Publications by authors named "Jonathan Irish"

373 Publications

Evaluating an Image-Guided Operating Room with Cone Beam CT for Skull Base Surgery.

J Neurol Surg B Skull Base 2021 Jul 3;82(Suppl 3):e306-e314. Epub 2020 Feb 3.

Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada.

 Skull base surgery requires precise preoperative assessment and intraoperative management of the patient. Surgical navigation is routinely used for complex skull base cases; however, the image guidance is commonly based on preoperative scans alone.  The primary objective of this study was to assess the image quality of intraoperative cone-beam computed tomography (CBCT) within anatomical landmarks used in sinus and skull base surgery. The secondary objective was to assess the registration error of a surgical navigation system based on intraoperative CBCT.  Present study is a retrospective case series of image quality after intraoperative cone beam CT.  The study was conducted at Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto.  A total of 46 intraoperative scans (34 patients, 21 skull base, 13 head and neck) were studied.  Thirty anatomical landmarks (vascular, soft tissue, and bony) within the sinuses and anterior skull base were evaluated for general image quality characteristics: (1) bony detail visualization; (2) soft-tissue visualization; (3) vascular visualization; and (4) freedom from artifacts (e.g., metal). Levels of intravenous (IV) contrast enhancement were quantified in Hounsfield's units (HU). Standard paired-point registration between imaging and tracker coordinates was performed using 6 to 8 skin fiducial markers and the corresponding fiducial registration error (FRE) was measured.  Median score for bony detail on CBCT was 5, remaining at 5 after administration of IV contrast. Median soft-tissue score was 2 for both pre- and postcontrast. Median vascular score was 1 precontrast and 3 postcontrast. Median score for artifacts on CBCT were 2 for both pre-and postcontrast, and metal objects were noted to be the most significant source of artifact. Intraoperative CBCT allowed preresection images and immediate postresection images to be available to the skull base surgeon. There was a significant improvement in mean (standard deviation [SD]) CT intensity in the left carotid artery postcontrast 334 HU (67 HU) (  < 10 ). The mean FRE was 1.8 mm (0.45 mm).  Intraoperative CBCT in complex skull base procedures provides high-resolution bony detail allowing immediate assessment of complex resections. The use of IV contrast with CBCT improves the visualization of vasculature. Image-guidance based on CBCT yields registration errors consistent with standard techniques.
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http://dx.doi.org/10.1055/s-0040-1701211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289492PMC
July 2021

HLA-DR cancer cells expression correlates with T cell infiltration and is enriched in lung adenocarcinoma with indolent behavior.

Sci Rep 2021 Jul 13;11(1):14424. Epub 2021 Jul 13.

Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.

Lung adenocarcinoma (ADC) is a heterogeneous group of tumors associated with different survival rates, even when detected at an early stage. Here, we aim to investigate whether CyTOF identifies cellular and molecular predictors of tumor behavior. We developed and validated a CyTOF panel of 34 antibodies in four ADC cell lines and PBMC. We tested our panel in a set of 10 ADCs, classified into long- (LPS) (n = 4) and short-predicted survival (SPS) (n = 6) based on radiomics features. We identified cellular subpopulations of epithelial cancer cells (ECC) and their microenvironment and validated our results by multiplex immunofluorescence (mIF) applied to a tissue microarray (TMA) of LPS and SPS ADCs. The antibody panel captured the phenotypical differences in ADC cell lines and PBMC. LPS ADCs had a higher proportion of immune cells. ECC clusters (ECCc) were identified and uncovered two ADC groups. ECCc with high HLA-DR expression were correlated with CD4+ and CD8+ T cells, with LPS samples being enriched for those clusters. We confirmed a positive correlation between HLA-DR expression on ECC and T cell number by mIF staining on TMA slides. Spatial analysis demonstrated shorter distances from T cells to the nearest ECC in LPS. Our results demonstrate a distinctive cellular profile of ECC and their microenvironment in ADC. We showed that HLA-DR expression in ECC is correlated with T cell infiltration, and that a set of ADCs with high abundance of HLA-DR+ ECCc and T cells is enriched in LPS samples. This suggests new insights into the role of antigen presenting tumor cells in tumorigenesis.
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http://dx.doi.org/10.1038/s41598-021-93807-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277797PMC
July 2021

Association of Plate Contouring With Hardware Complications Following Mandibular Reconstruction.

Laryngoscope 2021 Jun 24. Epub 2021 Jun 24.

Department of Otolaryngology - Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre and Guided Therapeutics (GTx) Program, University of Toronto, Toronto, Ontario, Canada.

Objectives/hypothesis: Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications.

Study Design: Retrospective cohort study.

Methods: A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer-based three-dimensional models were generated and used to calculate the mean plate-to-bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome.

Results: Ninety-four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow-up time was 31.4 months (range 3-94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate-to-bone gap (<1 mm) was independently associated with 86% reduced odds of plate exposure (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.02-0.55). Mean plate-to-bone gap less than 1 mm was also independently associated with reduced odds of developing a composite of plate exposure or intraoral dehiscence (OR, 0.29; 95%CI, 0.11-0.75).

Conclusion: Optimizing plate contouring during mandibular reconstruction may decrease the development of postoperative hardware complications.

Level Of Evidence: IV Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29706DOI Listing
June 2021

tissue pathology from spatially encoded mass spectrometry classifiers visualized in real time through augmented reality.

Chem Sci 2020 Jul 23;11(33):8723-8735. Epub 2020 Jul 23.

Techna Institute for the Advancement of Technology for Health, University Health Network 100 College Street, Room 7-207, MaRS Building, Princess Margaret Cancer Research Tower, 7th floor (STTARR) Toronto ON M5G 1P5 Canada +1-416-581-8473.

Integration between a hand-held mass spectrometry desorption probe based on picosecond infrared laser technology (PIRL-MS) and an optical surgical tracking system demonstrates tissue pathology from point-sampled mass spectrometry data. Spatially encoded pathology classifications are displayed at the site of laser sampling as color-coded pixels in an augmented reality video feed of the surgical field of view. This is enabled by two-way communication between surgical navigation and mass spectrometry data analysis platforms through a custom-built interface. Performance of the system was evaluated using murine models of human cancers sampled in the presence of body fluids with a technical pixel error of 1.0 ± 0.2 mm, suggesting a 84% or 92% (excluding one outlier) cancer type classification rate across different molecular models that distinguish cell-lines of each class of breast, brain, head and neck murine models. Further, through end-point immunohistochemical staining for DNA damage, cell death and neuronal viability, spatially encoded PIRL-MS sampling is shown to produce classifiable mass spectral data from living murine brain tissue, with levels of neuronal damage that are comparable to those induced by a surgical scalpel. This highlights the potential of spatially encoded PIRL-MS analysis for use during neurosurgical applications of cancer type determination or point-sampling tissue during tumor bed examination to assess cancer removal. The interface developed herein for the analysis and the display of spatially encoded PIRL-MS data can be adapted to other hand-held mass spectrometry analysis probes currently available.
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http://dx.doi.org/10.1039/d0sc02241aDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163395PMC
July 2020

CMV exposure drives long-term CD57+ CD4 memory T cell inflation following allogeneic stem cell transplant.

Blood 2021 Jun 3. Epub 2021 Jun 3.

Fred Hutchinson Cancer Research Center, Seattle, Washington, United States.

Donor and recipient cytomegalovirus (CMV) serostatus correlate with transplant related mortality that is associated with reduced survival following allogeneic stem cell transplant (SCT). Prior epidemiologic studies have suggested that CMV seronegative recipients (R-) receiving a CMV seropositive graft (D+) experience inferior outcomes compared to other serostatus combinations, an observation that appears independent of viral reactivation. We therefore investigated the hypothesis that prior donor CMV exposure irreversibly modifies immunologic function after SCT. We identified a CD4+/CD57+/CD27- T cell subset that was differentially expressed between D+ and D- transplants and validated results with 120 patient samples. This T cell subset represents an average of 2.9% (D-/R-), 18% (D-/R+), 12% (D+/R-), and 19.6% (D+/R+) (p<0.0001) of the total CD4+ T cell compartment and stably persists for at least several years post-SCT. Even in the absence of CMV reactivation post-SCT, D+/R- transplants displayed a significant enrichment of these cells compared to D-/R- transplants (p=0.0078). These are effector memory cells (CCR7-/ CD45RA+/-) that express T-bet, EOMES, granzyme B, secrete Th1 cytokines, and are enriched in CMV-specific T cells. These cells are associated with decreased T cell receptor diversity (p<0.0001) and reduced proportions of major histocompatibility class II expressing classical monocytes (p<0.0001), myeloid (p=0.024), and plasmacytoid dendritic cells (p=0.0014). These data describe a highly expanded CD4+ T cell population and putative mechanisms by which prior donor or recipient CMV exposure may create a lasting immunologic imprint following SCT, providing a rationale for using D- grafts for R- transplant recipients.
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http://dx.doi.org/10.1182/blood.2020009492DOI Listing
June 2021

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement.

Head Neck 2021 Aug 3;43(8):2281-2294. Epub 2021 Jun 3.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.

Background: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

Methods: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

Conclusions: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.
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http://dx.doi.org/10.1002/hed.26774DOI Listing
August 2021

DebarcodeR increases fluorescent cell barcoding capacity and accuracy.

Cytometry A 2021 May 7. Epub 2021 May 7.

Department of Cell & Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA.

Fluorescent cell barcoding (FCB) enables efficient collection of tens to hundreds of flow cytometry samples by covalently marking cells with varying concentration of spectrally distinct dyes. A key consideration in FCB is to balance the density of dye barcodes, the complexity of cells in the sample, and the desired accuracy of the debarcoding. Unfortunately, barcoding bench and computational methods have not benefited from the high dimensional revolution in cytometry due to a lack of automated computational tools that effectively balance these common cytometry needs. DebarcodeR addresses these unmet needs by providing a framework for computational debarcoding augmented by improvements to experimental methods. Adaptive regression modeling accounted for differential dye uptake between different cell types and Gaussian mixture modeling provided a robust method to probabilistically assign cells to samples. Assignment tolerance parameters are available to allow users to balance high cell recovery with accurate assignments. Improvements to experimental methods include: (1) inclusion of an "external standard" control where a pool of all cells was stained a single level of each barcoding dyes and (2) an "internal standard" where each cell is stained with a single level of a separate dye. DebarcodeR significantly improved speed, accuracy, and reproducibility of FCB while avoiding selective loss of unusual cell subsets when debarcoding microtiter plates of cell lines and heterogenous mixtures of primary cells. DebarcodeR is available on Github as an R package that works with flowCore and Cytoverse packages at github.com/cytolab/DebarcodeR.
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http://dx.doi.org/10.1002/cyto.a.24363DOI Listing
May 2021

Reply to K. Yokoyama et al.

J Clin Oncol 2021 Jul 5;39(21):2417-2419. Epub 2021 May 5.

Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

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http://dx.doi.org/10.1200/JCO.21.00688DOI Listing
July 2021

An integrated augmented reality surgical navigation platform using multi-modality imaging for guidance.

PLoS One 2021 30;16(4):e0250558. Epub 2021 Apr 30.

TECHNA Institute, University Health Network, Toronto, ON, Canada.

An integrated augmented reality (AR) surgical navigation system that potentially improves intra-operative visualization of concealed anatomical structures. Integration of real-time tracking technology with a laser pico-projector allows the surgical surface to be augmented by projecting virtual images of lesions and critical structures created by multimodality imaging. We aim to quantitatively and qualitatively evaluate the performance of a prototype interactive AR surgical navigation system through a series of pre-clinical studies. Four pre-clinical animal studies using xenograft mouse models were conducted to investigate system performance. A combination of CT, PET, SPECT, and MRI images were used to augment the mouse body during image-guided procedures to assess feasibility. A phantom with machined features was employed to quantitatively estimate the system accuracy. All the image-guided procedures were successfully performed. The tracked pico-projector correctly and reliably depicted virtual images on the animal body, highlighting the location of tumour and anatomical structures. The phantom study demonstrates the system was accurate to 0.55 ± 0.33mm. This paper presents a prototype real-time tracking AR surgical navigation system that improves visualization of underlying critical structures by overlaying virtual images onto the surgical site. This proof-of-concept pre-clinical study demonstrated both the clinical applicability and high precision of the system which was noted to be accurate to <1mm.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250558PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087077PMC
April 2021

Importance of Margins, Radiotherapy, and Systemic Therapy in Mucosal Melanoma of the Head and Neck.

Laryngoscope 2021 Apr 15. Epub 2021 Apr 15.

Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.

Objectives/hypothesis: The ideal strategy in the treatment of mucosal melanoma of the head and neck (MMHN) remains unclear. Our objective was to evaluate the importance of surgical margins, radiotherapy, and systemic therapy in MMHN.

Study Design: Retrospective Single Institutional Review.

Methods: Retrospective review of patients with MMHN treated at a tertiary care oncology center between 1999 and 2016.

Results: Seventy-six patients were included, 60 of whom were treated with curative intent. Negative or close margins compared with positive margins were associated with higher 3-year overall survival (OS) (62% vs. 29% vs. 13% P = .012), disease-free survival (33% vs. 29% vs. 4% P = .003), and distant control (48% vs. 29% vs. 22% P = .039). Cases with pre-/postoperative radiotherapy had a marginally higher locoregional control versus without (69% vs. 59%, P = .117). Immunotherapy for recurrent and/or metastatic disease was associated with an increase in 3-year OS (15% vs. 3% P = .01).

Conclusion: Achieving negative surgical margins is relevant in disease control. Despite small sample size, our data suggest that radiotherapy may enhance surgical outcomes. Immunotherapy has therapeutic benefit.

Level Of Evidence: 3 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29555DOI Listing
April 2021

Objective evaluation of orbito-zygomatic reconstruction with scapular tip free flaps to restore facial projection and orbital volume.

Oral Oncol 2021 Jun 10;117:105268. Epub 2021 Apr 10.

Department of Otolaryngology - Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada. Electronic address:

Background: Restoring anatomical contour and position of the malar eminence and orbital rim following ablative mid-face procedures is critical in maintaining facial contour and orbit position.

Objective: To report our reconstructive approach using the scapular tip free-flap (STFF) for orbito-zygomatic defects, evaluating contour and overall shape restoration.

Methods: The study included 2 series: a clinical cohort of 15 consecutive patients who underwent an orbito-zygomatic reconstruction with a STFF and a cohort of 10 patients who had CT scan imaging but did not have orbito-zygomatic surgical resection or reconstruction. Using a 3D software, overall conformance (OC) and contour conformance (CC) with respect to the mirrored contralateral (clinical cohort) or native zygoma (preclinical cohort) were analyzed. Postoperative orbital volumes were also measured in the clinical cohort. Mean, median, root-mean-square (RMS), minimum and maximum measurements were obtained both for OC and CC. Conformance values of clinical and preclinical cohort were compared to objectively evaluate the quality of reconstruction in terms of orbito-zygomatic framework restoration (Mann-Whitney test).

Results: All measurements for OC and CC between scapular tip and the zygoma showed no differences, both on the clinical (RMS: OC 3.29 mm vs CC 3.32 mm -p = NS-) and preclinical (RMS: OC 2.03 mm and CC 2.31 mm -p = NS-) cohorts. Moreover, there were no differences in post-operative orbital volumes in the clinical cohort. Clinical outcomes of the case-series are also reported.

Conclusion: The STFF is highly effective in restoring facial projection and orbital volume in orbito-zygomatic reconstruction.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105268DOI Listing
June 2021

Restructuring Skin Cancer Care in Ontario: A Provincial Plan.

Curr Oncol 2021 Mar 12;28(2):1183-1196. Epub 2021 Mar 12.

Sunnybrook Health Sciences Centre, Department of Medical Oncology, Toronto, ON M4N 3M5, Canada.

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.
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http://dx.doi.org/10.3390/curroncol28020114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025818PMC
March 2021

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review.

Health Expect 2021 06 26;24(3):978-990. Epub 2021 Mar 26.

University Health Network Centre for Mental Health, University of Toronto, Toronto, Canada.

Background: Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

Objective: To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

Methods: Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

Results: We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

Conclusions: Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

Patient Or Public Contribution: Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.
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http://dx.doi.org/10.1111/hex.13241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235883PMC
June 2021

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer.

Can Urol Assoc J 2021 Mar 18. Epub 2021 Mar 18.

Weill-Cornell School of Medicine, Cornell University, New York, NY, United States.

Introduction: Unplanned visits (UPV) - re-admissions and emergency room (ER) visits - are markers of healthcare system quality. Radical prostatectomy (RP) is a commonly performed cancer procedure, where variation in UPV represents a gap in care for prostate cancer patients. Here, we systematically synthesize the rates, reasons, predictors, and interventions for UPV after RP, to inform evidence-based quality improvement (QI) initiatives.

Methods: A systematic review was performed for studies from 2000-2020 using keywords: "readmission," "emergency room/department," "unplanned visit," and "prostatectomy." Studies that focused on UPV following RP and that reported rates, reasons, predictors, or interventions, were included. Data was extracted via a standardized form. Meta-analysis was completed.

Results: Sixty studies, with 406 107 RP patients, were eligible; 16 028 UPV events (~5%) were analyzed from 317 050 RP patients. UPV rates after RP varied between studies (ER visit range 6-24%; re-admissions range 0-56%). The 30-day and 90-day ER visit rates were 12% and 14%, respectively; the 30-day and 90-day re-admission rates were 4% and 9%, respectively. A total of 55% of all re-admissions after RP are directly due to postoperative genitourinary (GU)-related complications such as strictures, obstructions, fistula, bladder-related, incontinence, urine leak, renal problems, and other unspecified urinary complications. The next most common readmission reasons were anastomosis-related, infection-related, cardiovascular/pulmonary events, and wound-related issues. Thirty-four percent of all ER visits after RP are directly due to urine-related issues such as retention, urinoma, obstruction, leak, and catheter problems. The next most common ER visit reasons were abdominal/gastrointestinal issues, infection-related, venous thromboembolic events, and wound-related issues. Predictors for increased re-admission included: open RP, lymph node dissection, Charlson comorbidity index≥2, low surgeon/hospital case volume, and socioeconomic determinants of health. Of the 10 interventions evaluated, a 3.4% average reduction in UPV rate was observed, highlighting an approximate two-fold decrease. Meta-analysis demonstrated a significant benefit of interventions over controls with odds ratio 0.62 (95% confidence interval 0.46-0.84). Interventions that used multidisciplinary, nurse-centered, programs, with patient self-care/empowerment were more beneficial than algorithmic patient care pathways and preoperative patient education.

Conclusions: Twenty years of international, retrospective, experience suggests UPV after RP are often related to GU complications, infection- or wound-related factors. QI interventions to reduce UPV should target these factors. While many re-admissions after RP appear to be unavoidable, ER visits have more opportunity for volume reduction by QI. The interventions evaluated herein have potential to reduce UPV after RP.
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http://dx.doi.org/10.5489/cuaj.6931DOI Listing
March 2021

Computer-assisted surgical planning of complex bone tumor resections improves negative margin outcomes in a sawbones model.

Int J Comput Assist Radiol Surg 2021 Apr 16;16(4):695-701. Epub 2021 Mar 16.

Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.

Purpose: Several technologies have been implemented in orthopedic surgery to improve surgical outcomes, usually focusing on more accurate execution of a surgical plan, but the development of the plan itself is also of great importance. The purpose of this study is to examine whether the use of preoperative computer planning platforms can improve the surgical plan?

Methods: Eight surgeons created a preoperative surgical plan to resect a distal femur parosteal osteosarcoma in two settings: (1) Using a 2-D and 3-D CT scan only (current standard); and (2) using a computer-assisted planning platform. The plans were thereafter virtually executed using a novel surgical navigation system and a Sawbones model. This simulated model was derived from, and identical to, an actual patient scenario. The outcomes of interest were the number of positive margin cuts, and the volume of the resected specimen.

Results: Using the surgical plan developed with computer assistance, there were 4 positive margin cuts made by 2 surgeons. In comparison, using standard planning, there were 14 positive margin cuts made by all 8 surgeons (p = 0.02). The resection volume was larger in the computer-assisted plans (96 ± 10 mm) than in the standard plans (88 ± 7 mm) (p = 0.055).

Conclusions: Computer-assisted planning significantly decreased the risk of a positive margin resection in this Sawbones tumor model used to simulate resection of a primary bone sarcoma. This proof of concept study highlights the importance of advanced surgical planning and sets the ground for developing beneficial surgical planning systems.
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http://dx.doi.org/10.1007/s11548-021-02337-wDOI Listing
April 2021

Single-cell analysis by mass cytometry reveals metabolic states of early-activated CD8 T cells during the primary immune response.

Immunity 2021 Apr 10;54(4):829-844.e5. Epub 2021 Mar 10.

Departments of Otolaryngology-Head and Neck Cancer, University of California, San Francisco, San Francisco, CA 94143, USA; G.W. Hooper Research Foundation, Department of Immunology and Microbiology, University of California, San Francisco, San Francisco, CA 94143, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA 94158, USA; Chan Zuckerberg Biohub, San Francisco, CA 94158, USA; Parker Institute for Cancer Immunotherapy, San Francisco, CA 94129, USA. Electronic address:

Memory T cells are thought to rely on oxidative phosphorylation and short-lived effector T cells on glycolysis. Here, we investigated how T cells arrive at these states during an immune response. To understand the metabolic state of rare, early-activated T cells, we adapted mass cytometry to quantify metabolic regulators at single-cell resolution in parallel with cell signaling, proliferation, and effector function. We interrogated CD8 T cell activation in vitro and in response to Listeria monocytogenes infection in vivo. This approach revealed a distinct metabolic state in early-activated T cells characterized by maximal expression of glycolytic and oxidative metabolic proteins. Cells in this transient state were most abundant 5 days post-infection before rapidly decreasing metabolic protein expression. Analogous findings were observed in chimeric antigen receptor (CAR) T cells interrogated longitudinally in advanced lymphoma patients. Our study demonstrates the utility of single-cell metabolic analysis by mass cytometry to identify metabolic adaptations of immune cell populations in vivo and provides a resource for investigations of metabolic regulation of immune responses across a variety of applications.
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http://dx.doi.org/10.1016/j.immuni.2021.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046726PMC
April 2021

Circulating Myeloid Regulatory Cells: Promising Biomarkers in B-Cell Lymphomas.

Front Immunol 2020 2;11:623993. Epub 2021 Feb 2.

UMR_S_1236, Univ Rennes, Inserm, Rennes, France.

The monocyte/macrophage lineage has been shown to be involved in the promotion of a protumoral tumor microenvironment and resistance to treatment in B cell lymphomas. However, it is still poorly described at the single cell level, and tissue samples are not easily accessible. Thus, a detailed analysis of the circulating myeloid cell compartment in the different B lymphomas is needed to better understand the mechanisms of resistance to treatment and identify at risk patients. In this Perspective, we review current knowledge on the phenotypic and functional description of the circulating monocytic lineage in B cell lymphomas and provide first insights into the heterogeneity of these cell populations in health and lymphoma, using mass cytometry. Indeed, the monocytic compartment is a continuum more than distinct subpopulations, as demonstrated by our high-resolution approach, explaining the sometimes confusing and contradictory conclusions on the prognostic impact of the different populations, including monocytes and monocytic myeloid derived suppressor cells (M-MDSC). By identifying S100A9 monocytic cells as a potential biomarker in diffuse large B cell lymphoma (DLBCL) in this proof-of-concept preliminary study including a limited number of samples, we underline the potential of circulating myeloid regulatory cells as diagnostic and prognostic biomarkers in B-cell lymphomas.
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http://dx.doi.org/10.3389/fimmu.2020.623993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884747PMC
June 2021

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics.

JAMA Otolaryngol Head Neck Surg 2021 Apr;147(4):343-349

Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Importance: Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent.

Objective: To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months.

Design, Setting, And Participants: This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020.

Main Outcomes And Measures: The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency.

Results: A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons.

Conclusions And Relevance: This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.
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http://dx.doi.org/10.1001/jamaoto.2020.5233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879387PMC
April 2021

Targeting In Vivo Metabolic Vulnerabilities of Th2 and Th17 Cells Reduces Airway Inflammation.

J Immunol 2021 Mar 8;206(6):1127-1139. Epub 2021 Feb 8.

Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232;

T effector cells promote inflammation in asthmatic patients, and both Th2 and Th17 CD4 T cells have been implicated in severe forms of the disease. The metabolic phenotypes and dependencies of these cells, however, remain poorly understood in the regulation of airway inflammation. In this study, we show the bronchoalveolar lavage fluid of asthmatic patients had markers of elevated glucose and glutamine metabolism. Further, peripheral blood T cells of asthmatics had broadly elevated expression of metabolic proteins when analyzed by mass cytometry compared with healthy controls. Therefore, we hypothesized that glucose and glutamine metabolism promote allergic airway inflammation. We tested this hypothesis in two murine models of airway inflammation. T cells from lungs of mice sensitized with extract displayed genetic signatures for elevated oxidative and glucose metabolism by single-cell RNA sequencing. This result was most pronounced when protein levels were measured in IL-17-producing cells and was recapitulated when airway inflammation was induced with house dust mite plus LPS, a model that led to abundant IL-4- and IL-17-producing T cells. Importantly, inhibitors of the glucose transporter 1 or glutaminase in vivo attenuated house dust mite + LPS eosinophilia, T cell cytokine production, and airway hyperresponsiveness as well as augmented the immunosuppressive properties of dexamethasone. These data show that T cells induce markers to support metabolism in vivo in airway inflammation and that this correlates with inflammatory cytokine production. Targeting metabolic pathways may provide a new direction to protect from disease and enhance the effectiveness of steroid therapy.
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http://dx.doi.org/10.4049/jimmunol.2001029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946768PMC
March 2021

Comparing Contour Restoration of Mandibular Body Defects With Fibula, Iliac Crest, and Scapular Tip Flaps: A Conformance Virtual Study.

J Oral Maxillofac Surg 2021 06 29;79(6):1345-1354. Epub 2020 Dec 29.

Professor, Department of Otolaryngology - Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, Ontario, Canada.

Purpose: The purpose of this study was to determine which of the most commonly used flaps restore contour more accurately in mandibular body reconstructions using conformance analyses and virtual measurements.

Methods: Using normal computed tomography (CT) scans and a 3D software, mandibular body defects were virtually created. "Single shot" and osteotomized fibula flaps (SS-FF and O-FF), iliac crest flaps (ICF) and scapular tip flaps (STF) were digitally harvested and coregistered to reconstruct those defects. Conformance analyses were performed by calculating the root mean square (RMS) for overall and contour conformance.

Results: Ten patients normal CT scans were included. The STF demonstrated improved overall conformance compared with the ICF, the SS-FF and the O-FF (RMS = 2.03 mm vs 4.53 mm vs 2.76 vs 2.37 mm, respectively; p<.001). Similar trends were seen for contour conformance in STF compared with the ICF and the SS-FF (RMS = 2.48 mm vs 4.50 mm vs 3.28 mm, respectively), whereas the O-FF performed better than STF (RMS = 1.85 mm vs 2.48 mm; p<.001).

Conclusions: The osseous component of the STF resembles the mandibular body more accurately than the one in the ICF and FF without the need for an osteotomy. Future clinical studies can help to elucidate the clinical impact of these virtual findings.
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http://dx.doi.org/10.1016/j.joms.2020.12.031DOI Listing
June 2021

Reprise du retard en chirurgie causé par la COVID-19 en Ontario : étude de modélisation de séries chronologiques.

CMAJ 2021 01;193(2):E63-E73

Santé Ontario (Action Cancer Ontario) (Wang, Vahid, Eberg, Milroy, Milkovich, Wright, Hunter, Zanchetta, Irish); Division de chirurgie générale (Wright), Centre des sciences de la santé Sunnybrook; Réseau Trillium pour le don de vie (Kalladeen); Schulich Heart Centre (Wijeysundera), Centre des sciences de la santé Sunnybrook; Division de cardiologie (Wijeysundera), Département de médecine et Département d'otorhinolaryngologie et de chirurgie cervico-faciale - Oncologie chirurgicale (Irish), Centre de cancérologie Princess-Margaret, Réseau universitaire de santé, Université de Toronto, Toronto (Ontario).

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http://dx.doi.org/10.1503/cmaj.201521-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773039PMC
January 2021

Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study.

J Clin Oncol 2021 Feb 6;39(6):675-684. Epub 2021 Jan 6.

Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Purpose: To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population.

Methods: This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering.

Results: There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero.

Conclusion: ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.
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http://dx.doi.org/10.1200/JCO.20.01845DOI Listing
February 2021

Imaging-based navigation technologies in head and neck surgery.

Curr Opin Otolaryngol Head Neck Surg 2021 Apr;29(2):149-155

Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto.

Purpose Of Review: Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery.

Recent Findings: Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery.

Summary: The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery.
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http://dx.doi.org/10.1097/MOO.0000000000000686DOI Listing
April 2021

Needs assessment for a decision support tool in oral cancer requiring major resection and reconstruction: a mixed-methods study protocol.

BMJ Open 2020 11 23;10(11):e036969. Epub 2020 Nov 23.

Otolaryngology -- Head & Neck Surgery, University Health Network, Toronto, Ontario, Canada

Introduction: Advanced oral cancer and its ensuing treatment engenders significant morbidity and mortality. Patients are often elderly with significant comorbidities. Toxicities associated with surgical resection can be devastating and they are often highlighted by patients as impactful. Given the potential for suboptimal oncological and functional outcomes in this vulnerable patient population, promotion and performance of shared decision making (SDM) is crucial.Decision aids (DAs) are useful instruments for facilitating the SDM process by presenting patients with up-to-date evidence regarding risks, benefits and the possible postoperative course. Importantly, DAs also help elicit and clarify patient values and preferences. The use of DAs in cancer treatment has been shown to reduce decisional conflict and increase SDM. No DAs for oral cavity cancer have yet been developed.This study endeavours to answer the question: Is there a patient or surgeon driven need for development and implementation of a DA for adult patients considering major surgery for oral cancer?

Methods And Analysis: This study is the first step in a multiphase investigation of SDM during major head and neck surgery. It is a multi-institutional convergent parallel mixed-methods needs assessment study. Patients and surgeon dyads will be recruited to complete questionnaires related to their perception of the SDM process (nine-item Shared Decision-Making Questionnaire, SDM-Q-9 and SDM-Q-Doc) and to take part in semistructured interviews. Patients will also complete questionnaires examining decisional self-efficacy (Ottawa Decision Self-Efficacy Scale) and decisional conflict (Decisional Conflict Scale). Questionnaires will be completed at time of recruitment and will be used to assess the current level of SDM, self-efficacy and conflict in this setting. Thematic analysis will be used to analyse transcripts of interviews. Quantitative and qualitative components of the study will be integrated through triangulation, with matrix developed to promote visualisation of the data.

Ethics And Dissemination: This study has been approved by the research ethics boards of the Nova Scotia Health Authority (Halifax, Nova Scotia) and the University Health Network (Toronto, Ontario). Dissemination to clinicians will be through traditional approaches and creation of a head and neck cancer SDM website. Dissemination to patients will include a section within the website, patient advocacy groups and postings within clinical environments.
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http://dx.doi.org/10.1136/bmjopen-2020-036969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684801PMC
November 2020

Assessment of a liposomal CT/optical contrast agent for image-guided head and neck surgery.

Nanomedicine 2021 02 19;32:102327. Epub 2020 Nov 19.

Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery-Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON, Canada.. Electronic address:

This study evaluates a long-acting liposomal fluorescence / CT dual-modality contrast agent (CF800) in head and neck cancer to enhance intraoperative tumor demarcation with fluorescence imaging and cone-beam computed tomography (CBCT). CF800 was administered to 12 buccal cancer-bearing rabbits. Imaging was acquired at regular time points to quantify time-dependent contrast enhancement. Surgery was performed 5-7 days after, with intraoperative near-infrared fluorescence endoscopy and CBCT, followed by histological and ex-vivo fluorescence assessment. Tumor enhancement on CT was significant at 24, 96 and 120 hours. Volumetric analysis of tumor segmentation showed high correlation between CBCT and micro-CT. Fluorescence signal was apparent in both ex-vivo and in-vivo imaging. Histological correlation showed [100%] specificity for primary tumor. Sensitivity and specificity of CF800 in detecting nodal involvement require further investigation.CF800 is long acting and has dual function for CT and fluorescence contrast, making it an excellent candidate for image-guided surgery.
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http://dx.doi.org/10.1016/j.nano.2020.102327DOI Listing
February 2021

Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review.

Oral Oncol 2020 12 23;111:105039. Epub 2020 Oct 23.

Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada. Electronic address:

Objective: To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients.

Methods: Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework.

Results: Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either 'patient-related', 'cancer severity' or 'process' factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization.

Conclusions: Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.
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http://dx.doi.org/10.1016/j.oraloncology.2020.105039DOI Listing
December 2020

Sentinel lymph node mapping using ICG fluorescence and cone beam CT - a feasibility study in a rabbit model of oral cancer.

BMC Med Imaging 2020 09 14;20(1):106. Epub 2020 Sep 14.

Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.

Background: Current sentinel lymph node biopsy (SLNB) techniques, including use of radioisotopes, have disadvantages including the use of a radioactive tracer. Indocyanine green (ICG) based near-infrared (NIR) fluorescence imaging and cone beam CT (CBCT) have advantages for intraoperative use. However, limited literature exists regarding their use in head and neck cancer SLNB.

Methods: This was a prospective, non-randomized study using a rabbit oral cavity VX2 squamous cell carcinoma model (n = 10) which develops lymph node metastasis. Pre-operatively, images were acquired by MicroCT. During surgery, CBCT and NIR fluorescence imaging of ICG was used to map and guide the SLNB resection.

Results: Intraoperative use of ICG to guide fluorescence resection resulted in identification of all lymph nodes identified by pre-operative CT. CBCT was useful for near real time intraoperative imaging and 3D reconstruction.

Conclusions: This pre-clinical study further demonstrates the technical feasibility, limitations and advantages of intraoperative NIR-guided ICG imaging for SLN identification as a complementary method during head and neck surgery.
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http://dx.doi.org/10.1186/s12880-020-00507-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491106PMC
September 2020

A Cytometrist's Guide to Coordinating and Performing Effective COVID-19 Research.

Cytometry A 2021 01 8;99(1):11-18. Epub 2020 Sep 8.

Caprion Biosciences, Montreal, Quebec, Canada.

Cytometry is playing a crucial role in addressing the COVID-19 pandemic. In this commentary-written by a variety of stakeholders in the cytometry, immunology, and infectious disease communities-we review cytometry's role in the COVID-19 response and discuss workflow issues critical to planning and executing effective research in this emerging field. We discuss sample procurement and processing, biosafety, technology options, data sharing, and the translation of research findings into clinical environments. © 2020 International Society for Advancement of Cytometry.
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http://dx.doi.org/10.1002/cyto.a.24210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461086PMC
January 2021

Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study.

CMAJ 2020 11 1;192(44):E1347-E1356. Epub 2020 Sep 1.

Ontario Health (Cancer Care Ontario) (Wang, Vahid, Eberg, Milroy, Milkovich, Wright, Hunter, Zanchetta, Irish); Division of General Surgery (Wright), Sunnybrook Health Sciences Centre; Trillium Gift of Life Network (Kalladeen); Schulich Heart Centre (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (Irish), Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Ont.

Background: To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog.

Methods: We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario.

Results: Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval [CI] 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week.

Interpretation: The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.
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http://dx.doi.org/10.1503/cmaj.201521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647484PMC
November 2020
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