The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

The COVID-19 pandemic has placed an extraordinary demand on the United States health care system. Many institutions have canceled elective and nonurgent procedures to conserve resources and limit exposure. While operational definitions of elective and urgent categories exist, there is a degree of surgeon judgment in designation. In the present commentary, we provide a framework for prioritizing head and neck surgery during the pandemic. Unique considerations for the head and neck patient are examined including risk to the oncology patient, outcomes following delay in head and neck cancer therapy, and risk of transmission during otolaryngologic surgery. Our case prioritization criteria consist of four categories: urgent-proceed with surgery, less urgentconsider postpone > 30 days, less urgent-consider postpone 30 to 90 days, and case-by-case basis. Finally, we discuss our preoperative clinical pathway for transmission mitigation including defining low-risk and high-risk surgery for transmission and role of preoperative COVID-19 testing.

Objective Total laryngectomy (TL) is a high-cost procedure with patients at risk for significant postoperative health care use. Face-to-face preoperative counseling provided by speech-language pathologists is a relatively inexpensive intervention that may improve care quality and decrease costs. We evaluated if preoperative counseling for patients undergoing TL was associated with differences in length of stay (LOS), use of the emergency department (ED), or unplanned readmissions within 30 days of discharge. A secondary analysis identified predictors of these 3 outcomes. Study Design Case series with chart review. Setting Academic medical center in the United States. Subjects and Methods Patients were included if they underwent TL from 2011 to 2015. Patient demographics and comorbidities, surgical characteristics, and perioperative care data were retrieved and analyzed for 116 patients. Univariate and multivariate models were constructed for 3 outcomes. Results LOS was significantly lower for patients receiving counseling (-3.0 days, P = .02). No differences were observed in rates of 30-day ED visits or unplanned readmissions. Care provided by high-volume surgeons was associated with decreased LOS ( P = .005), while having postoperative complications increased LOS ( P < .001). High rates of ED visits (12.1%) and readmissions (20.6%) were observed. Discharge to inpatient rehabilitation and the patient's home distance from the institution were predictors of ED visits. TL as salvage therapy and occurrence of postoperative complications were risk factors for readmission. Conclusion Preoperative counseling was associated with marked reduction in LOS following TL without increased readmissions, which suggests that it may promote safe, earlier patient readiness for discharge.

SummaryObjective: Patient portals are online applications that allow patients to interact with healthcare organizations. Portal adoption is increasing, and secure messaging between patients and healthcare providers is an emerging form of outpatient interaction. Research about portals and messaging has focused on medical specialties. We characterized adoption of secure messaging and the contribution of messaging to outpatient interactions across diverse clinical specialties after broad portal deployment. Methods: This retrospective cohort study at Vanderbilt University Medical Center examined use of patient-initiated secure messages and clinic visits in the three years following full deployment of a patient portal across adult and pediatric specialties. We measured the proportion of outpatient interactions (i.e., messages plus clinic visits) conducted through secure messaging by specialty over time. Generalized estimating equations measured the likelihood of message-based versus clinic outpatient interaction across clinical specialties. Results : Over the study period, 2,422,114 clinic visits occurred, and 82,159 unique portal users initiated 948,428 messages to 1,924 recipients. Medicine participated in the most message exchanges (742,454 messages; 78.3% of all messages sent), followed by surgery (84,001; 8.9%) and obstetrics/gynecology (53,424; 5.6%). The proportion of outpatient interaction through messaging increased from 12.9% in 2008 to 33.0% in 2009 and 39.8% in 2010 (p<0.001). Medicine had the highest proportion of outpatient interaction conducted through messaging in 2008 (23.3% of outpatient interactions in medicine). By 2010, this proportion was highest for obstetrics/gynecology (83.4%), dermatology (71.6%), and medicine (56.7%). Growth in likelihood of message-based interaction was greater for anesthesiology, dermatology, obstetrics/gynecology, pediatrics, and psychiatry than for medicine (p<0.001). Conclusions: This study demonstrates rapid adoption of secure messaging across diverse clinical specialties, with messaging interactions exceeding face-to-face clinic visits for some specialties. As patient portal and secure messaging adoption increase beyond medicine and primary care, research is needed to understand the implications for provider workload and patient care. Citation: Cronin RM, Davis SE, Shenson JA, Chen Q, Rosenbloom ST, Jackson GP. Growth of secure messaging through a patient portal as a form of outpatient interaction across clinical specialties. Appl Clin Inf 2015; 6: 288-304 http://dx Research Article

Background Use of secure messaging through patient portals has risen substantially in recent years due to provider incentives and consumer demand. Secure messaging may increase patient satisfaction and improve outcomes, but also adds to physician workload. Most prior studies of secure messaging focused on primary care and medical specialties. We examined surgeons’ use of secure messaging and the contribution of messaging to outpatient interactions in a broadly-deployed patient portal. Methods We determined the number of clinic visits and secure messages for surgical providers in the first three years (2008–10) after patient portal deployment at an academic medical center. We calculated the proportion of outpatient interaction conducted through messaging for each specialty. Logistic regression models compared the likelihood of message-based versus clinic outpatient interaction across surgical specialties. Results Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 messages, with more than 200% growth in monthly message volume. Surgical specialties receiving the most messages were orthopedics/podiatry (25.1%), otolaryngology (20.1%), urology (10.8%), and general surgery (9.6%); vascular surgery (0.8%) and pediatric general surgery (0.2%) received the fewest. The proportion of outpatient interactions conducted through secure messaging increased significantly from 5.4% in 2008 to 15.3% in 2010 (p<0.001) with all specialties experiencing growth. Heart/lung transplantation (74.9%), liver/kidney/pancreas transplantation (69.5%), and general surgery (48.7%) had the highest proportion of message-based outpatient interaction by the end of the study. Conclusions This study demonstrates rapid adoption of online secure messaging across surgical specialties with significant growth in its use for outpatient interaction. Some specialties, particularly those with long-term follow-up, interacted with patients more through secure messaging than in person. As surgeons devote more time to secure messaging, additional research will be needed to understand the care delivered through online interactions and to develop models for reimbursement.

Objective Safe surgery requires the accurate discrimination of tissue intraoperatively. We assess the feasibility of using multispectral imaging and deep learning to enhance surgical vision by automated identification of normal human head and neck tissues. Study Design Construction and feasibility testing of novel multispectral imaging system for surgery. Setting Academic university hospital. Subjects and Methods Multispectral images of fresh-preserved human cadaveric tissues were captured with our adapted digital operating microscope. Eleven tissue types were sampled, each sequentially exposed to 6 lighting conditions. Two convolutional neural network machine learning models were developed to classify tissues based on multispectral and white-light color images (ARRInet-M and ARRInet-W, respectively). Blinded otolaryngology residents were asked to identify tissue specimens from white-light color images, and their performance was compared with that of the ARRInet models. Results A novel multispectral imaging system was developed with minimal adaptation to an existing digital operating microscope. With 81.8% accuracy in tissue identification of full-size images, the multispectral ARRInet-M classifier outperformed the white-light-only ARRInet-W model (45.5%) and surgical residents (69.7%). Challenges with discrimination occurred with parotid vs fat and blood vessels vs nerve. Conclusions A deep learning model using multispectral imaging outperformed a similar model and surgical residents using traditional white-light imaging at the task of classifying normal human head and neck tissue ex vivo. These results suggest that multispectral imaging can enhance surgical vision and augment surgeons’ ability to identify tissues during a procedure.

Type 1 diabetes (T1D) 2 in humans is an autoimmune disease involving the destruction of insulin-producing ␤ cells in the islets of Langerhans by CD8ϩ T cells (1-6). In humans, the disease develops over a period of years after the first appearance of autoantibodies that identify individuals who are at risk. The kinetics of progression to T1D differs from those of other cellmediated immune responses. In responding to foreign pathogens, there is rapid expansion of antigen-specific effector T cells followed by contraction and the appearance of memory T cells. Immune targets are destroyed within weeks. Primarily based on serologic data from studies of discordant triplets and relatives at risk for the disease, ␤ cell destruction in T1D is thought to occur over a period of years, although we and others have postulated that there was waxing and waning of the process. More recent data has suggested that the progression is not uniform. The time required for metabolic changes in glucose tolerance was thought to reflect the need to destroy a large ␤ cell mass before glucose tolerance deteriorates, but our studies of ␤ cell killing in NOD mice and humans suggests instead that the progression of ␤ cell killing may be rapid in the peridiagnosis period. In NOD mice, which first develop insulitis at 5-6 weeks of age, the rate of ␤ cell killing does not show a significant increase until after11 weeks of age coincident with the appearance of glucose intolerance. In our studies of ␤ cell killing in relatives of patients with T1D, only 25% of the 49 measurements that were obtained approximately every 6 months for up to 4.14 years before diagnosis showed increased levels, indicating that the destruction of ␤ cells is an uncommon event. However, in at-risk subjects who were closer to diagnosis and manifest dysglycemia, 81% of the measurements in 27 subjects showed elevated levels of ␤ cell death. These data showed that ␤ cell killing is significantly greater when glucose intolerance is present.These observations led us to consider whether there were interactions between the pathogenic immune cells and host factors that may affect the progression of disease. To understand these interactions, we focused our studies on CD8ϩ T cells that are reactive to an epitope of glucose-6-phosphatase catalytic subunit related protein (IGRP) and are known to cause ␤ cell killing. These CD8ϩ T cells are the best characterized among pathogenic T cells (2-4, 7-15). In human autopsy studies, CD8ϩ T cells reactive to an epitope of IGRP have been found in pancreata from patients several years after the onset of disease (6). IGRP-reactive CD8ϩ T cells can be found in NOD mice by staining with MHC-I tetramer loaded with NRP-V7 peptide (5,12,16). They can cause diabetes when they receive help from CD4ϩ T cells (13). We analyzed gene expression among these cells to identify mechanisms that might account * This work was supported, in whole or in part, by National Institutes of Health Grants R01 DK057846, U01 AI02011, and UC4 DK104205. The authors declare that th...

Objectives To evaluate new drugs and devices relevant to otolaryngology–head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020. Data Sources Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees. Review Methods Members of the American Academy of Otolaryngology–Head and Neck Surgery’s Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA’s device and therapeutic approvals. Two independent reviewers assessed the drug’s or device’s relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature. Conclusions The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology’s armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology. Implications for Practice New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.