Introduction:The 2019 novel coronavirus disease (COVID-19) was initially identified in December 2019 in Wuhan, China. Following its spread across the globe within a matter of months, the World Health Organization classified COVID-19 as a pandemic.1 Its rapid transmission and high hospitalization rate have forced health professionals to drastically alter their practices in order to slow its proliferation. The rapid influx of COVID-19 related admissions in hospitals around the United States has led to a widespread shortage of crucial healthcare resources, particularly personal protective equipment (PPE), ventilators, and free ICU beds. Surgical procedures further deplete such resources in a time of acutely high need. Additionally, evidence has shown that healthcare workers may be particularly susceptible to infection from the causative pathogen, SARS-CoV-2, with roughly 20% of exposed professionals becoming infected in Italy.2Following these developments, the Centers for Disease Control and Prevention (CDC) recommended that all inpatient facilities postpone or cancel any elective surgeries.3 In the ensuing weeks, the American College of Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery followed suit with this recommendation.4,5Furthermore, many hospitals and practices have opted to cancel in-person outpatient clinic visits, where patients oftentimes receive critical longitudinal care. Like other surgeons, otolaryngologists, and specifically head and neck surgical oncologists, have been deeply affected by these drastic measures. It is evident, however, that physicians must find ways to continue to monitor such patients’ conditions or treat them in some aspect. The popularity and prevalence of telemedicine has grown rapidly during this pandemic as many physicians have sought ways to maintain a continuum of care with their patients.6 Such initiatives have previously been shown to decrease costs, decrease visit time, and lead to high patient satisfaction in surgical fields.7,8Within otolaryngology specifically, certain telehealth assessments have been shown to allow for quicker examinations without compromising the communication of crucial information from the patient to the physician, or vice versa.9 However, the rapid implementation of telehealth has been a relatively new phenomenon during the COVID-19 pandemic, meaning that physicians oftentimes have to learn how to optimize their virtual visits to maximize their efficiency and effectiveness. In otolaryngology, telemedicine has not been routinely used to evaluate patients, despite estimates that 62% of otolaryngology patients would be amenable to virtual appointments.10Thus, it may be difficult for physicians to anticipate barriers to their care during a telehealth visit. Based on the authors’ experience, there exists a steep learning curve following the onset of such visits due to a variety of factors on both the patient’s and physician’s side.To our knowledge, there are no set guidelines or best practices for patients or head and neck cancer physicians conducting virtual visits. Drawing upon our experience, we aim to compile a set of guidelines for physicians and patients alike to navigate telehealth visits during the era of COVID-19. We also created a handout that can be distributed to patients prior to the visit, such that patients can familiarize themselves with general expectations and key examination steps that they may be asked to perform during the visit.
Multidisciplinary conferences (MDC) are an important component of head and neck oncologic care including diagnosis, treatment, and survivorship. Virtual MDC allows for improved collaboration between providers at distant sites and proper allocation of healthcare resources in a time of crisis. When approached systematically, a virtual MDC is feasible to design and implement in a large academic medical center with multiple satellite hospitals.
EditorialShortly after I finished delivering a keynote lecture on minor salivary gland cancers on February 23, 2020 at the Candiolo Cancer Institute in Turin, Italy, the conference chairs Drs. Giovanni Succo and Piero Nicolai announced that the conference was urgently adjourned and the rest of the program canceled. This unexpected announcement was in compliance with the Italian government’s orders to immediately end all public gatherings. Two days earlier as I set out to travel to Italy, where no cases of coronavirus infection had yet been reported, news reports were focused mostly on South Korea and Iran as hotspots of COVID-19. Out of an abundance of caution, I double-checked again before leaving for the airport and confirmed that Italy had no reported cases. Upon my arrival in Turin I was greeted by the usual warm welcome and well-known hospitality of our Italian colleagues. At the welcome reception they discussed the earlier morning report of the first five confirmed cases of COVID-19 in Lombardy region and its capital Milan. The next day, as the unplanned adjournment was announced on the first day of the 3-day conference, there were more than 120 reported cases ushering what would be the first significant outbreak in Europe. The conference chair read the Italian government emergency prohibition of public gatherings, canceling the Milan fashion week, the Venice carnival, and closing all schools and universities. But when he announced that the football (aka Soccer) game was canceled I knew that the situation was grave. As most of us know it almost takes an act of God to cancel a football game in Italy! Without delay I scrambled to get a flight back home only 24 hours after I arrived in Turin. On my way to the airport I saw on my news app that France had stopped a train of passengers from Italy and diverted it back. I was concerned about my connection in Frankfurt and ultimately getting back to USA. As I passed every step of screening and temperature checks I finally landed in Houston with a huge sigh of relief. Following instructions that were urgently sent that day, I immediately contacted our employee health at MD Anderson where I was carefully screened and cleared to go back to work.
Background: The SARS-CoV-2 (COVID-19) pandemic has caused rapid changes in head and neck cancer (HNC) care. ‘Real-time’ methods to monitor practice patterns can optimize provider safety and patient care.Methods: Head and neck surgeons from 14 institutions in the United States regularly contributed their practice patterns to a shared spreadsheet. Data from March 27th, 2020 to April 5th, 2020 was analyzed.Results: All institutions had significantly restricted HNC clinic evaluations. 2 institutions stopped free flap surgery with the remaining scheduling surgery by committee review. Factors contributing to reduced clinical volume included lack of personal protective equipment (PPE) (35%) and lack of rapid COVID-19 testing (86%).Conclusions: The COVID-19 pandemic has caused a reduction in HNC care. Rapid COVID-19 testing and correlation with infectious potential remain paramount to resuming the care of head and neck cancer patients. Cloud-based platforms to share practice patterns will be essential as the pandemic evolves.
Purpose : Pulmonary ultrasound can rapidly identify the etiology of acute respiratory failure (ARF) and assess treatment response. The often-subjective classification of abnormalities makes it difficult to document change over time and communicate findings across providers. The study goal was to develop a simple, scoring system that would allow for standardized documentation, have high inter-provider agreement, and correlate with clinical metrics.Methods : rospective of adults intubated for ARF performed at intubation, 48-hours, and extubation. A total lung score (TLS) was calculated. Clinical metrics and final diagnosis were extracted from the medical record.Results : TLS correlated positively with mortality (p=0.0), ventilator hours (p0.00), intensive care unit and hospital length of stay (p=0.00, p=0.0), and decreasing PaO2/FiO2 (p0.00). Agreement of findings was very good (kappa=0.83). Baseline TLS differed significantly between ARF categories (non-pulmonary, obstructive, and parenchymal disease).Conclusions : A quick, was associated with clinical metrics including mortality among a diverse population of patients intubated for ARF. In addition to diagnostic and prognostic information at the bedside, a standardized and quantifiable approach to PU provides objectivity in serial assessment and may enhance communication of findings between providers.
BackgroundIn the face of the COVID-19 pandemic, cancer care has had to adapt rapidly given the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) issuing recommendations to postpone non-urgent surgeries. MethodsAn institutional multidisciplinary group of Head and Neck Surgical Oncology, Surgical Endocrinology, and Medical Endocrinology devised Surgical Triaging Guidelines for Endocrine Surgery during COVID-19, aligned with phases of care published by the ACS.ResultsPhases of care with examples of corresponding endocrine cases are outlined. Most cases can be safely postponed with active surveillance, including most differentiated and medullary thyroid cancers. During the most acute phase, all endocrine surgeries are deferred except thyroid tumors requiring acute airway management.ConclusionsThese guidelines provide context for endocrine surgery within the spectrum of surgical oncology, with the goal of optimal individualized multidisciplinary patient care, and the expectation of significant resource diversion to care for COVID-19 patients.
Background and Methods: There is an added level of complexity in the management of head and neck cancer patients with underlying immunosuppressive disorders during the COVID-19 pandemic. Head and neck oncologists are tasked with balancing the dual risks of cancer progression in the setting of impaired tumor immunity and increased susceptibility to life-threatening complications from exposure to viral infection for patients and providers. Through two cases of immunocompromised patients with newly diagnosed head and neck malignancies, we aim to provide guidance to clinicians struggling with how to best counsel and manage this unique subset of patients under these difficult circumstances. Results: After careful consideration of the options, we took different approaches in the care of these two patients. Conclusions: Ultimately, there is no uniform set of rules to apply to this heterogeneous group of immune-compromised patients. We provide some general principles to help guide patient management during the current pandemic.
The COVID-19 pandemic has placed an extraordinary demand on the United States healthcare system. Many institutions have cancelled 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 30–90 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.
In December 2019, the world started to face a new pandemic situation, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 clinical manifestations are mainly respiratory, major cardiac complications are being reported. Cardiac manifestations etiology seems to be multifactorial, comprising direct viral myocardial damage, hypoxia, hypotension, enhanced inflammatory status, ACE2-receptors downregulation, drug toxicity, endogenous catecholamine adrenergic status, among others. Studies evaluating COVID-19 patients presenting cardiac injury markers show that it is associated with poorer outcomes, and arrhythmic events are not uncommon. Besides, drugs currently used to treat the COVID-19 are known to prolong the QT interval and can have a proarrhythmic propensity. This review focus on COVID-19 cardiac and arrhythmic manifestations and, in parallel, makes an appraisal of other virus epidemics as SARS-CoV, MERS-CoV, and H1N1 influenza.
Published in Journal of Cardiovascular Electrophysiology. DOI forthcoming.Author list and affiliationNorman C. Wang, MD, MS; Sandeep K. Jain, MD; N.A. Mark Estes III, MD; William W. Barrington, MD; Raveen Bazaz, MD; Aditya Bhonsale, MD, MHS; Krishna Kancharla, MBBS; Alaa A. Shalaby, MD, MSc; Andrew H. Voigt, MD; Samir Saba, MD Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PennsylvaniaAuthor disclosures: Dr. Wang serves as a consultant for Abbott. Dr. Jain serves as a consultant for Medtronic, receives research support from Medtronic, and is a research investigator for Abbott, Boston Scientific, and Medtronic. Dr. Estes serves as a consultant for Abbott, Boston Scientific, and Medtronic. Dr. Saba receives research support from Abbott and Boston Scientific. The remaining authors have nothing to disclose. University of Pittsburgh Medical Center receives institutional cardiac electrophysiology fellowship support from Abbott, Boston Scientific, and Medtronic.Funding: This manuscript did not receive any specific grant(s) from funding agencies in the public, commercial, or not-for-profit sectors.Proposed Tweet: Priority plan for invasive cardiac EP procedures during the COVID-19 pandemic. #EPeeps #COVID19
Respiratory complications have been well remarked in the novel coronavirus disease (SARS-CoV-2/COVID-19), yet an emerging body of research indicates that cardiac involvement may be implicated in poor outcomes for these patients. This review seeks to gather and distill the existing body of literature that describes the cardiac implications of COVID-19. Notably, COVID-19 patients with pre-existing cardiovascular disease are counted in greater frequency in intensive care unit settings, and ultimately suffer greater rates of mortality. Other studies have noted cardiac presentations for COVID-19, rather than respiratory, such as acute pericarditis and left ventricular dysfunction. In some patients there has been evidence of acute myocardial injury, with correspondingly increased serum troponin I levels. With regard to surgical interventions, there is a dearth of data describing myocardial protection during cardiac surgery for COVID-19 patients. Although some insights have been garnered in the study of cardiovascular diseases for these patients, these insights remain fragmented and have yet to cement clear guidelines for actionable clinical practice. Further studies are imperative for a more cohesive understanding of the cardiac pathophysiology in COVID-19 patients to promote more informed treatment and, ultimately, better clinical outcomes.
The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities.There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists and otolaryngologists. Health workers represent between 3.8% to 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter).All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55-65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Healthcare facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for cancer patients.For those who are working with COVID-19 infected patients’ isolation is compulsory in the following settings: a) unprotected close contact with COVID-19 pneumonia patients: b) onset of fever, cough, shortness of breath and other symptoms (gastrointestinal complaints, anosmia and dysgeusia have been reported in a minority of cases).For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (e.g.; rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia) it is strongly recommended that all healthcare personnel wear personal protective equipment (PPE) such as N95, gown, cap, eye protection and gloves.The procedures described are essential in trying to maintain safety of healthcare workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.