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STUDY OBJECTIVES: Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. METHODS: Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. RESULTS: Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74–0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). CONCLUSIONS: More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes. CITATION: Donovan LM, Fernandes LA, Williams KM, et al. Agreement of sleep specialists with registered nurses’ sleep study orders in supervised clinical practice. J Clin Sleep Med. 2020;16(2):279–283.

The frequency-energy plots (FEPs) of two-degree-of-freedom linear structures attached to a piecewise nonlinear energy sink (PNES) are generated here and thoroughly investigated. This study provides the FEP analysis of such systems for further understanding to nonlinear targeted energy transfer (TET) by the PNES. The attached PNES to the considered linear dynamical systems incorporates a symmetrical clearance zone of zero stiffness content where the boundaries of the zone are coupled with the linear structure by linear stiffness elements. In addition, linear viscous damping is selected to be continuous during the PNES mass oscillation. The underlying nonlinear dynamical behavior of the considered structure-PNES systems is investigated by generating the fundamental backbone curves of the FEP and the bifurcated subharmonic resonance branches using numerical continuation methods. Accordingly, interesting dynamical behavior of the nonlinear normal modes (NNMs) of the structure-PNES system on different backbones and subharmonic resonance branches has been observed. In addition, the imposed wavelet transform frequency spectra on the FEPs have revealed that the TET takes place in multiple resonance captures where it is dominated by the nonlinear action of the PNES.

Background: Amyloidosis is a protein misfolding disorder that leads to the deposition of beta-pleated sheets of a fibrillar derivative of various protein precursors. Identification of the type of precursor protein is integral in treatment decision-making. The presence of two different types of amyloid in the same patient is unusually rare, and there are no previous reports of two different types of amyloid deposition in the ligamentum flavum (LF) in the same patient. Case Description: Here, we describe two patients with spinal stenosis who underwent laminectomies and were found to have AL and ATTR amyloid deposits in the LF. Conclusion: As the spine is becoming recognized as a site for ATTRwt amyloid deposition, patients undergoing spinal decompression surgery may potentially benefit from evaluation for amyloidosis in the LF.

Rationale Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. In order to manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. While prior work shows that RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. Objective Assess staff experiences with a team-based approach to sleep medicine referrals. Methods From June 2019 to September 2020, we conducted semi-structured interviews with staff members who interacted with RCI in sleep medicine. We recruited a variety of staff including RCI team members (nurses, medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. Results We conducted 48 interviews among 35 unique staff members and identified six themes. 1) Efficiency: Staff described impacts of the RCI program with regard to efficient use of staff time and resources. 2) Patient access and experience: Staff noted improvements to patient's ability to receive care. 3) Staff wellbeing and satisfaction: Specialists and RCI staff described how RCI mitigated the adverse impact of triage volume on staff wellbeing. 4) Sharing specialty knowledge: Nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage. 5) Nurse autonomy: Staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy. 6) Coordination and communication: Staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. Conclusion Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff wellbeing.

The incidence of hospital- and community-acquired infections has been dramatically increased worldwide. Accordingly, hands hygiene and the use of disinfectants have been increased leading to the expansion in hand sanitizers production to meet public demand. This study was conducted to assess the efficiency of common disinfectants in the market of Riyadh, Saudi Arabia in inhibiting the microbial growth during the time of Coronavirus disease 2019 (COVID-19) pandemic. Five bacterial strains of commonly hospital-acquired infections (Pseudomonas aeruginosa, Escherichia coli, Salmonella enteritidis, Staphylococcus aureus, and Enterococcus faecalis) (ATCC reference strains and clinical isolates) were examined for their susceptibility against 18 disinfectants collected from the Saudi market. The tested 18 disinfectants were broadly clustered into different groups based on their active chemical composition as following: 12 products contained alcohol, 2 products had chlorhexidine, 3 products contained mixed concentration of alcohol/chlorhexidine and 1 product had a mixture of chlorhexidine/Hexamidine/Chlorocresol. By measuring the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC), our results revealed that all the 18 disinfectants have reduced the microbial growth of all the tested strains. Generally, the MICs and the MBCs for the clinical strains are higher than those of the reference strains. Taken together, our findings showed that all tested products have high disinfectants’ killing rate against microbes of different origins, which suggest the high quality of these disinfectants and the good surveillance practice by the local authorities in Saudi Arabia.

High concentrations of chlorophyll-a can be used to predict where fish gather. On the other hand, tropical cyclones are one of the triggering factors for vertical stirring and upwelling that cause fertility of waters. The Sangihe Island area is not an effective area for the formation of tropical cyclones. However, due to its geographical location with a tropical cyclone area and trajectory, the potential for disturbances caused by cyclones is impactful on Sangihe Island. The distribution of wind speed, salinity, sea surface temperature and chlorophyll-a concentration can be detected by satellite remote sensing imagery. This study aims to analyze the impact of Tropical Cyclone Amang on the variability of wind speed, salinity, sea surface temperature and on the concentration of chlorophyll-a in Sangihe Island. This study useswind speed, salinity, sea surface temperature and chlorophyll-a data during the Amang Tropical Cyclone (January 6-27, 2019) from the AQUA-MODIS satellite imagery. The results show that the relationship between wind speed and chlorophyll-a concentration has impact on other parameters where both parameters showed a strong correlation value. It was also showed on the relationship between sea surface temperature and chlorophyll-a.However, the relationship between salinity and chlorophyll-a concentration showed lowest effect among those parameters.Indonesian title: Dampak siklon tropis Amang terhadap variabilitas kecepatan angin, salinitas, suhu permukaan laut, dan hubungannya dengan klorofil-a di perairan laut Pulau Sangihe

Background: The global spread of SARS-CoV-2 is a serious public health issue. Large-scale surveillance screenings are crucial but can exceed diagnostic test capacities. We optimized test conditions and implemented high throughput pool testing of respiratory swabs into SARS-CoV-2 diagnostics. Methods: In preparation for pool testing, we determined the optimal pooling strategy and pool size, and evaluated aspects of pre-analytics including method and timepoint of sample collection during course of infection. In addition, we measured the impact of vortexing prior to sample processing, compared pipette- and swab-pooling method as well as the sensitivity of three different PCR assays. Findings: Using optimized strategies for pooling, we systematically pooled 16,164 samples in a period of 18 weeks resulting in a reduction of 14,170 PCR reactions. In a low prevalence setting, we defined a preferable pool size of ten in a two-stage hierarchical pool testing strategy. Vortexing of the swab increased cellular yield by a factor of 2·34, and sampling at or shortly after symptom onset by oropharyngeal or combined nasal/oropharyngeal swabs was associated with higher viral loads. By comparing different pooling strategies, pipette-pooling was more efficient compared to swab-pooling. Interpretation: For implementing pooling strategies into high throughput diagnostics, we recommend to apply a pipette-pooling method, using pool sizes of ten samples, performing sensitivity validation of the PCR assays used, and vortexing swabs prior to analyses. Our data shows, that pool testing for SARS-CoV-2 detection is feasible and highly effective in a low prevalence setting. Funding: No external funding was received. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: All samples and clinical data were collected on the wards or outpatient departments of the University Hospital of Cologne. No identifying data were used for the patient’s characterization. According to §15 subparagraph 3 (Professional Code for Physicians in Germany) ethical principles of WMA Declaration of Helsinki were respected, and no ethics committee approval and informed consent were necessary for this study.

Human papillomavirus type 8 (HPV8) is associated with the development of non-melanoma skin cancer. In the past we already delved into the mechanisms involved in keratinocyte invasion, showing that the viral E7 oncoprotein is a key player that drives invasion of basal keratinocytes controlled by the extracellular protein fibronectin. To unravel further downstream effects in E7 expressing keratinocytes we now aimed at characterizing gene and protein/phosphoprotein alterations to narrow down on key cellular targets of HPV8-E7. We now show that gene expression of GADD34 and GDF15 are strongly activated in the presence of E7 in primary human keratinocytes. Further analyses of fibronectin-associated factors led to the identification of the Src kinase family members Fyn and Lyn being aberrantly activated in the presence of HPV8-E7. Phospho-proteomics further revealed that E7 not only targets cell polarity and cytoskeletal organization, but also deregulates the phosphorylation status of nuclear proteins involved in DNA damage repair and replication. Many of these differentially phosphorylated proteins turned out to be targets of Fyn and Lyn. Taken together, by using unbiased experimental approaches we have now arrived at a deeper understanding on how fibronectin may affect the signaling cascades in HPV8 positive keratinocytes, which may be key for skin tumorigenesis and that may also aid in the development of novel therapeutic approaches for betaHPV-mediated cancers.

BACKGROUND Paragangliomas (PGLs) are rare neoplasms that may be associated with hereditary PGL syndromes and variable risk of metastasis. Middle ear adenomas are extremely rare tumors with no known hereditary predisposition and extremely low risk of metastasis. Although often easily differentiated, they may share clinical and pathological features that misdirect and confuse the diagnosis. OBSERVATIONS The authors discussed a 35-year-old woman with left-sided hearing loss and bleeding from the external ear canal who presented to an outside hospital. She underwent resection of a middle ear and mastoid mass, initially diagnosed as a middle ear adenoma with neuroendocrine features, with later mastoidectomy and ligation of the sigmoid sinus with microsurgical excision of persistent tumor in the jugular foramen and temporal bone. Histopathologically, her tumor was vascular, composed of benign-appearing epithelioid cells with “salt and pepper” neuroendocrine chromatin arranged in vague nests. Lesional cells were GATA3-immunopositive, glucagon-negative, and succinate dehydrogenase-immunonegative, consistent with PGL rather than middle ear adenoma, and required further workup for hereditary PGL syndromes. LESSONS This case demonstrates potential challenges in differentiating a PGL from a middle ear adenoma. The authors offer clinical, histopathological, and imaging principles to aid in diagnosis and workup.

Oral rehydration therapy (ORT) as an appropriate technology in the treatment of acute diarrhoeal diseases (ADD) has been accepted throughout the world. It has been proved that besides lifesaving, ORT has reduced about 70-80% of the use of intravenous solution and average cost of the treatment of ADD. If there is still problem, question or doubtfulness, is the use of WHO ORS in full concentration for the neonates and young infants less than 3 months of age. During one-year period it has been treated 72 cases of ADD in young infants less than 3 months of age with moderate dehydration. They were divided into 3 groups. The first group was treated with 100 mil kg bw of fluid consisting oftwothirds as WHO ORS in full concentration for 4 hours period and the rest, one-third, was given as plain water for 2 hours period. The second group was treated with kristalyte with the Na concentration of 51 mEq/L and the third group was treated with intravenous Ringer's lactate for 6 hours period. After the end of the study only 18 patients in each group could be matched and evaluated. From clinical observation and laboratory examinations, the result of the treatment in general, statistically shows no significant difference. Diarrhoea and vomiting stopped in all groups on the second day of treatment. Hyponatremia which occurred in 3 patients in Group I and 2 patients each in Group II and III improved after 6 hours of treatment. Acidosis was corrected in all of the treatment groups in 6 hours period. Weight gain up to 6-9% of body weight on admission was achieved after 6 hours of treatment in all groups. No complication of hypernatremia, convulsion nor hypoglycaemia in all the treatment group. From this study it could be concluded that WHO ORS is quite safe and effective as ORS with low sodium concentration and intravenous treatment, as far as it is given slowly, little by little with a strict supervision.

Let R be an associative ring with identity, and let M be a unitary left R-module. The main purpose of this paper is to introduce and study properties of class of modules including lifting module. We use the Radical submodule to introduce this class of modules. We start by defining a generalized lifting module as a generalization of lifting module, then we give another generalization of generalized lifting module we called it cofinitely generalized lifting module. Thus, we give characterization and prove some properties of this type of modules.

This study was conducted to determine the types of seagrasses and calculate biomass and calculate how much carbon absorption in seagrasses was found in the location of Tongkaina Beach, Bunaken District, Manado City, North Sulawesi. The sampling procedure in the field is the method of cruising surveys. A cruising survey is a sample collection method that is carried out by walking through the coastal area of all seagrasses found. After the sampling at the site is completed, the sample in the inventory is then photographed. The samples that have been obtained are analyzed in the laboratory using the loss on ignition (LOI) method. The results of the study on Tongkaina coastal waters covering an area of 25,000 meters with a coastal length of ±500 meters, in an area parallel to the coastline as wide as ±50 meters towards the sea and six types of seagrasses were obtained, namely: Enhalus acoroides, Thalassia hemprichii, Syringodium isoetifolium, Cymodocea rotundata, Halodule uninervis, and Halodule pinifolia. The biomass in seagrasses found had an average value of 78.10% with the highest individual seagrass biomass found in seagrass type Enhalus acoroides with a biomass value of 87.23grams of dry weight (gbk)/individual and the lowest type of seagrass individual biomass value was found in seagrass type seagrass with a biomass value of 66.67grams of dry weight (gbk)/individual. The total carbon content calculated in the entire seagrass obtained was 46,0941gCKeywords: Tongkaina Beach; seagrasses; biomass; carbon absorptionAbstrakPenelitian ini dilakukan untuk mengetahui jenis-jenis lamun dan menghitung biomassa serta menghitung berapa serapan karbon pada lamun yang ditemukan dilokasi Perairan Pantai Tongkaina Kecamatan Bunaken Kota Manado Provinsi Sulawesi Utara. Prosedur pengambilan sampel di lapangan menggunakan metode survei jelajah. Survei jelajah adalah metode pengumpulan sampel yang di lakukan dengan cara menyusuri daerah pantai terhadap semua lamun yang ditemukan. Setelah pengambilan sampel di lokasi selesai, sampel di inventarisir kemudian difoto. Sampel yang telah diperoleh dianalisa di laboratorium dengan menggunakann metode loss on ignition (LOI). Hasil penelitian pada perairan pantai Tongkaina seluas 25.000 meter dengan panjang pantai ±500 meter sejajar garis pantai dan lebar ±50 meter ke arah laut. Ditemukan enam jenis lamun yaitu: Enhalus acoroides, Thalassia hemprichii, Syringodium isoetifolium, Cymodocea rotundata, Halodule uninervis dan Halodule pinifolia. Biomassa pada lamun yang ditemukan memiliki nilai rata-rata 78,53% dengan biomassa individu lamun tertinggi terdapat pada lamun jenis Enhalus acoroides dengan nilai biomassa mencapai 87,23gram berat kering (gbk)/individu dan nilai biomassa individu jenis lamun terendah terdapat pada lamun jenis Syringodium isoetifolium dengan nilai biomassa 66,67gram berat kering (gbk)/individu. Untuk total kandungan karbon yang dihitung pada keseluruhan lamun yang didapat sebesar 46,0941gC.Kata kunci: Pantai Tongkaina; Lamun; biomasa, serapan carbon

The waters surrounding the Minahasa Peninsula are important areas of various activities by use of coastal and marine space. This research aims, firstly to describe direction, period and height of waves at several water areas around the Minahasa Peninsula in various season. Secondly to analyze the characteristic of daily and seasonal waves. The wave parameter, which reanalysis by ECMWF for 5 years (September 2014 to august 2019) were used in this research. By the analysis spasial-temporal, the results are presented by the rose grapich waves direction and stock chart. The wave propagation in the north season and transition season I, is dominated by the northeasterly wave. While the wave propagation in the southern season and the transitional season II, is more diverse directions. The characteristics of the waves formed in the southeast Minahasa waters in the north season and transitional season I, show that the wave period is greater than in the waters of Manado Bay and Bitung waters. Furthermore, the wave characteristics formed in the waters of the Minahasa Peninsula show a significant wave height in Bitung waters which is higher than the waters of Manado Bay and Southeast Minahasa waters.Keywords: Waves, ECMWF, Minahasa Peninsula Waters Perairan sekitar Semenanjung Minahasa merupakan kawasan penting dalam berbagai aktivitas pemanfaatan ruang pantai dan laut. Penelitian ini bertujuan, pertama untuk mendeskripsikan arah, periode, dan tinggi gelombang di beberapa kawasan perairan sekitar Semenanjung Minahasa dalam berbagai musim yang berlangsung. Kedua adalah menganalisis karakteristik gelombang harian dan musiman pada perairan sekitar Semenanjung Minahasa. Data yang digunakan dalam penelitian adalah data reanalysis ECMWF (European Centre for Medium-Range Weather Forecasts) parameter gelombang selama 5 tahun mulai bulan September 2014 sampai Agustus 2019. Dengan metode analisis spasial-temporal hasilnya disajikan dalam bentuk grafik mawar arah datang gelombang dan grafik kotak (stock chart). Rambatan gelombang pada musim Utara dan musim Peralihan I, arah datangnya didominasi dari arah Timur Laut. Sedangkan rambatan gelombang pada musim Selatan dan musim Peralihan II, arah datangnya lebih beragam. Karakteristik gelombang yang terbentuk di perairan Minahasa Tenggara pada musim Utara dan musim Peralihan I memperlihatkan periode gelombangnya lebih besar dari pada perairan Teluk Manado dan Perairan Bitung. Selanjutnya karakteristik gelombang yang terbentuk di perairan Semenanjung Minahasa memperlihatkan tinggi gelombang signifikan di perairan Bitung lebih tinggi dari pada perairan Teluk Manado dan perairan Minahasa Tenggara.Kata kunci: Gelombang, ECMWF, Perairan Semenanjung Minahasa

Marine debris is one of the biggest pollution problems in the world. There are various potentials of marine and beach tourism to attract tourists, but in turn, cause a waste disposal accumulation and coupled with the built-in garbage that comes from the sea. The research was conducted at Tasik Ria Beach, Tombariri, and Marine Field Station of the Faculty of Fisheries and Marine Sciences, Sam Ratulangi University in Likupang. The aims of this study were (1) to identify the types of marine debris, and (2) to determine and compare the spatial distribution pattern of marine debris in the two designed locations. The sampling technique adapted from the shoreline survey methodology designed by NOAA was used in the study. Data were then statistically processed and analyzed using data mining software (MS Excel and Orange). This study found that the category of plastic and rubber waste is the most common category with the total amount on Tasik Ria Beach 54.39% and 97.55% in the Marine Field Station of Faculty of Fisheries and Marine Sciences in Likupang respectively. The correlation coefficient between the composition of the amount and mass of marine debris is 0.89 which indicates a close relationship between the amount and mass composition. There are many factors that cause the distribution of various types of marine debris, one of which is the activities of the people around the coastal area.Keywords: Marine debris; Category; Type; CompositionAbstrakSampah laut merupakan salah satu masalah polusi yang besar di dunia. Beragam potensi wisata bahari dan pantai menjadi daya tarik wisatawan namun aktivitas wisata dapat mengakibatkan adanya buangan sampah oleh masyarakat dan wisatawan, ditambah lagi dengan sampah bawaan yang berasal dari laut. Penelitian ini dilakukan di Pantai Tasik Ria, Tombariri dan Laboratorium Fakultas Perikanan dan Ilmu Kelautan Universitas Sam Ratulangi untuk mengidentifikasi jenis sampah laut di perairan pantai Minahasa bagian utara dan mengetahui persebaran dan perbandingan distribusi sampah laut dua lokasi penelitian. Berdasarkan hasil pengambilan sampel dengan mengadaptasi metode Shoreline Survey Methodology berdasarkan NOAA yang kemudian diolah dan dianalisis secara statistik dengan menggunakan beberapa perangkat lunak (MS Excel dan Orange) diperoleh kategori sampah plastik dan karet sebagai kategori yang paling banyak ditemukan dengan komposisi jumlahnya di Pantai Tasik Ria sebesar 54,39% dan 97,55% di Laboratorium Fakultas Perikanan dan Ilmu Kelautan. Nilai koefisien korelasi antara komposisi jumlah dan massa sampah laut sebesar 0.89 yang menyatakan hubungan yang erat antara komposisi jumlah dan massa. Banyaknya faktor yang menyebabkan terdistribusinya beragam jenis sampah laut, salah satunya adalah aktivitas masyarakat di sekitar wilayah pesisir.Kata kunci: Sampah Laut; Kategori; Jenis; Komposisi

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients’ experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645–1651.