Assessment of musculoskeletal pain and surgical ergonomic parameters among members of the American Society of Pediatric Otolaryngology.

OBJECTIVES: To assess rates of self-reported work-related pain and knowledge of ergonomic principles among fellowship trained pediatric otolaryngologists within the American Society of Pediatric Otolaryngology (ASPO). We hypothesized that pediatric otolaryngologists experience rates of musculoskeletal pain and injury similar to what has been reported among adult otolaryngologists and other surgical subspecialties. METHODS: An IRB-approved survey was distributed to members of ASPO through email listserv. Collected variables included surgeon demographic information, practice settings, surgical volume, procedure types, work-related musculoskeletal pain-related metrics, modifying factors, and knowledge/attitudes on surgical ergonomics. RESULTS: A total of 685 ASPO members were approached via email, of which 435 opened the survey email and 118 attending pediatric otolaryngologists completed the survey (response rate 27%). In all, 78% of respondents reported current or prior pain and/or injury attributed to performing surgery, 20% higher than that reported in the previous ergonomics survey of ASPO members in 2012. The most affected areas were neck/cervical spine (63%), shoulders/arms (44%), lower back/lumbar spine (36%), and hands/wrist (31%). Half of the respondents were diagnosed with musculoskeletal condition(s) attributed to performing surgery. Two-thirds required treatment (62% pharmacologic only, 9% pharmacologic and surgical intervention) for their work-related pain. Leveraging intermittent pauses during surgical procedures to adjust body position was the most reported method of addressing pain in the operating room. Only 21% report ever having received ergonomic training during their training or career. CONCLUSION: Musculoskeletal pain associated with performing pediatric otolaryngology procedures is highly prevalent and has not attenuated despite increased awareness of surgical ergonomics. Results from this study underscore the need to develop standardized surgical ergonomics curricula for pediatric otolaryngologists and trainees.

Tuning mobile phase properties to improve empty and full particle separation in adeno-associated virus productions by anion exchange chromatography.

In the past decade, recombinant adeno-associated virus (rAAV) has gained increased attention as a prominent gene therapy technology to treat monogenetic diseases. One of the challenges in rAAV production is the enrichment of full rAAV particles containing the gene of interest (GOI) payload. By adjusting the mobile phase properties of anion-exchange chromatography (AEX), it was demonstrated that empty and full separation of rAAV was improved in monolith based preparative AEX chromatography. When compared to the baseline method using NaCl, the use of tetraethylammonium acetate (TEA-Ac) in the AEX mobile phase resulted in enhanced resolution from 0.75 to 1.23 between "Empty" and "Full" peaks by salt linear gradient elution, as well as increased the percentage of full rAAV particles from 20% to 36% and genome recovery from 59% to 62%. Furthermore, a dual wash plus step elution AEX method was developed. Wherein, the first wash step harnesses TEA-Ac to separate empty and full capsids, which is followed by a second wash step that ensures no TEA-Ac salt is carried over into AEX eluate. The resulting optimized AEX purification method has the potential to be adapted for manufacturing and purification processes involving various rAAV production platforms that experience empty and full rAAV separation challenges.

International pediatric otolaryngology group (IPOG) consensus on approach to aspiration.

OBJECTIVE: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic.

Background: Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two. Objectives: To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics. Design: Qualitative evaluation. Setting: British Columbia, Canada. Participants: Patients and health care providers associated with multidisciplinary kidney care clinics. Methods: Development and delivery of semi-structured interviews of patients and health care providers. Results: 11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session. Limitations: Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC. Conclusions: A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery. Trial registration: Not registered.

Contexte: Après le début de la pandémie de COVID-19, les cliniques d'insuffisance rénale chronique (IRC) de la Colombie-Britannique sont passées d'une prestation de soins traditionnelle fondée principalement sur les visites en personne à des soins en mode virtuel, puis à un modèle hybride combinant les deux méthodes. Objectifs: Déterminer les avantages et les faiblesses des soins en mode virtuel, ainsi que la qualité de la prestation des soins et les principaux facteurs à considérer relativement à l'utilization des soins en mode virtuel, afin d'informer sur les meilleurs moyens d'intégrer les méthodes virtuelles et traditionnelles de prestation des soins dans les cliniques multidisciplinaires de néphrologie. Conception: Évaluation qualitative. Cadre: Colombie-Britannique (Canada). Sujets: Patients et prestataires de soins associés à des cliniques multidisciplinaires de soins rénaux. Méthodologie: Élaboration et réalisation d'entrevues semi-structurées auprès de patients et de prestataires de soins de santé. Résultats: En tout, 11 patients et/ou soignants et 12 prestataires de soins de santé ont participé aux entrevues. Les participants ont fait état d'expériences mitigées avec les soins en mode virtuel. Tous les participants envisageaient un futur où les soins seront offerts tant en mode virtuel qu'en personne. Un des avantages mentionnés des soins en mode virtuel est la commodité pour les patients. Parmi les défis mentionnés figuraient la difficulté à établir de nouvelles relations thérapeutiques et les capacités variables des patients et des prestataires de soins de santé à établir une relation et à communiquer en mode virtuel. Les participants ont noté une préférence pour les soins en personne dans les situations plus complexes. Quatre thèmes ont été identifiés comme facteurs à prendre en compte dans le choix entre les soins virtuels ou en personne: le contexte non médical de la personne, l'aide disponible, les paramètres cliniques et les tâches à accomplir, et les opérations de la clinique. Les participants ont indiqué que le choix de la modalité pour les visites est un processus individualisé et continu impliquant le patient et ses préférences, lesquelles peuvent changer au fil du temps. Les prestataires de soins ont indiqué que le fait d'offrir à la fois des soins virtuels et en personne dans une même séance clinique créait de nouveaux défis en matière de flux de travail. Limites: La taille limitée de l'échantillon pour les entrevues individuelles et l'utilization d'un échantillonnage de commodité pourraient avoir manqué certains points de vue, notamment celui de personnes déjà confrontées à des difficultés d'accès aux soins et qui pourraient être les plus désavantagées par la mise en œuvre de soins en mode virtuel. Conclusion: Une liste de facteurs-clé à prendre en compte pour une prestation de soins de qualité a été établie à l'attention des prestataires de soins de santé et des programs qui continuent à utiliser les soins en mode virtuel, et décrit la meilleure façon d'utiliser les différentes modalités de visites dans différentes situations cliniques et pour différents patients. D'autres travaux seront nécessaires pour valider ces résultats et évaluer les résultats cliniques lorsqu'il y a combinaison des modes virtuel et traditionnel pour la prestation des soins.

Physician experiences of workplace racial and gender microaggressions.

OBJECTIVES: To investigate racial and gender-specific microaggressions that are experienced by pediatric otolaryngologists at work. METHODS: An anonymous web-based survey consisting of 18 questions was sent to American Society of Pediatric Otolaryngology (ASPO) members via an email link. The survey included questions from the Workplace and School Microaggressions component of the Racial and Ethnic Microaggressions (REM) Scale. RESULTS: 125 out of 610 ASPO members completed the survey for a response rate of 20.5%. 28% of respondents reported experiencing a racial/ethnic microaggression in the last six months. Respondents who identified as Asian American Pacific Islander had significantly higher REM scores when compared with Caucasian respondents (p < 0.05). There was no significant difference in scores when comparing the other Race categories. Female respondents reported significantly higher gendered-microaggression scores compared to those identifying as male (p < 0.001). 66% of female respondents experienced some form of gender-based microaggression in the last six months. CONCLUSION: By providing evidence that pediatric otolaryngologists continue to report experiences of discrimination in the form of microaggressions, this study aims to increase awareness and inspire a more inclusive work environment.

Effusion Prevalence at Tympanostomy During COVID-19: Follow-Up.

OBJECTIVE: We previously reported pandemic year (2020) intraoperative middle ear effusion (MEE) rate at time of bilateral myringotomy tube (BMT) placement was 18% lower compared to pre-pandemic year (2019). After mandatory stay at home orders (MSHO) and pandemic social distancing precautions were relaxed, we aimed to assess the impact of a persistent pandemic with new COVID-19 variants on MEE presence during BMT. METHODS: This study is a retrospective chart summary exempted by Nemours institutional review board at a single tertiary children's hospital. Children < 18 years who underwent BMT during March 1, 2019-June 31, 2019 (pre-COVID), March 1, 2020-June 31, 2020 (PY1), and March 1, 2021-June 31, 2021 (PY2) were included. Statistical analysis included chi-squared and KruskalWallis. RESULTS: A total of 1069 BMTs were reviewed: 551 (52%) during pre-COVID, 227 (21%) during PY1, and 291 (27%) during PY2. There were no significant differences in age, sex, or BMI across comparison groups. Intraoperative MEE was significantly higher pre-COVID (83%) compared to PY1 (65%) and PY2 (69%) (P < .001) despite a small rebound in PY2. CONCLUSION: Intraoperative MEE remains lower in subsequent pandemic years despite relaxed public health measures and may be impacted by persistent public health measures like masking, lower return to daycare, variable social distancing, and/or change to access to health care.

Protocol for a Multistage Mixed-Methods Evaluation of Multidisciplinary Chronic Kidney Disease Care Quality Following Integration of Virtual and In-Person Care During the COVID-19 Pandemic.

Background: Multidisciplinary care of patients with chronic kidney disease (CKD) as it previously existed was predicated on an evidence and experience base of improved patient outcomes within an established and well-described service delivery model. The onset of the COVID-19 pandemic brought with it a departure from this established care delivery model toward integration of virtual care and in-person care. Objective: To develop an evaluation framework to determine whether this shift in service delivery models has affected quality of multidisciplinary kidney care and/or patient-clinician interactions and relationships. Design: A sequential multiphase, mixed-methods evaluation. Setting: All 15 British Columbia (BC) multidisciplinary kidney care clinics (KCCs). Participants: All patients and all clinicians in all KCCs across BC will be invited to participate in the planned evaluation. Measurements: Qualitative and quantitative feedback from patients and families living with CKD and KCC clinicians. Methods: The planned multiphase evaluation of virtual care integration in KCCs will be conducted across all 15 KCCs in the province of BC, Canada. The following phases are proposed: (1) review of current virtual care integration and practices, (2) assessment of patient and clinician experiences and perspectives via semi-structured interviews, (3) validation of those patient and clinician perspectives via survey of a larger sample, (4) compilation and analysis of all phases to provide informed recommendations for patient and visit format selection in a mixed in-person and virtual multidisciplinary clinic setting. Limitations: This work will not capture any information about the relationship between differences in virtual usage parameters and clinical outcomes or financial implications. Conclusions: There is no existing framework for either evaluation of multidisciplinary CKD care quality in a virtual setting or evaluation of care quality following a substantial change in service delivery models. The proposed evaluation protocol will enable better understanding of the nuances in kidney care delivery in this new format and inform how best to optimize the integration of virtual and pre-existing formats into kidney clinic care delivery beyond the pandemic. Beyond the current evaluation, this protocol may be of use for other jurisdictions to evaluate their own local instances of virtual care implementation and integration. The model may be adapted to evaluate quality of multidisciplinary kidney care delivery following other changes to clinic service delivery models.

Contexte: Les soins multidisciplinaires prodigués aux patients atteints d'insuffisance rénale chronique (IRC), tels qu'ils existaient auparavant, étaient fondés sur une base de preuves et d'expérience de l'amélioration des résultats pour les patients dans le cadre d'un modèle de prestation de services établi et bien décrit. Le début de la pandémie COVID-19 a créé une fracture par rapport à ce modèle établi de prestation de soins, à la faveur d'une intégration des soins virtuels et des soins en personne. Objectif: Élaborer un cadre d'évaluation permettant de déterminer si ce changement dans les modèles de prestation de services a eu une incidence sur la qualité des soins multidisciplinaires en santé rénale et/ou sur les interactions et les relations entre le patient et le clinicien. Type d'étude: Une évaluation multiphase séquentielle à méthodes mixtes. Cadre: Les 15 cliniques multidisciplinaires de soins rénaux (CMSR) de la C.-B. Participants: Tous les patients et cliniciens de toutes les CMSR de la Colombie-Britannique seront invités à participer à l'évaluation. Mesures: Les rétroactions qualitative et quantitative des patients atteints d'IRC et de leurs familles, ainsi que celles des cliniciens des CMSR. Méthodologie: L'évaluation multiphase prévue de l'intégration des soins virtuels dans les soins prodigués dans les CMSR sera menée dans les 15 CMSR de la Colombie-Britannique (C.-B.), au Canada. Les phases suivantes sont proposées: (1) examen de l'intégration et des pratiques actuelles en matière de soins virtuels, (2) évaluation des expériences et des perspectives des patients et des cliniciens par le biais d'entrevues semi-structurées, (3) validation de ces mêmes perspectives par le biais d'un sondage sur un échantillon plus large, (4) compilation et analyze des données recueillies lors de toutes les phases afin de fournir des recommandations éclairées pour le choix des patients et du format de la visite dans un contexte de clinique multidisciplinaire intégrant les consultations en personne et virtuelles. Limites: Ces travaux ne permettront pas de recueillir des informations sur la relation entre les différences dans les paramètres d'utilization virtuelle et les résultats cliniques ou les implications financières. Conclusion: En ce moment, il n'existe pas de cadre pour évaluer la qualité des soins multidisciplinaires en IRC dans un cadre virtuel ni pour évaluer la qualité des soins après un changement important dans les modèles de prestation de services. Le protocole d'évaluation proposé permettra de mieux comprendre les nuances dans la prestation des soins rénaux dans ce nouveau format et d'indiquer la meilleure façon d'optimiser l'intégration des formats virtuels et préexistants dans la prestation des soins en clinique rénale au-delà de la pandémie. Au-delà de l'évaluation actuelle, ce protocole pourra être utilisé par d'autres provinces pour évaluer leurs propres instances locales de mise en œuvre et d'intégration des soins virtuels. Le modèle peut être adapté pour évaluer la qualité de la prestation de soins multidisciplinaires aux reins à la suite d'autres changements apportés aux modèles de prestation de services en clinique.

The Physician as Leader: Navigating the Breadth of Opportunity and Finding Your Best Fit.

Leadership is important in all aspects of a physician's professional life. Leadership skills can be developed with experience, training, coaching, and mentorship. Physicians have an obligation to learn as much as possible about effective leadership so that when an opportunity to lead comes, they will make optimal use of it and feel empowered to contribute to solutions and improvements at all levels of health care.

Balance Versus Integration: Work-Life Considerations.

The term work-life balance may cause physicians to feel inadequate in pursuing a reality in which work and life each have equal importance. Furthermore, the term implies competition between these 2 realms. Instead, work-life integration is a more constructive and realistic term. Achieving harmonious integration requires self-reflection on the current state, goals, and resources and strategies needed to achieve and maintain such a state. Prioritizing aspects of both, and aligning them with individual requirements, while incorporating consistent and intentional investment of time and efforts in both professional and personal arenas is crucial to cultivate and sustain longitudinal well-being.

Middle ear effusion prevalence at time of tympanostomy before and during COVID-19 pandemic.

BACKGROUND: Management of pediatric otitis media with effusion (OME) and recurrent otitis media typically includes observation up to 3 months. Bilateral myringotomy and tube (BMT) placement is performed due to persistent effusion with associated symptoms such as decreased hearing. With the COVID-19 pandemic and mandatory stay at home orders (MSHO), children were quarantined at home and many remained home after MSHO. We reviewed the prevalence of middle ear effusion (MEE) at the time of BMT during similar time periods in the year before, during and after MSHO in this pandemic year. STUDY DESIGN: Retrospective summary of BMT cases at a single tertiary children's hospital. METHODS: All children <18 years who underwent BMT between March 1, 2020 and July 1, 2020 and between March 1, 2019 and July 1, 2019 were included. Statistical analysis included chi-squared and Mann-Whitney U tests. RESULTS: A total of 778 cases were reviewed; 551 (71%) were performed pre-pandemic and 227 (29%) during onset of pandemic (N = 778). There were no significant differences in gender, age, and BMI between groups, but significantly fewer Caucasians (58% vs. 45%, p < 0.05) and more Hispanics (20% vs. 33%, p < 0.05) during-COVID. The prevalence of intraoperative effusion during-COVID was significantly lower compared to pre-COVID (65% vs. 83%, p < 0.001). CONCLUSION: Pandemic and COVID-19 MSHO were associated with significantly lower intraoperative OME prevalence. Further research may elucidate the impact of face covering, social distancing, and virtual schooling on the incidence of pediatric ROM, OME, and ENT symptoms.

Sub-Daily Exposure to Fine Particulate Matter and Ambulance Dispatches during Wildfire Seasons: A Case-Crossover Study in British Columbia, Canada.

BACKGROUND: Exposure to fine particulate matter (PM2.5) during wildfire seasons has been associated with adverse health outcomes. Previous studies have focused on daily exposure, but PM2.5 levels in smoke events can vary considerably within 1 d. OBJECTIVES: We aimed to assess the immediate and lagged relationship between sub-daily exposure to PM2.5 and acute health outcomes during wildfire seasons in British Columbia. METHODS: We used a time-stratified case-crossover study design to evaluate the association between modeled hourly PM2.5 and ambulance dispatches during wildfire seasons from 2010 to 2015. Distributed lag nonlinear models were used to estimate the lag-specific and cumulative odds ratios (ORs) at lags from 1 to 48 h. We examined the relationship for all dispatches and dispatches related to respiratory, circulatory, and diabetic conditions, identified by codes for ambulance dispatch (AD), paramedic assessment (PA) or hospital diagnosis (HD). RESULTS: Increased respiratory health outcomes were observed within 1 h of exposure to a 10-µg/m3 increase in PM2.5. The 48-h cumulative OR [95% confidence interval (CI)] was 1.038 (1.009, 1.067) for the AD code Breathing Problems and 1.098 (1.013, 1.189) for PA code Asthma/COPD. The point estimates were elevated within 1 h for the PA code for Myocardial Infarction and HD codes for Ischemic Heart Disease, which had 24-h cumulative ORs of 1.104 (0.915, 1.331) and 1.069 (0.983, 1.162), respectively. The odds of Diabetic AD and PA codes increased over time to a cumulative 24-h OR of 1.075 (1.001, 1.153) and 1.104 (1.015, 1.202) respectively. CONCLUSIONS: We found increased PM2.5 during wildfire seasons was associated with some respiratory and cardiovascular outcomes within 1 h following exposure, and its association with diabetic outcomes increased over time. Cumulative effects were consistent with those reported elsewhere in the literature. These results warrant further investigation and may have implications for the appropriate time scale of public health actions. https://doi.org/10.1289/EHP5792.

Prevalence of prescription medication use in preschool-age children seen in pediatric otolaryngology.

OBJECTIVE: To examine the prevalence of daily medication use and prescribing patterns in preschool aged children presenting to otolaryngology clinics. STUDY DESIGN: Retrospective summary of prescription-related data from PEDSnet database of two tertiary care children's hospitals within single health system. METHODS: All new patients between birth and 5 years of age seen in otolaryngology clinics from October 1, 2016 through September 30, 2017 were included. Existing diagnoses, active prescriptions at time of visit, prescription dates, and demographics were abstracted. Summary analysis was performed on medication prevalence, quantity and duration of use, comparing all variables between age, gender, and geographical regions. RESULTS: Of 7532 patient encounters, 20% presented with active daily medication use. Eustachian tube dysfunction and otitis media were the most common diagnoses regardless of daily medication usage. Corticosteroids, specifically hydrocortisone (Delaware) and Flovent (Florida), were the most common medication prescribed. The number of medications strongly correlated with the number of encounter diagnoses. Overall, patients in Delaware were 4.5 times more likely to have at least one prescription prior to encounter (p < 0.05, 95% CI 3.2-4.8). This pattern was preserved across age and gender. Patients with medication in Delaware and Florida had a median of 2 (IQR 3.0-1.0) and 1 prescriptions (IQR 2.0-1.0), respectively (p < 0.001). There were no differences based on insurance type and no correlations between medication count and age or gender. CONCLUSION: Children in Delaware presented to otolaryngology clinics with significantly more prescribed medications than in Florida. Regional differences were consistent across age and gender. Most children were on these medications for a significant duration.

Population-based analysis of the effect of a comprehensive, systematic change in an emergency medical services resource allocation plan on 24-hour mortality.

BACKGROUND: Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013. METHODS: A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends. RESULTS: The derived cohort comprised 562,546 cases (April 2012-March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886-0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808-0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001). CONCLUSION: Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

A Survival Analysis of Pediatric Tonsillar Malignancies and Review of a Rare Case.

OBJECTIVE: To examine the survival of pediatric tonsillar cancer patients and review a rare case of pediatric tonsillar cancer. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of tonsillar malignancy using the ICD O-3 tonsil primary site codes of: C09.0, C09.1, C09.8, and C09.9. Patients were included from birth-18 years. Survival analysis was performed using Kaplan-Meier analysis. Additionally, a case of pediatric natural killer (NK) cell tonsillar lymphoma diagnosed and treated at the Nemours Children's hospital in Orlando, Florida is presented. RESULTS: One hundred forty-one cases of tonsil cancer were identified. The mean age at diagnosis was 9.9 years (SD: 5.1, range: 0.0 (months)-18.0). Ninety five (67.4%) patients were male and 116 (82.3%) had unilateral malignancies. Burkitt lymphoma (32.6%) followed by diffuse large B-cell lymphoma (DLBCL) (27.0%) were the two most common histological types of tonsillar cancers. 79.4% of patients received chemotherapy and 81.6% received surgery as a part of their care. The 5-year disease-specific survival rate was >90% for patient cohorts diagnosed from 1984 to 1993, 1994-2003, and 2004-2014 as compared to 64% for patients diagnosed from 1973 to 1983 (p = 0.01). CONCLUSIONS: Survival rates for pediatric patients with tonsillar cancer are excellent. Pediatric primary tonsil cancer occurred most commonly in adolescent males and usually presents as a unilateral mass. Lymphoma remains the predominant histological type of cancer. Most patients are likely to receive surgery and chemotherapy.

Pediatric head and neck fibrosarcomas: A demographical, treatment, and survival analysis and review of a rare case.

OBJECTIVE: To examine pediatric head and neck fibrosarcoma cases and review the demographics, management, and survival for these patients. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of a head and neck fibrosarcoma using ICD-O-3 head and neck primary sites and histology codes. Patients were included from birth-18 years of age. Additionally, a pediatric case of a head and neck infantile fibrosarcoma treated at the Nemours Children's hospital in Orlando, Florida is presented. RESULTS: One hundred-thirteen pediatric head and neck fibrosarcomas were identified within the SEER database over the study period. The mean age at diagnosis was 9.8 years (SD: 6.2, range: 0.0-18.0). The mean age at diagnosis for infantile fibrosarcomas was 1.7 years (SD: 3.2, range: 0.0-12.0). Fifty-one (45.1%) patients were female. A majority (N = 67, 59.3%) of patients had dermatofibrosarcoma followed by 18 (15.9%) who had infantile fibrosarcomas. Nearly all patients (N = 107, 94.7%) received surgical intervention. 27.8% of patients with an infantile fibrosarcoma received chemotherapy as a part of their care compared to 1.5% of patients with a dermatofibrosaroma (p = .004). The 5-year disease-specific survival was 97%. CONCLUSIONS: Pediatric patients with head and neck fibrosarcomas are most likely to present in Caucasian males or females during late childhood or early adolescence. Infantile fibrosarcomas present in pediatric patients at a much earlier age. Surgical management is common for pediatric head and neck fibrosarcomas. Additionally, chemotherapy may be used for infantile fibrosarcomas of the head and neck. Survival rates for pediatric patients with a head and neck fibrosarcoma are excellent.

Enabling adoption of 2D-NMR for the higher order structure assessment of monoclonal antibody therapeutics.

The increased interest in using monoclonal antibodies (mAbs) as a platform for biopharmaceuticals has led to the need for new analytical techniques that can precisely assess physicochemical properties of these large and very complex drugs for the purpose of correctly identifying quality attributes (QA). One QA, higher order structure (HOS), is unique to biopharmaceuticals and essential for establishing consistency in biopharmaceutical manufacturing, detecting process-related variations from manufacturing changes and establishing comparability between biologic products. To address this measurement challenge, two-dimensional nuclear magnetic resonance spectroscopy (2D-NMR) methods were introduced that allow for the precise atomic-level comparison of the HOS between two proteins, including mAbs. Here, an inter-laboratory comparison involving 26 industrial, government and academic laboratories worldwide was performed as a benchmark using the NISTmAb, from the National Institute of Standards and Technology (NIST), to facilitate the translation of the 2D-NMR method into routine use for biopharmaceutical product development. Two-dimensional 1H,15N and 1H,13C NMR spectra were acquired with harmonized experimental protocols on the unlabeled Fab domain and a uniformly enriched-15N, 20%-13C-enriched system suitability sample derived from the NISTmAb. Chemometric analyses from over 400 spectral maps acquired on 39 different NMR spectrometers ranging from 500 MHz to 900 MHz demonstrate spectral fingerprints that are fit-for-purpose for the assessment of HOS. The 2D-NMR method is shown to provide the measurement reliability needed to move the technique from an emerging technology to a harmonized, routine measurement that can be generally applied with great confidence to high precision assessments of the HOS of mAb-based biotherapeutics.