Search

A 2-month-old, full-term female presents with a left upper neck mass. What is your diagnosis?

To investigate which components of pediatric otolaryngology fellowship applications are more closely predictive of future academic productivity in applicants who go on to complete their fellowship training.Applications to our institution's ACGME accredited pediatric otolaryngology fellowship program through the SF Match program for the years 2011-2016 were reviewed. Applicant files on record were utilized to extract independent variables including sex, mean USMLE score, residency program Doximity ranking, military experience, number of national honors/awards, AOA status, total number of publications listed on application, number of first author publications listed on application, and AAOHNS Committee involvement. Academic productivity was determined by number of PubMed indexed publications per year, practice setting, and H-index (Scopus). Statistical analysis consisted of multivariate and univariate regression models, with p 0.05 being considered statistically significant.Multivariate regression showed that USMLE Step 1 and 2 mean score and number of publications listed on application exhibited statistically significant correlations with a higher number of future post fellowship publications per year. Residency program Doximity rank, applicant number of awards and honors, AOA status, and number of first author publications were not predictive of future academic productivity. No statistically significant associations were found between any variables and the faculty position outcome variable.Quantifiable criteria in pediatric otolaryngology fellowship applications, such as number of listed publications and mean USMLE scores are strongly correlated with future academic productivity metrics.

We aimed to evaluate factors associated with time to return to OR in children presenting with post-tonsillectomy hemorrhage to a tertiary children's hospital.Retrospective study of pediatric patients presenting to a single institution from January 2012 to January 2020, with post-tonsillectomy hemorrhage (PTH) requiring surgical intervention for control of bleeding. Correlation, univariate, and multivariate analysis were conducted.Of 15,984 tonsillectomies performed at our institution during the study period, 144 required return to the OR for bleeding control, in addition to 15 other children whose tonsillectomy had been performed at an outside institution. Mean time to the OR was 119.7 min (SD 101.5) in the morning, 77.4 min (SD 60.6) in the afternoon, 55.6 min (SD 34.8) in the evening, and 49.4 min (SD 26.4) overnight (ANOVA p 0.0001). The mean hemoglobin decline from pre-to post-tonsillectomy was 1.3 g/dl (SD 1.7). Primary hemorrhages had a mean time to OR of 62.39 min (SD 63.42) while secondary hemorrhages mean time to OR was 85.54 min (SD 76.21) (p = 0.0064). There was no significant difference in time to OR among race/ethnicity (p = 0.928), insurance status (p = 0.359), weekday (p = 0.557), surgeon seniority (p = 0.8104) or by hemoglobin drop (p = 0.2773). When controlling for each of these variables, multiple linear regression showed that only time of day had significant correlation with time to OR (p = 0.0003).At a tertiary children's hospital, patients presenting with PTH requiring revision surgery waited the longest to get to the OR in the morning versus all other times of day. These results can aid in individualization of anticipatory guidance in order to reduce morbidity and mortality from complications requiring revision in the operating room.

We aim to analyze factors associated with readmission after tonsillectomy to understand socioeconomic factors associated with readmission.Single institution retrospective study of pediatric patients undergoing tonsillectomy over an 8 year study period, comparing patients who required readmission for bleeding concerns or pain/dehydration to those who did not require readmission.Of the 14,152 tonsillectomy patients, 508 (3.6%) were readmitted with 423 (83.3%) for bleeding concerns and 85 (16.7%) for pain or dehydration. Overall readmission was more likely in age6 years (OR: 1.61, 95% CI: 1.34-1.92, P 0.001), while poverty level below 10% (OR: 0.79, 95% CI: 0.66-0.94, P = 0.008) and parental college education above 25% (OR: 0.79, 95% CI: 0.65-0.96, P = 0.016) were associated with lower incidence of overall readmission. For patients readmitted for bleeding concerns, age6 years (OR 1.66, 95% CI: 1.37-2.02, P 0.001) was associated with readmission on multivariate analysis. Within the pain/dehydration group, African American race was associated with increased readmission rates, while poverty level below 10% and parental college education above 25% were associated with decreased readmission rates.Socioeconomic factors and age play a role in readmission rates following pediatric tonsillectomy.

Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database. Results In the 53 cases reported to the database over 22 months, the majority involved errors that had resulted in harm (n = 34, 64%), followed by errors that occurred and did not result in harm (n = 7, 13%). Errors occurred predominantly in the hospital (n = 23, 44%) and operating room (n = 19, 35%). Most entries were classified as either technical (n = 21, 39%) or related to postoperative care (n = 15, 30%). Discussion This preliminary descriptive analysis of a novel otolaryngology patient safety event reporting tool shows that this platform brings unique value to the identification of errors and adverse events in our specialty. Most reported events were classified as errors resulting in harm. The most common type of reported event was a technical error, most often resulting in a nerve injury. Implications for Practice This reporting tool will likely allow for identification and prioritization of improvement opportunities. This example may serve as a guide for other societies to create similar platforms as we strive for a standardized process for event reporting.

This article highlights the important relationship between the otolaryngologist and anesthesiologist, focusing on intraoperative patient safety for otolaryngologic surgery. In addition, consideration of preoperative history, physical examination, and potential postoperative complications helps guide the otolaryngologist and anesthesiologist in formulating an appropriate and collaborative management strategy.

Vascular anomalies are divided into tumors and malformations based on their clinical and cytologic attributes. Vascular malformations are further subcategorized as low-flow lymphatic, venous, capillary, or mixed lesions and as high-flow arteriovenous malformations. Treatment is reserved for vascular anomalies that are symptomatic or cosmetically disfiguring, and surgical and nonsurgical treatment options are widely varied with variable outcomes.

Microbeam measurements and TCAD simulations are used to examine the effects of ion angle of incidence on the charge collected from events occurring in a Silicon Germanium (SiGe) Heterojunction Bipolar Transistor (HBT). The results identify the geometrically driven charge-collection mechanisms that dominate the low LET broad beam SEU response. The deep trench isolation that surrounds the transistor significantly modulates the charge transport and, therefore, the charge collected by the collector. A new way of estimating critical charge, , for upset in SiGe HBT circuits is proposed based on TCAD simulation results and measured broadbeam data.

The off-state drain current leakage characteristics of 130 nm CMOS technology are investigated using x-ray irradiation and operating temperature as variables. Radiation-induced interface traps in the gate oxide to gate-drain overlap region strongly enhance the off-state leakage as a function of gate bias. Due to the thin gate oxide in these 130 nm devices, we find that drain-edge direct tunneling is more plausible than conventional gate-induced-drain-leakage in explaining the observed increase in drain leakage. Radiation-induced traps in the shallow trench isolation oxide create parasitic channels in the p-well and produce another source of off-state drain leakage with increasing total dose. The drain current increase from both the gate overlap region and the shallow trench edge are enhanced with increasing total dose and suppressed by cooling

The probability of proton-induced multiple-bit upset (MBU) has increased in highly-scaled technologies because device dimensions are small relative to particle event track size. Both proton-induced single event upset (SEU) and MBU responses have been shown to vary with angle and energy for certain technologies. This work analyzes SEU and MBU in a 130 nm CMOS SRAM in which the single-event response shows a strong dependence on the angle of proton incidence. Current proton testing methods do not account for device orientation relative to the proton beam and, subsequently, error rate prediction assumes no angular dependencies. Proton-induced MBU is expected to increase as integrated circuits continue to scale into the deep sub-micron regime. Consequently, the application of current testing methods will lead to an incorrect prediction of error rates

We compare, for the first time, the effects of 63 MeV protons on 1st generation and 3rd generation SiGe HBTs irradiated at both liquid nitrogen temperature (77 K) and at room temperature (300 K). The 1st generation SiGe HBTs irradiated at 77 K show less degradation than when irradiated at 300 K. Conversely, the 3rd generation SiGe HBTs exhibits an opposite trend, and the devices irradiated at 77 K show enhanced degradation compared to those irradiated at 300 K. The emitter-base spacer regions for these two SiGe technologies are fundamentally different in construction, and apparently are responsible for the observed differences in temperature-dependent radiation response. At practical circuit biases, both SiGe technology generations show only minimal degradation for both at 77 K and 300 K exposure, to Mrad dose levels, and are thus potentially useful for electronics applications requiring simultaneous cryogenic temperature operation and significant total dose radiation exposure

A comprehensive investigation of the effects of proton irradiation on the performance of SiGe BiCMOS precision voltage references intended for extreme environment operational conditions is presented. The voltage reference circuits were designed in two distinct SiGe BiCMOS technology platforms (first generation (50 GHz) and third generation (200 GHz)) in order to investigate the effect of technology scaling. The circuits were irradiated at both room temperature and at 77 K. Measurement results from the experiments indicate that the proton-induced changes in the SiGe bandgap references are minor, even down to cryogenic temperatures, clearly good news for the potential application of SiGe mixed-signal circuits in emerging extreme environments

Delayed charge collection from ionizing events outside the deep trench can increase the SEU cross section in deep trench isolation technologies. Microbeam test data and device simulations demonstrate how this adverse effect can be mitigated through substrate engineering techniques. The addition of a heavily doped p-type charge-blocking buried layer in the substrate can reduce the delayed charge collection from events that occur outside the deep trench isolation by almost an order of magnitude, implying an approximately comparable reduction in the SEU cross section

We investigate the reliability issues associated with the application of CMOS devices contained within an advanced SiGe HBT BiCMOS technology to emerging cryogenic space electronics (e.g., down to 43 K, for Lunar missions). Reduced temperature operation improves CMOS device performance (e.g., transconductance, carrier mobility, subthreshold swing, and output current drive), as expected. However, operation at cryogenic temperatures also causes serious device reliability concerns, since it aggravates hot-carrier effects, effectively decreasing the inferred device lifetime significantly, especially at short gate lengths. In the paper, hot-carrier effects are demonstrated to be a stronger function of the device gate length than the temperature, suggesting that significant trade-offs between the gate length and the operational temperature must be made in order to ensure safe and reliable operation over typical projected mission lifetimes in these hostile environments.

This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care.PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials.We queried 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient or parent satisfaction or experience of care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent or patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles.The initial search yielded 4748 publications (1503 duplicates), of which 170 underwent full-text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (3/35), parent (23/35), or both (9/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (8), by satisfaction tools (8), or by nonstandard institutional or author-developed tools (19). Experience was measured in the outpatient (7), preoperative (11), operative (14), and postoperative (3) care settings. Specific findings were unique to setting; however, in many studies higher satisfaction correlated with education/information giving, health care provider interpersonal behaviors, and facile/efficient care processes.The patient experience of care is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Findings related to patient satisfaction and experience of care may be limited due to lack of measurement using validated tools. Findings from this review may bear significance as patient experience measures become routinely integrated with quality and reimbursement.

Objectives:Synthesize evidence-based findings related to patient satisfaction as a quality indicator in pediatric surgical care.Methods:We conducted a qualitative systematic review, querying 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient/parent satisfaction or experience-of-care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent/patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles.Results:The initial search yielded 4678 publications (1433 duplicates) of which 170 underwent full text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (4/35), parent (19/35), or both (12/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (9) or satisfaction tools (13), or by non-standard institutional ...

Objective: 1) To identify and define the cervical esophageal branches (CEB) of the recurrent laryngeal nerve (RLN), in vivo. 2) To study the feasibility of positively identifying the nonlaryngeal, ...

The effects of 63 MeV proton irradiation on 90 nm strained silicon CMOS on insulator is examined for the first time. The devices show no observable degradation in DC performance up to an equivalent total dose of 600 krad(Si). The performance of the strained pFETs is identical to unstrained pFETs and demonstrates the immunity of strain to displacement damage. There is no significant enhancement observed in back channel leakage for the maximum dose. Passive exposure to 2 Mrad(Si) using 4 MeV protons doesn't induce any significant performance degradation.

0C (43K) in the polar shadows), makes operation of the electronics sub-systems on the surface of the Moon exceptionally difficult, but is nonetheless required for the envisioned complex suite of electronics systems used in sensing, actuation, and control of robotic systems. Such applications are typically fairly low frequency in nature (e.g., < 100 MHz), hence not requiring the most aggressively scaled CMOS technology; however, a full suite of mixed-signal circuit building blocks, and reliable operation of those circuits across extremely large variations in temperature (e.g., +120 to -230C) is needed. Adequate device reliability must clearly be achieved to accomplish this task. CMOS device degradation due to hot carriers effect (HCE) is known to be considerably worse at low temperatures [2]. Device lifetime data at cryogenic temperatures, and a solid understanding of the corresponding degradation mechanisms, are thus critical in this context of space electronics, and are addressed in this work. The Si CMOS devices investigated here are from an advanced 0.5µm SiGe BiCMOS technology, with a fixed channel width of 10.0 µm, and effective gate lengths ranging from 0.35 µm (minimum geometry), to 5.0 µm. The devices were characterized on a custom cryogenic probe system from 300K down to 43 K (-230 0 C). For brevity we will focus on the nFET data, since it represents the worst case in this technology. Fig. 1 and 2 shows typical I-V characteristics for the CMOS devices at different temperatures. The current drive capability increases significantly for the same bias conditions, as the temperature decreases. The nFET lifetime was inferred using stress-induced changes to the ID-VG characteristics. The lifetime τ is defined here as the inferred stress time for which a certain parameter of the ID-VG characteristics has shifted by a predefined amount (e.g., 10% degradation of gm). A typical lifetime assessment analysis using the ID-VG characteristics for a 1.0 µm nFET are shown in Fig. 3 and Fig. 4. The slope of 0.6 for the linear fitting in Fig. 4 suggests that interface state generation is responsible for the observed device degradation at the maximum substrate current (VG ≈ ½ VD); while that of 0.3 for the maximum gate current bias condition (VG = VD) suggests that oxide trapped charge dominates [3]. For the nFETs operating at 300K, the worst case bias condition for hot carrier degradation is known to be under maximum substrate current bias. There has been speculation that the worst case bias conditions for hot carrier degradation can, however, be a function of temperature [4]. It can be verified from Fig. 4 that for this technology, maximum substrate current is indeed the worst bias condition, at least down to 82K, and hence was the condition used here for device lifetime evaluation. The substrate current is comprised of the generated hot carriers, and is thus a good monitoring parameter for HCE in practical measurements. Fig. 5 and Fig. 6 show the effects of temperature and gate length on substrate current, respectively. It can be seen from Fig. 5 that the maximum substrate current under the same bias condition increases by 3x as temperature decreases from 300K to 43K; while Fig. 6 suggests that the maximum substrate current increases by more than 10x as L shrinks from 1.0 µm to 0.35 µm, and becomes negligible as L increases to 5.0 µm. This suggests that HCE is impacted more by device geometry than by the temperature. Fig. 7 shows the inferred lifetime at different drain bias’ at different temperatures. As seen in Fig. 7, τ decreases by ~10x as the temperature is reduced from 300K to 82K. Furthermore, τ differs by more than 100x between the 1.0 µm and 0.35/5 µm transistors, and hence the longer-channel devices are preferred for cryogenic applications of this technology Assuming fast interface trap generation dominates the HCE degradation, plotting τID versus ISUB/ID on a log-log scale should yield a straight line behavior [5]. The critical electron energy for generating an interface trap is calculated to be 3.9 eV from the slop of the line. Both the slope and the critical energy from Fig. 8 correlate well with literature data (2.9 and 3.7 eV in [5]), suggesting that interface state generation is the dominant limiting reliability factor at low temperatures.

Importance Reviews of patient and caregiver experience with health practitioners are increasingly important to consumers. Understanding physician qualities valued by patients and their families may facilitate more effective care and communication. Objective To identify physician qualities and care dimensions valued by parents during their child’s outpatient surgical care encounter. Design Mixed-methods analysis of comments from patient-satisfaction surveys. Setting Outpatient pediatric otolaryngology and surgical specialty clinics in an urban tertiary care center. Participants Parents of children seen in pediatric otolaryngology and surgical specialty clinics who completed the physician section of the patient satisfaction survey. Main Outcomes and Measures Free-text comments written in the physician section of the survey. Results A total of 195 survey comments from visits to 18 surgical specialty clinics were analyzed; 64 comments (33%) were global in nature, of which 58 (90%) were positive; 25 of 195 comments (13%) discussed recommendation of care. Of the 131 comments (67%) with specific content, 79 (60%) were positive. Major themes were physician interpersonal style (n = 78, 45%), physician technical skills/knowledge/preparation (n = 82, 47%), and systems issues (n = 14, 8%). The most commonly noted interpersonal subthemes were inclusion/interaction with the child (20%) and empathy/concern for the patient’s needs (29%). The most common skills themes related to whether the physician answered questions (16%) or explained treatment (23%). The most common negative subgroup was inadequate explanation of treatment (18%). The majority of comments related to systems were negative (13 of 14, 93%). Conclusions and Relevance Parents highly value physician interpersonal style and visit-specific skills (involving the child in discussion; showing empathy/concern for the patient/family; answering questions; explaining treatment). While most comments about surgeons were affirmative, clinical systems were more often negatively perceived. Attention to parent-reported experiences may help physicians improve communication and overall effectiveness of care provided.