Closed-loop modulation of remote hippocampal representations with neurofeedback.

Humans can remember specific events without acting on them and can influence which memories are retrieved based on internal goals. However, current animal models of memory typically present sensory cues to trigger retrieval and assess retrieval based on action 1-5 . As a result, it is difficult to determine whether measured patterns of neural activity relate to the cue(s), the retrieved memory, or the behavior. We therefore asked whether we could develop a paradigm to isolate retrieval-related neural activity in animals without retrieval cues or the requirement of a behavioral report. To do this, we focused on hippocampal "place cells." These cells primarily emit spiking patterns that represent the animal's current location (local representations), but they can also generate representations of previously visited locations distant from the animal's current location (remote representations) 6-13 . It is not known whether animals can deliberately engage specific remote representations, and if so, whether this engagement would occur during specific brain states. So, we used a closed-loop neurofeedback system to reward expression of remote representations that corresponded to uncued, experimenter-selected locations, and found that rats could increase the prevalence of these specific remote representations over time; thus, demonstrating memory retrieval modulated by internal goals in an animal model. These representations occurred predominately during periods of immobility but outside of hippocampal sharp-wave ripple (SWR) 13-15 events. This paradigm enables future direct studies of memory retrieval mechanisms in the healthy brain and in models of neurological disorders.

Spyglass: a framework for reproducible and shareable neuroscience research.

Scientific progress depends on reliable and reproducible results. Progress can also be accelerated when data are shared and re-analyzed to address new questions. Current approaches to storing and analyzing neural data typically involve bespoke formats and software that make replication, as well as the subsequent reuse of data, difficult if not impossible. To address these challenges, we created Spyglass, an open-source software framework that enables reproducible analyses and sharing of data and both intermediate and final results within and across labs. Spyglass uses the Neurodata Without Borders (NWB) standard and includes pipelines for several core analyses in neuroscience, including spectral filtering, spike sorting, pose tracking, and neural decoding. It can be easily extended to apply both existing and newly developed pipelines to datasets from multiple sources. We demonstrate these features in the context of a cross-laboratory replication by applying advanced state space decoding algorithms to publicly available data. New users can try out Spyglass on a Jupyter Hub hosted by HHMI and 2i2c: https://spyglass.hhmi.2i2c.cloud/.

Hypoglossal Nerve Stimulator in the Active Duty Population: Military Readiness and Satisfaction.

INTRODUCTION: Because inadequate sleep impairs mission performance, the U.S. Army regards sleep as a core pillar of soldier readiness. There is an increasing incidence of obstructive sleep apnea (OSA) among active duty (AD) service members, which is a disqualifying condition for initial enlistment. Moreover, a new diagnosis of OSA in the AD population often prompts a medical evaluation board, and if symptomatic OSA proves refractory to treatment, this may result in medical retirement. Hypoglossal nerve stimulator implantation (HNSI) is a newer implantable treatment option, which requires minimal ancillary equipment to function and may provide a useful treatment modality to support AD service members while maintaining readiness in appropriate candidates. Because of a perception among AD service members that HNSI results in mandatory medical discharge, we aimed to evaluate the impact of HNSI on military career progression, maintenance of deployment readiness, and patient satisfaction. METHODS: The Department of Research Programs at the Walter Reed National Military Medical Center provided institutional review board approval for this project. This is a retrospective, observational study and telephonic survey of AD HNSI recipients. Military service information, demographics, surgical data, and postoperative sleep study results were collected from each patient.Additional survey questions assessed each service member's experience with the device. RESULTS: Fifteen AD service members who underwent HNSI between 2016 and 2021 were identified. Thirteen subjects completed the survey. The mean age was 44.8 years (range 33-61), and all were men. Six subjects (46%) were officers. All subjects maintained AD status following HNSI yielding 14.5 person-years of continued AD service with the implant. One subject underwent formal assessment for medical retention. One subject transferred from a combat role to a support role. Six subjects have since voluntarily separated from AD service following HNSI. These subjects spent an average of 360 (37-1,039) days on AD service. Seven subjects currently remain on AD and have served for an average of 441 (243-882) days. Two subjects deployed following HNSI. Two subjects felt that HSNI negatively affected their career. Ten subjects would recommend HSNI to other AD personnel. Following HNSI, of the eight subjects with postoperative sleep study data, five achieved surgical success defined as >50% reduction of apnea-hypopnea index and absolute apnea-hypopnea index value of <20. CONCLUSIONS: Hypoglossal nerve stimulator implantation for AD service members offers an effective treatment modality for OSA, which generally allows for the ability to maintain AD status, however: The impact on deployment readiness should be seriously considered and tailored to each service member based on their unique duties before implantation. Seventy-seven percent of HNSI patients would recommend it to other AD service members suffering from OSA.

The neural basis of mental navigation in rats.

A brain-machine interface demonstrates volitional control of hippocampal activity.

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility (UVFI) in adults. DATA SOURCES: Ovid MEDLINE, Embase, Web of Science, and Cochrane Central. REVIEW METHODS: A structured literature search was utilized, and a 2-researcher systematic review was performed following PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure. RESULTS: A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injection laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identified as having dysphagia as a result of UVFI and had individually extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications predominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analysis demonstrated consistent benefit for a majority of patients for each procedure. CONCLUSION: Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients.

Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003-2017.

INTRODUCTION: Laryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq and Afghanistan describes initial treatment outcomes. METHODS: US service members who sustained 'laryngotracheal' and 'pharyngoesophageal' injuries while deployed in military operations from 2003 to 2017 were identified from the Expeditionary Medical Encounter Database. Those with inhalation or ingestion injuries and an Injury Severity Score (ISS) <16 were excluded. Data on demographics, survival, mechanism and type of injury and diagnostic and therapeutic intervention were recorded. RESULTS: A total of 111 service members met inclusion criteria. Nearly one-third (32.4%) were killed in action (KIA) or died of wounds (DoW). Fatality was not significantly associated with age, theatre of operation, type of injury or mechanism of injury, but was associated with a higher ISS and those in the Marines. Although survival rates were not significantly different, the frequency of these injuries decreased after the introduction of cervical collar protection in 2007. Of those who DoW or survived, 41.1% required a surgical airway. Tracheobronchoscopy was performed in 25.6%, oesophagoscopy in 20.0% and oesophagram in 6.7%. Of the 85 with penetrating neck injuries, 43 (50.6%) underwent neck exploration, in which 31 (72.1%) required intervention. CONCLUSIONS: Severe laryngotracheal and pharyngo-oesophageal injuries have a high fatality rate and demand prompt treatment from skilled providers. Further work will elucidate preventive measures and clear management algorithms to optimise outcomes.

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility in Children: A Systematic Review.

OBJECTIVE: To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility in children. DATA SOURCES: Ovid Medline, Embase, Web of Science, and CENTRAL databases. REVIEW METHODS: A systematic review of the medical literature was performed following the PRISMA guidelines. An a priori protocol was defined to identify all articles that presented quantifiable outcome data in children aged <18 years who underwent surgical treatment to improve glottal competence for dysphagia. Two authors independently determined references meeting the inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled via a random effects model where possible. The quality of studies was graded with the MINORS criteria. RESULTS: An overall 398 publications were screened, with 9 meeting inclusion criteria. A total of 115 patients were included. Of these, 75% had preoperative swallowing symptoms. Surgical intervention for dysphagia included 61 injection laryngoplasties, 11 medialization laryngoplasties, and 10 reinnervations (ansa cervicalis to recurrent laryngeal nerve). The articles consistently reported success in improving dysphagia symptoms, and limited meta-analysis demonstrated a mean improvement after surgical intervention in 79% (95% CI, 67%-91%) of children. The reported rate of minor and major complications was 15% (95% CI, 1%-29%). The MINORS scores ranged from 5 to 12. CONCLUSION: Surgical management of unilateral vocal fold immobility in properly selected children can be an effective treatment for dysphagia when symptoms are present. Selection of surgical modalities relies on patient- and surgeon-related factors, and the rate of success is high across different interventions in treating these complex children.

The Quality of Otolaryngology- Head and Neck Surgery Literature over the Last Decade.

OBJECTIVE: To describe the changes in the quality of the Otolaryngology-Head and Neck Surgery (OTOHNS) literature over the last decade, and compare it to other surgical-based fields. METHODS: Based on impact factors, the top eight clinical U.S. OTOHNS journals were selected, and articles were analyzed from 2020 (Oto 2020) and compared to 2010 (Oto 2010). This was done similarly for Neurosurgery, Orthopedic, Ophthalmology, and General Surgery journals in 2020 (non-Oto). To limit bias and account for random variability, the first 10 research articles from each journal in each group were included. Data regarding the study type, level of evidence, use of confidence intervals, and funding source were collected. RESULTS: Based on an a priori power analysis, 160 articles were analyzed for Oto 2010 and Oto 2020. Compared to Oto 2020, Oto 2010 had more level 1 and 2 evidence (12 vs. 4; p = 0.032) and less reporting of confidence intervals (10 vs. 32; p < 0.001). Comparing the top 160 articles from 2020 from Non-Oto and OTOHNS (Oto), Non-Oto had more level 1 and 2 evidence (19 vs. 6; p = 0.0047), more randomized controlled trials (8 vs. 1; p = 0.016), and less reporting of confidence intervals (42 vs. 58; p = 0.009). CONCLUSION: High quality studies remain relatively scarce in the OTOHNS literature. Although reporting of confidence intervals has improved over the last decade, aggregate levels of evidence and extramurally funded studies lag behind other surgical-based fields. Better study design will provide stronger evidence basis, in hopes of improving clinical care. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:1853-1856, 2023.

Hippocampal replay of experience at real-world speeds.

Representations related to past experiences play a critical role in memory and decision-making processes. The rat hippocampus expresses these types of representations during sharp-wave ripple (SWR) events, and previous work identified a minority of SWRs that contain 'replay' of spatial trajectories at ∼20x the movement speed of the animal. Efforts to understand replay typically make multiple assumptions about which events to examine and what sorts of representations constitute replay. We therefore lack a clear understanding of both the prevalence and the range of representational dynamics associated with replay. Here, we develop a state space model that uses a combination of movement dynamics of different speeds to capture the spatial content and time evolution of replay during SWRs. Using this model, we find that the large majority of replay events contain spatially coherent, interpretable content. Furthermore, many events progress at real-world, rather than accelerated, movement speeds, consistent with actual experiences.

Hippocampal replay reflects specific past experiences rather than a plan for subsequent choice.

Executing memory-guided behavior requires storage of information about experience and later recall of that information to inform choices. Awake hippocampal replay, when hippocampal neural ensembles briefly reactivate a representation related to prior experience, has been proposed to critically contribute to these memory-related processes. However, it remains unclear whether awake replay contributes to memory function by promoting the storage of past experiences, facilitating planning based on evaluation of those experiences, or both. We designed a dynamic spatial task that promotes replay before a memory-based choice and assessed how the content of replay related to past and future behavior. We found that replay content was decoupled from subsequent choice and instead was enriched for representations of previously rewarded locations and places that had not been visited recently, indicating a role in memory storage rather than in directly guiding subsequent behavior.

DNA Adductomics by mass tag prelabeling.

RATIONALE: As a new approach to DNA adductomics, we directly reacted intact, double-stranded (ds)-DNA under warm conditions with an alkylating mass tag followed by analysis by liquid chromatography/mass spectrometry. This method is based on the tendency of adducted nucleobases to locally disrupt the DNA structure (forming a "DNA bubble") potentially increasing exposure of their nucleophilic (including active hydrogen) sites for preferential alkylation. Also encouraging this strategy is that the scope of nucleotide excision repair is very broad, and this system primarily recognizes DNA bubbles. METHODS: A cationic xylyl (CAX) mass tag with limited nonpolarity was selected to increase the retention of polar adducts in reversed-phase high-performance liquid chromatography (HPLC) for more detectability while maintaining resolution. We thereby detected a diversity of DNA adducts (mostly polar) by the following sequence of steps: (1) react DNA at 45°C for 2 h under aqueous conditions with CAX-B (has a benzyl bromide functional group to label active hydrogen sites) in the presence of triethylamine; (2) remove residual reagents by precipitating and washing the DNA (a convenient step); (3) digest the DNA enzymatically to nucleotides and remove unlabeled nucleotides by nonpolar solid-phase extraction (also a convenient step); and (4) detect CAX-labeled, adducted nucleotides by LC/MS2 or a matrix-assisted laser desorption/ionization (MALDI)-MS technique. RESULTS: Examples of the 42 DNA or RNA adducts detected, or tentatively so based on accurate mass and fragmentation data, are as follows: 8-oxo-dGMP, ethyl-dGMP, hydroxyethyl-dGMP (four isomers, all HPLC-resolved), uracil-glycol, apurinic/apyrimidinic sites, benzo[a]pyrene-dGMP, and, for the first time, benzoquinone-hydroxymethyl-dCMP. Importantly, these adducts are detected in a single procedure under a single set of conditions. Sensitivity, however, is only defined in a preliminary way, namely the latter adduct seems to be detected at a level of about 4 adducts in 109 nucleotides (S/N ~30). CONCLUSIONS: CAX-Prelabeling is an emerging new technique for DNA adductomics, providing polar DNA adductomics in a practical way for the first time. Further study of the method is encouraged to better characterize and extend its performance, especially in scope and sensitivity.

Delayed Facial Palsy After Resection of Vestibular Schwannoma: An Analysis of Long-term Facial Nerve Outcomes.

OBJECTIVES: 1) Identify clinical factors associated with delayed facial palsy (DFP) after microsurgical resection of vestibular schwannoma. 2) Determine whether DFP predicts worse facial nerve (FN) outcomes. METHODS: Adult patients (≥18 yrs) who underwent vestibular schwannoma resection between February 2008 and December 2017 were retrospectively reviewed. Postoperative House-Brackmann (HB) FN function was assessed on the day of surgery, daily during patients' inpatient admissions, and at postoperative clinic visits. Follow-up exceeded ≥12 months for all patients. DFP was defined as a decline (≥1 HB grade) in FN function (relative to the preoperative state) occurring between postoperative days 1 and 30. RESULTS: Two hundred ninety-one patients were analyzed. Mean age was 51.5 years (±12.3) and mean tumor size 20.6 mm (±10.8). Immediate FP occurred in 61 (21%) patients, and DFP occurred in 112 (38%) patients. Tumor size was largest in patients with immediate FP (p < 0.0001). On univariate analysis, DFP was associated with better final FN outcomes (OR 0.447, p = 0.0101) compared with immediate FP. Multivariate analysis, however, showed that timing of FP was no longer significant, whereas larger tumor size and preoperative HB2 function predicted worse FN outcomes (OR 2.718, p < 0.0001 and OR 9.196, p = 0.0039, respectively). In patients with DFP, longer time to onset of palsy predicted more favorable FN outcomes. CONCLUSIONS: When accounting for tumor size, the timing of onset of postoperative facial palsy does not predict final FN outcomes. In patients who develop DFP, the longer the interval between surgery and onset of weakness, the better the chances of good long-term FN function.

Sine Qua Non: Sinonasal Inverted Papilloma.

Inverted papilloma (IP) is a common proliferation of squamous epithelial cells of the sinonasal tract. Although considered benign, IP is known to cause local destruction, has a high rate of recurrence, and a low, but significant rate of malignant transformation. Differentiating an IP from its histologic mimickers is essential for appropriate risk stratification and long-term surveillance. A classic case of sinonasal inverted papilloma is discussed.

Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria.

OBJECTIVE: To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. METHODS: Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). RESULTS: 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. CONCLUSION: In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.

Jettison-MS of Nucleic Acid Species.

While MALDI-MS of intact genomic DNA is unheard of, actually many DNA adducts can be detected in this way under certain MALDI conditions: relatively high molar ratio of DNA nucleobases to matrix (0.01 to 0.3), hot matrix (CCA), and high laser fluence. This is because many DNA adducts create "bubbles" on dsDNA (disruption of base pairing), making it easier for these adducts as modified nucleobases to be jettisoned by the laser-derived energy of MALDI (jettison mass spectrometry or JeMS). The method also works for other nucleic acid species, namely nucleobases, nucleosides, nucleotides, and RNA. Examples of what we have detected in this way are as follows: methyladenine in E. coli DNA, 5-hydroxymethylcytosine in human brain DNA, melphalan-adenine in leukocyte DNA from patients on corresponding chemotherapy, wybutosine in tRNA, benzyl DNA adducts in E. coli cell culture treated with benzyl bromide, and various DNA adducts formed in test tube exposure experiments with calf thymus DNA. Noteworthy, in the chemotherapy study, principle component analysis of the data encourages the hypothesis that patient DNA undergoes much more damage than just melphalan adducts. Overall, our work leads to the preliminary generalization that about 5 fmol of a nucleobase deficient in base pairing, and present in a MALDI spot, will be detected by JeMS (on the equipment that we used), irrespective of the type of nucleic acid species which houses it, as long as the nucleobase is relatively basic such as A, C, or G.

Regulation of human cerebral cortical development by EXOC7 and EXOC8, components of the exocyst complex, and roles in neural progenitor cell proliferation and survival.

PURPOSE: The exocyst complex is a conserved protein complex that mediates fusion of intracellular vesicles to the plasma membrane and is implicated in processes including cell polarity, cell migration, ciliogenesis, cytokinesis, autophagy, and fusion of secretory vesicles. The essential role of these genes in human genetic disorders, however, is unknown. METHODS: We performed homozygosity mapping and exome sequencing of consanguineous families with recessively inherited brain development disorders. We modeled an EXOC7 splice variant in vitro and examined EXOC7 messenger RNA (mRNA) expression in developing mouse and human cortex. We modeled exoc7 loss-of-function in a zebrafish knockout. RESULTS: We report variants in exocyst complex members, EXOC7 and EXOC8, in a novel disorder of cerebral cortex development. In EXOC7, we identified four independent partial loss-of-function (LOF) variants in a recessively inherited disorder characterized by brain atrophy, seizures, and developmental delay, and in severe cases, microcephaly and infantile death. In EXOC8, we found a homozygous truncating variant in a family with a similar clinical disorder. We modeled exoc7 deficiency in zebrafish and found the absence of exoc7 causes microcephaly. CONCLUSION: Our results highlight the essential role of the exocyst pathway in normal cortical development and how its perturbation causes complex brain disorders.

Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer.

PURPOSE: To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer. MATERIALS AND METHODS: Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence. RESULTS: IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values. CONCLUSION: TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.

Prevalence, Characteristics and Impact of Dysphonia in US Marine Corps Drill Instructors.

IMPORTANCE: Prior studies have evaluated various populations at increased risk of voice impairment. However, minimal data is available for military Drill Instructors, a population known to have significant vocal demands. OBJECTIVE: The purpose of this study was to determine the prevalence of subjective, perceptual, and objective dysphonia in this population and to evaluate contributing factors and impact on job performance. DESIGN: Cross-sectional analysis. SETTING: United States Marine Corps base (Marine Corps Recruit Depot, San Diego, California). PARTICIPANTS: Active US Marine Corps Drill Instructors. INTERVENTIONS: A survey was administered investigating subjective measures of dysphonia and its impact on occupational function. Standardized voice samples were recorded for objective and perceptual voice analysis. MAIN OUTCOMES AND MEASURES: Prevalence of subjective (Voice Handicap Index-10 and Glottal Function Index scores), perceptual (CAPE-V score), and acoustic (Cepstral-spectral index of dysphonia) measures of dysphonia. RESULTS: Subjective dysphonia was present in 47.7% by the Voice Handicap Index-10 and 70.2% by the Glottal Function Index. 51% of subjects reported periods of aphonia, while 47% reported voice problems limiting job function in the month prior to being surveyed. The Cepstral-Spectral Index of Dysphonia Mean was abnormal in 95.3% and CAPE-V overall severity score was abnormal in 94%. There was significant improvement in subjective, perceptual, and acoustic voice outcomes as the amount of time since last training cycle (ie, relative voice rest) and as experience as a Drill Instructor increased, however the VHI-10 was the only measure that normalized. CONCLUSION AND RELEVANCE: There is a very high prevalence of self-reported dysphonia in Drill Instructors, with near-universal prevalence of some degree of objectively and perceptually-rated dysphonia. Nearly half of those surveyed reported that dysphonia limited their job performance. Relative voice rest and experience seem to mitigate severity, but normal ratings were rare. While objective and perceptually-rated dysphonia are persistent and highly prevalent, it does not necessarily translate into a perceived impairment in this population. For these reasons and considering the importance of extraordinary vocal function in this occupation, Drill Instructors appear to be in dire need of proper voice care to both maximize job performance and mitigate long-term voice-related problems.

Linked-read analysis identifies mutations in single-cell DNA-sequencing data.

Whole-genome sequencing of DNA from single cells has the potential to reshape our understanding of mutational heterogeneity in normal and diseased tissues. However, a major difficulty is distinguishing amplification artifacts from biologically derived somatic mutations. Here, we describe linked-read analysis (LiRA), a method that accurately identifies somatic single-nucleotide variants (sSNVs) by using read-level phasing with nearby germline heterozygous polymorphisms, thereby enabling the characterization of mutational signatures and estimation of somatic mutation rates in single cells.

Squamous Cell Papillomatosis in the Setting of Recurrent Respiratory Papillomatosis.

A 23 year old male presented to the Otolaryngology clinic with 6 months of hoarseness and poor voice projection without improvement from speech therapy or medical anti-reflux medication. Upon examination he was found to have multiple polypoid lesions emanating from bilateral false vocal folds, left true vocal fold, and the anterior commissure. Biopsy and potassium titanyl phosphate (KTP) laser ablation with bevacizumab injection provided treatment and confirmed the clinical suspicion of squamous cell papilloma. Despite 3 years of treatment, the papillomatosis proved difficult to control, requiring a procedure approximately every 3 months. In an attempt to control the course of the disease the patient received a series of three bevacizumab and three cidofovir injections. Serial biopsies showed mild atypia within the squamous cell papillomas. Two separate biopsies confirmed presence of human papillomavirus (HPV) 6/11 via in situ hybridization with appropriate controls. There is promising research that the quadrivalent HPV (types 6, 11, 16, and 18) vaccine both reduces the disease burden in patients with active disease and reduces the incidence of recurrent respiratory papillomatosis (RRP). Other studies have shown that local immunologic dysregulation may play a role in RRP pathogenesis. Therefore new treatment options, to include PDL-1 blockade, offer hope in treating this benign condition with high morbidity and rare mortality.