oocytes demonstrates that most transcription units possess only one or two nascent ribonucleoprotein fibrils while a few have more. These and other published data indicate that mouse oocytes do not have true lampbrush chromosomes at any stage of their development.

Sperm chromosomal complements of a man heterozygous for two reciprocal translocations and exhibiting the karyotype 46,XY,t(5;11) (p13;q23.2),t(7;14)(q11;q24.1) were analyzed following in vitro fusion with golden hamster zona-free eggs (the hamster in vitro penetration [HIP] system). Products of alternate, adjacent 1, and 3:1 segregation at meiosis I of both translocation quadrivalents were recovered, and the analysis of their output, which was dissimilar between the two translocations, permitted prediction of probable sites of chiasma formation in the chromosomes involved in the translocation. These data, which comprise the first reported analysis of the products of two translocations in a single individual (hence, in a common genetic background), emphasize the uniqueness in genetic behavior of individual translocations; they further demonstrate the usefulness of the HIP system to carry out such studies.