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Underrepresented Women Leaders: Lasting Impact of Gender Homophily in Surgical Faculty Networks

Suurna, Maria V; Leibbrandt, Andreas
OBJECTIVE:Despite the increase of women in surgical fields and resources toward advancing women, there is no corresponding increased representation of women in higher academic ranks and leadership. The following hypotheses are explored: 1) men and women build/maintain different relationship networks and 2) women are not similarly included within the organization and do not receive the same sponsorship as male counterparts. STUDY DESIGN/METHODS:Prospective observational study. METHODS:Three months of prospective, passive organizational network data of full-time faculty at an academic medical center were collected by analysis of deidentified internal email communication logs. Data were analyzed and strength of network relationships was assessed using algorithms measuring the tie, or connection, score. Data analysis was performed with standard statistical methods and multivariable regression models, comparing network relationships based on gender and academic rank. RESULTS:Among 345 full-time faculties from surgical departments, 45.2% were female Assistant Professors, but only 9.8% were female full Professors. Men had 55% more network relationships with other men than women had with men. Gender homophily was particularly pronounced at the higher academic ranks. Men compared to women in higher ranks had 157% more network relationships to other men in lower ranks. Multivariable regression models suggested direct association of these gender differences in relationships with more women in lower academic ranks. CONCLUSION/CONCLUSIONS:Higher academic rank can be predicted by male gender, tenure, and number of meaningful relationships. Women are underrepresented at the leadership level in surgical departments. Gender homophily is present in collaboration networks among academic surgeons and is associated with impeded female career advancement. LEVEL OF EVIDENCE/METHODS:2 Laryngoscope, 2021.
PMID: 34106470
ISSN: 1531-4995
CID: 4899962

Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum

Suurna, Maria V; Jacobowitz, Ofer; Chang, Jolie; Koutsourelakis, Ioannis; Smith, David; Alkan, Uri; D'Agostino, Mark; Boon, Maurits; Heiser, Clemens; Hoff, Paul; Huntley, Colin; Kent, David; Kominsky, Alan; Lewis, Richard; Maurer, Joachim T; Ravesloot, Madeline; Soose, Ryan; Steffen, Armin; Weaver, Edward; Williams, Amy M; Woodson, Tucker; Yaremchuk, Kathleen; Ishman, Stacey L
Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.
PMID: 34279214
ISSN: 1550-9397
CID: 4947902

Obstructive Sleep Apnea: Non-positive Airway Pressure Treatments

Suurna, Maria V; Krieger, Ana C
Undiagnosed and untreated obstructive sleep apnea (OSA) is associated with health comorbidities and negatively affects quality of life. Alternative treatments should be considered in patients who are unable to tolerate or benefit from positive airway pressure treatment. When properly indicated, positional devices, oral appliances, airway surgery, and hypoglossal nerve stimulation have been shown to be effective in treating OSA. Hypoglossal nerve stimulation is a successful second-line treatment with low associated morbidity and complication rate.
PMID: 34210448
ISSN: 1879-8853
CID: 4927162

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study

Huyett, Phillip; Kent, David T; D'Agostino, Mark A; Green, Katherine K; Soose, Ryan J; Kaffenberger, Thomas M; Woodson, B Tucker; Huntley, Colin; Boon, Maurits S; Heiser, Clemens; Birk, Amelie; Suurna, Maria V; Lin, Ho-Sheng; Waxman, Jonathan A; Kezirian, Eric J
OBJECTIVES/HYPOTHESIS/OBJECTIVE:To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN/METHODS:Cohort study. METHODS:A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS:. AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS:The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE/METHODS:3 Laryngoscope, 2021.
PMID: 33443811
ISSN: 1531-4995
CID: 4747172

Model-based analysis of implanted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea

Johnson, Matthew D; Dweiri, Yazan M; Cornelius, Jason; Strohl, Kingman P; Steffen, Armin; Suurna, Maria; Soose, Ryan J; Coleman, Michael; Rondoni, John; Durand, Dominique M; Ni, Quan
STUDY OBJECTIVES:Individuals with obstructive sleep apnea (OSA), characterized by frequent sleep disruptions from tongue muscle relaxation and airway blockage, are known to benefit from on-demand electrical stimulation of the hypoglossal nerve. Hypoglossal nerve stimulation (HNS) therapy, which activates the protrusor muscles of the tongue during inspiration, has been established in multiple clinical studies as safe and effective, but the mechanistic understanding for why some stimulation parameters work better than others has not been thoroughly investigated. METHODS:In this study, we developed a detailed biophysical model that can predict the spatial recruitment of hypoglossal nerve fascicles and axons within these fascicles during stimulation through nerve cuff electrodes. Using this model, three HNS programming scenarios were investigated including grouped cathode (---), single cathode (o-o), and guarded cathode bipolar (+-+) electrode configurations. RESULTS:Regardless of electrode configuration, nearly all hypoglossal nerve axons circumscribed by the nerve cuff were recruited for stimulation amplitudes <3 V. Within this range, monopolar configurations required lower stimulation amplitudes than the guarded bipolar configuration to elicit action potentials within hypoglossal nerve axons. Further, the spatial distribution of the activated axons was more uniform for monopolar versus guarded bipolar configurations. CONCLUSIONS:The computational models predicted that monopolar HNS provided the lowest threshold and the least sensitivity to rotational angle of the nerve cuff around the hypoglossal nerve; however, this setting also increased the likelihood for current leakage outside the nerve cuff, which could potentially activate axons in unintended branches of the hypoglossal nerve. CLINICAL TRIAL REGISTRATION:NCT01161420.
PMID: 33647987
ISSN: 1550-9109
CID: 5094992

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial

Patsalides, Athos; Santillan, Alejandro; Sundararajan, Sri Hari; Michael, Marissa; Suurna, Maria; Alexiades, George
OBJECTIVES/OBJECTIVE:This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis. METHODS:Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded. RESULTS:A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events. CONCLUSION/CONCLUSIONS:Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.
PMID: 33243042
ISSN: 2385-2011
CID: 4680982

Intraoperative identification of mixed activation profiles during hypoglossal nerve stimulation

Sturm, Joshua J; Lee, Clara H; Modik, Oleg; Suurna, Maria V
STUDY OBJECTIVES/OBJECTIVE:The effectiveness of hypoglossal nerve stimulation (HGNS) in the treatment of obstructive sleep apnea (OSA) depends upon the selective stimulation of nerve fibers that innervate tongue muscles that produce tongue protrusion (genioglossus) and stiffening (transverse/vertical), while avoiding fibers that innervate muscles that produce tongue retraction (styloglossus/hyoglossus). Post-operative treatment failures can be related to mixed activation of retractor and protrusor muscles despite intraoperative efforts to identify and avoid nerve fibers that innervate retractor muscles. This study describes a novel intraoperative protocol that more optimally identifies mixed activation by utilizing an expanded set of stimulation/recording parameters. METHODS:Case series in a university hospital setting of patients undergoing unilateral HGNS implantation for OSA. Data included EMG responses in genioglossus and styloglossus/hyoglossus to intraoperative stimulation with an implantable pulse generator (IPG) using unipolar (---, o-o) and bipolar (+-+) settings. RESULTS:In a subset of patients (3/55), low-intensity unipolar IPG stimulation revealed significant mixed activation of styloglossus/hyoglossus and genioglossus muscles that was not evident under standard bipolar IPG stimulation conditions. Additional surgical dissection and repositioning of the electrode stimulation cuff reduced mixed activation. CONCLUSIONS:A novel intraoperative neurophysiological monitoring protocol was able to detect significant mixed activation during HGNS that was otherwise absent with standard parameters. This enabled successful electrode cuff repositioning and dramatic reduction of mixed activation.
PMID: 32677611
ISSN: 1550-9397
CID: 4528582

Establishing an Office-Based Framework for Resuming Otolaryngology Care in Academic Practice During the COVID-19 Pandemic

Pearlman, Aaron N; Tabaee, Abtin; Sclafani, Anthony P; Sulica, Lucian; Selesnick, Samuel H; Kutler, David I; Montano, Joseph J; Levinger, Joshua I; Suurna, Maria V; Modi, Vikash K; Stewart, Michael G
OBJECTIVE:The COVID-19 health crisis abruptly disrupted the practice of otolaryngology. This article aims to define the changes needed to operate an academic otolaryngology practice safely and efficiently from within the epicenter of the pandemic. We define the areas of normal patient workflow that have been affected by COVID-19, and we offer mitigation strategies with attention paid to the specific needs of subspecialties. DATA SOURCES/METHODS:. REVIEW METHODS/METHODS:Expert opinion. CONCLUSIONS:Through careful planning and execution, it is possible to reestablish safe otolaryngologic patient care during the COVID-19 pandemic. It will require a significant change from prior practice models for successful implementation. Additionally, telemedicine can be positively integrated into the treatment of otolaryngology diseases for new and established patients. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:The information conveyed in this review can be used as a guide by large and small otolaryngology groups to identify aspects of the patient visit that are "at risk" due to COVID-19, and it suggests sensible responses that can be made without a significant disruption to normal practice. The methods used to identify vulnerabilities with the patient visit process can be applied to future unforeseen crises, such as a resurgence of COVID-19 or a novel pandemic.
PMID: 32867585
ISSN: 1097-6817
CID: 4582902

Neurophysiological monitoring of tongue muscle activation during hypoglossal nerve stimulation

Sturm, Joshua J; Modik, Oleg; Suurna, Maria V
OBJECTIVES/HYPOTHESIS/OBJECTIVE:Upper airway stimulation for obstructive sleep apnea (OSA) via implantable hypoglossal nerve stimulation (HGNS) reduces airway obstruction by selectively stimulating nerve fibers that innervate muscles that produce tongue protrusion, while avoiding fibers that produce tongue retraction. This selective stimulation likely depends upon the location, intensity, and type of electrical stimulation delivered. This study investigates the impact of changing stimulation parameters on tongue muscle activation during HGNS using intraoperative nerve integrity monitoring in conjunction with electromyography (EMG). STUDY DESIGN/METHODS:Prospective case series. METHODS:Ten patients undergoing unilateral HGNS implantation for OSA in a university hospital setting were studied. Data included EMG responses in tongue muscles that produce protrusion (genioglossus), retraction (styloglossus/hyoglossus), and stiffening (transverse/vertical) in response to intraoperative bipolar probe electrical stimulation of lateral and medial branches of the hypoglossal nerve (HGN) and to implantable pulse generator (IPG) unipolar and bipolar settings after placement of the stimulation cuff. RESULTS:Stimulation of medial division HGN branches resulted in EMG responses in genioglossus muscles, but not in styloglossus/hyoglossus muscles, whereas stimulation of the lateral division HGN branches drove responses in styloglossus/hyoglossus muscles. Variable responses in transverse/vertical muscles were observed with stimulation of lateral and medial division branches. After electrode cuff placement, unipolar and bipolar HGN stimulation configurations of IPG resulted in unique patterns of muscle activation. CONCLUSIONS:The relative activation of extrinsic and intrinsic tongue musculature by HGNS is determined by stimulus location, intensity, and type. Intraoperative neurophysiological monitoring of tongue muscle activation enables proper electrode cuff placement and may provide essential data for stimulus optimization. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2019.
PMID: 31742709
ISSN: 1531-4995
CID: 4208822

Personalized Treatment of Obstructive Sleep Apnea [Editorial]

Suurna, Maria V; Jacobowitz, Ofer
PMID: 32284202
ISSN: 1557-8259
CID: 4383212