Both Nuclear and Membrane Estrogen Receptor Alpha Impact the Expression of Estrogen Receptors and Plasticity Markers in the Mouse Hypothalamus and Hippocampus.

Estrogens via estrogen receptor alpha (ERα) genomic and nongenomic signaling can influence plasticity processes in numerous brain regions. Using mice that express nuclear only ERα (NOER) or membrane only ERα (MOER), this study examined the effect of receptor compartmentalization on the paraventricular nucleus of the hypothalamus (PVN) and the hippocampus. The absence of nuclear and membrane ERα expression impacted females but not males in these two brain areas. In the PVN, quantitative immunohistochemistry showed that the absence of nuclear ERα increased nuclear ERß. Moreover, in the hippocampus CA1, immuno-electron microscopy revealed that the absence of either nuclear or membrane ERα decreased extranuclear ERα and pTrkB in synapses. In contrast, in the dentate gyrus, the absence of nuclear ERα increased pTrkB in synapses, whereas the absence of membrane ERα decreased pTrkB in axons. However, the absence of membrane only ERα decreased the sprouting of mossy fibers in CA3 as reflected by changes in zinc transporter immunolabeling. Altogether these findings support the idea that both membrane and nuclear ERα contribute overlapping and unique actions of estrogen that are tissue- and cellular-specific.

Angiotensin II differentially affects hippocampal glial inflammatory markers in young adult male and female mice.

Hypertension is a risk factor for neurodegenerative disorders involving inflammation and inflammatory cytokine-producing brain cells (microglia and astrocytes) in the hippocampus and medial prefrontal cortex (mPFC). Here we investigated the effect of slow-pressor angiotensin II (AngII) on gliosis in the hippocampus and mPFC of young adult (2-mo-old) male and female mice. In males, AngII induced hypertension, and this resulted in an increase in the density of the astrocyte marker glial fibrillary acidic protein (GFAP) in the subgranular hilus and a decrease in the density of the microglial marker ionized calcium binding adapter molecule (Iba-1) in the CA1 region. Females infused with AngII did not show hypertension but, significantly, showed alterations in hippocampal glial activation. Compared with vehicle, AngII-infused female mice had an increased density of Iba-1 in the dentate gyrus and CA2/3a region. Like males, females infused with AngII exhibited decreased Iba-1 in the CA1 region. Neither male nor female mice showed differences in GFAP or Iba-1 in the mPFC following AngII infusion. These results demonstrate that the hippocampus is particularly vulnerable to AngII in young adulthood. Differences in gonadal hormones or the sensitivity to AngII hypertension may account for divergences in GFAP and Iba-1 in males and females.

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses.

Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.

Outcome Disparities and Resource Utilization Among Limited English Proficient Patients After Tonsillectomy.

OBJECTIVE: There is evidence to suggest adverse outcomes on patients' medical and surgical care when there is language discordance in patient-physician relationships. No studies have evaluated the impact of limited English proficiency (LEP) on complications after common surgical procedures in otolaryngology. Furthermore, no studies have evaluated how patients with LEP utilize remote resources to connect with otolaryngology providers to better triage such complications. The purpose was to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) comparing patients with LEP to those with English proficiency (EP). Patients with PTH were retrospectively evaluated to identify preceding telephone encounters, a marker of resource utilization. METHODS: Demographics, English proficiency, and PTH management (surgical vs non-surgical) were evaluated in addition to PTH-associated triage telephone encounters with otolaryngology providers. RESULTS: Of 2466 tonsillectomies, there were 141 episodes of reported hemorrhage (50 LEP vs 91 EP) in the 5 years studied. Rates were not significantly different between LEP and EP patients (4.9% vs 6.3%, P = .127). There was no statistically significant difference in rate of preceding telephone encounters between LEP and EP patients (24% vs 40%, P = .062). Of patients presenting directly to the Emergency Department without a triage telephone encounter, there was no difference in operative versus non-operative management when comparing LEP versus EP patients. However, patients presenting directly to the Emergency Department were nearly twice as likely to undergo operative intervention compared to patients with preceding telephone encounters (RR = 1.79). CONCLUSION: Patients with limited English proficiency are not at increased risk for developing PTH. There is equitable access to remote otolaryngologic triage care, although overall the utilization rate of this resource was low for both cohorts.

Predictors of a Normal Sleep Study in Healthy Children with Sleep Disordered Breathing Symptoms.

OBJECTIVE: To determine the prevalence and characteristics of children with normal elective polysomnography for obstructive sleep disordered breathing (oSDB) based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines. STUDY DESIGN: In this retrospective cohort study, we identified patients ages 2 to 18 who underwent diagnostic polysomnography (PSG) ordered by our otolaryngology department for SDB between 2012 and 2018. SETTING: All patients were seen by otolaryngologists at an urban tertiary safety net hospital. SUBJECTS AND METHODS: There were a total of 456 patients studied (average age 5.66 ± 3.19; 263 (57.7%) males, 193 (42.3%) females. Demographic factors (age, gender, race, ethnicity, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate and multivariate analysis. RESULTS: Two hundred four patients (44.7%) had no obstructive sleep apnea (OSA) based on AHI<2 on PSG. Children with a larger tonsil size had 3.18 times the odds of OSA compared to those with a medium tonsil size (95% CI 1.64, 6.19) when adjusting for symptoms, age category, and race (P = .0007). Children ages 4 to 6 years had 0.25 times the odds of OSA compared to those ages 2-3 years (95% CI 0.12, 1.54) when adjusting for symptoms, tonsil size, and race (P = .0011). White children had 0.28 times the odds of OSA compared to Black children (95% CI 0.14, 0.57) when adjusting for symptoms, tonsil size, and age category (P = .0004). CONCLUSION: Among our patient population, 44.7% had normal sleep studies. Younger children (ages 2-3) were less likely to have normal polysomnography. This research demonstrates that obtaining sleep studies in otherwise healthy children with SDB can affect management decisions, and they should be discussed with families with a focus on patient centered decision making.

Chronic stress differentially alters mRNA expression of opioid peptides and receptors in the dorsal hippocampus of female and male rats.

Chronic immobilization stress (CIS) results in sex-dependent changes in opioid peptide levels and receptor subcellular distributions within the rat dorsal hippocampus, which are paralleled with an inability for males to acquire conditioned place preference (CPP) to oxycodone. Here, RNAScope in situ hybridization was used to determine the expression of hippocampal opioid peptides and receptors in unstressed (US) and CIS estrus female and male adult (∼2.5 months old ) Sprague Dawley rats. In all groups, dentate granule cells expressed PENK and PDYN; additionally, numerous interneurons expressed PENK. OPRD1 and OPRM1 were primarily expressed in interneurons, and to a lesser extent, in pyramidal and granule cells. OPRK1-was expressed in sparsely distributed interneurons. There were few baseline sex differences: US females compared to US males had more PENK-expressing and fewer OPRD1-expressing granule cells and more OPRM1-expressing CA3b interneurons. Several expression differences emerged after CIS. Both CIS females and males compared to their US counterparts had elevated: (1) PENK-expressing dentate granule cells and interneurons in CA1 and CA2/3a; (2) OPRD1 probe number and cell expression in CA1, CA2/3a and CA3b and the dentate gyrus; and (3) OPRK1-expressing interneurons in the dentate hilus. Also, CIS males compared to US males had elevated: (1) PDYN expression in granule cells; (2) OPRD1 probe and interneuron expression in CA2/3a; (3) OPRM1 in granule cells; and (4) OPRK1 interneuron expression in CA2/3a. The sex-specific changes in hippocampal opioid gene expression may impact network properties and synaptic plasticity processes that may contribute to the attenuation of oxycodone CPP in CIS males.

Oxycodone injections not paired with conditioned place preference have little effect on the hippocampal opioid system in female and male rats.

Oxycodone (Oxy) conditioned place preference (CPP) in Sprague Dawley rats results in sex-specific alterations in hippocampal opioid circuits in a manner that facilitates opioid-associative learning processes, particularly in females. Here, we examined if Oxy (3 mg/kg, I.P.) or saline (Sal) injections not paired with behavioral testing similarly affect the hippocampal opioid system. Sal-injected females compared to Sal-injected males had: (1) higher densities of cytoplasmic delta opioid receptors (DOR) in GABAergic hilar dendrites suggesting higher baseline reserve DOR pools and (2) elevated phosphorylated DOR levels, but lower phosphorylated mu opioid receptor (MOR) levels in CA3a suggesting that the baseline pools of activated opioid receptors vary in females and males. In contrast to CPP studies, Oxy-injections in the absence of behavioral tests resulted in few changes in the hippocampal opioid system in either females or males. Specifically, Oxy-injected males compared to Sal-injected males had fewer DORs near the plasma membrane of CA3 pyramidal cell dendrites and in CA3 dendritic spines contacted by mossy fibers, and lower pMOR levels in CA3a. Oxy-injected females compared to Sal-injected females had higher total DORs in GABAergic dendrites and lower total MORs in parvalbumin-containing dendrites. Thus, unlike Oxy CPP, Oxy-injections redistributed opioid receptors in hippocampal neurons in a manner that would either decrease (males) or not alter (females) excitability and plasticity processes. These results indicate that the majority of changes within hippocampal opioid circuits that would promote opioid-associative learning processes in both females and males do not occur with Oxy administration alone, and instead must be paired with CPP.

Barriers to Voice Therapy Attendance in a Language-Diverse Population.

OBJECTIVES/HYPOTHESIS: Voice therapy is an effective treatment for many voice disorders, but success depends on attendance and adherence. Many factors hinder treatment attendance, and language discordance with the provider may present an additional obstacle to attending therapy. This study evaluates factors associated with voice therapy attendance at a language-diverse, safety-net hospital. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective review of adult patients referred to speech language pathology for treatment of voice disorders from January, 2018 to April, 2019. Primary spoken language, interpreter collaboration, and patient demographics were obtained from medical records. Multivariate analysis compared patient factors with voice therapy attendance versus nonattendance. RESULTS: Of 422 patients, 219 (52%) attended at least one therapy session, whereas 203 (48%) did not attend (n = 120) or schedule therapy (n = 83). In multivariate analysis, only the association between public insurance and nonattendance was statistically significant (P = .016). After adjusting for interpreter use and interval between referral and first appointment, patients with private health insurance were 2.35 times more likely to attend therapy compared to those with public insurance (95% confidence interval: 1.18-4.71). Non-English language; interpreter collaboration; distance from hospital; and patient demographics, including age, gender, ethnicity, and birthplace, did not significantly correlate with attendance. CONCLUSIONS: In a culturally and language-diverse cohort of dysphonic patients, individuals with public health insurance were significantly less likely to attend voice therapy. Language-discordant therapy and interpreter collaboration was not a statistically significant barrier to therapy attendance. Additional investigation is warranted to optimize allocation of voice therapy resources for those with public health insurance and for diverse speakers of all languages. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1835-1839, 2021.

Sex and chronic stress alter delta opioid receptor distribution within rat hippocampal CA1 pyramidal cells following behavioral challenges.

Following oxycodone (Oxy) conditioned place preference (CPP), delta opioid receptors (DORs) differentially redistribute in hippocampal CA3 pyramidal cells in female and male rats in a manner that would promote plasticity and opioid-associative learning processes. However, following chronic immobilization stress (CIS), males do not acquire Oxy-CPP and the trafficking of DORs in CA3 pyramidal neurons is attenuated. Here, we examined the subcellular distribution of DORs in CA1 pyramidal cells using electron microscopy in these same cohorts. CPP: Saline (Sal)-females compared to Sal-males have more cytoplasmic and total DORs in dendrites and more DOR-labeled spines. Following Oxy-CPP, DORs redistribute from near-plasmalemma pools in dendrites to spines in males. CIS: Control females compared to control males have more near-plasmalemmal dendritic DORs. Following CIS, dendritic DORs are elevated in the cytoplasm in females and near-plasmalemma in males. CIS PLUS CPP: CIS Sal-females compared to CIS Sal-males have more DORs on the plasmalemma of dendrites and in spines. After Oxy, the distribution of DORs does not change in either females or males. CONCLUSION: Following Oxy-CPP, DORs within CA1 pyramidal cells remain positioned in naïve female rats to enhance sensitivity to DOR agonists and traffic to dendritic spines in naïve males where they can promote plasticity processes. Following CIS plus behavioral enrichment, DORs are redistributed within CA1 pyramidal cells in females in a manner that could enhance sensitivity to DOR agonists. Conversely, CIS plus behavioral enrichment does not alter DORs in CA1 pyramidal cells in males, which may contribute to their diminished capacity to acquire Oxy-CPP.

Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography.

OBJECTIVE: To determine the prevalence and demographics features of pediatric patients with severe obstructive sleep apnea (OSA) who would not undergo preoperative polysomnography (PSG) under current American Academy of Otolaryngology (AAO) guidelines. STUDY DESIGN: In this retrospective cohort study, we identified patients from the electronic medical record who underwent elective polysomnography for evaluation of sleep-disordered breathing between 2012 and 2018. SETTING: Urban tertiary safety net hospital. SUBJECTS AND METHODS: A total of 456 patients with a mean (SD) age of 5.7 (3.2) years (263 male, 193 female). Demographic factors (age, sex, race, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate analysis. RESULTS: Of 456 patients identified, 66 (14.5%) were found to have severe OSA. African American patients had 3.7 times the odds of severe OSA compared to white patients (95% CI, 1.2-10.8). Patients aged 2 to 3 years had 2.2 times the odds of severe OSA compared to patients aged 4 to 6 years (95% CI, 1.2-4.0). Sex, ethnicity, language, and insurance type were not significantly associated with severity of OSA. The presence of apneic episodes and tonsil size were not found to be statistically significant. CONCLUSION: Up to 14.5% of healthy pediatric patients with sleep-disordered breathing may have severe OSA; young age and African American race are statistically significant predictors. Clinical findings, such as tonsil size and symptom severity, were not found to be statistically significant predictors.

Satisfaction in Academic Otolaryngology: Do Physician Demographics Impact Press Ganey Survey Scores?

OBJECTIVES/HYPOTHESIS: Patient satisfaction is increasingly emphasized and measured in healthcare delivery. However, patient satisfaction is multifactorial and difficult to comprehensively assess. The objective of this study was to assess for correlation between patient satisfaction measured by Press Ganey surveys (PGS) and physician demographics of gender, years in practice, academic rank, and specialty in academic otolaryngology. STUDY DESIGN: Review of publicly available PGS scores in academic otolaryngology practice. METHODS: Public websites of academic otolaryngology departments were assessed for inclusion of PGS scores. Individual physician profiles were queried for years in practice, academic rank, and specialty. Gender was determined by picture or profile pronouns. Univariate and multivariate analyses compared PGS scores with studied variables. RESULTS: Forty-seven of 113 (42.8%) academic practices publicly reported physician PGS score. Of 1,360 affiliated otolaryngologists, 742 (54.6%,592 male:150 female) revealed PGS scores. Average PGS score for male and female providers was equivalent (PGS = 4.73, P = .84). There was no significant difference in PGS scores by academic rank (P = .28). A weak statistically significant decrease in mean PGS scores was associated with longer duration of practice (r = -0.11, P = .018). Head and neck oncologic surgeons had higher mean PGS score in comparison to other specialties (PGS = 4.81, P < .05). General/comprehensive otolaryngologists had lower average PGS score (PGS = 4.66) in comparison to specialists (P < .05). CONCLUSIONS: Physician gender and academic rank do not correlate with patient satisfaction in academic otolaryngology as measured by publicly reported PGS scores. Head and neck oncology is rated more highly than other specialties, and physicians in practice for longer demonstrate decreased PGS scores. With PGS scores tied to physician evaluation and reimbursement, investigation into the generalizability of PGS in otolaryngology is warranted. LEVEL OF EVIDENCE: NA Laryngoscope, 130: 1902-1906, 2020.

Sex and age differentially affect GABAergic neurons in the mouse prefrontal cortex and hippocampus following chronic intermittent hypoxia.

Obstructive sleep apnea (OSA), a chronic sleep disorder characterized by repetitive reduction or cessation of airflow during sleep, is widely prevalent and is associated with adverse neurocognitive sequelae including increased risk of Alzheimer's disease (AD). In humans, OSA is more common in elderly males. OSA is characterized by sleep fragmentation and chronic intermittent hypoxia (CIH), and recent epidemiological studies point to CIH as the best predictor of neurocognitive sequelae associated with OSA. The sex- and age- specific effects of OSA-associated CIH on specific cell populations such as γ-aminobutyric acid (GABA)-ergic neurons in the hippocampus and the medial prefrontal cortex (mPFC), regions important for cognitive function, remain largely unknown. The present study examined the effect of 35 days of either moderate (10% oxygen) or severe (5% oxygen) CIH on GABAergic neurons in the mPFC and hippocampus of young and aged male and female mice as well as post-accelerated ovarian failure (AOF) female mice. In the mPFC and hippocampus, the number of GABA-labeled neurons increased in aged and young severe CIH males compared to controls but not in young moderate CIH males. This change was not representative of the individual GABAergic cell subpopulations, as the number of parvalbumin-labeled neurons decreased while the number of somatostatin-labeled neurons increased in the hippocampus of severe CIH young males only. In all female groups, the number of GABA-labeled cells was not different between CIH and controls. However, in the mPFC, CIH increased the number of parvalbumin-labeled neurons in young females and the number of somatostatin-labeled cells in AOF females but decreased the number of somatostatin-labeled cells in aged females. In the hippocampus, CIH decreased the number of somatostatin-labeled neurons in young females. CIH decreased the density of vesicular GABA transporter in the mPFC of AOF females only. These findings suggest sex-specific changes in GABAergic neurons in the hippocampus and mPFC with males showing an increase of this cell population as compared to their female counterparts following CIH. Age at exposure and severity of CIH also differentially affect the GABAergic cell population in mice.

Sex and chronic stress differentially alter phosphorylated mu and delta opioid receptor levels in the rat hippocampus following oxycodone conditioned place preference.

Following oxycodone conditioned place preference (CPP) in naïve female and male Sprague Dawley rats, delta- and mu-opioid receptors (DORs and MORs) redistribute in hippocampal CA3 pyramidal cells and GABAergic interneurons in a manner that would promote opioid-associative learning processes, particularly in females. MORs and DORs similarly redistribute in CA3 and hilar neurons following chronic immobilization stress (CIS) in females, but not males, essentially "priming" the opioid system for oxycodone-associative learning. Following CIS, only females acquire oxycodone CPP. The present study determined whether sex and CIS differentially affect the levels of phosphorylated MORs and DORs (pMORs and pDORs) in the hippocampus following oxycodone CPP as phosphorylation is important for opioid receptor internationalization and trafficking. In naïve oxycodone-injected (Oxy) female rats, the density of pMOR-immunoreactivity (ir) was increased in CA1 stratum oriens and CA3a,b strata lucidum and radiatum compared to saline-injected (Sal)-females. Additionally, the density of pDOR-ir increased in the pyramidal cell layer and stratum radiatum of CA2/3a in Oxy-males compared to Sal-males. In CIS females that acquire CPP, pDOR-ir levels were increased in the CA2/3a. These findings indicate only rats that acquire oxycodone CPP have activated MORs and DORs in the hippocampus but that the subregion containing activated opioid receptors differs in females and males. These results are consistent with previously observed sex differences in the hippocampal opioid system following Oxy-CPP.

Sex Differences in Neuroplasticity- and Stress-Related Gene Expression and Protein Levels in the Rat Hippocampus Following Oxycodone Conditioned Place Preference.

Prescription opioid abuse is a serious public health issue. Recently, we showed that female and male Sprague-Dawley rats acquire conditioned place preference (CPP) to the mu opioid receptor agonist oxycodone. Anatomical analysis of the hippocampus from these rats unveiled sex differences in the opioid system in a way that would support excitation and opiate associative learning processes especially in females. In this study, we examined the expression and protein densities of opioid, plasticity, stress and related kinase and signaling molecules in the hippocampus of female and male rats following oxycodone CPP. Oxycodone CPP females have: a) increases in ARC (activity regulated cytoskeletal-associated protein)-immunoreactivity (ir) in CA3 pyramidal cells; b) decreases in Npy (neuropeptide Y) gene expression in the medial hippocampus but higher numbers of NPY-containing hilar interneurons compared to males; c) increases in Crhr2 (corticotropin releasing factor receptor 2) expression in CA2/3; d) increases in Akt1 (AKT serine/threonine kinase 1) expression in medial hippocampus; and e) decreases in phosphorylated MAPK (mitogen activated protein kinase)-ir in CA1 and dentate gyrus. Oxycodone CPP males have: a) increases in Bdnf (brain derived-neurotrophic factor) expression, which is known to be produced in granule cells, relative to females; b) elevated Mapk1 expression and pMAPK-ir in the dentate hilus which harbors newly generated granule cells; and c) increases in CRHR1-ir in CA3 pyramidal cell soma. These sex-specific changes in plasticity, stress and kinase markers in hippocampal circuitry parallel previously observed sex differences in the opioid system after oxycodone CPP.