Faculty Bibliography

OBJECTIVE:To investigate the impact of resident involvement on pediatric otolaryngology procedure duration and study its financial implications on healthcare delivery. METHODS:A retrospective chart review of all patients who underwent tonsillectomy, adenoidectomy, tonsillectomy and adenoidectomy, nasal cautery, closed nasal reduction, and bilateral myringotomy tube insertion from April 2016 to October 2023 at a tertiary care center. Procedure duration, patient demographics, American Society of Anesthesiology class, body mass index percentile, case schedule time, and surgeon type were collected. The financial investment in trainees was calculated based on the difference in procedure duration between attending physicians and trainees, and the institution's preset value for otolaryngology case revenue. RESULTS:Surgical time was greater for trainees compared to attending physicians in all procedures except for closed nasal reduction. When comparing trainees to attending physicians, surgical time was proportionally prolonged with increase in patient age in bilateral myringotomy tube insertion. Regarding tonsillectomy and adenoidectomy, American Society of Anesthesiology Class I, body mass index greater than 95th percentile and afternoon scheduling were associated with prolonged surgical time. Female sex was associated with increased surgical time when comparing trainees to attending physicians in patients who underwent an adenoidectomy alone. The financial investment was greatest for second year residents, recorded as $616.988 over the study period. CONCLUSION/CONCLUSIONS:Surgical time decreases with surgeon experience for most pediatric otolaryngology procedures. Sex, body mass index, American Society of Anesthesiology class, case schedule time, and age are variables that impact surgical time. Resident training comes with a significant, yet necessary, cost spread over several years.

BACKGROUND AND OBJECTIVE/UNASSIGNED:Intraoperative parathyroid gland recognition is a key step during thyroidectomy to decrease the risk of postoperative hypocalcemia and during parathyroidectomy to distinguish normal and abnormal glands. Current methods for intraoperative identification rely largely upon visual identification. Recent investigation of methods such as near-infrared (NIR) autofluorescence and indocyanine green (ICG) for enhanced recognition have demonstrated steep learning curves. Artificial intelligence (AI) augmentation of all methods of parathyroid gland identification may improve intraoperative recognition rates and ultimately decrease rates of postoperative hypoparathyroidism. This narrative review aims to summarize the status of intraoperative application of AI for parathyroid gland recognition. METHODS/UNASSIGNED:A systematic, comprehensive literature search was conducted using the search terms "artificial intelligence", "deep learning", "surgery", "parathyroid gland", and "parathyroid glands". Inclusion criteria included articles in English with the majority of the article devoted to intraoperative applications of AI on parathyroid gland recognition. Eleven studies were identified and included. KEY CONTENT AND FINDINGS/UNASSIGNED:Eight studies focused on utilizing AI intraoperatively to identify parathyroid glands from surrounding tissues. Three studies focused on using AI to predict abnormal from normal parathyroid glands. Five studies used NIR autofluorescence, two studies used visual recognition during open thyroidectomy, two studies used visual recognition during endoscopic thyroidectomy, one study used NIR autofluorescence with ICG angiography, and one study used coaxial dual-red-green-blue/near-infrared (dual-RGB/NIR) imaging system to identify parathyroid glands. Recall and precision scores for the models ranged from 50-95% and 72-94%, respectively. Four studies compared model performance with that of senior and junior surgeons and found that the models outperformed junior surgeons while performing comparably to senior surgeons. CONCLUSIONS/UNASSIGNED:AI augmentation of intraoperative parathyroid gland recognition demonstrates adequate accuracy results across a range of parathyroid gland recognition methods. Although these models are not currently available for widespread commercial use, the eventual integration into clinical practice may allow for enhanced intraoperative recognition of parathyroid glands, particularly in lower volume centers and for junior level surgeons.

OBJECTIVES/OBJECTIVE:The primary objective of this study was to evaluate international practice patterns related to environmental sustainability in pediatric otolaryngology ORs, with a focus on the use of single-use versus reusable supplies. METHODS:An electronic survey was distributed using REDCap to members of an international pediatric otolaryngology WhatsApp group (n = 324). The survey included multiple-choice, Likert-scale, and open-ended questions regarding drape, gown, and glove usage for adenotonsillectomy, ear tube insertion, and laryngoscopy/bronchoscopy procedures, and broader sustainability practices including barriers and enablers. RESULTS:Response rate was 16.0 % (n = 52/324). Respondents were from North America (30.8 %), Europe (25.0 %), Australia/New Zealand (23.1 %), Asia (15.4 %), South America (3.8 %), and Africa (1.9 %). For adenotonsillectomy 61.5 % reported using single-use patient drapes, 61.5 % use single-use table drapes, and 44.2 % use single-use gowns. For ear tube insertions, single-use table drapes (53.8 %) were most frequently reported; single-use patient drapes (38.4 %) and gowns (21.2 %) were less common. For laryngoscopy/bronchoscopy, the majority did not use patient drapes (31.4 %) or gowns (32.7 %), while 62.8 % use single-use table drapes. Top barriers to improving sustainability in the OR were cost (51.9 %) and infection prevention and control (IPAC) practices (44.2 %). Enablers included sufficient technological (46.2 %) and financial (36.6 %) resources, dedicated policies (30.8 %), and supportive leadership (34.6 %). CONCLUSION/CONCLUSIONS:There remains a strong reliance on single-use materials in pediatric otolaryngology ORs globally. Cost, IPAC, education, and leadership are important considerations in sustainability efforts. These findings identify actionable targets for waste reduction and support the need for specialty-specific sustainability interventions.

INTRODUCTION/BACKGROUND:Papillary thyroid cancer (PTC) often follows an indolent course with a favorable prognosis. This has led to evolving guideline-based, low-intensity treatment options for low-risk patients. Recently, the purported benefit of total thyroidectomy (TT) over unilateral lobectomy for PTC with clinical lateral neck nodal metastasis (cN1b) has come into question. MATERIALS AND METHODS/METHODS:A retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results database was performed to study patients with PTC with ipsilateral cN1b disease from 1975 to 2020. Kaplan-Meier curves and log-rank tests were used to compare disease-specific survival (DSS) difference between lobectomy and TT at 10 y. Multivariable Cox proportional hazards analysis was performed to determine the independent association of lobectomy versus TT with DSS, correcting for age and lymph node ratio, defined as the ratio of pathologically positive lymph nodes to total number examined. RESULTS:Among 2943 patients (median [interquartile range] age, 45 [26] y), 42 underwent lobectomy and 2901 underwent TT. Unadjusted DSS at 10 y in the lobectomy and TT groups were 51.0% (95% confidence interval, 31.4%-82.8%) and 86.8% (95% confidence interval, 84.8%-88.9%), respectively. On multivariable analysis of all patients, older age (hazard ratio [HR], 1.08; P < 0.001) and male gender (HR, 1.74; P < 0.001) were associated with lower adjusted DSS, whereas treatment with TT (HR, 0.387; P = 0.005) and receipt of radioactive iodine (RAI) (HR, 0.604; P < 0.001) were associated with improved adjusted DSS. In addition, we observed that the magnitude of survival benefit conferred by RAI and TT were reduced with decreasing age (P < 0.001). CONCLUSIONS:This longitudinal cohort study suggests that, while TT is associated with a DSS benefit in most patients with PTC and ipsilateral cN1b disease, this association may not exist in a smaller cohort of younger patients. These findings raise the possibility that unilateral surgical clearance without RAI could offer adequate oncologic outcomes in selected younger individuals; however, further investigation is warranted to confirm these observations and inform clinical decision-making.

Animals need daily intakes of three macronutrients: sugar, protein, and fat. Under fasted conditions, however, animals prioritize sugar as a primary source of energy. They must detect ingested sugar-specifically D-glucose-and quickly report its presence to the brain. Hypothalamic neurons that can respond to the caloric content in the gut regardless of the identity of macronutrient have been identified, but until now, the existence of neurons that can encode the specific macronutrients remained unknown. We found that a subset of corticotropin-releasing factor (CRF)-expressing neurons in the hypothalamic paraventricular nucleus (CRF^PVN) respond specifically to D-glucose in the gut, separately from other macronutrients or sugars. CRF^PVN neuronal activity is essential for fasted mice to develop a preference for D-glucose. These responses of CRF^PVN neurons to intestinal D-glucose require a specific spinal gut-brain pathway including the dorsal lateral parabrachial nuclei. These findings reveal the neural circuit that encodes the identity of D-glucose.

Epigenetic changes drive gene expression alterations, contributing to oncogenesis and drug resistance. Lysosomes play a key role in cell signaling and sequestering toxins, including chemotherapeutic agents, which are then expelled through lysosomal exocytosis-a process linked to drug resistance. However, the epigenetic regulation of lysosomal exocytosis is poorly understood. We hypothesize that epigenetic modifier drugs (epidrugs) inhibiting this exocytosis could serve as potential cancer therapeutics. To explore this, we screened more than 150 epidrugs targeting various epigenetic proteins for their combined cytotoxic effects with cisplatin, their impact on lysosomal exocytosis, and lysosomal biogenesis. Two type I PRMT inhibitors, MS023 and GSK3368715, showed synergy with cisplatin, reduced cell viability, and inhibited lysosomal exocytosis without altering lysosomal biogenesis gene expression. RNA-seq analysis revealed differentially expressed genes involved in vesicular trafficking and lysosome dynamics, suggesting novel regulatory mechanisms. These inhibitors also synergized with other lysosome-sequestered drugs, indicating a broader application in overcoming drug resistance. Analysis of patient data further linked lower type I PRMT levels to better responses, highlighting their potential as combination therapy candidates to enhance chemotherapy efficacy and improve cancer survival rates.

BACKGROUND:To address financial barriers that limit access to genomic profiling and precision medicine, philanthropy supported clinical genomic testing was offered worldwide at no cost to patients with select rare cancers via the Make-an-IMPACT program. Herein, we report our findings in pediatric patients with solid or central nervous system (CNS) tumors. METHODS:Tumor DNA or CSF-derived circulating tumor DNA (CSF ctDNA) was analyzed using the MSK-IMPACT assay, supplemented by targeted RNA panel sequencing in select cases. Results were returned to the patients/families and treating oncologists. RESULTS:63 patients from 11 countries had successful MSK-IMPACT testing. The results provided clinically relevant new diagnostic or prognostic information in 41% and 38% of solid and CNS tumor patients, respectively. Potentially therapeutically actionable alterations were identified in 44% of pediatric solid tumor and 21% of pediatric CSF ctDNA samples, respectively. Four patients subsequently received molecularly guided therapy, resulting in partial responses in two and prolonged stable disease in one. Serial tumor and CSF sampling identified resistance mutations in two patients, informing additional molecular targeted therapy recommendations. CONCLUSIONS:The Make-an-IMPACT program provided global access to state-of-the-art tumor and CSF genomic profiling across a diverse cohort of pediatric cancer patients, providing clinically relevant and actionable diagnostic, prognostic and therapeutic information reported in real time to patients and local physicians.

Cochlear implants are neuroprosthetic devices that restore hearing and speech comprehension to profoundly deaf humans, and represent an exemplar application of biomedical engineering and research to clinical conditions. However, the utility of these devices in many subjects is limited, largely due to lack of information about how neural circuits respond to implant stimulation. Recently we showed that deafened rats can use cochlear implants to recognize sounds, and that this training refined the responses of single neurons in the primary auditory cortex. Here we asked how local populations of cortical neurons represent acute implant stimuli, using electrode arrays we developed for cortical surface recordings for micro-electrocorticography (μECoG), a form of intracranial electroencephalography (iEEG). We found that there was a limited tonotopic organization across recording sites, relative to a clearer tonotopic spatial representation in normal-hearing rats. Single-trial iEEG responses to acoustic inputs were more reliable than responses to cochlear implant stimulation, although stimulus identity could be successfully decoded in both cases. However, the spatio-temporal response profiles to acoustic vs cochlear implant stimulation were substantially different. Decoders trained on acoustic responses showed essentially zero information transfer when tested on electrical stimulation responses in the same animals after deafening and cochlear implant stimulation. Thus while acute cochlear implant stimulation might activate the auditory cortex in a cochleotopic manner, the dynamics of network activity are quite distinct, suggesting that pitch percepts from acoustic and electrical stimulation are fundamentally different.

Nasal bone and nasal septal fractures are common facial traumas. The proper management of these injuries and their associated complications can both functionally improve nasal breathing and also lead to improved cosmetic outcomes. Closed reduction of these fractures can often be performed at bedside if within the appropriate time window; regardless of whether reduction is performed under local anesthesia, these patients can follow-up in clinic to discuss further management, which might include delayed septorhinoplasty in the operating room.