News for Supporters and Friends
2020 SPRING EDITION
Applying Research Methods to Study and Improve Surgery by Heather Chronis Danek
Since 1972, the Department of Otolaryngology at the University of Pittsburgh has endeavored to train not only its surgeons, residents, and fellows on best in class techniques but also otolaryngologists from around the world through training seminars at the Eye and Ear Institute.
Dr. Carl Snyderman and Lawton Snyder with Dr. Michael Mirro touring the Mirro Center for Research and Innovation at Parkview Health in Ft. Wayne, Indiana.
In This Issue A Life Dedicated to Restoring Vision
Alumni and Surgeons Supporting Training for the Next Generation
Enhancing PatientCentered Care
Solving the Mystery of Cortical Visual Impairment
Big Data, Big Possibilities
Q&A with Dr. Andrew McCall, Otologist 7 UPMC Vision and Rehabilitation Tower: Construction Update 8
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n 2016, Otolaryngology entered into a new era of surgical training with the development of Pittsburgh CREATES (Collaborative Research, Education, and Technology Enhancement in Surgery), a unique center on the first floor of Eye and Ear Institute that facilitates collaboration between clinicians, researchers, and industry, working at the forefront of innovation across surgical disciplines. Its mission is to improve minimally invasive surgical technologies and practices for the betterment of patient outcomes and to lower the cost of care. While technology advancement is a significant focus for CREATES, innovations in training, credentialing, and best practices are equally important for realizing the potential of new technologies. CREATES, through its partnership with UPMC, has been at the forefront of developing advanced curricula for surgical training using clinical observation, combined with simulation and skills-based exercises that are objectively measured and scored. CREATES is also working with partners in augmented reality, artificial intelligence, and machine learning to optimize the learning process and create realistic, immersive experiences. Thanks to a grant by the English Bonter Mitchell Foundation of PNC Charitable Trust, a unique opportunity for collaboration between the Parkview-Mirro Center for Research and Innovation in Ft. Wayne, Indiana, and Pittsburgh CREATES becomes a reality in 2020. The ParkviewMirro Center seeks a common goal with CREATES, which is to establish best practices for the benefit of patients. Led by Carl Snyderman, MD, MBA of the Department of Otolaryngology at the University of Pittsburgh, the proposed collaboration aligns with the mission of the Center and Parkview Health’s desire to recognize and integrate new technologies to improve patient outcomes and healthcare experiences. According to Dr. Snyderman, “We now have the tools to understand the learning process for minimally invasive endoscopic techniques and develop more effective training methods.” It is first necessary to establish quality and skill-based metrics, to promote safe surgical practices and establish higher standards of care, At the University of Pittsburgh and UPMC, there are ongoing efforts to assess trainee skills through objective metrics, using models, simulation, and video reviews of live surgeries. Through our collaboration, the Mirro Center and CREATES will further develop general, as well as procedure-specific metrics that will be measured through innovative means, using a combination of laboratory-based, computerbased, and remote access tools. Input from surgeons, medical education trainers, and best practices evidence will be used to develop metrics that are meaningful and practical. These will form the basis for training and assessment methods that are standardized and more objective than anything currently available.
A Life Dedicated to Restoring Vision by Lawton Snyder
he Eye & Ear Foundation family was very saddened by the recent loss of Jim Funderburgh, PhD one of the Department of Ophthalmology’s most accomplished scientists. I have had the pleasure of working with Jim for the past ten years. Jim’s research provided the Eye & Ear Foundation with one of our greatest accomplishments and sources of pride when the first patient in India received the stem cell therapy, which has now restored sight (in a clinical trial) for patients who lost vision due to corneal opacities. I am always very appreciative that our Foundation had a pivotal role at this moment, and Jim acknowledged this frequently. These are memories I will always cherish along with the joyful nature Jim brought with him when he walked into the building after riding his bike to Oakland each day. Jim was a Professor of Ophthalmology at the University of Pittsburgh School of Medicine. Working with his wife Martha as a research partner and best friend, he specialized in research on corneal scarring
and pioneered the use of stem cells to clear scarred corneas, first in mice and ultimately in humans with colleagues in India. His innovative achievements were recognized by Research to Prevent Blindness, and the continuing project for corneal regeneration will now bear his name. Jim generously shared his knowledge with colleagues, post-docs, and students - undergrad, graduate, and medical - many of whom have gone on to successful careers. Jim, along with his team in the Department of Ophthalmology, studied the biological processes involved in corneal wound healing, the identification of corneal stromal stem cells (CSSC), and, more recently, the translational use of CSSC on preventing corneal scarring after injury. The Funderburgh method of clearing corneal scarring was first performed on patients in India, where over 80 patients with acute and chronic corneal opacities participated in a clinical trial. In this trial, approximately 90% of patients saw significant regression of scarring and improvement of vision.
Dr. José-Alain Sahel, Dr. Robert Hendricks, Dr. Jim Funderburgh, Martha Funderburgh, and Dr. Eugene Myers 2
Jim Funderburgh, PhD Because of the huge potential that this method has to cure corneal blindness in humans, the Department Ophthalmology has formed a Cornea Taskforce and established the Funderburgh Corneal Regeneration Project, to aim for the clinical use of the new therapy to prevent and treat corneal scarring in the United States and worldwide. The Taskforce includes Martha Funderburgh, PhD, Yiqin Du, MD, PhD, with the help of clinician-scientists, Deepinder Dhaliwal, MD and Vishal Jhanji, MD. Rounding out the team and recruited by Dr. Funderburgh, is new faculty member, Gary Yam, PhD from Singapore, who also specializes in corneal stem cell work. Isabelle Billing, PhD was hired as a project manager to keep the project on target for FDA approval and clinical trials. The Funderburgh Project is at a critical stage, needing support to move the stem cell therapy into trials in the United States and to begin working through the FDA processes toward the submission of an IND (Investigational New Drug) application. Providing a rapid non-surgical regenerative therapy for corneal scarring will not only reduce the need for invasive transplant surgery, with the costs and complications associated with it, but the added convenience and accessibility will revolutionize the treatment of corneal blindness. If you wish to support Jim’s legacy, donations to the Funderburgh Corneal Regeneration Project can be made to the Eye & Ear Foundation at eyeandear.org or by returning the envelope attached to this newsletter.
Alumni and Surgeons Supporting Training for the Next Generation by Heather Chronis Danek
or nearly 50 years, the Department of Otolaryngology at the University of Pittsburgh has been led by two innovators: Eugene N. Myers, MD, and currently, Jonas T. Johnson, MD. These two Chairs have instilled and nurtured a sense of community and camaraderie among the resident and fellow alumni of the Department that runs deep. It is a lasting bond that has carried over into every aspect of their respective careers. Under the leadership of Dr. Johnson, Uma Duvvuri, MD, PhD, and Carl Snyderman, MD, MBA, of the Department of Otolaryngology, pooled their respective interests in Surgical Innovation and Surgical Education to form Pittsburgh CREATES (Collaborative Research, Education and Technology Enhancement for Surgery). Drawing on world-renowned expertise in robotics, advanced surgical techniques, and health care technology
development, CREATES brings together physicians from the University of Pittsburgh Medical Center, as well as engineers and researchers from the University of Pittsburgh and Carnegie Mellon University, to support the growing industry in advanced surgical devices and systems. In 2020, Pittsburgh CREATES continues to expand its programs to support its partners through the design and facilitation of an innovative multidisciplinary training space that will be available every day to help surgeons sharpen their skills. To support the endeavor, the alumni of Otolaryngology have stepped up yet again. Dr. Myers and his family, including Jeffrey Myers, MD were one of the first groups of individuals to provide financial support with a donation toward the purchase of a telemedicine tower. One of the most important aspects of the of the new educational space is the mobile surgical
simulation carts that are being developed specifically to allow for teams of surgeons from multiple disciplines to practice surgical techniques on the first floor of Eye and Ear Institute. “The surgical simulation carts will provide great flexibility in allowing surgeons to develop their surgical skills using a wide variety of simulation materials. Such carts do not exist elsewhere and will allow us to meet the growing demand for training outside of the operating theater,” states Dr. Snyderman. With a goal of over twenty carts needed to make the educational space complete, to date, five carts have been purchased by alumni. Opportunities are still available to help the next generation of Otolaryngology residents and fellows develop worldclass training skills. For information on sponsoring a cart, please contact Heather Chronis Danek at email@example.com or 412 864 1452.
“The surgical simulation carts will provide great flexibility in allowing surgeons to develop their surgical skills using a wide variety of simulation materials. Such carts do not exist elsewhere and will allow us to meet the growing demand for training outside of the operating theater,” - Carl Snyderman, MD
Enhancing Patient-Centered Care by Carrie Fogel
hen Marci Nilsen, PhD, RN, Assistant Professor in the Department of Acute and Tertiary Care in the University of Pittsburgh School of Nursing, and Jonas T. Johnson, MD, Chairman of the Department of Otolaryngology at the University of Pittsburgh, began their work to establish the Head and Neck Cancer Survivorship Clinic 2016, they knew that the list of side effects and symptoms related to treatment was long. Now, having operated the clinic for more than three years, Drs. Johnson and Nilsen are beginning to understand the most common symptoms that patients deal with, and are beginning to turn the data they have collected from their patients into bench to bedside research initiatives. Dr. Nilsen knew that an important element of the Survivorship Clinic was the collection of data using ‘Patient-Reported Outcomes’ (PROs). According to Dr. Nilsen, “the utilization of PROS encourages the patient to be engaged in their health care and allows their voice to be heard. For providers, this is essential in order to provide high-quality care”. These measures allow for systematic and standardized collection of symptoms and treatment-related effects. The utilization and real-time evaluation of PROs in clinical practice can enhance patient-centered care and help health care providers to identify interventions to optimize the results a patient sees in his or her health. The ‘patientreported outcomes’ process of the clinic visits has provided tremendous insight into the struggles that head and neck cancer (HNC) patients have as they move through life post-treatment. Drs. Johnson and Nilsen have identified three areas where research studies could provide important knowledge to the rapidly growing field of survivorship medicine: intensive symptoms management, cognitive decline in head and neck cancer patients, and the impact of caregiver burden.
Dr. Jonas Johnson and Dr. Marci Nilsen in the UPMC Head and Neck Survivorship Clinic. • Intensive Symptoms Management As the intensity of standard therapy (chemotherapy and radiation) for head and neck cancer has amplified, survivors experience a substantial increase in acute and late treatment-related toxicities. Studies have shown that some patients are hospitalized following treatment once or multiple times. From the data the survivorship team has collected, they hypothesize that systematic symptom assessment and intensive symptom management will decrease hospital utilization of their patients (i.e., hospital admissions, emergency room visits, inpatient observation). • Cognitive Impairment after Head and Neck Cancer Treatment One of the most concerning, yet poorly understood treatment-related effects is reduced cognitive function. Deterioration in cognitive function among cancer survivors is a strong predictor of high symptom-burden, disease recurrence, and morbidity. However, it is unclear
whether these deficits in neurocognitive function in HNC survivors are due to population variation, the disease, or the treatment modality superimposed upon a pre-existing cognitive impairment. We intend to study these connections to gain a clearer sense of why this decrease in cognitive ability occurs. • Caregiver Burden Patients with head and neck cancer face a diversity of symptoms and functional impairments due to treatment-dependent toxicity. Patient caregivers (CGs) play a vital role in the treatment and recovery process, providing routine care and psychological support. Emotional distress is a problem commonly faced by CGs and can impact not only CGs themselves but their ability to provide care to patients. The survivorship team seeks to determine if there exists a difference in illness perception between patients and CGs and if this difference is associated with increased levels of distress in caregivers. Continued on next page
Because the field of Survivorship is relatively new, it has proven somewhat difficult to find sources for support for research projects aiming to collect pilot data and pose new hypotheses. In the fall of 2019, the Eye & Ear Foundation received a grant from the Jack Buncher Foundation to launch these research projects to better understand the correlation of these trends relative to head and neck cancer treatment. The Jack Buncher Foundation
has long supported important work in the Pittsburgh community, especially in cases where their support can offer assistance to those who are economically disadvantaged or vulnerable to poor health outcomes. I have been told many times that support for unmet needs for individuals who cannot afford care, has been a long standing priority for the Jack Buncher Foundation,” states Lawton Snyder, CEO of the Eye & Ear Foundation.
The support from the Jack Buncher Foundation will allow the Survivorship team to hire a research coordinator to formulate the PRO data into research questions for each of the three areas of focus and will hopefully contribute to the growing body of knowledge that exists about head and neck cancer survivorship, with the ultimate goal of offering patients a more comprehensive plan to continue optimize their life after cancer.
Solving the Mystery of Cortical Visual Impairment by Craig Smith
hanks to a generous gift from the Jack Buncher Foundation, physicians, scientists, and staff from the Department of Ophthalmology at the University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, and the Western Pennsylvania School for Blind Children (WPSBC) are working together to help find a solution for Cortical Visual Impairment (CVI). CVI is the leading visual diagnosis among children, affecting nearly 75% of the students at WPSBC alone. CVI is caused by damage or dysfunction of the primary or associated cortices of the brain. This means that while a child’s eye may be perfectly healthy, the sensory message is not delivered or interpreted properly by the brain, leading to visual, cognitive, and behavioral deficiencies, and leaving parents and educators without successful learning strategies for the child. While CVI is a prevalent problem in children and is increasing in its rate of diagnosis around the world, currently, there has been no major funding committed nationally to address the growing crisis and properly study and understand the problem. With this lack of understanding comes missed or incorrect diagnoses, and ultimately a lack of
proper learning strategies tailored specifically for CVI patients. This new funding from the Jack Buncher Foundation will allow for a collaborative effort between the three institutions to create better practices for diagnosing CVI as well as creating custom treatment and educational strategies that best fit the needs of individual patients. Uniquely positioned in Pittsburgh, an area with a high concentration of CVI patients, a combination of world-class researchers and educators, and a partnership with artificial intelligence experts from Carnegie Mellon University, researchers on the project, are confident they will become the leaders in CVI research and subsequent treatment strategies.
Thanks to the generous support from the Jack Buncher Foundation and additional Eye & Ear Foundation donors, this innovative and collaborative effort can help change the lives of children living with Cortical Visual Impairment.
“There are many interventions both by educators and clinicians suggested for children with CVI. The problem is that we do not really have a great classification of the diseases itself. So we do not know which intervention is best for which subtype of CVI. This funding will go along way to help devise a clinically useful classification so that we can eventually then go on to assess the effect of any interventions,” states Dr. Ken K. Nischal, Director of Pediatric Ophthalmology, University of Pittsburgh Medical Center.
Big Data, Big Possibilities by Carrie Fogel
uch has been discussed regarding the potential for what is termed ‘Big Data’ to revolutionize how we understand patterns and trends relative to human behavior and interactions. Big Data, loosely defined as extremely large data sets that can be analyzed computationally to systematically draw out information and form new understandings and predictions for trends, is being used in nearly every industry to be more precise and more efficient in the way business is done. The use of Big Data in health care has already led to many improvements, allowing physicians to provide more accurate insights about a disease and comprehensive recommendations for treatment. The availability of electronic health records offers an unprecedented opportunity to apply predictive analytics to improve and change the practice of medicine. By leveraging scalable computational power, machine learning offers the potential to predict outcomes from real-world data extracted from electronic medical records. Recent studies have shown that computers can learn rich, hierarchical representations of raw data with much less human effort than previously required. Several successful examples of large-scale risk assessment
models include hospital readmission models, disease onset prediction, and prediction of health care utilization and cost. With ongoing support from the Shear Family Foundation, the Department of Ophthalmology has invested time and resources into building an artificial intelligence model that would predict the way that a disease, like macular degeneration, would progress in each individual and to allow us to test therapeutic interventions on a virtual patient or a ‘Digital Twin.’ The Digital Twin platform is a shared idea between José-Alain Sahel, MD, Distinguished Professor and Chairman of the Department of Ophthalmology at the University of Pittsburgh, along with clinician-scientist Kunal Dansingani, MBBS, MA, FRCOphth, Associate Professor of Ophthalmology, and Ryad Benosman, PhD, a robotic vision expert, as well as Jay Chabblani, MD, Shan Suthaharan, PhD, a computer science professor, and Kiran Kumar Vupparaboina, PhD, an electrical engineer that would use big data to show patients what the outcomes would be of the many different treatment options, be they drug therapies, surgery, or no intervention, and what the costs associated with each option would be. This, Dr. Sahel believes, is the best way for patients to
make an informed choice about their care that fits best with their lives and abilities. The Digital Twin project was first begun in Paris as part of an European project. It is now developed between the two sites with a strong team now established in Pittsburgh, working with experts at Carnegie Mellon University and UPMC. One of the goals is to build and test novel machine-learning algorithms which learn from data acquired over disparate time scales and models and can predict disease progression. Dr. Dansingani now intends to move this model into clinical testing with data from real patients, with the hope that the model can function in real-time as an early detection and decision support tool for physicians, by modeling the potential clinical course of a range of diseases under various treatment conditions and by learning continuously from exposure to new case data. The team is working toward the development of a framework – the ‘Digital Twin’ platform - for an automated personalized medicine system, allowing for more effective treatment based on individual health data paired with predictive analytics. Most recently, the team working on artificial intelligence in the Ophthalmology Department was awarded a generous grant from the Shear Family Foundation to continue improving the model, inputting data that has been collected from patients with macular degeneration and comparing the predictions given by the model to the actual disease pathology of the patient. In the long term, as the algorithm is refined and the model is tested in many different diseases beyond blindness, such as cancer, inflammatory diseases and others, we hope that the technology will put Pittsburgh on the map for being at the forefront of the Big Data health care revolution.
Q&A with Dr. Andrew McCall, Otologist
ight & Sound launches a new feature with this edition – a Question & Answer (Q&A) session with one of our popular University of Pittsburgh faculty members and UPMC clinicians. This series focuses on questions and concerns that clinicians are asked daily by patients. Additionally, Q&A will offer insight into a diverse mix of clinicians at the UPMC Eye Centers, ENT Clinics, Sleep, Sino-Nasal & Allergy, Swallowing & Balance Disorders, and Voice Centers! In this issue, Andrew McCall, MD, FACS, Assistant Professor, Department of Otolaryngology at the University of Pittsburgh Medical School, is our inaugural Q&A subject. An otologist, Dr. McCall, treats a wide range of ear problems from chronic otitis media to hearing loss. I have frequent ear infections – what can I do to help prevent them from reoccurring? The answer to this question depends upon the type of ear infection you are experiencing. If you have recurrent otitis externa (“swimmer’s ear”), protecting the ears from water exposure is important for preventing infection. For example, some swimmers will wear silicone earplugs when swimming to lessen the chances of infection. For recurrent otitis media (infection of the middle ear space), a condition most commonly seen amongst children, placing tubes in the eardrums is commonly performed to reduce the risk of infection. What is the best way to remove wax from ears? The American Academy of Otolaryngology Head and Neck Surgery endorses safe removal of cerumen through one of two methods: manual removal and ear flushing. Note that trained professionals should perform both of these techniques, and in the case of flushing, the underlying eardrum should be intact. Many patients attempt to clean their ears with Qtips; unfortunately, Qtips will commonly worsen wax impactions due to pushing the wax further down the ear canal, rather than retrieving the wax.
I am experiencing ringing in my ears – is this common as you age? Ringing in the ears is one form of tinnitus amongst many other variants (e.g., buzzing, hearing tones, etc.). While tinnitus is a very common condition – millions of Americans experience tinnitus – age alone does not lead to tinnitus. The most common association with tinnitus is underlying hearing loss. For this reason, when a patient experiences tinnitus, an audiogram is commonly recommended to assess for underlying, and potentially unrecognized, hearing loss. When should I begin to consider hearing aids? Hearing aids are recommended for the treatment of hearing loss. Often times, family members, friends, or colleagues will help a given individual with hearing loss realize that they are missing out on conversations and lead that individual to seek treatment. Other times patients will self-identify that they hear less than they used to, will seek care, get a hearing test and ear examination confirming their hearing loss, and then get fitted with hearing aids through an audiologist. I’ve been using hearing aids for years, but find I can no longer understand most of what people are saying, is there any help for me? If hearing aids that are well-fit by a trained audiologist are no longer beneficial, a reasonable consideration may be cochlear implantation. A cochlear implant is an electronic device that is surgically placed under the skin behind the ear with an electrode that extends into the hearing portion of the inner ear (the cochlea). While it can take some time for the brain to adapt to the signals generated by such implants, the vast majority of very hard of hearing patients who receive cochlear implants experience a significant benefit. Are there any ear conditions that warrant urgent evaluation by an otolaryngologist or ear specialist? A sudden drop in hearing, such as complete loss of hearing in one ear that occurs in a
Andrew McCall, MD, FACS, Assistant Professor, Department of Otolaryngology at the University of Pittsburgh Medical School moment of time, is concerning and warrants urgent evaluation with a hearing test. This symptom may indicate an entity called “idiopathic sudden sensorineural hearing loss” requiring early intervention. Note that this entity is relatively uncommon, such that many patients with this symptom may have other less serious causes for the change in hearing (such as wax impaction). If you would like to make an appointment with Dr. McCall at the ENT Clinic, located in the Eye and Ear Institute in Oakland, please call 412-647-2100. University Ear, Nose & Throat Specialists other locations: Aspinwall: 412-784-5570 Horizon: 724-962-3210 Mercy: 412-232-3687 Monroeville: 412-374-1260 Shadyside: 412-621-0123 Children’s Hospital: 412.692.5460 (Pediatric ENT) If you have questions you would like to ask for future Q&A sessions, please email firstname.lastname@example.org. 7
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UPMC Vision and Rehabilitation Tower: Construction Update by Craig Smith
onstruction on the stateof-the-art UPMC Vision and Rehabilitation Tower in the Uptown neighborhood of Pittsburgh is starting to take shape. Located on the campus of UPMC Mercy, the nine-story tower is slated to open in late 2022. Once open, the facility will feature 410,000 square feet of collaborative space for clinicians, researchers, educators, and industry partners to work together to solve ophthalmic and rehabilitative health problems. The first of three new UPMC specialty hospitals being built, the tower will also act as a new community partner to the
Uptown neighborhood, incorporating the area into an innovative vision rehabilitation experience while providing jobs and job training to local residents.
made Pittsburgh residents aware that we are making progress on an exciting project that will help transform Pittsburgh into the leading city in the world for vision care.
A year into construction, after a few setbacks, construction crews have begun to pour concrete for foundation walls and footings, giving onlookers an initial idea of the footprint the new building will have on the neighborhood. Elevator shear walls, an electrical vault, and an underground conduit have also begun to be constructed, the important first steps in creating the inner workings of such an enormous facility. The recent appearance of multiple cranes has also
Construction of the nine-story tower on the campus of UPMC Mercy.
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