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WEST OCEAN CITY – One local man was arrested on burglary and theft charges this week and another is still being sought by local law enforcement officials after a month-long investigation connected them to a string of thefts of stolen fishing equipment in the West Ocean City area.
Maryland Natural Resources Police (NRP) this week charged Clayton James Entwistle, 19, of Berlin, with burglary and theft charges and as of mid-week were seeking a second suspect, identified as Chad Michael Shipley, 19, also of Berlin, after connecting the pair to a burglary spree involving fishing equipment. After a month-long investigation, NRP officers noticed the two suspects selling fishing equipment out of a backpack on the Harry Kelley (Route 50) Bridge during a routine patrol check.
After further investigation, NRP officers were able to determine the equipment had been reported stolen from a vehicle parked as Sunset Marina and a 45-foot sportfishing boat docked at Fisherman's Marina in West Ocean City around Oct. 3.
Entwistle was arrested and charged with first-degree burglary, fourth-degree burglary, theft over $1,000 and theft from $100 to $1,000. He is currently being held in the Worcester County Detention Center on a $50,000 bond.
Meanwhile, as of Wednesday, NRP officers and the Worcester County Bureau of Investigation (WCBI) was still seeking Shipley. He has been charged with fourth-degree burglary and theft over $1,000 as well as charges related to other thefts in the area.
Cop Assault During DUI Stop
WEST OCEAN CITY – A Snow Hill woman, who was passenger in a vehicle stopped for suspicion of drunk driving, was arrested for assaulting an officer in West Ocean City on Wednesday.
Around 1:15 a.m. on Wednesday, a Maryland State Police trooper was assisting another trooper with a suspected DUI stop on Route 50 near Golf Course Rd. in West Ocean City. During the investigation, a passenger in the vehicle, identified as Corey Patrice Johnson, 31, became belligerent and attempted to hit the assisting officer.
When the trooper attempted to place the unruly passenger under arrest, she allegedly kicked the officer numerous times on the shin with high-heeled boots. According to police reports, Johnson was extremely intoxicated at the time. Johnson was charged with second-degree assault and resisting arrest. She was processed and taken before a District Court Commissioner and later released on her own recognizance.
Glen Riddle Burglary
BERLIN – Maryland State Police (MSP) troopers this week are looking for a suspect or suspects who broke into a residence in the Glen Riddle community last weekend.
Shortly before 8 p.m. last Sunday, MSP troopers from the Berlin barrack received a call from Alarm Engineering in reference to a burglary alarm at a residence on Maid at Arms Lane in the Glen Riddle community. Upon arrival, troopers discovered an unknown suspect or suspects had gained entry to the residence after breaking out a rear glass door to a lower level room.
During the investigation, troopers discovered two flat-screen televisions had been taken along with other electronics. A crime scene technician from the Worcester County Bureau of Investigation (WCBI) responded to the scene to process the residence and the investigation is ongoing.
Domestic Assault Arrest
WEST OCEAN CITY – A West Ocean City man was arrested on assault charges this week after allegedly striking his wife during a domestic dispute.
Around 1:30 a.m. on Sunday, Maryland State Police troopers responded to a residence on Tudor Rd. in West Ocean City for a reported domestic assault. Upon arrival, the troopers met with a female victim who told police she was assaulted by her husband, identified as Francisco Hernandez.
The troopers observed the victim, who reportedly had bruising and swelling under her left eye. She also had a chunk of her hair pulled out during the altercation. According to police reports, Hernandez was extremely intoxicated at the time. He was arrested and charged with second-degree assault.
Traffic Stop Nets Pot Bust
WEST OCEAN CITY – A Salisbury man was arrested on marijuana possession charges this week after a routine traffic stop in West Ocean City.
Around 1:17 a.m. on Tuesday, a Maryland State Police trooper on routine patrol stopped a 1993 Oldsmobile Cutlass on Route 50 at Inlet Isle Lane. Upon making contact with the driver, identified as Henry Lee Coleman, Jr., 20, of Salisbury, the trooper detected the odor of burnt marijuana. A subsequent search of the vehicle turned up an undisclosed amount of marijuana and a glass-smoking device. In addition, a black digital scale was also seized from the vehicle. Coleman was charged with possession of marijuana and was taken before a District Court Commissioner before being released.
Pot Possession Arrest
BERLIN – A Berlin man was arrested on marijuana charges last week after a routine traffic stop.
Around 12:20 p.m. on Nov. 9, a Berlin Police officer on routine patrol stopped a 1987 Buick driven by Armando Silva, 20, of Berlin, near Tripoli Streets. Following the traffic stop, Silva consented to a search of his vehicle, which turned up a smoking device with marijuana residue in the passenger compartment. Silva was arrested and charged with possession of controlled dangerous substance and paraphernalia. He was later released.
Speeding Leads To Dope
BERLIN – An Ocean City woman was arrested on marijuana charges last week after Berlin Police pulled her over for speeding.
Around 11:30 p.m. on Nov. 9, Berlin Police were a conducting stationary assignment on Route 113 near Burley Street when they stopped a 2000 Mitsubishi for speeding. The driver, identified as Jessie Christine Adkins, 24, of Ocean City, consented to a search of her vehicle, which revealed several small bags of marijuana and a glass-smoking device with marijuana residue in it. Adkins was arrested and charged with possession of marijuana and possession of paraphernalia.
No Injuries In Berlin Fire
BERLIN – No injuries were reported during an afternoon residential fire in Berlin on Wednesday.
Around 1 p.m. on Wednesday, a fire was reported at a residence on Newport Farms Drive near the end of Hays Landing Drive off Route 113 in Berlin. First arriving firefighters reported smoke showing from the rear roof of the residence. Firefighters from Berlin, Newark and Ocean Pines responded and quickly extinguished the fire, although they remained on the scene for about two hours. No injuries were reported at the residence.
The Worcester County Fire Marshal's Office responded and determined the fire ignited while roofing contractors were working on the structure. The cause of the fire has been listed as accidental. Anyone with additional information about the fire is urged to contact Worcester County Deputy Fire Marshal Matt Owens at 410-632-5666, extension 2.
Jail Time For Assault
SNOW HILL – A Berlin man arrested in a convenience store in August after police recognized him as a man wanted on a warrant for an alleged assault back in May pleaded guilty last week in District Court to second-degree assault and was sentenced to a year in jail.
Shortly after 1 p.m. on Aug. 6, Berlin police officers in the area of the Shop Kwick store on Old Ocean City Blvd. spotted a man they recognized as Zahi James Moreno, 28, of Berlin. The officers knew Moreno had an outstanding warrant through the Wicomico County Sheriff's Office for violating probation and he was wanted in connection with an assault case in Worcester County on May 29. The officers approached Moreno and took him into custody until they could confirm the warrant.
About 10 minutes later, the warrant was confirmed and Moreno was placed under arrest. Last week in District Court, Moreno pleaded guilty to second-degree assault and was sentenced to a year in jail. He was also fined $300 and placed on probation for one year.
Pines Burglar Pleads Guilty
SNOW HILL – A Salisbury man arrested in July after Ocean Pines Police were able to connect him to several house break-ins in the community pleaded guilty last week in Worcester County Circuit Court to third-degree burglary and now awaits his fate pending the outcome of a pre-sentence investigation.
Joseph Glenn Cherone, 43, was arrested in July after Ocean Pines Police were able to connect him to at least residential burglaries in the community over a three-year period from mid-May to early June. A total of five house burglaries occurred in Ocean Pines during the time period and Cherone was directly linked to at least three of them.
Cherone was charged initially with three counts of first-degree burglary, third- and fourth-degree burglary, felony theft and conspiracy to commit felony theft. Last week, Cherone pleaded guilty in Worcester County Circuit Court to one count of third-degree burglary and sentencing was deferred pending the completion of a pre-sentence investigation.
The third-degree burglary charge carries a maximum sentence of 10 years in jail. Cherone remains in custody pending the outcome of the pre-sentence investigation. In addition, an evaluation was ordered to determine whether Cherone would benefit for treatment of drug and alcohol abuse. The other charges against Cherone were not prosecuted as a result of the plea bargain.
Bond Review In
Attempted Murder Case
OCEAN CITY – A Grasonville, Md. man arrested in June on attempted murder charges after allegedly stabbing two people during a fight in a downtown Ocean City parking lot appeared for a bail review last week and was released after posting a $50,000 bond.
Just before midnight on June 8, a private citizen informed Ocean City police there was a fight in progress in the parking lot at 7 Atlantic Ave. As officers approached the area of the reported fight, they learned two individuals had been stabbed and the suspect had fled on foot.
The suspect, later identified as Randy Lopez-Medina, 23, of Grasonville, Md., was able to elude OCPD officers after a chase on foot. Ocean City police, with the assistance of the Maryland State Police, broadcasted a description of the suspect and were eventually able to locate Lopez-Medina in the area of 7th Street and the Boardwalk. He was eventually taken into custody without further incident.
The two victims were treated first at the scene by Ocean City EMS and later transported to the hospital. One victim received a slash wound across his upper back and a large wound to his left shoulder. The second victim suffered stab wounds to his chest, possibly puncturing his lung. No updates have been provided about the condition of the victims.
Lopez-Medina faces 11 total charges related to the attacks including two counts each of attempted second-degree murder, first-degree assault, second-degree assault, reckless endangerment, and malicious destruction of property. He also faces one count of carrying a dangerous weapon with intent to injure. He appeared for a bond review last week in Circuit Court and had his bail set at $50,000, which he posted and was released.
Guilty Plea Made In
High Speed Chase Case
SNOW HILL – A Frankford, Del. man arrested in June 2006 on several charges including assault on a Berlin Police officer after a hit-and-run and high speed chase that ended in Delaware pleaded guilty last week in Worcester County Circuit Court to second-degree assault and fleeing and eluding police and could face as many as 12 years behind bars.
Around 6:30 p.m. on June 6, 2006, a Silver Jeep Grand Cherokee driven by Stefphon Bowen, then 33, of Frankford, Del., ran into the back of a Toyota Tacoma on Route 113 just south of Route 50 in Berlin and kept going. Berlin Police observed the vehicle turn right from Route 113 onto Branch Street heading into Berlin and pursued Bowen.
A Berlin Police officer attempted to block Bowen's way, but the suspect rammed the officer's patrol car and kept going. A high-speed pursuit followed along northbound Route 113 as the suspect continued on into Delaware. About six miles after crossing the state line, with several officers in pursuit, Bowen lost control of his vehicle as he attempted to make a right turn onto Swamp Rd. and crashed into a ditch.
Bowen then fled the vehicle and ran away on foot, but was soon apprehended by a Berlin Police officer a short time later. It was later discovered Bowen had cocaine and marijuana in the vehicle. He was also under the influence of alcohol at the time of the incident.
Three years later, after a successful warrant service on the suspect, Bowen appeared in Circuit Court last week and pleaded guilty to second-degree assault and fleeing and eluding police. The first charge carries a maximum sentence of 10 years in jail, while the latter carries a two-year maximum sentence. Sentencing was deferred pending the outcome of a pre-sentence investigation.


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Peter Noonan '82 Hits the Right Notes in Business and Music
December 3, 2013
"Peter Noonan is an expert in what he calls 'cap-ology'," begins a St. Louis Business Journal article. "As senior vice president with Commerce Bank's tax credit services team, Noonan has written the book -- or at least the legislation -- on tax credit programs in states across the Midwest. In 2009, he was part of a team that wrote the legislation to put in place caps on the historic tax credit program in Missouri." (photo: Dilip Vishwanat/SLBJ)
The story by Angela Mueller notes, "Noonan, who is a native of Springfield, said he has been interested in historic buildings ever since a job with Mark Twain Bank brought him to St. Louis after he graduated from DePauw University."
Noonan, a 1982 graduate of DePauw, majored in economics and management. He recalls, "I was in commercial real estate banking, and I was really hoping to specialize in historic properties."
Mueller writes, "However, before making that hope a reality, Noonan decided to pursue an entirely different dream. A classically trained pianist, Noonan left the corporate world behind in 1995 and spent the next six years pursuing a career in music. He has released five CDs of original piano compositions, and is working on a new release. His total CD sales have surpassed $1 million. Noonan returned to banking in 2001, when he joined Commerce Bank. However, he has not left his music behind. He will be returning to the stage for a performance at the Sheldon Concert Hall on Dec. 14."
"I performed my first original pieces before my kindergarten class," Noonan tells the publication. "I was classically trained with the same piano teacher from first grade to college and would do original works even in middle school and high school. In the '80s when I moved here and was working at Mark Twain Bank, I sort of missed piano, so I started renting a piano and started writing some pieces. Then I decided to go to the recording studio, and then recorded and released in 1990, the Cafe at Arles CD. It was meant to pick up the sense of what one person could do at one time. Everything was live, nothing overdubbed. It's still my biggest seller."
The complete feature, which includes a Q&A with Noonan, is available to subscribers at the Business Journal's website. You're also invited to visit Peter Noonan's personal site.Back

subset: commoncrawl


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RMT Robotics® (www.rmtrobotics.com), a Cimcorp Oy company, manufacturer and integrator of innovative robotic gantry material handling systems, is pleased to announce the hiring of Dave Barker to the position of Customer Care Manager. Prior to accepting this position, Barker was employed at Automated Tooling Systems (ATS) for 12 years, working in a variety of roles that lead to his advancement to Manager of Technical Services. Barker was instrumental in building a very successful Technical Services team focused on delivering excellence in customer care through superior technical expertise. "Dave's proven track record of success in designing and managing customer care programs combined with his training in electronic engineering will be an invaluable asset in meeting RMT's service goals and objectives from its growing North American and global client base," says Rick Trigatti, Operations Manager, RMT Robotics.
About RMT Robotics RMT Robotics (www.rmtrobotics.com), a Cimcorp Oy Company, is a global company that manufactures and integrates turnkey robotic gantry-based solutions designed to reduce operating costs and streamline operations. Since 1981, RMT Robotics has been recognized around the globe as an innovator in robotics materials handling. RMT helps our customers compete in an increasingly aggressive and price-sensitive global marketplace by providing best-in-class robotic handling solutions.


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The latest incident occurred at about 11 p.m. Thursday in Jonesboro. The woman said the car followed her but the driver didn't activate the light. She drove to near a friend's house and asked the friend to step outside.
When the friend did so, the unmarked Ford Crown Victoria drove away.
The Jonesboro Sun reported on Oct. 28, a woman reported being followed by a similar vehicle near Bay. In that incident, the driver activated the light and the woman pulled over, though she was able to get away.
Authorities say motorists can call 911 to confirm whether they are being stopped by a legitimate officer.


text: Imogen Thomas (Twitter) is another one of our favorite type of model, a busty British Brunette. This Welsh glamour model has also been a beauty queen and television personality. She actually won Miss Wales back in 2003 and then just like Sophie Reade, appeared on the UK's version of Big Brother. She has made the rounds posing for all of the big Men's magazines over the past several years, sometimes topless. She announced in early August that she was pregnant with her first child, and at 29, its possible her best days of modeling are behind her. So let's enjoy her body of work with 160 amazing photos below :


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Sierra Nevada > Yosemite National Park > Lembert Dome > Climber's Log
Lembert Dome Climber's Log
[ Sign the Climber's Log ]
|Lembert Dome, NW Books
Date Climbed: Aug 6, 2006
|After a nice hike to Mt Hoffman we decided to sample Lembert Dome. Given our late start around 5pm this route fit just well. The first pitch was nice with slab, lieback and roof moves. The second pitch had a runout start without the mentioned bolt and a wide crack higher up but easier than the first pitch. The descent was an exciting affair on slabs. The sunset was incredible and a great way to end my short trip to Tuolumne.
|Posted Aug 9, 2006 7:17 am
|Simple walk up the backside
|Wow, it must have been 1993 when we did this hike. Good views of Tuolumne, better ones can be had from Mt. Dana though.
|Posted Aug 9, 2006 1:57 am
|Great Scramble
Date Climbed: Aug 2, 2006
|Followed direct from parking near south slope. Kept closer to the steep parts of the dome until I had no choice but move to the southern side.
|Posted Aug 7, 2006 2:18 am
|East Slope
Date Climbed: Jul 2, 2006
|Nice afternoon stroll to the top. Great views.
|Posted Aug 1, 2006 9:31 pm
|Bill Kish
|NW Books and Slabs
Date Climbed: Jul 7, 2006
|Many zen moments on the slabs. Especially nice by moonlight!
|Posted Jul 26, 2006 6:46 am
|Anniversary Climb on Lembert Dome
Date Climbed: Oct 2, 2004
|Robin and I marked our first anniversary by climbing in Yosemite. We intended to stay in Camp 4 (where we met) and climb in the Valley, but all camping was full, so instead we headed to the high country and climbed in Tuolumne. The first day there, we climbed Northwest Books. It was an enjoyable climb, but the howling wind made it a bit chilly. Fortunately for us, the next day, when we climbed Holdless Horror, was glorious.
|Posted Jun 4, 2006 7:32 pm
|Big Boys Don't Cry, Cryin Time Again, NW Books, Walk up
|Climbed Lembert many times in '04 and '05.
|Posted Mar 18, 2006 6:40 am
|Route Climbed: via the trail Date Climbed: July or August 1998
|This was the first hike I ever did in Yosemite NP and I loved it! It was a stormy day so I kept close watch on the clouds. Loved the views looking west over Tuolumne Meadows with Cathedral Peak in the distance.
|Posted Feb 9, 2006 6:16 pm
|Route Climbed: Direct Northwest Face Date Climbed: 1986
|I recall being poised just below the finger crack crux, chalking and pondering, pondering,chalking..........then chalking and pondering some more, when suddenly J. Bacher appeared from below, ropeless, and politely asked if he could climb through! I did this route with Miguel Carmona.
|Posted Feb 2, 2006 4:53 pm
|Route Climbed: NW Books Date Climbed: Summer 05
|My buddy Luke's first lead!!
|Posted Jan 9, 2006 3:34 pm
|Route Climbed: NW Books Date Climbed: 2004 2x
|An nice little afternoon "hike."
|Posted Jan 9, 2006 3:28 pm
|Route Climbed: NW Books- 5.7 Date Climbed: September 8, 2001
|Seemed a bit stiff for 5.7, but that's the way it is when you come from anywhere but maybe Southern Utah.
|Posted Dec 31, 2005 12:34 am
|Matthew Holliman
|Route Climbed: Northwest Books
Date Climbed: Sep 24, 2005
|Short climb with Glenn as an acclimatization day for Clarence King on Sunday--really just an excuse to get some more climbing in... pretty fun.
I've also hiked up the trail from Tioga Road (Oct 20, '02): short but enjoyable, with nice views at the end. Four or five other groups up at the summit.
|Posted Oct 28, 2005 1:02 am
|Route Climbed: Northwest Books? Date Climbed: 2000
|Fun, easy climb. Did it with a bunch of people and had a great day.
|Posted Oct 26, 2005 8:41 pm
|Route Climbed: various Date Climbed: many
|so close to the road, how could you not do it?
|Posted Oct 16, 2005 1:35 pm
|Route Climbed: East Slope Date Climbed: October 14, 2005
|Hiked up the east slope just for fun after climbing Mount Dana.
|Posted Oct 15, 2005 2:03 pm
|Route Climbed: East slope via Young Lakes Trail, descended South Face Date Climbed: July 17, 2005
|Hiked this with my girlfriend (her first named Sierra summit). Had some fun soloing the rock at the base of the south face.
|Posted Sep 10, 2005 4:36 am
|Route Climbed: E-slope Date Climbed: May 1992
|Hiked up there with Chuck, Sue and Sabine.
|Posted Sep 2, 2005 1:42 am
|Route Climbed: South Slope Date Climbed: August 2003
|Wife and I spend an afternoon in TM, and made the scramble to the top. enjoyable trip.
|Posted Aug 24, 2005 1:37 am
|Route Climbed: Northwest Books 5.9 variation Date Climbed: July 14, 2005
|A short two-pitch climb if you start high and end low before walking up and off. We got here behind another party, an older guy and his very young daughter. He disappeared over the lieback bulge and the rope didn't move for a long time, so I soloed up to see what he was doing. He was halfway up the crack and having a hard time. Is that the 5.9 variation? I asked. He said he didn't know what it was but that it was hard. Eventually, he backed off, did the traverse to the right and belayed his daughter up, who tried and failed to clean his highest piece in the crack. I followed and found the crack burly enough but not too much work and certainly the highlight of the route. My second couldn't clean the piece, either. A nice warm-up climb, especially now that there's fixed gear for any nervous leaders on the crux.
|Posted Jul 22, 2005 1:14 am


text:
Even crazier, staying with the Minnesota trade...
Bargs and J.J. for Flynn and #2
Trade Utah
Barbosa and the #2 for Jefferson and the #12
Even crazier, staying with the Minnesota trade...
Bargs and J.J. for Flynn and #2
Trade Utah
Barbosa and the #2 for Jefferson and the #12
The money works when we get rid of Reggie. The Raps and Jazz both have cap room to take on salary
Or Bargs and Bayless for and next years #1 for Jefferson and their 12th
As much as I would have liked Kanter with the 3rd, I'm just as happy with the thought of Bismack with the 5th. He's probably not going to be very good for the first year or two, but realistically the Raps are going to need another shot at finding a franchise player in the draft anyway, and being at least top-8 bad next year will help. But in terms of an asset that every team in the league can use, a defensive center with freakish length and a good motor is right up near the top of the list. In a draft where you're probably not going to find a significant piece of your future at the 5th spot, at least take the best asset.
Read my blog, The Picket Fence. Guaranteed to make you think or your money back!
Follow me on Twitter.
RealGM has Kanter dropping to 5th and the Raptors taking him there. I would like to choose that option, please.
Read my blog, The Picket Fence. Guaranteed to make you think or your money back!
Follow me on Twitter.
I don't see Kanter dropping to 5, especially in a weak draft.
I also don't see Colangelo selecting a Euro big. No telling when they would be able to suit up and he needs to pick a player that is a 'safer' pick and someone that can help this team now and over the next few years as the talent dearth on this team is a huge issue.
Have a feeling you are going to see Walker, Burcs or Knight in a Raps uniform next year.
I hate this draft because there is about a 5% chance that the number 3 pick is a starter, never mind the #5. If there is a silver lining here, someone let me know. Kanter should be gone, but who knows? Utah needs help at C and he'd fit their system and help with Jeffersons hustle and defensive deficiencies. He could go as high as 2. Cleveland needs help everywhere except PF (JJ and Andy V, maybe a C this year) so you have no idea where they'll go at either 1 or 4. Minny just sucks and doesn't know how to handle their best player (K Love) or their prima donna incoming PG who, in my estimation, is gonna be a wicked bust. With the genius David Kahn running the show, they'll inevitably screw up. Ahhhh, why can't I be a Bulls fan? So much easier....
hahah... funny bro (wait, we have the 5th pick... that's even funnier)
Kahn is really good at screwing up everyone's mock draft.
Bottom line, Walker or Knight should be available at #5 and the Raps gotta take one of em IMO.
Eh follow my TWITTER!
Read my blog, The Picket Fence. Guaranteed to make you think or your money back!
Follow me on Twitter.
Best player 3 years from now..Knight could be that guy, but the Jazz seem to be smitten with him. I don't really have faith in Walker. You never knows what happens with Valancuinas and how he pans out or if he'll ever come over (maybe another Fran Vazquez situation) and Biyombo is an enigma. Could Vesely be the guy? Or Leonard? I wouldn't be upset if Leonard is the guy we get. At least we know that he's a tremedous athlete and plays D right out of the gate.
I can't see Kanter falling to 5. However, stranger things have happened. If Minnesota passes on him at 2, I can't see Utah or Cleveland picking him up.
The hype does not make sense right now, no combine, no workouts. Kanter at 2 seems odd and risky to me.
I would take Williams at that position without hesitation.
All these internationals get extra hype around draft time. If you recall history, Rubbio wasn't going to last till 3, and he went 5th. Heard the same talk with Yi, and even Rudy Fernandez. They were all going to take the league by storm. It just seems that the players that are unknown quantaties always enjoy more hype.
Last edited by MyMomLovesMe; Wed May 18th, 2011 at 02:20 PM.
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Thomas Rongen has announced the 20-man squad that will contest the CONCACAF U-20 championship in Guatemala, and eight Major League Soccer players will travel to Central Americafor the two-week tournament.
The United States play Panama and Suriname in the first round of the 12-team event. The four semifinalists earn a berth in the 2011 U-20 World Cup.
"We try to look at players who can fit into the way we play, out of a 4-3-3, so there are specific technical, tactical, mental and physical attributes that are required at every position," Rongen said when discussing his choices. "We spent a lot of time looking at which players fit our system best. We feel good about our selection that will go forward and represent us in Guatemala against Panama and Suriname."
[inline_node:324123]The Philadelphia Union are the only MLS side with two players on the roster, as Rongen called goalkeeper Zac MacMath and midfielder Amobi Okugo.
Vancouver's Omar Salgado, the No. 1 pick in the 2011 MLS SuperDraft, is one of five players preparing for his rookie MLS season. MacMath, DC's Perry Kitchen, Chias USA's Zarek Valentin, and the Columbus Crew's Korey Veeder are the others.
Gale Agbossoumonde, who participated in the 2009 U-20 World Cup, will anchor a backline that also includes the New York Red Bulls' Sacir Hot and FC Dallas' Moises Hernandez.
Sebastian Lletget will join Okugo in the center of midfield with Bobby Wood, Joe Gyau, and Conor Doyle bolstering the forward line.
The roster also features two UCLA Bruins -- Kelyn Rowe, Eder Arreola -- as well as Notre Dame's Dillon Powers and Sebastien Ibeagha from Duke.
New York forward Juan Agudelo was expected to be part of the qualifying roster, but instead will be with the full US national team for friendlies against Argentina and Paraguay.
GOALKEEPERS (2): Zac MacMath (Philadelphia Union; St. Petersburg, Fla.), Cody Cropper (Ipswich Town; Athens, Ga.)
DEFENDERS (8): Gale Agbossoumonde (Djurgårdens IF; Syracuse, N.Y.), Greg Garza (G.D. Estoril Praia; Grapevine, Texas), Moises Hernandez (FC Dallas; Dallas, Texas), Sacir Hot (New York Red Bulls; Fair Lawn, N.J.), Sebastien Ibeagha (Duke; Missouri City, Texas), Perry Kitchen (D.C. United; Indianapolis, Ind.), Zarek Valentin (Chivas USA; Lancaster, Pa.), Korey Veeder (Columbus Crew; St. Petersburg, Fla.)
MIDFIELDERS (5): Sebastian Lletget (West Ham United; San Francisco, Calif.), Amobi Okugo (Philadelphia Union; Sacramento, Calif.), Moises Orozco (UANL Tigres; Oxnard, Calif.), Dillon Powers (Notre Dame; Plano, Texas), Kelyn Rowe (UCLA; Newport Beach, Calif.)
FORWARDS (5): Eder Arreola (UCLA; Chino Hills, Calif.), Conor Doyle (Derby County FC; McKinney, Texas), Joe Gyau (TSG 1899 Hoffenheim; Silver Spring, Md.), Omar Salgado (Vancouver Whitecaps FC; El Paso, Texas), Bobby Wood (TSV 1860 München; Irvine, Calif.)


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Once the pineapple capital of the world, Jensen Beach packs a tropical punch! From fine dining to fresh seafood, boutiques, and surf shops, Jensen Beach has clearly earned its place along Florida's Treasure Coast.
This charmingly festive location takes its arts and music seriously. Only a convenient walk away from our hotel, Jensen Beach artists proudly display their crafts and creations along Maple Avenue––and the city frequently plays host to jazz jams and music festivals. Give the kids a dose of interactive culture and science at The Children's Museum of The Treasure Coast.
Nature and fun await Jensen Beach vacationers! Our hotel guests can take dolphin-watching tours and turtle walks along the Hobe Sound, a globally imperiled habitat. And sports fans will want to head into St. Lucie to visit the New York Mets Spring Training Camp.
You can travel a short distance along the Treasure Coast from your Jensen Beach accommodations and dive at The Wreck of Georges Valentine Dive Site, where maritime fans can enjoy the many sailboats out on the water. And don't miss the Gilbert's Bar House of Refuge Museum on nearby Hutchinson Island; built in 1875, the museum highlights the area's earliest maritime history.


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Air Quality in Barns Critical for Horse and Human Health
- Jul 10, 2011
- Topics:
Most equestrians know firsthand the dangers that accompany their passion for horses: bumps and bruises (and the occasional broken bone) are nothing out of the ordinary. But fewer horse owners are aware of the damage they can receive by simply spending time in the barn; poor air quality can be just as dangerous for owners as it is for the horses in their care.
"We care about the airway quality in barns because of its effect on both horses and humans," noted Melissa Mazan, DVM, Dipl. ACVIM, associate professor and director of the equine sports medicine program at Tufts Cummings School of Veterinary Medicine's Hospital for Large Animals in North Grafton, Mass. Mazan presented on the topic at the 2011 America College of Veterinary Internal Medicine Forum, held June 15-18 in Denver, Colo.
Unlike in the swine and poultry industries, she explained, air quality in horse barns is not subject to regulations and lacks oversight from the Occupational Health and Safety Administration. Mazan said that up to 80% of stabled horses develop airway inflammation, and this statistic likely has consequences for humans working in barns as well: They are subjected to the same environmental conditions as their equine charges.
Responses to a widespread questionnaire sent to horse barn employees revealed that nasal and throat irritation were common complaints from workers, as were chest issues including breathing difficulty, wheezing, productive cough, and shortness of breath.
Mazan explained that the main causes of airway dysfunction in both people and horses are related to exposure to airborne particles including:
- Inorganic materials such as silica, metals, and diesel discharge;
- Organic debris from burning biomass, bacterial products, animal waste, molds, spores, pollens, and insect parts; and
- Endotoxins (the cell wall of Gram-negative bacteria released in horse manure) in particle dust.
Irritating particles come in different sizes, ranging from coarse (10 microns) to fine (about two and a half microns); for perspective, the thickness of a human hair is 60 microns. Particles less than 4 microns are "respirable" (i.e., they can be breathed in), potentially settling in the smallest portions of the lungs called the alveoli. Nasal hairs and sneezing typically filter the five to 10 micron particles, but if any of those do travel to the upper airways and trachea, nasal and throat irritation generally occur.
Particles up to 30 microns that aren't cleared by coughing and the mucociliary escalator (small fibers that "beat" in a coordinated manner to move the thin layer of mucus that floats on top of the cilia and the debris stuck to it out of the lungs and up the trachea, where the horse swallow it) can settle in lower airways, also causing irritation. Particles smaller than one micron can even account for human cardiovascular disease due to dissolution or uptake in the bloodstream.
Mazan suggested that air quality testing is a good way to identify the presence of a problem and localize the source within a barn, making it easier to reduce the risk of respiratory problems in horses and humans. Many commercial testing devices effectively capture particulates and/or volatile gases, such as ammonia, for analysis.
Respiratory disease in humans is caused by 0.43 mg/m3 (milligrams of respirable irritants per cubic meter of air), with 0.16 mg/m3 causing a decline in lung function over eight hours; the statistics were similar in horses, Mazan noted. She added that horse barns typically test at 0.52-4.16 mg/m3 of respirable dust.
Normal hay can generate 19.3 mg/m3 respirable dust in a horse's breathing zone whereas dusty hay can create up to 81 mg/m3, Mazan noted. These numbers increase significantly when a barn is closed up in winter, she added.
Arena dust is another culprit in circulating small particles of heavy metals as is road traffic adjacent to the stable. Endotoxins also have deleterious effects on airway function, particularly when inhaled in combination with other noxious particulates.
Regarding bedding options, Mazan explained that while straw has a higher particulate count than shavings, what is most notable is that forage (hay) is more important in determining what horses actually breathe in; she reported that horses living outdoors are exposed to negligible amounts of particulates even when fed the same hay as stabled horses.
Mazan suggested that when possible, house and work with horses outdoors, as the risk factors for airway diseases are reduced outside barn walls. Additionally, ensure your barn has proper ventilation and air movement, as these factors can also reduce the risk of developing airway diseases.
About the Author
Nancy S. Loving, DVM
Nancy S. Loving, DVM, owns Loving Equine Clinic in Boulder, Colorado, and has a special interest in managing the care of sport horses. Her book, All Horse Systems Go, is a comprehensive veterinary care and conditioning resource in full color that covers all facets of horse care. She has also authored the books Go the Distance as a resource for endurance horse owners, Conformation and Performance, and First Aid for Horse and Rider in addition to many veterinary articles for both horse owner and professional audiences.
Related Content
Diagnostics (AAEP Convention 2012)
Does Hyperbaric Oxygen Therapy Cause Lung Inflammation?
Electrolyte Use in Performance Horses
Alternative Treatment for "Roaring" in Horses (AAEP 2011)
Treating Equine Upper Respiratory Tract Ailments (AAEP 2011)
Equine Head Flexion and Airway Inflammation (AAEP 2011)
In Depth: Evaluating the Upper Respiratory Tract (AAEP 2011)
Managing Bacterial Pneumonia in Adult Horses (AAEP 2011)
Equine Rhinitis in Respiratory Infection Cases (AAEP 2011)
Human Behavior Changes Necessary to Improve Equine Welfare
POLL: Checking for Gastric Ulcers


text: The nonmetal quartz wand is hanging on the metal wand hanger, and the metal wand is hanging on the non-metal wand hanger. I don't know how long this has been the case, but it is very likely that people have used metal wand assuming that it is non-metal. I think the non-metal wand should be replaced immediately. Sanli


text:
Ewen McKenzie throws down gauntlet to All Blacks as Wallabies prepare for Bledisloe clash
Ewen McKenzie has challenged the All Blacks to "bring their A game" to the second Bledisloe Cup clash and defend their 28-year unbeaten run at Eden Park against the Wallabies.
The Wallabies bounded into Auckland on Thursday night and wasted little time setting the record straight.
Fronting the captain's news conference alongside Michael Hooper on Friday, McKenzie batted away a week's worth of barbs from counterpart Steve Hansen and said he hoped both teams would hold nothing back after a rain-affected draw in Sydney.
"They'll judge their own performance. I thought we put them under pressure," he said.
"We know we made uncharacteristic errors and I'm sure they decided the same thing, so it's not about poking a bear with a stick, it's a competitive game.
"We want them to bring their A game because we're going to bring ours. That's what it's about."
McKenzie offered some polite advice to Hansen, who earlier in the week claimed referee Jaco Peyper apologised for a number of incorrect calls against New Zealand in the 12-12 match in Sydney.
"I haven't seen the referee's comment, only Steve's interpretation of what the referee said," McKenzie said.
"He [Hansen] talks about free kicks at scrum time – I think there were three free kicks but there were still 14 penalties, so it depends on which bit you want to look at."
Frenchman Romain Poite will lead the officiating in Saturday's clash, prompting worries the Australian scrum would be haunted by Poite's perception of the deciding Test of the British and Irish Lions series.
McKenzie did his best to take the high road, but offered another tip to Hansen, saying he had learnt to look at the big picture of a team's treatment and performance over time.
"The IRB's done a pretty good job of trying to get some consistency in that area [refereeing] and SANZAR has as well," he said.
"Teams have to look at themselves over time, as opposed to looking at one game and saying 'there was one mistake'.
"We can look at the game and point out a few things that we weren't happy with, but you can do that every week."
Hooper dismissed talk of the Wallabies' Eden Park hoodoo, despite Australia's last win at the picturesque suburban fortress coming seven years before his birth.
"We're thinking about the improvements we can make on the field, rather than the big picture going around it," he said.
"We're footy players who want to know how we can get better in attack and defence; it's as simple as that."
The Wallabies trained at Eden Park on Friday afternoon in their first dry session of the week.
With no rain forecast on Saturday, McKenzie said he was confident the Wallabies would put in an improved performance, despite Hansen's suggestion they had little left to give after the opening round draw.
"I've been watching the All Blacks for a long time, so I know what the All Blacks as a team are capable of," he said.
"It depends on the group of individuals. They were going for a world record last week and didn't get there.
"They're a very consistent side, they've been the most consistent team for a number of years.
"We know that, but it doesn't mean they win every game, so we look forward to the challenge."
Georgina Robinson is a Sports Reporter for The Sydney Morning Herald
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text:
Commissioners are scheduled to discuss the request from Chancellor David Gearhart on Monday.
The Northwest Arkansas Times reported the contribution would come from the commission's reserve fund of about $2.3 million — if the panel approves it.
The $17 million project would build a 700-seat concert hall in what's now the university's Old Field House.
The university's music and drama departments now use the 238-seat Stella Boyle Smith Concert Hall and the 250-seat University Theatre. Gearhart said a larger facility would help the campus with recruitment.
The commission's main source of revenue is half of a 2 percent tax on hotels and restaurants in Fayetteville.


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Check Detail Round Frame Sunglasses
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- Italian-made round frame sunglasses in vintage havana acetate, featuring a twill-effect leather with a check detail at the arms. Gradient grey scratch-resistant lenses offer 100% UV protection.
- 100% acetate with goat leather and metal trim
- Made in Italy
- Presented in a protective case


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Agree. Teaching should fit the student.If teachers don't usually instruct in the direct way, the reason is either that they don't think people will understand it or they don't know it.
What do you mean by well prepared? What if you apply a low teaching to a "prepared" student? What if you tell one who is ready for direct teaching, to go and do something contrary? Teaching is chosen for students, but as we are not teachers here, we should talk about how things are, not about how teachings should look for some particular group of recipients.In either case it shows that the direct method is for those who are already well prepared.
And how different it is from the founders (Linji) approach...Rinzai Zen (Japanese) has a clear systematic training programme that actually culminates in the contemplation of the bodhisattva precepts.


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Thank you, Tim Nudd at AdWeek, for posting the 30 Freakiest Ads of 2011. Some of them were quite disturbing (I think the anti-child abuse PSA from Ireland hit me hardest (literally). And some are freaky in the way they just push the boundaries of what is taboo. But many are prime examples of the popularization of tropes of the uncanny in a way that is so orthodox, it's a little mind boggling. In my review of this annual top thirty list, it seems to me that the ads that take the symbolism from their slogans or product names the most literally are the ones who generate the strangest of all ads.
Note how Freudian these ads are in their symbolism. The number one pick is literally a series of dream scenarios offered up for viewer interpretation. The truth is, ALL ads are dream scenarios to begin with, so Nudd's selectio of this one — while being the most "freakiest" — is also at the same time the most honest.
I am always interested in advertisements for chewing gum (the first chapter of The Popular Uncanny focuses on the history of gum advertising in fact), because they must go out of their way to grab our attention and "sell us" on buying something akin to food — that is, something we chew but never swallow, in a simulacra of consumption.
Here's one from the list that is the most audaciously Freudian I've seen in quite awhile: a video from the "Unexpected Turn" campaign for Vivident Gum:
Another uncanny ad that struck me from the "freakiest" list is the giant ear that moves of its own accord, in ESPN's Sports for Your Ears advertisement. An obvious example of animism, with an ambulatory body part taking on all the characteristics of a sports fan, but it's more like a wacky dream than an advertisement. I find it telling that in the opening of the ad, the ear is shopping, and when it is at work it is a psychologist (subtly recalling (if not directly referencing) the faux radio host Frasier from TV: "I'm listening").
Some in the list are hilarious. Some are disturbing. Some are not safe for work. Most employ the uncanny to sell a product. See them all at AdWeek.
Leave a post if you want to tell us which ones you'd put in your top two.


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Post: FT: (2) Sat 12/30 For (2) Fri 12/29
~ Straightforward extras for extras exchange.
Tundrabear & co. ran into a ticket issue due to TicketBastard incompentance and promptly slayed that dragon using the knowledge of the Helping Friendly Book and skills of the Lizard people. Trade with Tundrabear in full confidence!
Merry Phishmas!12/27/17
Post: FT: Phish Dicks Have 1 Fri 9/1 Field Want 1 Sunday Or 1 Sat
~ tundrabear came through with a great trade. He was super easy to deal with and a pleasure all around!!!8/28/17
Post: FT: Phish Vegas Friday And Sunday For Any Dicks Fields.
~ Long time coming since dicks. Traded tundra a field for vegas night 3. Just linked up as planned at mgm, and here is to another awesome trade on here! Thanks tundra. Highly recommended. Great communication and worked with me. Thanks again c.o.t!10/28/16
Post: FS: 2 Phish Vegas MGM 10/29 Sec 221 And 223 And 1 Halloween 10/31 Sec 201 Must Buy All 3
~ Had exactly the tickets I was looking for, was quick to communicate and got them shipped to me fast. I *finally* get to attend a Halloween show after all these years, thank you!10/26/16
Post: FT: 2 Phish Alpharetta Sat 10/22 Pits Need 2 Sat 10/29 Vegas Floor Or Good Lowers
~ Quick easy trade. Would definitely trade again. Love me some ptbms10/11/16
Post: FT: Phish 4 Sat 10/22 Alpharetta Pits ISO All Nights Vegas Floors Or Lowers
~ Easy to make a deal with, quick shipping and great communication. Looking forward to the shows!10/08/16
Post: FT - MY Halloween For A Pit Alpharetta
~ Prompt, Friendly and Reliable.10/05/16
Post: FS: 2 Phish Alpharetta Fri 10/21 Sec 105 Row W
~ Beautifully executed transaction. Took the extra time to refund shipping after I sent it out without needing to.10/03/16
Post: ISO: 1 Phish Dicks Saturday Field
~ Second time trading with Bob and both times were perfectly smooth. See you at Dick's!8/28/16
Post: Have 2 Sat Phish Dicks Field Looking To Trade
~ Super great trade! Everything was fast, easy and efficient. Would highly recommend a trade with Robert. Great member of the community! So nice to deal with honest & awesome people.8/05/16
Post: ISO: 1 Phish Dicks 3 Day Field Pass 9/1-9/3 Denver
~ Bob was great to deal with. Super fast payment and great communication.
Hope you enjoy the shows!8/04/16
Post: 3 Forum Tix For Sale Or Trade
~ Bob was easy to work with, communicated well & had exactly the trade I needed. Thank you!7/26/16
Post: Any 2 Nights Of BGCA For Friday And Sunday Dicks (preferably Fields)
~ Great trade7/26/16
Post: FS: BGCA Mon And Tue
~ Bob paid right away and made it easy to meet up at The Gorge. Hope you have a blast at BGCA!7/18/16
Post: ISO: Phish 7/23 Chula Vista Pits Or 100 Pavs
~ Robert was super quick with his replies and his payment. 10/10, would deal with him again!7/07/16
Post: FS: 4 Phish Wrigley Field Sat 6/25 Sec 223
~ Easy seller to work with quick response and sent tickets over immediately. Would definitely trade with in the future. Thank you!6/06/16
Post: ISO: 1 Ticket For Each Night Of Phish At Bill Graham
~ My first transaction on COT, he was awesome with helping me through the process. Was understanding and sent funds promptly! Great person to do business with!4/19/16
Post: Trading Phish 1/2 Section 220 For Phish 12/30 Any Section
~ Prompt communication and delivery. 10/10 would buy/trade/sell with again.12/16/15
Post: ISO 2 11/9 Crystal Ballroom Tickets For Me And My Lovely Mama!
~ Helped me out with last minute tickets to the TAB show in Portland. Prompt responses, great guy, awesome transaction! Thank you so much for helping a girl out! Fantastic member of the Cash or a trade community :)11/09/15
Post: ISO: TAB At The Crystal Ballroom November 9th
~ I would definitely sell to Robert again in the future! I recieved payment for the tickets very quickly, and his communication was great as well!10/21/15
Post: ISO: 2 Phish Dicks Field 3 Day
~ Great transaction and easy to work with!9/13/15
Post: Grateful Dead Santa Clara 6/28 Section 412 Row 12
~ very easy. great communication. A buyer8/10/15
Post: ISO: 2 PHISH Nashville 8/4 Pavs Riverfront Park
~ Easy transaction and good communication even with the cell networks down in Nashville. Thanks Robert!8/07/15
Post: ISO: Phish Atlanta Fri 7/31 Sat 8/1 1-2 Pavillian
~ Bob was super easy to communicate with and lives up to all his great reviews. Thanks man, it was a great show indeed!8/01/15
Post: ISO: 1-4 GA Floor For Phish 7/25 At The LA Forum
~ Not only did he pay immediately upon agreement, but was also extremely patient during a difficult ticket transfer.7/28/15
Post: ISO: 2 Phish Bend Les Schwab 7/21 And 7/22
~ I would surely trade with Tundra Bear again!7/26/15
Post: 2- GD50 Santa Clara For Sale
~ I'd definitely trade with him again, no issues at all!7/25/15
Post: Phish Shoreline Section 101
~ Easy to communicate with. Everyone's happy. Have a great show!7/12/15
Post: ISO: 1 GA Floor Santa Clara 6/27 Grateful Dead
~ Robert was great to sell to. Even with spotty cell service in Santa Clara (of all places, come on Silicon Valley get with the program) he was prompt with payment and communicative throughout. Highly recommended for anyone looking for a painless transaction.6/29/15
Post: FS: 2 Grateful Dead Santa Clara Sunday 6/28 Sec 418 Row 3
~ Great communication every step of the way. Thanks Tundrabear!6/25/15
Post: FT: 2 Santa Clara Grateful Dead 6/28 GA Floor For 2 6/27 GA Floor
~ The tickets arrived! Perfect transaction. Great communication. I would happily trade with this individual again. 100% trust worthy. ***** 5 stars!6/18/15
Post: ISO: 2 Santa Clara 6/27 GA Floor Grateful Dead
~ I'd be happy to work with Tundrabear again, this was a great transaction! Fast payment, good communication, seems like a nice person. Not much more to say! A6/13/15
Post: ISO: 2 Santa Clara 6/27 (GA Floor Or Sec 110) Grateful Dead
~ This was easy and went really smoothly and rapidly. The experience you want!6/09/15
Post: FS: PTBM Tickets For Each Night Of Phish NYE Miami Run
~ Robert exemplified an ideal ticket sale. He communicated well, set accurate expectations and made sure his friend that had the ticket and I found each other in Miami. Would definitely deal with Robert again.2/01/15
Post: FS: Tickets For Each Night Of Phish NYE Miami Run
~ Great communication! Everything went as we planned. i'd trade with him again any day!!12/24/14
Post: F/S: 4 Tickets PHISH MGM 2 11/1 2 11/2 Las Vegas
~ Totally righteous dude (: Happy Feelings (: 11/10/14
Post: FT: 4 Floors To 11/1 For 4 Seats To 11/1
~ Easy trade. Thanks again! 11/06/14
Post: I Have A Single Halloween And 3 Sundays Sell Only As A Set.
~ bob is awesome! great communication, super easy to work with. awesome human being all around. would absolutely work with again. you rock bob!10/31/14
Post: FT: 2 Halloween 10/31 Sec 213 For 2 11/1 GA Floors OBO Not For Sale
~ Trade with Bob!
Awesome, quick, reliable, smiley, easy, flexible, on time, happy, friendly dude!
Post: VEGAS VIRGIN NEEDS SOME LOVE!!!!
~ Bob was easy to work with, communicative, and the trade was a piece of cake. Thanks, Bob!10/21/14
Post: FT: 10/31 For Eugene Floor Only
~ Good communication, easy transaction.10/20/14
Post: 2 Santa Barbara/1 Floor LA For Any Vegas
~ I'll definitely trade with Bob again if the opportunity arises. Super nice guy and easy to work with. 10/19/14
Post: For Tundrabear Only
~ Bob is a pleasure to trade with. We set up the trade months before, and we kept in touch waiting for the lotto tix to ship. Shipped promptly and securely and did everything right. A trader, and I would of course trade with him anytime.10/17/14
Post: SOLD/Avoid Onsale Hassle: FS: 2 Tickets To Phish Halloween In Vegas
~ I would definitely trade again with tundrabear. he was lightning quick with payment and really easy to communicate with, as was his friend who picked up his tickets for him. If you ever have the chance to trade with Bob or his buddy Matt, do it; they make trades like these easy! have a great time at the shows, guys!10/16/14
Post: Sunday 11/2 Vegas For Face And Fees
~ thanks for a super smooth and easy transaction!
Post: ISO: Two 10/29 San Fran N3
~ Easy and fast. Thanks!!9/22/14
Post: FT: 12/30 PTBM Sec 225 And 113 For NYE
~ Bob and I traded a pair of his 12/30 ptbms for a pair of my ticketmaster 12/31 tickets. I was running a little behind schedule to our meeting spot pre-show but Bob was fine with it, and hung around a couple extra minutes for me.
Smooth trade. Good guy, would trade with again.12/31/13
Post: FS: 2 PTBM 12/30 Sec 223
~ Very considerate and willing to go the extra mile to get the deal done.
Knows how to cashortrade very well!
Post: Phish: Lots Of 28th, 29th And 30th For NYE Trade
~ Wonderful, easy, fast, and very nice!!12/16/13
Post: I Need A Pair Of Phish Reading Pa.
~ Great communication, prompt payment, and very understanding of waiting until the PTBM arrived. Would absolutely deal with again!11/11/13
Post: ISO: AC 11/1 Phish
~ Trustworthy,Reliable just Perfect! Met in AC communication entire time.Would Buy/Sell or trade with him anytime!!11/02/13
Post: FS: Phish Worcester 2-Day Pass Sec 212
~ .10/28/13
Post: FS: Phish Rochester 4 PTBM GA Tickets
~ Very responsive and thorough. Easy to communicate with and I received timely detailed responses. Absolutely hope to trade again, Thank you. 10/14/13
Post: FT: 1 PTBM Dicks 3 Day Field Pass, And More For Any Atlantic City Trades Only
~ Had a blast this weekend thanks to tundrabear. Shipped the tickets via certified mail with tracking number and they got here just as promised. Definitely a standup guy. Thanks a lot!9/03/13
Post: Phish FT: 1 Chicago GA Floor 3 Day Pass For Jones Beach Orch Or BGCA Sat Or Sun
~ awesome trader8/21/13
Post: Phish FT. 2 Chicago GA Floor 3 Day Pass For SPAC PAVS Or BGCA
~ Bob was super responsive and kept in touch throughout the whole process. We had some shipping issues with the tickets getting to me and he extended himself to make sure that there would be tickets waiting for me at the box office. I really appreciate his effort to make sure the trade went smoothly.7/25/13
Post: SPAC FT:Fri 2 Box Seats Balcony Sec 16 Row B For 2 Pavs Fri Anywhere
~ great communication, great dude, great trade! thanks again7/08/13
Post: Phish FS. Pair PNC Sec. 403 Row C
~ easy communication., fast repsonses. quick delivery.6/15/13
Post: Have 12/31 (sec 226) Looking For 12/30 Or 12/29 - 4 Tickets Only
~ user was easy to deal with. i realized after the fact that i forgot to collect cash and he paypaled me. recommend. 12/31/12
Post: I Need Friday BGCA Have Lots Of Sundays And Some Saturdays FT
~ The ticket was good, as was communication for the trade. Best show of the SF run - thanks TB! 9/11/12
Post: I Need Friday BGCA Have Lots Of Sundays And Some Saturdays FT
~ Communicates well and sends timely tickets!! Thanks!8/21/12
Post: Trade 2 X 4 Day Passes For Phish In SFO.
~ Excellent communication and very trust worthy. Highly recommended. 8/07/12
Post: I Need One 4 Day Pass To Hornings
~ Bob communicated well, was on time, and had cash in hand. Thanks!7/06/12
Post: Superball Glen Close BELOW Face Or Trade For Any Gorge?
~ Bob is an excellent communicator. Posted an offer to my trade, and the next day paid on PayPal the exact amount. I'm shipping the ticket to Superball right now via FedEx. Would definitely trade with Bob again. Thank you!!6/14/11
Post: Trade Bethel Sat Sec 10 For Your Fri Pavs
~ great communication, no worries. 100% stand up guy5/23/11
Post: FS: 4 Lawn Bethel
~ Everything went off without a hitch.
Great communication and ticket turnaround was fast.
Would definitely trade again.
CashorTrade 2009 - 2017 Terms & Conditions | Privacy Policy


text:
I was driving down a one way street, and came upon a parking space, there was a line of cars behind, I indicated and stopped checked mirrors and behind me to see it was clear to make the manoeuvre, I selected reverse and checked once more, started reversing and clipped the car behind with my OSR damaging my bumper slightly, I got out to check the damage and only my car had the bumper damage, with only a small paint splash on the car behind front bumper, that instantly wiped off with no other visible damage at all.
Who is to blame, my insurance says me but I think the driver behind should have left enough room, they did say along with an independent witness statement that I did everything correctly.
This is my first ever accident, in 38 years, and my car was repaired within an hour of it happening due to the bumper dent just popping back out, and needing a small touch up paint job from a small bottle.
The police checked the CCTV but the camera was not quite on the area, so they said 50 50.
My insurance has said they have no option but to settle the claim, but how can they settle a claim to the TP if there is no damage or injury.
I have full NCB that's protected, will this affect my NCB???


text:
COURSE: 53-310 Teaching English Language Learners in P-12 Schools (3)
This course provides an overview of the identification, assessment and instructional needs of English Language Learners at the elementary and secondary levels. The importance of culture in addressing the educational and social needs of immigrant students is explored. Candidates will explore strategies to teach English language skills to limited English proficient students and adapt content area lessons to foster the success of all students in a multi-language, multi-ethnic learning community. Prerequisite: 2.75 GPA; 05-240, 53-312, 54-242 or equivalent.


text:
Perl 6
Rakudo: Revision 19
The "Rakudo Perl 6 Compiler"<http://rakudo.org/> ("rakudo" for short) targets the "Parrot Virtual Machine"<http://parrot.org/>, and it currently lives "on github"<http://github.com/rakudo/rakudo/>.
To build the Rakudo Perl 6 compiler, follow the "instructions on the official homepage"<http://rakudo.org/how-to-get-rakudo>.
Parrot and Rakudo change rapidly; if you have issues with the latest point release, be sure to try svn/git-latest of parrot/rakudo.
* [rakudo feature status]
* [perl6 tasks]
Also check out [Getting Involved] to learn about how to help with development, and see [A Guide to the Pugs Repository for Rakudo Hackers].
"Buy Wellbutrin"<http://www.buy-wellbutrin.com/>
"Wellbutrin Usage"<http://www.buy-wellbutrin.com/wellbutrin-dosage.html>
"Stop Smoking Pill"<http://www.buy-wellbutrin.com/stop-smoking-pill.html>


text:
If you are a subscriber to the JCSM (including members of the AASM), please login to access the journal.
Click here to Subscribe:
$75/volume year for individuals or $140/volume year for institutions to access all current articles and archives published in JCSM.
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*Purchase of an electronic download of JCSM provides permission to access and print the issue/article for personal scholarly, research and educational use. Please note: access to the article is from the computer on which the article is purchased ONLY. Purchase of the article does not permit distribution, electronic or otherwise, of the article without the written permission of the AASM. Further, purchase does not permit the posting of article text on an online forum or website.
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Join the American Academy of Sleep Medicine and receive a subscription to JCSM with your membership
Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have a high prevalence of obstructive sleep apnea (OSA) that can have significant clinical implications. An accurate clinical screening tool for OSA that identifies patients for further diagnostic testing would assist in the identification of this comorbidity. The Berlin Questionnaire (BQ), Adjusted Neck Circumference (ANC), and STOP-BANG questionnaire are 3 such instruments that have been validated in patients with normal kidney function.
The objective of this study was to determine the validity of these screening instruments in patients with CKD and ESRD, using overnight cardiopulmonary monitoring to diagnose OSA.
One hundred seventy-two patients were recruited from nephrology clinics and hemodialysis units (CKD: n = 109; ESRD: n = 63). All patients completed the BQ, ANC, STOP-BANG, and overnight cardiopulmonary monitoring to diagnose OSA (respiratory disturbance index [RDI] ≥ 15). Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for the BQ, ANC, and STOP-BANG.
Obstructive sleep apnea was present in 41 CKD patients (38%) and 32 ESRD patients (51%). All screening instruments had satisfactory sensitivity (56% to 94%) but poor specificity (29% to 77%) and low accuracy (51% to 69%) in both CKD and ESRD patients with RDI ≥ 15. Using an RDI ≥ 30 yielded similar results.
Current screening questionnaires do not accurately identify patients at high risk for OSA or rule out the presence of OSA in patients with CKD and ESRD. Consequently, objective monitoring during sleep is required to reliably identify sleep apnea in these patient populations.
Nicholl DDM; Ahmed SB; Loewen AHS; Hemmelgarn BR; Sola DY; Beecroft JM; Turin TC; Hanly PJ. Diagnostic value of screening instruments for identifying obstructive sleep apnea in kidney failure. J Clin Sleep Med 2013;9(1):31-38.
Obstructive sleep apnea (OSA) is common in patients with chronic kidney disease (CKD)1–7 and end-stage renal disease (ESRD).1,8–12 The prevalence of OSA in these populations has been reported to range from 27% to 54% in CKD patients2,3,5–7 and 45% to 70% in ESRD patients,1,8–12 which is significantly higher than the general population.13 Further, the clinical presentation of OSA in the CKD and ESRD populations differs from that in the general sleep apnea population, reflected by a lower prevalence of sleep related symptoms.14,15 Consequently, OSA is more likely to be unrecognized in these populations.
The co-existence of OSA in patients with CKD and ESRD is clinically relevant and has potential to alter important outcomes. In addition to causing impairment of sleep quality and daytime function,16,17 OSA increases the risk of vascular disease18,19 and systemic hypertension,20 both of which are common complications of CKD and ESRD.21 OSA may also accelerate the deterioration of kidney function in patients with CKD, either directly through the effect of hypoxia on the kidney22–24 or indirectly through increases in systemic blood pressure, inflammatory cytokines, and sympathetic nervous system activity.25–28 OSA can be effectively treated in many patients with continuous positive airway pressure (CPAP).29 Consequently, it is important that OSA be recognized and formally diagnosed in these patient populations.
Current Knowledge/Study Rationale: Patients with Chronic kidney disease (CKD) and end-stage renal disease (ESRD have a high prevalence of obstructive sleep apnea (OSA) which can have a significant impact on clinical outcomes. We sought to determine the validity of existing OSA screening instruments in patients with CKD and ESRD.
Study Impact: Current OSA screening questionnaires do not accurately identify patients at risk for OSA and do not rule out the presence of OSA in patients with CKD and ESRD. Consequently, objective cardiopulmonary monitoring is needed to reliably identify OSA in these populations.
Several instruments have been developed to screen patients for OSA in order to direct objective diagnostic monitoring to those considered at high risk of having the disorder. Given the high prevalence of OSA in patients with CKD and ESRD, an instrument to screen for OSA in these populations would be useful. The Berlin Questionnaire (BQ),30 adjusted neck circumference (ANC),31,32 and STOP-BANG33 questionnaire are three such instruments that have been validated in patients with normal kidney function, but not in patients with CKD and ESRD. The objective of this study was to determine the diagnostic value of these screening instruments in patients with CKD and ESRD, using overnight cardiopulmonary monitoring to diagnose OSA.
Consecutive adult patients (≥ 18 years) with CKD (defined by an estimated GFR [eGFR] < 60 mL/min/1.73m2)34 and ESRD (requiring thrice weekly conventional hemodialysis) attending outpatient nephrology clinics and dialysis units in Calgary, Alberta, Canada, were invited to participate in the study. eGFR at the time of the study visit was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.35 Exclusion criteria were current treatment with supplemental oxygen, tracheostomy, Cheyne-Stokes respiration (CSR), and inability to give informed consent. Patients currently treated with CPAP therapy were included in the study if their original diagnostic sleep study and sleep questionnaire were available for review and their eGFR at the time of OSA diagnosis was known. The study was approved by the University of Calgary Conjoint Health Research Ethics Board. Informed consent was obtained from all participants in accordance with the Declaration of Helsinki.
All patients completed a sleep history questionnaire, which included questions regarding a history of snoring, witnessed apnea during sleep, and nocturnal choking. Additionally, the questionnaire surveyed demographic information and medical history, including a history of hypertension, vascular disease (angina, myocardial infarction, coronary artery bypass surgery, congestive heart failure, stroke, or transient ischemic attack), and diabetes. Each patient's risk of having OSA was estimated from the BQ,30 calculation of the ANC,31,32 and STOP-BANG questionnaire.33
Based on the history of snoring (category 1), daytime sleepiness or fatigue (category 2), and hypertension/obesity (BMI > 30 kg/m2) (category 3), the BQ considers frequent and persistent symptoms in 2 of these 3 categories to indicate a high risk of OSA (Appendix).30 The BQ has a sensitivity of 54% and specificity of 97% for a designation criterion of respiratory disturbance index (RDI) ≥ 15 and a sensitivity of 17% and specificity of 97% for a designation criterion of RDI ≥ 30 in a primary care population.30
The ANC is calculated by measuring the patient's neck circumference (in centimetres) and adding additional centimetres if there is a history of hypertension (4 cm), habitual snoring (3 cm), and nocturnal choking (3 cm).31,32 An ANC < 43 indicates a low probability of sleep apnea, 43-48 intermediate probability (4 to 8 times as probable as low probability), and > 48 indicates a high probability (20 times as probable).31,32
The STOP-BANG questionnaire consists of 4 simple yes/no questions regarding habitual snoring, tiredness/sleepiness, observed apneas, and high blood pressure.33 An additional point is added for each of the following clinical characteristics: BMI > 35 kg/m2, age > 50 years, neck circumference > 40 cm, and male gender. A score ≥ 3 out of a total possible score of 8 is considered high risk for OSA. The STOP-BANG questionnaire has a sensitivity of 92.9% and specificity of 43.0% for a designation criterion of RDI ≥ 15, and a sensitivity of 100% and specificity of 37% for a designation criterion of RDI ≥ 30.33
All patients, regardless of OSA symptoms, performed an unattended, overnight cardiopulmonary monitoring study at home (Remmers Sleep Recorder Model 4.2, Saga Tech Electronic, Calgary, AB, Canada) to determine OSA status. ESRD patients underwent the overnight study after a non-dialysis day. The monitor consists of an oximeter to record oxyhemoglobin saturation (SpO2) and heart rate variability, a pressure transducer to record nasal airflow, a microphone to record snoring, and a body position sensor. The oximeter provides the data for an automated scoring algorithm, which calculates the RDI based on the number of episodes of oxyhemoglobin desaturation ≥ 4% per hour of monitoring. Nocturnal oxygen saturation was sampled at 1 Hz. The Remmers Sleep Recorder has been validated by comparison to attended polysomnography.36,37 Sleep apnea was defined as RDI ≥ 15 and RDI ≥ 30, which correspond with moderate-severe and severe sleep apnea, respectively, and are most likely to be clinically significant. The Remmers Sleep Recorder has a sensitivity of 98% and specificity of 88% for a designation criterion of RDI ≥ 15, and a sensitivity of 95% and specificity of 93% for a designation criterion of RDI ≥ 30.37 The raw data were reviewed by a sleep medicine physician (PJH), blinded to patients' kidney function and symptoms, who confirmed that the estimated RDI was accurate and determined whether apnea was central (CSR) or obstructive (OSA), based on the morphology of the airflow recordings. Nasal pressure recordings with a characteristic crescendo/decrescendo pattern and no evidence of airflow limitation were classified as CSR, whereas recordings without a crescendo/decrescendo pattern and with airflow limitation were classified as OSA.
Data are presented as mean ± standard deviation or number (percentage), unless otherwise indicated. Estimated OSA risk, as assessed by the BQ, ANC, and STOP-BANG questionnaire, was compared to the diagnosis of OSA (RDI ≥ 15 and ≥ 30, respectively) as determined by objective cardiopulmonary monitoring for both CKD and ESRD patients. Subjects with CSR were excluded from our primary analyses, but were included as part of a sensitivity analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), accuracy (total number of correct risk assessments divided by total number of risk assessments), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated for high risk for the BQ, both moderate to high risk (≥ 43 cm) and high risk (> 48 cm) for the ANC, and high risk for the STOP-BANG questionnaire at moderate (RDI ≥ 15) and severe (RDI ≥ 30) diagnostic criteria for OSA. These were undertaken for CKD and ESRD patients separately. The unpaired t-test or the Mann-Whitney U-test was used for comparisons between continuous variables, while the χ2 test with Fischer's Exact Test was used for dichotomous variables. Finally, we examined the impact of using higher thresholds to assess OSA risk in the ANC (> 53 cm) and the STOP-BANG questionnaire (' 4). All statistical analyses were two-sided and performed with SPSS V.17.0 (SPSS, Chicago, IL, USA). P-values < 0.05 were considered statistically significant.
Six hundred fifty-seven patients were informed of the study between May 2007 and November 2010 (Figure 1); 254 patients declined to participate. In addition, eGFR was too high (≥ 60) in 87 patients, and 14 patients did not complete the questionnaires. The remaining 302 patients (CKD, n = 174; ESRD, n = 128) were eligible for cardiopulmonary monitoring, which was declined by 116 patients (CKD: n = 61; ESRD: n = 56). One hundred thirteen CKD patients and 72 ESRD patients completed cardiopulmonary monitoring. Thirteen patients with CSR (CKD, n = 4; ESRD, n = 9) were excluded from further analyses, resulting in a final study population of 109 CKD patients and 63 ESRD patients. Eight CKD patients and 5 ESRD patients were currently treated with CPAP.
CSR, Cheyne-Stokes respiration; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; RSR, Remmers Sleep Recorder.
Patient recruitmentCSR, Cheyne-Stokes respiration; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; RSR, Remmers Sleep Recorder.
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CKD patient characteristics stratified by OSA status (RDI ≥ 15) are presented in Table 1. The mean duration of nocturnal cardiopulmonary monitoring was 7.3 ± 1.5 h for CKD patients, while the proportion of monitoring time that patients reported sleeping was 81% ± 15%. Consequently, estimated sleep efficiency and monitoring time were sufficiently long to capture important respiratory events. Moderate to severe OSA (RDI ≥ 15) was present in 38% of CKD patients. Using a more conservative definition of OSA (RDI ≥ 30), the prevalence of OSA remained high at 23%. As expected, the severity of associated nocturnal hypoxemia was greater in CKD patients with OSA. CKD patients with OSA had an increased BMI and greater neck circumference, but did not differ from CKD patients without OSA in terms of age or gender distribution.
Chronic kidney disease patient characteristics
There were no differences in the individual categories or the final assessed risk of the BQ between CKD patients with and without OSA, although category 1 (snoring) and final risk were of borderline significance. Using the ANC, CKD patients with OSA had greater neck circumference than CKD patients without OSA, although nocturnal choking was of borderline significance. However, these components contributed to higher ANC scores, which resulted in a greater proportion of CKD patients with OSA being assessed as higher risk. Component analyses of the STOP-BANG questionnaire revealed that CKD patients with OSA were more likely to report a history of witnessed apneas, have a BMI > 35 kg/m2, and neck circumferences > 40 cm. Male gender and age > 50 years were of borderline significance. Accordingly, this corresponded to higher STOP-BANG total scores and a greater proportion of CKD patients with OSA being assessed as high risk.
The sensitivity, specificity, PPV, and NPV for a positive BQ, ANC, and STOP-BANG to identify OSA in patients with CKD using RDI thresholds of 15 and 30 are shown in Table 2.
Diagnostic value of obstructive sleep apnea screening instruments in chronic kidney disease patients
Using an RDI ≥ 15, the BQ, ANC ≥ 43, and STOP-BANG performed with good sensitivity but poor specificity; an ANC > 48 had a modest sensitivity and specificity. The BQ, ANC, and STOP-BANG had good NPVs, but poor PPVs. The accuracies of the BQ, ANC ≥ 43, ANC > 48, and STOP-BANG were 52%, 58%, 69%, and 54%, respectively, for identifying OSA at an RDI ≥ 15.
At an RDI ≥ 30, the BQ, ANC ≥ 43, and STOP-BANG had high sensitivity but poor specificity, while an ANC > 48 had both a modest sensitivity and specificity. The BQ, ANC, and STOP-BANG had good NPVs, but poor PPVs. The accuracies of the BQ, ANC ≥ 43, ANC > 48, and STOP-BANG were 45%, 47%, 69%, and 45%, respectively, for identifying OSA using a RDI ≥ 30.
Inclusion of the 4 subjects with CSR did not alter these results. Increasing the threshold for the ANC (> 53) resulted in improved specificity and PPV at the expense of reduced sensitivity and NPV. Accuracy was not improved at RDI ≥ 15, but was improved to 76% at RDI ≥ 30. Increasing the threshold for the STOP-BANG (≥ 4) improved specificity and PPV and mildly reduced sensitivity and NPV at both RDI thresholds. Accuracy was increased to 64% at RDI ≥ 15 and 57% at RDI ≥ 30.
ESRD patient characteristics stratified by OSA status (RDI ≥ 15) are presented in Table 3. The mean duration of nocturnal cardiopulmonary monitoring was 6.4 ± 2.0 h for ESRD patients, while the proportion of monitoring time that patients reported sleeping was 78% ± 18% for ESRD. Consequently, monitoring time and estimated sleep efficiency were sufficiently long to capture important respiratory events. Moderate to severe OSA (RDI ≥ 15) was present in 51% of ESRD patients, and the prevalence of severe OSA (RDI ≥ 30) was also high at 40%. The severity of nocturnal hypoxemia was greater in ESRD patients with OSA. ESRD patients with OSA had an increased BMI and greater neck circumference, but did not differ from ESRD patients without OSA in terms of age or gender distribution.
End-stage renal disease patient characteristics
There were no differences in the individual categories or the final assessed risk of the BQ between ESRD patients with and without OSA. Similarly, apart from neck circumference, there were no differences in the other components of the ANC between ESRD patients with and without OSA. However, the increased neck circumference resulted in higher ANC scores and corresponded to a greater proportion of ESRD patients with OSA being assessed as higher risk. Component analyses of the STOP-BANG questionnaire revealed that ESRD patients with OSA were more likely to report loud snoring, a history of witnessed apneas, have a BMI > 35 kg/m2, and neck circumferences > 40 cm. Accordingly, this resulted in higher STOP-BANG total scores and a greater proportion of ESRD patients with OSA being assessed as high risk.
The sensitivity, specificity, PPV, and NPV for a positive BQ, ANC, and STOP-BANG in identifying OSA in ESRD patients are shown in Table 4.
Diagnostic value of obstructive sleep apnea screening instruments in end-stage renal disease patients
At an RDI ≥ 15, an ANC ≥ 43 and STOP-BANG had good sensitivity, but poor specificity. The BQ had modest sensitivity but poor specificity, while an ANC > 48 had both modest sensitivity and specificity. Each screening instrument had a moderate PPV and NPV. The accuracies of the BQ, ANC ≥ 43, ANC > 48, and STOP-BANG were 51%, 67%, 67%, and 62%, respectively, for determining OSA using RDI ≥ 15.
At an RDI ≥ 30, the BQ and an ANC ≥ 43 had moderate sensitivity and NPV, but poor specificity and PPV. An ANC > 48 had moderate sensitivity, specificity, PPV, and NPV. The STOP-BANG had excellent sensitivity and NPV, but poor specificity and PPV. The accuracies of the BQ, ANC ≥ 43, ANC > 48, and STOP-BANG were 55%, 56%, 71%, and 54%, respectively, for determining OSA using a RDI ≥ 30.
Inclusion of the 9 subjects with CSR did not alter these results. Increasing the threshold for the ANC (> 53) resulted in improved specificity and PPV at the expense of reduced sensitivity and NPV, but did not improve accuracy, at both RDI ≥ 15 and ≥ 30. However, increasing the threshold for the STOP-BANG (≥ 4) improved specificity and PPV, while maintaining good sensitivity and NPV at both RDI thresholds. Accuracy was increased to 75% at an RDI ≥ 15 and 67% at an RDI ≥ 30.
This is the first study to systematically examine the validity of OSA screening questionnaires in the CKD and ESRD populations using objective cardiopulmonary monitoring to diagnose OSA. We found that (a) OSA screening instruments had limited accuracy in the CKD and ESRD populations, with accuracies ranging between 45% to 69% in CKD patients and 51% to 71% in ESRD patients at RDI levels of 15 and 30, respectively; (b) the ANC was the most accurate screening tool in both the CKD and ESRD populations; (c) the ANC and STOP-BANG assigned more CKD and ESRD patients with OSA as high risk; and (d) the BQ was unable to distinguish between CKD and ESRD patients with and without OSA.
Several small studies have reported increased OSA risk in the dialysis38–40 and transplant41 populations using the Berlin questionnaire, but in contrast to this study, none included objective overnight monitoring to confirm the diagnosis of OSA. We found that the BQ had a better sensitivity but poorer specificity and predictive value in both the CKD and ESRD populations compared to measures obtained in the initial validation in the primary care setting.30 The ANC has not been validated outside of a sleep centre population.31,32 The STOP-BANG questionnaire performed similarly in our CKD and ESRD populations to what has previously been reported in the preoperative assessment of surgical patients33 and in a more recent community study.42
In order to screen patients for a disorder with an important health outcome, a good screening tool requires a high sensitivity with an acceptable specificity. Overall, we found the BQ, ANC, and STOP-BANG demonstrated high sensitivities, but the specificities were significantly below acceptable levels. High sensitivities are useful in order to avoid missing cases that may lead to adverse health outcomes and healthcare costs, but low specificities result in the inclusion of low-risk patients and higher false positive rates. This limits the utility of these screening tools in the patient population we studied. Given the good negative predictive values we found, there may be a role for these screening questionnaires to exclude OSA and avoid further testing. However, further evaluation will be required in those who have a positive screening questionnaire. Of interest, increasing the thresholds for the ANC and STOP-BANG questionnaire did improve accuracy in our CKD and ESRD patients. However, further studies are required to examine the use of alternative thresholds for OSA diagnosis in these populations, as well as to examine the implications and efficacy of these screening strategies. The poor performance of the BQ is consistent with what has been demonstrated in other disease-specific populations. Although the BQ performed well in the primary-care setting30 and in patients with atrial fibrillation43 and resistant hypertension,44 it did not effectively screen for OSA in the stroke,45 systemic hypertension,46 and sleep clinic populations,47 nor in patients who were evaluated following acute myocardial infarction.48 To date, the ANC and the STOP-BANG have not been validated in disease-specific populations.
The high prevalence of hypertension, which was found in over 90% of our patients and was equally common in those with and without OSA, is one reason the BQ, ANC, and STOP-BANG were unable to reliably distinguish patients with and without OSA in the CKD and ESRD populations. By definition, most CKD and ESRD patients have hypertension either as a cause or consequence of kidney disease.21 Additionally, the reliance of these screening questionnaires on sleep related symptoms, such as snoring, witnessed apneas, nocturnal choking, and daytime sleepiness, limit their accuracy in CKD and ESRD patients, as these populations are less likely to present with the stereotypical features of OSA.14,15 Furthermore, fatigue is a common symptom of CKD and ESRD, which can overlap with complaints of sleepiness and develop independently of sleep disordered breathing.49,50 Fluid status is another potential confounder that is thought to influence upper airway obstruction and neck circumference in kidney failure patients.51–54 Although it is possible that fluid accumulation in the neck accounted for some of the increased neck circumference in patients with OSA, our study was not designed to evaluate this. However, we tried to minimize the potential for fluid status to confound our results by standardizing when ESRD patients were evaluated in relation to the time they received dialysis. Further, the dichotomous categorization of age (> 50 years) used in the STOP-BANG questionnaire is also a limitation as CKD and ESRD are more prevalent in the elderly.55 Consequently, the presence of these factors could significantly reduce the accuracy of these screening tools.
Our study has a number of strengths. First, we recruited a relatively large sample size from a renal population representative of the general CKD and ESRD populations, which increases the relevance of our findings to these patient populations. In fact, our CKD population had a similar clinical profile to the Chronic Renal Insufficiency Cohort study,56 and our ESRD population resembled a larger cohort of ESRD patients from the Southern Alberta Renal Program.57 Second, we used the same methodology, including objective cardiopulmonary monitoring, in patients with a broad spectrum of kidney disease, which enabled us to compare the accuracy of these screening instruments in the CKD and ESRD populations. Third, no inclusion or exclusion criteria were set with respect to age, gender, comorbidities, or medications, which improved the generalizability of our findings to the CKD and ESRD populations. Notwithstanding these strengths, our study also has limitations. First, the potential for selection bias exists as patients attending the nephrology clinics may have been more likely to participate if they suspected they had sleep apnea. We tried to limit this by emphasising that sleep related complaints were not required for recruitment. If such a bias did exist, it should have been reflected in a higher prevalence of sleep related symptoms and higher accuracy of the screening instruments, which was not the case. Second, we used portable monitoring in place of polysomnography. The RDI was calculated based on monitoring time rather than objective sleep duration and thus the frequency of OSA events could have been underestimated. Further, this methodology did not employ a measurement of respiratory effort and consequently we could only estimate the prevalence of central sleep apnea based on the morphology of the nasal pressure recording. We addressed these potential limitations by asking patients to estimate their sleep time, and having the portable monitoring results reviewed by a sleep medicine physician to determine whether the findings were consistent with either Cheyne-Stokes respiration or OSA.
In summary, our study demonstrates that current screening questionnaires do not accurately identify patients at high risk for OSA or rule out the existence of OSA in patients with CKD and ESRD. This is unfortunate given the high prevalence of OSA in these patient populations1–12 and its potential impact on important clinical outcomes.16–20,22–28 Further studies are required to develop and validate more accurate screening strategies for OSA in patients with CKD and ESRD. In the meantime, objective cardiopulmonary monitoring during sleep is required to reliably identify sleep apnea in these patients.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
The authors thank the Southern Alberta Renal Program for assistance with patient recruitment, the FMC Sleep Centre for sleep diagnostic testing, and Ms. Patty Nielsen for her clerical assistance. This research was supported by Alberta Innovates–Health Solutions, O'Brien Centre, University of Calgary, and the Department of Medicine, University of Calgary. An abstract for this study was presented at the American Society of Nephrology Kidney Week in Philadelphia, PA, November 8-13, 2011.
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Berlin Questionnaire and scoring algorithm