Signal to noise ratio quantifies the contribution of spectral channels to classification of human head and neck tissues ex vivo using deep learning and multispectral imaging.

Significance: Accurate identification of tissues is critical for performing safe surgery. Combining multispectral imaging (MSI) with deep learning is a promising approach to increasing tissue discrimination and classification. Evaluating the contributions of spectral channels to tissue discrimination is important for improving MSI systems. Aim: Develop a metric to quantify the contributions of individual spectral channels to tissue classification in MSI. Approach: MSI was integrated into a digital operating microscope with three sensors and seven illuminants. Two convolutional neural network (CNN) models were trained to classify 11 head and neck tissue types using white light (RGB) or MSI images. The signal to noise ratio (SNR) of spectral channels was compared with the impact of channels on tissue classification performance as determined using CNN visualization methods. Results: Overall tissue classification accuracy was higher with use of MSI images compared with RGB images, both for classification of all 11 tissue types and binary classification of nerve and parotid ( p < 0.001 ). Removing spectral channels with SNR > 20 reduced tissue classification accuracy. Conclusions: The spectral channel SNR is a useful metric for both understanding CNN tissue classification and quantifying the contributions of different spectral channels in an MSI system.

Clinical outcomes of combined cervical and transthoracic surgical approaches in patients with advanced thyroid cancer.

BACKGROUND: Advanced thyroid disease involving the mediastinum may be managed surgically with a combined transcervical and transthoracic approach. Contemporary analysis of this infrequently encountered cohort will aid the multidisciplinary team in personalizing treatment approaches. METHODS: Retrospective review of patients undergoing combined transcervical and transthoracic surgery for thyroid cancer at a single high-volume institution from 1994 to 2015. RESULTS: Thirty-eight patients with median age 59 years (range 28-76) underwent surgery without perioperative mortality. Most patients had primary disease. A majority had distant metastases outside the mediastinum but had locoregionally curable disease. Common complications were temporary (39%) and permanent (18%) hypoparathyroidism, and wound infection (13%). One-year overall survival was 84%; 1-year locoregional disease-free survival was 64%. Median time to locoregional recurrence was 36 months. Only esophageal invasion was associated with worse oncologic outcomes. CONCLUSIONS: Combined transcervical and transthoracic surgery for advanced thyroid cancer can be performed without mortality and with acceptable morbidity.

Primary and recurrent regional metastases for lateralized oral cavity squamous cell carcinoma.

OBJECTIVES: Map regional lymph node metastases for lateralized oral cavity squamous cell carcinoma (OCSCC) and evaluate factors associated with regional metastases and recurrence. MATERIALS AND METHODS: Retrospective cohort study of 715 patients with lateralized OCSCC surgically treated in 1997-2011. Analysis was performed using log-rank, Kaplan-Meier, and multivariable logistic and Cox regression. RESULTS: Regional metastases were identified in ipsilateral levels IIA (24%), IB (18%), III (13%), V (9%), IV (7%), IA (2%) and IIB (1%) and the contralateral neck (3%). Lymphovascular invasion (LVI) (Hazard Ratio [HR] 2.2, 95% Confidence Interval [CI] 1.2-3.9) and T category (T3 vs. T1: HR 4.1, 95% CI 1.9-9.3; T4 vs. T1: HR 2.3, 95% CI 1.2-4.3) were associated with regional metastases. Most (71%) isolated regional metastatic recurrences were in undissected levels of the neck, including 58% in levels IV and V. Tumors of the hard palate (HR 4.3, 95% CI 1.2-16.1), upper alveolus (HR 3.2, 95% CI 1.0-4.7) or with LVI (HR 2.0, 95% CI 1.0-3.9) were associated with isolated regional recurrence. For upper alveolar/hard palate tumors, depth of invasion (DOI) ≥4 mm (P = .003) and LVI (P = .04) were associated with regional metastases. CONCLUSIONS: For lateralized OCSCC, elective neck dissection of level IIB or the contralateral neck may rarely be needed, but additional surgical or radiation treatment of levels IV and V may be considered based on patient risk factors, including T category 3-4 or LVI. For upper alveolar/hard palate tumors, DOI ≥4 mm is an appropriate threshold for elective neck dissection.

Engaging Housestaff as Informatics Collaborators: Educational and Operational Opportunities.

BACKGROUND: In academic hospitals, housestaff (interns, residents, and fellows) are a core user group of clinical information technology (IT) systems, yet are often relegated to being recipients of change, rather than active partners in system improvement. These information systems are an integral part of health care delivery and formal efforts to involve and educate housestaff are nascent. OBJECTIVE: This article develops a sustainable forum for effective engagement of housestaff in hospital informatics initiatives and creates opportunities for professional development. METHODS: A housestaff-led IT council was created within an academic medical center and integrated with informatics and graduate medical education leadership. The Council was designed to provide a venue for hands-on clinical informatics educational experiences to housestaff across all specialties. RESULTS: In the first year, five housestaff co-chairs and 50 members were recruited. More than 15 projects were completed with substantial improvements made to clinical systems impacting more than 1,300 housestaff and with touchpoints to nearly 3,000 staff members. Council leadership was integrally involved in hospital governance committees and became the go-to source for housestaff input on informatics efforts. Positive experiences informed members' career development toward informatics roles. Key lessons learned in building for success are discussed. CONCLUSION: The council model has effectively engaged housestaff as learners, local champions, and key informatics collaborators, with positive impact for the participating members and the institution. Requiring few resources for implementation, the model should be replicable at other institutions.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020.

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.

Multispectral Imaging for Automated Tissue Identification of Normal Human Surgical Specimens.

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.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus.

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.

Utility of videolaryngoscopy for diagnostic and therapeutic interventions in head and neck surgery.

BACKGROUND: Videolaryngoscopy is commonly used by anesthesiologists to manage difficult airways. Recently otolaryngologists have reported use in select procedures; to date there is limited evaluation in head and neck surgery. MATERIALS AND METHODS: Patients who underwent direct laryngoscopy (DL) with use of GlideScope videolaryngoscopy (GVL) were retrospectively identified from a tertiary care Veterans Affairs hospital. GVL was used to assist or replace traditional laryngoscopes for diagnostic and therapeutic procedures. RESULTS: Nineteen patients (48-83 years old) underwent 21 procedures. Difficult endotracheal intubation was reported in 53% of patients. GVL replaced traditional DL in 76% of cases, assisted evaluation prior to traditional DL in 10%, and rescued failed traditional DL in 14%. No complications occurred. Three indications for GVL were identified. DISCUSSION: GVL was safe in our experience and provides unique benefits in selected scenarios in head and neck surgery. Otolaryngologists can consider videolaryngoscopy as a complement to traditional DL.

Framework for prioritizing head and neck surgery during the COVID-19 pandemic.

The COVID-19 pandemic has placed an extraordinary demand on the United States health care system. Many institutions have canceled elective and non-urgent 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 urgent-consider 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.

Effect of Preoperative Counseling on Hospital Length of Stay and Readmissions after Total Laryngectomy.

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.

Rapid growth in surgeons' use of secure messaging in a patient portal.

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 3 years (2008-2010) 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.

Adoption of Secure Messaging in a Patient Portal across Pediatric Specialties.

Few studies have explored adoption of patient portals for pediatric patients outside primary care or disease-specific applications. We examined use of patient-provider messaging in a patient portal across pediatric specialties during the three years after implementation of pediatric portal accounts at Vanderbilt University Medical Center. We determined the number of patient-initiated message threads and clinic visits for pediatric specialties and percentage of these outpatient interactions (i.e., message threads + clinic visits) done through messaging. Generalized estimating equations measured the likelihood of message-based interaction. During the study period, pediatric families initiated 33,503 messages and participated in 318,386 clinic visits. The number of messages sent (and messaging percentage of outpatient interaction) increased each year from 2,860 (2.7%) to 18,772 (17%). Primary care received 4,368 messages (3.4% of outpatient interactions); pediatric subspecialties, 29,135 (13.0%). Rapid growth in messaging volume over time was seen in primary care and most pediatric specialties (OR>1.0; p<0.05).

Application of a Consumer Health Information Needs Taxonomy to Questions in Maternal-Fetal Care.

Pregnancy is a time when expectant mothers may have numerous questions about their unborn children, especially when congenital anomalies are diagnosed prenatally. We sought to characterize information needs of pregnant women seen in the Vanderbilt Children's Hospital Fetal Center. Participants recorded questions from diagnosis through delivery. Questions were categorized by two researchers using a hierarchical taxonomy describing consumer health information needs. Consensus category assignments were made, and inter-rater reliability was measured with Cohen's Kappa. Sixteen participants reported 398 questions in 39 subcategories, of which the most common topics were prognosis (53 questions; 13.3%) and indications for intervention (31 questions; 7.8%). Inter-rater reliability of assignments showed moderate (κ=0.57) to substantial (κ=0.75) agreement for subcategories and primary categories, respectively. Pregnant women with prenatal diagnoses have diverse unmet information needs; a taxonomy of consumer health information needs may improve the ability to meet such needs through content and system design.