Faculty Bibliography

BACKGROUND:Early detection of oral potentially malignant disorders (OPMDs) and oral cavity cancer can improve patient prognosis. In this guideline, the authors address the use of vital staining, specifically toluidine blue, as an adjunct to screen adults without mucosal abnormalities and to determine the need for biopsy among adults with mucosal abnormalities in the oral cavity. TYPES OF STUDIES REVIEWED/METHODS:The authors conducted systematic searches to identify evidence on the benefits and harms of using vital staining as an adjunct as well as patient and clinician values and preferences regarding the use of this adjunct. The guideline panel used the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. As part of the framework, the panel also considered the resources required, equity, acceptability, and feasibility when formulating recommendations. RESULTS:The panel formulated 2 recommendations and 2 good practice statements. For adults with and without mucosal abnormalities, the panel recommend against the use of vital staining as an adjunct (conditional recommendation, very low certainty). The good practice statements encourage clinicians to perform a clinical oral examination in all adult patients. CONCLUSIONS AND PRACTICAL IMPLICATIONS/CONCLUSIONS:Biopsy remains the first choice for obtaining a definitive diagnosis of an OPMD and oral squamous cell carcinoma. Clinical oral examination should be performed in all asymptomatic adults with no clinically evident mucosal abnormality. When implementing or adapting these recommendations, local contexts should be taken into account to ensure equitable access to early detection.

OBJECTIVE:To describe a novel surgical technique utilizing the placement of an apical ground electrode to facilitate intracochlear current modulation in patients with cochlear ossification and incomplete electrode array insertion. PATIENTS/METHODS:Patients with incomplete standard electrode array insertion due to cochlear ossification. INTERVENTION/METHODS:Standard cochlear implant (CI) electrode array insertion, in addition to the placement of the extracochlear ground electrode into the cochlear apex to enable current steering through areas of cochlear ossification and towards the cochlear apex. MAIN OUTCOME MEASURES/METHODS:Procedural safety and patient-reported perceptual differences between programming configurations utilizing the apical ground. RESULTS:Placement of an apical ground electrode was safe and feasible in 3 patients with complex ossified cochlea and was able to augment sound perception, and improve performance, after adjustments to device programming. CONCLUSIONS:Apical ground electrode placement represents a technically achievable adjunct in selected patients with ossified cochlea and incomplete electrode array insertion. This approach may expand the functional stimulation field utilizing intracochlear current modulation to improve patient performance.

OBJECTIVE:HPV vaccination recommendations have expanded to include both sexes and a broadened age range since approval in 2006. These changes and increasing HPV-related head and neck cancer rates support vaccination of older and male patients, necessitating changes in HPV education. We aim to analyze vaccination trends and to identify opportunities for increasing awareness. STUDY DESIGN/METHODS:Cross-sectional study analyzing vaccination trends between 2007 and 2023. SETTING/METHODS:US hospitals and clinics using Epic. METHODS:Using Epic Cosmos, a national database, vaccination trends for patients aged 9 to 45 were stratified by year, demographics, and administering provider specialty. RESULTS:19.6 million HPV vaccinations were administered between 2007 and 2023. The inclusion of males aged 9 to 21 in the recommendations beginning in 2009 corresponded with an 836% increase in vaccinations in this group from 2010 to 2016. Males comprised 49.9% of vaccinated patients aged 9 to 18 in 2023, a percentage that increased annually since 2010. Head and neck cancer prevention became a designated vaccine indication in 2020. Despite broadened indications, total vaccination declined by 47.1% from 2016 to 2023 in patients aged 9 to 26. In 2012, 74.8% of vaccinations were administered in pediatrics and 18.3% in family medicine. In 2023, pediatrics administered 46.6%, family medicine 33.3%, OBGYN 7.1%, and primary care 6.8%. CONCLUSION/CONCLUSIONS:Expanding guidelines have had inconsistent impacts on vaccination trends, as rates decreased in target populations since 2016. Males contribute equally to pediatric but not adult vaccinations. Departments administering vaccines are diversifying, though pediatrics predominates. Gendered and outdated education and marketing could contribute to disparities and discordance with guidelines.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Little is known about how accelerated discharge strategies compare with established enhanced recovery pathways after endoscopic endonasal surgery (EES). This study aimed to evaluate the efficacy and safety of an accelerated discharge protocol after EES. METHODS:This was a retrospective analysis of adults who underwent EES for pituitary adenomas at a single academic center between 2012 and 2025. Patients were managed under 1 of 4 postoperative pathways dependent on year of surgery: (1) No institutional protocol; (2) First-generation recovery protocol; (3) Enhanced recovery after surgery (ERAS); and (4) Expedited one-day discharge. Demographic and clinical variables were extracted from the electronic medical record using automated natural-language-processing methods. Primary outcomes were length of stay (LOS) and 30-day all-cause readmission or reoperation. All data processing, visualization, and statistical analyses were performed using Python version 3.12. RESULTS:Six hundred patients who underwent 630 surgeries were included. Median LOS was 3 days, with a 30-day readmission rate of 14.3% and a 30-day postdischarge reoperation rate of 2.5%. LOS differed significantly across protocol eras, with progressively shorter hospital stays observed over time and the shortest median stay occurring under the expedited discharge protocol (P < .0001). Readmission rates were highest in the preprotocol (16.2%) and initial protocol periods (17.2%), declining to 8.3% under the ERAS protocol and 10.0% under the expedited discharge protocol (P = .039). 30-day postdischarge reoperation rates did not statistically differ across protocols. In multivariate analyses, both the ERAS (rate ratio = 0.899, P = .021) and expedited discharge protocols (rate ratio = 0.819, P = .024) demonstrated significantly shorter hospital stays compared with the preprotocol era, without differences in 30-day readmission or reoperation rates. CONCLUSION/CONCLUSIONS:The expedited discharge protocol safely shortened hospital stays without increasing 30-day readmissions or reoperations. These findings support the feasibility of accelerated postoperative pathways after EES. Broad adoption has the potential to produce substantial resource savings without compromising patient safety.

De novo protein synthesis is required for long-lasting synaptic plasticity and memory, but it comes with a great metabolic cost. In the mammalian brain, it remains unclear which cell types and biological mechanisms are critical for sensing and responding to increased metabolic demand. Here, we demonstrate that microglia, the resident macrophages of the brain, are required for metabolic coupling between endothelial cells, astrocytes, and neurons, which fuels protein synthesis in active neurons. Increasing metabolic demand via a motor task stimulates microglia to secrete the hypoxia-responsive protein CYR61, which increases glucose transporter expression in brain vasculature. Depleting microglia reduces training-induced metabolic fluxes and neuronal protein synthesis, which can be reproduced by blocking CYR61 signaling. Thus, we define a neuroimmune metabolic circuit that is required for on-demand protein synthesis in mouse motor cortex.

BACKGROUND:Early detection of oral potentially malignant disorders and oral cavity cancer can improve patient prognosis. The guideline panel addressed the use of cytology adjuncts to screen adults without mucosal abnormalities and determine the need for biopsy among adults with mucosal abnormalities. TYPES OF STUDIES REVIEWED/METHODS:The guideline panel used the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. The authors conducted reviews to assess the benefits and harms of cytology adjuncts and people and clinician values and preferences as they relate to adjunct tests and biopsy of mucosal abnormalities. As part of the framework, the panel also considered resources required, equity, acceptability, and feasibility when formulating recommendations. RESULTS:The panel formulated 3 recommendations and 3 good practice statements. For adults with and without mucosal abnormalities, they formulated conditional recommendations against cytology adjuncts. Their use should be reserved for specific circumstances among adults with mucosal abnormalities when a biopsy is not possible or indicated. In the good practice statements, clinicians are urged to perform a clinical oral examination in all adult patients. CONCLUSIONS AND PRACTICAL IMPLICATIONS/CONCLUSIONS:Biopsy remains the first choice for reaching a definitive diagnosis of an oral potentially malignant disorder and oral squamous cell carcinoma, and cytology adjuncts should be reserved for specific situations when the clinician and patient agree it is the best course of action. When implementing or adapting these recommendations, local contexts should be considered to ensure equitable access to early detection.

The rising incidence of oral cancer and associated poor prognosis, primarily due to delayed diagnosis, highlight the urgent need for artificial intelligence tools in clinical detection. However, efforts in this regard are hampered by the lack of large and ethnically heterogenous image datasets of oral lesions with clinically validated diagnoses. To address this gap, oral mucosa images captured with mobile device cameras were collected from cohorts spanning five countries. The images were systematically annotated with lesion type classifications as well as specific clinical diagnoses, then assessed for quality. The diagnoses were verified retrospectively by biopsy, where applicable, or by consensus verification by dental experts. The final dataset consists of 30,039 oral mucosa images supplemented by clinical metadata, made available on the MeMoSA Workbench platform. We believe that the MeMoSA dataset will serve as a significant resource to drive the training, evaluation, and refinement of AI-driven diagnostic algorithms, potentially improving diagnostic accuracy and enabling rigorous benchmarking against clinical expert assessments, for the early detection of oral cancer.

OBJECTIVE:To describe intraoperative fluoroscopic and transimpedance matrix (TIM) findings during cochlear implantation in a patient with bilateral cochlear malformations, highlighting the dynamic relationship between electrode position and evolving TIM heatmap patterns. STUDY DESIGN/METHODS:Case report. METHODS:Retrospective review of patient medical and radiographic records, intraoperative fluoroscopy, and TIM data. RESULTS:Initial insertion produced a previously characterized TIM skip heat pattern seen in patients with incomplete partition type II and deficient interscalar septal width. This prompted partial electrode withdrawal under fluoroscopy, which subsequently resulted in a TIM central heat pattern, representing a symmetric voltage concentration around the mid-array region. Advancing the array slightly resulted in a skip heat pattern with a more defined current delineation and a more favorable x-ray profile. Interestingly, SmartNav analysis interpreted the TIM data as a tip fold over, despite good positioning. CONCLUSION/CONCLUSIONS:This case visually demonstrates which small positional changes of electrodes within malformed cochleae can transform TIM morphology, helping to elucidate why certain patterns occur, and the next steps to study clinical relevance.

BACKGROUND AND OBJECTIVES/OBJECTIVE:General purpose vision-language models (VLMs) demonstrate impressive capabilities, but their opaque training on uncurated internet data poses critical limitations for high-stakes decision making, such as in neurosurgery. We present CNS-Obsidian, a neurosurgical VLM trained on peer-reviewed neurosurgical literature, and demonstrate its clinical utility compared with GPT-4o in a real-world setting. METHODS:We compiled 23 984 articles from Neurosurgery Publications journals, yielding 78 853 figures and captions. Using GPT-4o and Claude Sonnet-3.5, we converted these image-text pairs into 263 064 training samples across 3 formats: instruction fine-tuning, multiple-choice questions, and differential diagnosis. We trained CNS-Obsidian, a fine-tune of the 34-billion parameter Large Language and Visual Assistant-Next model. In a blinded, randomized deployment trial at NYU Langone Health (August 30-November 30, 2024), neurosurgeons were assigned to use either CNS-Obsidian or a Health Insurance Portability and Accountability Act-compliant GPT-4o end point as a diagnostic copilot after patient consultations. Primary outcomes were diagnostic helpfulness and accuracy, assessed through user ratings and presence of the correct diagnosis within the VLM-provided differential, respectively. RESULTS:CNS-Obsidian matched GPT-4o on synthetic questions (76.13% vs 77.54%, P = .235), but only achieved 46.81% accuracy on human-generated questions vs GPT-4o's 65.70% (P < 10-15). In the randomized trial, 70 consultations were evaluated (32 CNS-Obsidian, 38 GPT-4o) from 959 total consults (7.3% utilization). CNS-Obsidian received positive ratings in 40.62% of cases vs 57.89% for GPT-4o (P = .230). Both models included correct diagnosis in approximately 60% of cases (59.38% vs 65.79%, P = .626). CONCLUSION/CONCLUSIONS:Domain-specific VLMs trained on curated scientific literature can approach frontier model performance in specialized medical domains despite being orders of magnitude smaller and less expensive to train. This establishes a transparent framework for scientific communities to build specialized artificial intelligence models. However, low clinical utilization suggests chatbot interfaces may not align with specialist workflows, indicating need for alternative artificial intelligence integration strategies.

Protease-activated receptor 2 (PAR₂) mediates oral cancer pain. Patients with metastatic (N + ) cancers report greater pain. PAR₂ is activated by N-terminal proteolytic cleavage. Here we show that proteases encoded by genes overexpressed in N+ cancers from patients with pain (matrix metallopeptidase 1, MMP1 and serine protease 23, PRSS23) elicit protease-specific receptor redistribution (trafficking) and signaling that differs from that promoted by proteases encoded by genes not differentially expressed (transmembrane serine protease matriptase, ST14 and cathepsin S, CTSS). Mixtures of the proteases prepared to model the oral cancer microenvironment revealed that ST14-mediated PAR₂ activation predominated at low protease concentrations. At high concentrations, MMP1 and PRSS23 prevailed over the greater potency of ST14. We propose that PAR₂ activation in oral N+ cancers from patients with pain is driven by high levels of MMP1 and PRSS23. Our study informs design of signaling and location-specific antagonists to provide more efficacious analgesia.