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- Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
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- Research Review Aug. 8, 2011
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- Research Protocol Mar. 15, 2010
- Disposition of Comments Report Oct. 25, 2011
- Surveillance Report Jun. 11, 2013
Original Nomination
Executive Summary – Aug. 8, 2011
Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
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Table of Contents
- Background
- Objectives
- Key Questions
- Analytic Framework
- Methods
- Results
- Discussion
- Limitations
- Implications for Future Research
- Full Report
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- Notes
Obstructive sleep apnea (OSA) is a relatively common disorder in the United States that affects people of all ages, but is most prevalent among the middle-aged and elderly. Affected individuals experience repeated collapse and obstruction of the upper airway during sleep, which results in reduced airflow (hypopnea) or complete airflow cessation (apnea), oxygen desaturation, and arousals from sleep. Adverse clinical outcomes associated with OSA include: cardiovascular disease, hypertension, non-insulin-dependent diabetes, and increased likelihood of motor vehicle and other accidents due to daytime hypersomnolence. Studies estimate the prevalence of OSA at approximately 10 to 20 percent of middle-aged and older adults. Evidence also indicates that these rates are rising, likely due to increasing rates of obesity.
Based on the considerable mortality and morbidity associated with it and its attendant comorbidities, OSA is an important public health issue. Complicating diagnosis and treatment, however, is the great degree of clinical uncertainty that exists regarding the condition, due in large part to inconsistencies in its definition. Ongoing debate surrounds what type and level of respiratory abnormality should be used to define the disorder as well as what is the most appropriate diagnostic method for its detection. In addition, there is no current established threshold level for the apnea-hypopnea index (AHI) that would indicate the need for treatment. By consensus, people with relatively few apnea or hypopnea events per hour (often <5 or <15) are not formally diagnosed with OSA. Also of concern are the high rates of perioperative and postoperative complications among OSA patients, as are the numbers of asymptomatic and symptomatic individuals who remain undiagnosed and untreated.
Three main categories of outcomes of interest in comparative effectiveness research are clinical (or health) outcomes (i.e., events or conditions that the patient can feel, such as disability or quality of life or death), intermediate or surrogate outcomes (such as laboratory measurements), and adverse events. Objective clinical outcomes relevant to patients with OSA include comorbidities found to be associated with untreated sleep apnea, primarily cardiovascular disease (including congestive heart failure, hypertension, stroke, and myocardial infarction) and non-insulin-dependent diabetes. In addition, mortality due to cardiovascular disease, diabetes, motor vehicle accidents, and other causes represent important adverse outcomes of OSA. Intermediate outcomes of interest in the management of patients with OSA include sleep study measures (e.g., AHI), blood pressure (an intermediate outcome for cardiovascular disease), and hemoglobin A1c (a measure of control of diabetes mellitus).
All interventions have the potential for adverse events. Therefore, it is important to gather information on both the benefits and harms of interventions in order to fully assess the net comparative benefits. Compliance with continuous positive airway pressure (CPAP) and other devices is an important issue related to the effective treatment of OSA. Interventions that have better compliance or that may improve compliance are clearly of interest. Also of relevance is establishing definitive diagnostic standards and measures that would more clearly identify OSA patients, both symptomatic and asymptomatic. Such standards would serve to reduce OSA-related morbidities as well as related health care costs. Studies have found that prior to diagnosis, OSA patients have higher rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis. Therefore, this review is of additional interest to the requesting organizations and broadly for the identification of diagnostic tests that would contribute to the early and definitive diagnosis of patients with OSA.
In response to several nominations received through the Effective Healthcare Web site, which were evaluated and found to meet program criteria, the Agency for Healthcare Research and Quality (AHRQ) requested that the Tufts Evidence-based Practice Center (Tufts EPC) conduct a Comparative and Effectiveness Review (CER) of studies regarding the diagnosis and treatment of OSA. Key Questions that are clinically relevant for the diagnosis and treatment of OSA were developed with input from domain experts and other stakeholders and from comments received in response to public review. Seven Key Questions are addressed in this report. Three pertain to diagnosis of and screening for OSA (Key Questions 1–3), two address the comparative effectiveness of treatments (Key Questions 5 and 7), and two address associations between baseline patient characteristics and long-term outcomes and treatment compliance (Key Questions 4 and 6).
Key Questions
- How do different available tests compare in their ability to diagnose sleep apnea in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients, based on: race, sex, body mass index, existing non-insulin-dependent diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics?
- How does phased testing (screening tests or battery followed by full test) compare to full testing alone?
- What is the effect of preoperative screening for sleep apnea on surgical outcomes?
- In adults being screened for obstructive sleep apnea, what are the relationships between apnea-hypopnea index or oxygen desaturation index and other patient characteristics with respect to long-term clinical and functional outcomes?
- What is the comparative effect of different treatments for obstructive sleep apnea in adults?
- Does the comparative effect of treatments vary based on presenting patient characteristics, severity of obstructive sleep apnea, or other pretreatment factors? Are any of these characteristics or factors predictive of treatment success?
- Characteristics: Age, sex, race, weight, bed partner, airway, other physical characteristics, and specific comorbidities
- Obstructive sleep apnea severity or characteristics: Baseline questionnaire (and similar tools) results, formal testing results (including hypoxemia levels), baseline quality of life, positional dependency
- Other: Specific symptoms
- Does the comparative effect of treatments vary based on the definitions of obstructive sleep apnea used by study investigators?
- Does the comparative effect of treatments vary based on presenting patient characteristics, severity of obstructive sleep apnea, or other pretreatment factors? Are any of these characteristics or factors predictive of treatment success?
- In obstructive sleep apnea patients prescribed nonsurgical treatments, what are the associations of pretreatment patient-level characteristics with treatment compliance?
- What is the effect of interventions to improve compliance with device use (positive airway pressure, oral appliances, positional therapy) on clinical and intermediate outcomes?
Analytic Framework
To guide the development of the Key Questions for the diagnosis and treatment of OSA, we developed an analytic framework (Figure A) that maps the specific linkages associating the populations and subgroups of interest, the interventions (for both diagnosis and treatment), and outcomes of interest (intermediate outcomes, health-related outcomes, compliance, and adverse effects). Specifically, this analytic framework depicts the chain of logic that evidence must support to link the interventions to improved health outcomes.
Figure A. Analytic framework for the diagnosis and treatment of obstructive sleep apnea in adults
CVD, cardiovascular disease; KQ, Key Question; NIDDM, non-insulin-dependent diabetes mellitus; QoL, quality of life.
Input from Stakeholders
During a topic refinement phase, the initial questions were refined with input from a panel of Key Informants. The Key Informants included experts in sleep medicine, general internal medicine, and psychiatry; a representative from Oregon Division of Medical Assistance programs; a person with OSA; a representative of a sleep apnea advocacy group; and the AHRQ Task Order Officer.
After a public review of the proposed Key Questions, the clinical experts from among the Key Informants were reconvened to form the Technical Expert Panel, which served to provide clinical and methodological expertise and input to help refine Key Questions, identify important issues, and define parameters for the review of evidence, including study eligibility criteria.
Data Sources and Selection
We conducted literature searches of studies in MEDLINE® (inception–September 2010) and the Cochrane Central Register of Controlled Trials (through 3rd quarter 2010). All English-language studies with adult human subjects were screened to identify articles relevant to each Key Question. The search strategy included terms for OSA, sleep apnea diagnostic tests, sleep apnea treatments, and relevant research designs.
The reference lists of related systematic reviews and selected narrative reviews and primary articles were also reviewed, and relevant articles were screened. After screening of the abstracts, full-text articles were retrieved for all potentially relevant articles and rescreened for eligibility.
Data Extraction and Quality Assessment
Study data were extracted into customized forms. Together with information on study design, patient and intervention characteristics, outcome definitions, and study results, the methodological quality of each study was rated from A (highest quality, least likely to have significant bias) to C (lowest quality, most likely to have significant bias).
Data Synthesis and Analysis
For all Key Questions or specific comparison of interventions with at least two studies, summary tables present the study and baseline patient characteristics, the study quality, and the relevant study results. For each comparison, separate tables include all the studies that reported specific outcomes. For Key Question 1 (diagnosis), we graphically display the Bland-Altman limits of agreement and the sensitivity and specificity of studies comparing portable monitors to polysomnography (PSG). For Key Question 5 (treatment), when there were three or more similar studies evaluating the same outcome, we performed random effects model meta-analyses of the following: the sleep study measures AHI, arousal index, minimum oxygen saturation; the standard measure of sleepiness, the Epworth Sleepiness Scale (ESS); the quality-of-life measure Functional Outcomes Sleep Questionnaire (FOSQ); and compliance. We performed subgroup meta-analyses based on study design (parallel or crossover), minimum AHI threshold to diagnose OSA, specific intervention (when appropriate), and other factors. Of note, where interventions (either diagnostic tests or treatments) are not discussed, this does not imply that the interventions were excluded from analysis (unless explicitly stated); instead, no studies of these interventions met eligibility criteria.
As per the AHRQ updated methods guide series, we assessed the evidence for each question (or comparison of interventions) based on the risk of bias, study consistency, directness of the evidence, and degree of certainty of the findings. Based on these factors, we graded the overall strength of evidence as high, moderate, low, or insufficient.
When there were substantial differences in conclusions for different outcomes within the same comparison, we also described the evidence supporting each outcome as sufficient, fair, weak, limited, or no evidence.
Key Question 1. How do different available tests compare in their ability to diagnose sleep apnea in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients based on: race, sex, body mass index, existing noninsulin dependent diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics?
Comparison of Portable Devices and Polysomnography
PSG devices are classified as Type I monitors. Portable monitors are classified as either Type II, which record all the same information as PSG; Type III, which do not differentiate between whether the patient is asleep or awake, but have at least two respiratory channels (two airflow channels or one airflow and one effort channel); or Type IV, which fail to fulfill criteria for Type III monitors but usually record more than two bioparameters.
The strength of evidence is moderate, among 15 quality A, 45 quality B, and 39 quality C studies, that Type III and Type IV monitors may have the ability to accurately predict AHI suggestive of OSA with high positive likelihood ratios and low negative likelihood ratios for various AHI cutoffs in PSG. Type III monitors perform better than Type IV monitors at AHI cutoffs of 5, 10, and 15 events/hr. Analysis of difference versus average analyses plots suggest that substantial differences in the measured AHI may be encountered between PSG and both Type III and Type IV monitors. Large differences compared with in-laboratory PSG cannot be excluded for all portable monitors. The evidence is insufficient to adequately compare specific monitors to each other.
No recent studies compared Type II monitors with PSG. A prior Technology Assessment of home diagnosis of OSA concluded that "based on [three quality B studies], type II monitors [used at home] may identify AHI suggestive of OSA with high positive likelihood ratios and low negative likelihood ratios," though "substantial differences in the [measurement of] AHI may be encountered between type II monitors and facility-based PSG."
Comparison of Questionnaires and Polysomnography
Of the six studies reviewed (one quality A, one quality B, four quality C), the strength of evidence is low among three studies supporting the use of the Berlin questionnaire in screening for sleep apnea because of the likely selection biases. The strength of evidence is insufficient to draw definitive conclusions concerning the use of the STOP, STOP-Bang, ASA Checklist, Epworth Sleepiness Scale, and Hawaii Sleep questionnaires to screen for sleep apnea because each questionnaire was assessed in only a single study.
Clinical Prediction Rules and Polysomnography
The strength of evidence is low among seven studies (three quality A, three quality B, and one quality C) that some clinical prediction rules may be useful in the prediction of a diagnosis of OSA. Ten different clinical prediction rules have been described. Nine clinical prediction rules have been used for the prediction of a diagnosis of OSA (using different criteria). The oropharyngeal morphometric model gave near perfect discrimination (area under the curve [AUC] = 0.996) to predict the diagnosis of OSA, and the pulmonary function data model had 100 percent sensitivity with 84 percent specificity to predict diagnosis of OSA. The remaining models reported lower diagnostic sensitivities and specificities. Each model was deemed useful to predict the diagnoses of OSA by the individual study authors. However, while all the models were internally validated, external validation of these predictive rules has not been conducted in the vast majority of the studies.
Key Question 2. How does phased testing (screening tests or battery followed by full test) compare to full testing alone?
The strength of evidence is insufficient to determine the utility of phased testing, followed by full testing when indicated, to diagnose sleep apnea, as only one study that met our inclusion criteria investigated this question. This prospective quality C study did not fully analyze the phased testing, thus the sensitivity and specificity of the phased strategy could not be calculated due to a verification bias; not all participants received PSG (full) testing.
Key Question 3. What is the effect of preoperative screening for sleep apnea on surgical outcomes?
The strength of evidence is insufficient regarding postoperative outcomes with mandatory screening for sleep apnea. Two quality C prospective studies assessed the effect of preoperative screening for sleep apnea on surgical outcomes. One study found no significant differences in outcomes between patients undergoing bariatric surgery who had mandatory PSG or PSG based on clinical parameters. The second study found that general surgery patients willing to undergo preoperative PSG were more likely to have perioperative complications, particularly cardiopulmonary complications, possibly suggesting that patients willing to undergo PSG are more ill than other patients.
Key Question 4. In adults being screened for obstructive sleep apnea, what are the relationships between apnea-hypopnea index or oxygen desaturation index, and other patient characteristics with respect to long-term clinical and functional outcomes?
The strength of evidence is high from four studies (three quality A, one quality B) indicating that an AHI >30 events/hr is an independent predictor of all-cause mortality; although one study found that this was true only in men under age 70. All other outcomes were analyzed by only one or two studies. Thus, only a low strength of evidence exists that a high AHI (>30 events/hr) is associated with incident diabetes. This association, however, may be confounded by obesity, which may result in both OSA and diabetes. The strength of evidence is insufficient regarding the association between AHI and other clinical outcomes. The two studies of cardiovascular mortality did not have consistent findings, and the two studies of hypertension had unclear conclusions. One study of nonfatal cardiovascular disease found a significant association with baseline AHI (as they did for cardiovascular mortality). One study each found no association between AHI and stroke or long-term quality of life.
Key Question 5. What is the comparative effect of different treatments for obstructive sleep apnea in adults?
- Does the comparative effect of treatments vary based on presenting patient characteristics, severity of obstructive sleep apnea, or other pretreatment factors? Are any of these characteristics or factors predictive of treatment success?
- Characteristics: age, sex, race, weight, bed partner, airway, other physical characteristics, and specific comorbidities
- Obstructive sleep apnea severity or characteristics: baseline questionnaire (and similar tools) results, formal testing results (including hypoxemia levels), baseline quality of life, positional dependency
- Other: specific symptoms
- Does the comparative effect of treatments vary based on the definitions of obstructive sleep apnea used by study investigators?
With some exceptions for studies of surgical interventions, we reviewed only randomized controlled trials (RCT) of interventions used specifically for the treatment of obstructive sleep apnea (OSA).
Comparison of Continuous Positive Airway Pressure and Control
There are 22 trials (11 each of quality B and C) that provide sufficient evidence supporting large improvements in sleep measures with continuous positive airway pressure (CPAP) compared with control. There is only weak evidence that demonstrated no consistent benefit in improving quality of life, neurocognitive measures, or other intermediate outcomes. Despite no evidence or weak evidence for an effect of CPAP on clinical outcomes, given the large magnitude of effect on the intermediate outcomes AHI and ESS, the strength of evidence that CPAP is an effective treatment to alleviate sleep apnea signs and symptoms was rated moderate.
Comparison of CPAP and Sham CPAP
There are 24 trials (5 quality A, 13 quality B, 6 quality C) that provide sufficient evidence supporting large improvements in sleep measures with CPAP compared with sham CPAP, but weak evidence of possibly no difference between CPAP and sham CPAP in improving quality of life, neurocognitive measures, or other intermediate outcomes. Despite no evidence or weak evidence for an effect of CPAP on clinical outcomes, given the large magnitude of effect on the intermediate outcomes of AHI, ESS, and arousal index, the strength of evidence that CPAP is an effective treatment for the relief of signs and symptoms of sleep apnea was rated moderate.
Comparison of Oral and Nasal CPAP
Three small trials (one quality B, two quality C) with inconsistent results preclude any substantive conclusions concerning the efficacy of oral (or full face mask) versus nasal CPAP in improving compliance in patients with OSA. Largely due to small sample size, the reported effect estimates in the studies reviewed were generally imprecise. Thus, overall, the strength of evidence is insufficient regarding differences in compliance or other outcomes between oral and nasal CPAP.
Comparison of Autotitrating CPAP and Fixed CPAP
The strength of evidence is moderate that autotitrating CPAP (autoCPAP) and fixed pressure CPAP result in similar levels of compliance (hours used per night) and treatment effects for patients with OSA. Twenty-one studies (1 quality A, 10 quality B, 10 quality C) comprising an experimental population of over 800 patients provided evidence that autoCPAP reduces sleepiness as measured by ESS by approximately 0.5 points more than fixed CPAP. The two devices were found to result in similar compliance and changes in AHI from baseline, quality of life, and most other sleep study measures. However, there is also evidence that minimum oxygen saturation improves more with fixed CPAP than with autoCPAP, although by only about one percent. Evidence is limited regarding the relative effect of fixed CPAP and autoCPAP on blood pressure. There were no data on objective clinical outcomes.
Comparison of Bilevel CPAP and Fixed CPAP
The strength of evidence is insufficient regarding any difference in compliance or other outcomes between bilevel CPAP and fixed CPAP. Five small, highly clinically heterogeneous trials (one quality B, four quality C) with largely null findings did not support any substantive differences in the efficacy of bilevel CPAP versus fixed CPAP in the treatment of patients with OSA. Largely due to small sample sizes, the studies mostly had imprecise estimates of the comparative effects.
Comparison of Flexible Bilevel CPAP and Fixed CPAP
The strength of evidence is insufficient regarding the relative merits of flexible bilevel CPAP and fixed CPAP as there was only one quality B study that investigated this comparison. This study found that flexible bilevel CPAP may yield increased compliance (use ³4 hr/night) compared with fixed CPAP.
Comparison of C-Flex™ and Fixed CPAP
No statistically significant differences in compliance or other outcomes were found between C-Flex and fixed CPAP. The strength of evidence is low for this finding because of the mixed quality (Bs and Cs) of the four primary studies.
Comparison of Humidification in CPAP
The strength of evidence is insufficient to determine whether there is a difference in compliance or other outcomes between positive airway pressure treatment with and without humidification. Five trials examined different aspects of humidified CPAP treatment for patients with OSA. While some studies reported a benefit of added humidity in CPAP treatment in improving patient compliance, this effect was not consistent across all the studies. Overall, the studies were clinically heterogeneous, small, and of quality B (three studies) or C (two studies).
Comparison of Mandibular Advancement Devices and No Treatment or Inactive Oral Devices
The strength of evidence is moderate to show that the use of mandibular advancement devices (MAD) improves sleep apnea signs and symptoms. Five trials (four quality B, one quality C) compared MAD with no treatment, using a variety of different types of MAD, and found significant improvements with MAD in AHI, ESS, and other sleep study measures. Any differences in quality of life measures or neurocognitive tests were equivocal between treatment groups. No trial evaluated objective clinical outcomes. Another five trials (four quality B, one quality C) compared the effects of MAD with inactive oral devices and reported similar findings.
Comparison of Different Oral Devices
The strength of evidence is insufficient to draw conclusions with regard to the relative efficacy of different types of oral MAD in patients with OSA because the reviewed studies were generally small, and each was concerned with a unique comparison. Five studies (four quality B, one quality C) with unique comparisons found little to no differences between different types and methods of use of MAD or other oral devices in sleep study or sleepiness measures. No study evaluated objective clinical outcomes. Only one study evaluated compliance; no significant differences were observed. One trial found that a greater degree of mandibular advancement resulted in an increased number of patients achieving an AHI <10 events/hr; however, the mean AHI was similar between treatment groups.
Comparison of Mandibular Advancement Devices and CPAP
The strength of evidence is moderate that CPAP is superior to MAD in improving sleep study measures. Ten mostly quality B trials overall found that CPAP resulted in greater reductions in AHI and arousal index, and increases in minimum oxygen saturation. The evidence regarding the relative effects on ESS were too heterogeneous to allow conclusions. In a single study, patients were more compliant with MAD than CPAP (hours used per night and nights used). No study evaluated objective clinical outcomes. The strength of evidence is insufficient to address which patients might benefit most from either treatment.
Comparison of Surgery and Control
The strength of evidence is insufficient to evaluate the relative efficacy of surgical interventions for the treatment of OSA. Six trials and one nonrandomized prospective study with unique interventions compared surgery with control treatment for the management of patients with OSA. Three studies were rated quality A, one quality B, and three quality C. The results were inconsistent across studies as to which outcomes were improved with surgery compared with no or sham surgery.
Comparison of Surgery and CPAP
The strength of evidence is insufficient to determine the relative merits of surgical treatments versus CPAP. Of 12 studies (1 quality A, 11 quality C) comparing surgical modalities with CPAP, only two were RCTs, and they compared CPAP with uvulopalatopharyngoplasty (UPPP), removal of the soft tissue at the back of the throat, the uvula, and soft palate. While one of these trials found that CPAP resulted in a higher mortality benefit, the other found no difference between groups. Due to the heterogeneity of interventions and outcomes examined, the variability of findings across studies, and the inherent bias of all but one study regarding which patients received surgery, it is not possible at this time to draw useful conclusions comparing surgical interventions with CPAP in the treatment of patients with OSA. The quality A trial was the only unbiased comparison of surgery and CPAP (patients had previously received neither treatment). It did not find statistically significant differences in ESS and quality of life measures between patients with mild to moderate OSA who had temperature-controlled radiofrequency tissue volume reduction of the soft palate and those who had CPAP at 2 months followup. Likewise, the other trial, comparing maxillomandibular advancement osteotomy and CPAP, did not find statistically significant differences in AHI and ESS in patients with severe OSA. For the nonrandomized studies, comparisons between surgery and CPAP are difficult to interpret since baseline patient characteristics (including sleep apnea severity) differed significantly between groups, particularly in regards to what previous treatments patients had. The reported findings on sleep study and quality of life measures were heterogeneous across studies.
Comparison of Surgery and Mandibular Advancement Devices
The strength of evidence is insufficient regarding the relative merit of MAD versus surgery in the treatment of OSA, as there was only one study (quality B) that examined this question. A statistically significant improvement in AHI was observed in the MAD group compared with the surgery group. No study evaluated objective clinical outcomes.
Comparison of Other Treatments
The strength of evidence is low to show that some intensive weight loss programs may be effective treatment for OSA in obese patients. Three trials (one quality A, two quality B) compared weight loss interventions with control interventions. All three trials found significant relative reductions in AHI with diet. Other outcomes were inconsistent.
The strength of evidence is insufficient to determine the effects of other potential treatments for OSA. Twenty-one studies evaluated other interventions including atrial overdrive pacing, eight different drugs, palatal implants, oropharyngeal exercises, a tongue-retaining device, a positional alarm, combination tongue-retaining device and positional alarm, bariatric surgery, nasal dilator strips, acupuncture, and auricular plaster. All of these interventions were evaluated by one or two studies only. The findings were heterogeneous. No study evaluated objective clinical outcomes.
Key Question 6. In OSA patients prescribed nonsurgical treatments, what are the associations of pretreatment patient-level characteristics with treatment compliance?
Across five studies (one quality A, one quality B, three quality C), the strength of evidence is moderate that more severe OSA as measured by higher AHI is associated with greater compliance with CPAP use. Each study measured compliance differently, including thresholds of 1, 2, or 3 hours of use per night or as a continuous variable, and undefined "objective compliance" measured by the device. The strength of evidence is moderate that a higher ESS score is also associated with improved compliance. There are low strengths of evidence that younger age, snoring, lower CPAP pressure, higher BMI, higher mean oxygen saturation, and the sleepiness domain on the Grenoble Sleep Apnea Quality of Life test are each possible independent predictors of compliance. It is important to note, however, that selective reporting, particularly of nonreporting of nonsignificant associations, cannot be ruled out. The heterogeneity of analyzed and reported potential predictors greatly limits these conclusions. Differences across studies as to which variables were independent predictors may be due to the adjustment for different variables, in addition to differences in populations, outcomes, CPAP machines, and CPAP training and followup. One quality C study of mandibular advancement devices failed to identify potential predictors of compliance.
Key Question 7. What is the effect of interventions to improve compliance with device (positive airway pressure, oral appliances, positional therapy) use on clinical and intermediate outcomes?
The strength of evidence is low that some specific adjunct interventions may improve CPAP compliance, but studies are heterogeneous and no general type of intervention (e.g., education, telemonitoring) was more promising than others. The 18 trials (two quality A, eight quality B, and eight quality C) had inconsistent effects across a wide variety of interventions. Studies generally had small sample sizes with less than 1 year of followup. Compared with usual care, several interventions were shown to significantly increase hours of CPAP use per night in some studies. These included intensive support or literature (designed for patient education), cognitive behavioral therapy (given to patients and their partners), telemonitoring, and a habit-promoting audio-based intervention. However, the majority of studies did not find a significant difference in CPAP compliance between patients who received interventions to promote compliance with device use and those who received usual care. No study of nurse-led care (which was not focused primarily on compliance) showed an effect on compliance rates.
The findings of the systematic review have been summarized in Table A. Interventions (either diagnostic tests or treatments) that are not discussed lack studies meeting eligibility criteria. Interventions were not excluded from analysis unless explicitly stated as such.
In theory, obstructive sleep apnea (OSA) is relatively simple to diagnose. However, PSG, the standard diagnostic test, is inconvenient, resource-intensive, and may not be representative of a typical night's sleep (particularly the first night the test is given). Furthermore, there are variations across laboratories in the definitions of OSA (using different thresholds of AHI, from 5 to 15 events/hr) and in the way that the PSG results are read and interpreted. Moreover, AHI, which is used as the single metric to define OSA, can vary from night to night and does not take into account symptoms, comorbidities, or response to treatment.
Two approaches have been taken to reduce the resources involved in diagnosing OSA, including tests (questionnaires and clinical prediction rules) to screen for OSA and portable monitors to be used instead of sleep-laboratory PSG. Five questionnaires and 10 validated clinical prediction rules have been compared with PSG. However, very few of the screening tests have been evaluated by more than one set of researchers, and few have been directly compared with each other. Thus, the strength of evidence is low that the Berlin questionnaire is accurate in its ability to screen for OSA; the commonly used STOP and STOP-Bang questionnaires have not been adequately tested. For such tests to be of clinical value, apart from having very high sensitivity and specificity, they should be easy to administer and require only information from symptoms and signs easily obtainable during a physical examination. The evaluated clinical prediction models were all internally validated, but definitive conclusions on the external validity (i.e., generalizability) of these predictive rules in independent populations cannot be drawn from the available literature. The strength of evidence is low that some clinical prediction rules may be useful in the prediction of a diagnosis of OSA. No study examined the potential clinical utility of applying the questionnaires or prediction rules to clinical practice.
Numerous portable monitors (evaluated in 99 studies) have been developed for use in nonlaboratory settings; these use fewer "channels" (specific physiologic measures) than typical 16-channel PSG. The more recent studies do not substantially change the conclusions from the Tufts Evidence-based Practice Center's (Tufts EPC) 2007 Technology Assessment on Home Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome. Although most of the tested portable monitors fairly accurately predict OSA, it is unclear whether any of these monitors can replace laboratory-based PSG. The evidence suggests that the measured AHI from portable monitors is variable compared with PSG-derived AHI, but the source of this variability is unclear. So far, no studies have evaluated the predictive ability for clinical outcomes or response to treatment by portable monitors. Furthermore, no available studies have evaluated the impact of patient triage via screening tests and/or portable monitors.
The value of preoperative screening for OSA remains poorly defined. The only study that directly addressed this question was a retrospective study of patients undergoing bariatric surgery. It showed better perioperative outcomes from routine PSG. There are also no adequate studies that compared phased testing (simple tests followed by more intensive tests in selected patients) with full evaluation (by PSG).
Apnea-Hypopnea Index as a Predictor of Clinical Outcomes
The strength of evidence is high that high baseline (>30 events/hr or range) AHI is a strong and independent predictor of all-cause mortality over several years of followup, with the association being strongest among people with severe OSA (AHI >30 events/hr). However, the strength of evidence for the association between baseline AHI and other long-term clinical outcomes is generally insufficient, and thus the association between reductions in AHI by OSA treatment and improvements in long-term outcomes remains theoretical.
The strength of evidence is moderate that fixed CPAP is an effective treatment to minimize AHI and improve sleepiness symptoms, as supported by more than 40 trials of patients treated with CPAP or no treatment. However, no trial reported long-term clinical outcomes, and compliance with CPAP treatment is poor. Because patients frequently do not tolerate CPAP, many alternative treatments have been proposed. First, several alternative CPAP machines have been designed to vary the pressure during the patient's inspiratory cycle or to titrate the pressure to a minimum necessary level. Other modifications include different masks, nasal pads, and added humidification. The large majority of relevant trials have compared autotitrating CPAP (autoCPAP) with fixed CPAP and the strength of evidence of no clinical differences between them is moderate. The strength of evidence is insufficient for other device comparisons and, overall, the evidence does not support the use of one device for all patients, since such decisions should be individualized.
The second alternative to CPAP therapeutic option is the use of oral devices, which have been designed with the goal of splinting open the oropharynx to prevent obstruction. The most commonly tested are the mandibular advancement devices (MAD), for which the strength of evidence for their efficacy in sleep outcomes is moderate. Based on direct and indirect comparisons, CPAP appeared to be more effective than MAD. However, given the issues with noncompliance with CPAP, the decision as to whether to use CPAP or MAD will likely depend on patient preference.
The third major alternative to OSA treatment includes surgical interventions to alleviate airway obstruction. Given the very few randomized trials and the differences in the populations that choose to undergo surgery versus conservative treatment, the strength of evidence is insufficient to determine the relative value of surgery to no treatment, to CPAP, to MAD, or to alternative types of surgery. Additional interventions were also evaluated in randomized trials, (including weight loss programs, atrial overdrive pacing, eight different drugs, and other interventions) but in general the strength of evidence is insufficient to determine the effects of these potential treatments.
For all the treatment comparisons, it is important to identify which subgroups of patients may benefit most from specific treatments. Unfortunately, the trials are nearly silent on this issue. Very few trials reported subgroup analyses based on baseline characteristics, and for most comparisons there were too few studies or the interventions examined were too heterogeneous to analyze potential differences. Such analyses were feasible for the comparison between CPAP and control, where subgroup meta-analyses based on definitions of OSA (different minimum AHI thresholds) failed to demonstrate any difference in effectiveness of CPAP in reducing AHI or ESS. Though statistical heterogeneity existed across the trials, this was primarily attributed to study design factors that have no clinical implications. Despite statistical heterogeneity, and based on the consistency of findings that support CPAP as effective to minimize AHI in all patients with OSA, it is reasonable to conclude that the relative effectiveness in different populations is a moot point. The one exception to this may be patients with mild OSA (with AHI <15 events/hr), since people with low AHI cannot have as large an improvement in their AHI as people with severe OSA. Notably, across interventions there is little evidence supporting the hypothesis that any OSA treatment improves quality of life or neurocognitive function.
The strength of evidence is insufficient regarding the effect of interventions to improve CPAP compliance. The studies were very heterogeneous in their interventions and each evaluated different interventions. Higher baseline AHI and increased sleepiness as measured by the Epworth Sleepiness Scale are both predictors of improved compliance with CPAP (high strength and moderate strength of evidence, respectively). The unsurprising interpretation of this finding is that patients with more severe symptoms are more likely to accept the discomfort or inconvenience of using CPAP overnight.
The most important limitations in the evidence were the lack of trials that evaluated long-term clinical outcomes, the sparseness of evidence to address several Key Questions, and the fact that no study of diagnostic tests or treatments attempted to assess how results may vary in different subgroups of patients. In general, the intervention trials were of quality B or C, with few quality A studies. Followup durations tended to be very short, and study dropout rates were frequently very high. Other frequent methodological problems with studies included incomplete reporting and/or inadequate analyses, which required estimations of pertinent results by the authors of this systematic review. The heavy reliance on industry support for trials of devices may lead to the concern of publication bias. However, this concern may be reduced since most of our conclusions were that the strength of evidence is either low or inadequate for interventions. Furthermore, the effects of CPAP and MAD on sleep measures are sufficiently large that conclusions about the effectiveness of these devices would be unlikely to change with the addition of unpublished trials.
Implications for Future Research
General Recommendation
- The recurrent problem of high dropout rates as evidenced in the literature we reviewed bears further investigation and is crucial for the conduct of future trials. It is important to understand whether this a problem peculiar to this field, whether patients' symptoms interfere with their desire to fulfill their obligations as research participants, whether patients are not well informed about the serious consequences of sleep apnea and therefore are less motivated to comply with followup, or whether the treatments are so onerous that patients are refusing to continue with them.
Diagnostic Tests
- The most clinically useful evaluation of prediction rules and questionnaires (to screen for or diagnose OSA) would be trials to evaluate whether use of the tests improves clinical outcomes. Individual patient-data meta-analysis of measurements with portable monitors would provide insights on the diagnostic information contributed by different neurophysiologic signals. Future studies of the accuracy or bias of diagnostic tests should focus more on head-to-head comparisons of portable monitors, questionnaires, and prediction rules, to determine the optimal tool for use in a primary care setting to maximize initial evaluation of OSA and triage high-risk patients for prompt PSG. Direct comparisons among existing alternatives to PSG are more important than the current focus on developing new diagnostic tests.
- Trials are needed comparing potential phased testing strategies with direct PSG or addressing the value of preoperative screening for OSA. Studies of appropriate tests for patients, based on the type or severity of their symptoms, would be useful.
- Only 3 of the 190 studies of treatments reported clinical outcomes; comparative studies focusing on long-term followup and clinical outcomes are needed.
- Fixed CPAP is clearly an effective treatment for OSA, and no further trials are needed to assess its efficacy, with the exception of trials assessing long-term clinical outcomes. All other interventions should either be:
- directly compared with fixed CPAP, among patients naïve to CPAP, or
- compared with no treatment or alternative treatment among patients who have failed to comply with CPAP treatment.
- Treatment effect heterogeneity should be investigated.
- The benefit from different degrees of mandibular advancement has to be determined.
- Head-to-head comparisons are needed of alternative treatments for patients who do not tolerate CPAP.
- Rigorously conducted head-to-head comparisons of surgical interventions versus CPAP are needed to overcome limitations of existing observational evidence.
- More studies are needed on the various additional interventions (including weight loss, drugs, and specific exercises), and their incremental benefit to accepted treatments for OSA should be examined.
- Interventions to improve compliance to CPAP and MAD should be tested in direct comparisons.
Predictors of Clinical Outcomes and Compliance
- The question of whether OSA severity is associated with long-term outcomes (beyond all-cause mortality) may be informed by patient-level meta-analyses of available large cohorts.
- Predictive models of compliance and response to treatment are needed.
|Key Question
|Strength of Evidence
AHI = apnea-hypopnea index, AUC = area under the ROC curve, autoCPAP = autotitrating CPAP, CI = confidence interval, CPAP = continuous positive airway pressure, ESS = Epworth Sleepiness Scale, HR = hazard ratio, MAD = mandibular advancement device, OSA = obstructive sleep apnea, PSG = polysomnography (sleep-laboratory based), RFA = radiofrequency ablation, ROC = receiver operating characteristics, SF-36 = Short Form Health Survey 36, UPPP = uvulopalatopharyngoplasty.
Type II monitors are portable devices that record all the same information as PSG (Type I monitors).
Type III monitors are portable devices that contain at least two airflow channels or one airflow and one effort channel.
Type IV monitors comprise all other devices that fail to fulfill criteria for Type III monitors. They include monitors that record more than two physiological measures as well as single channel monitors.
|Key Question 1: Diagnosis
Portable monitors vs. PSG
|Low (Type II monitors);
Moderate (Types III & IV monitors)
|Key Question 1: Diagnosis
Questionnaires vs. PSG
|Low / Insufficient
|Key Question 1: Diagnosis
Clinical Prediction, Rules vs. PSG
|Key Question 2: Diagnosis
Phased testing
|Key Question 3: Diagnosis
Preoperative screening
|Key Question 4: Predictors
AHI as a predictor of long-term clinical outcomes
(High for all-cause mortality; Low for diabetes; Insufficient for other long-term clinical outcomes)
|Key Question 5: Treatment
OSA treatments
CPAP vs. control
|Key Question 5: Treatment
OSA treatments
Different CPAP devices vs. each other
(Moderate for autoCPAP vs. CPAP; Low for C-Flex™ vs. CPAP; Insufficient for others)
|Key Question 5: Treatment
OSA treatments
MAD vs. control
|Key Question 5: Treatment
OSA treatments
Oral devices vs. each other
|Key Question 5: Treatment
OSA treatments
CPAP vs. MAD
|Key Question 5: Treatment
OSA treatments
Surgery vs. control
|Key Question 5: Treatment
OSA treatments
Surgery vs. CPAP
|Key Question 5: Treatment
OSA treatments
Surgery vs. MAD
|Key Question 5: Treatment
OSA treatments/
Other treatments
(Low for weight loss vs. control; Insufficient for others)
|Key Question 6: Predictors
Predictors of treatment compliance
|Variable (see Conclusions)
|Key Question 7: Treatment
Treatments to improve compliance
Full Report
This executive summary is part of the following document: Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, Bannuru RR, Kitsios GD, Sen S, Iovin RC, Gaylor JM, D'Ambrosio C, Lau J. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32. (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-100551). AHRQ Publication No. 11-EHC052-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.
For More Copies
For more copies of Diagnosis and Treatment of Obstructive Sleep Apnea in Adults: Executive Summary No. 32 (AHRQ Publication No. 11-EHC052-1), please call the AHRQ clearinghouse at 1-800-358-9295 or email firstname.lastname@example.com.
a Please refer to the main report for references.
b Criteria for selecting topics for systematic review include appropriateness, importance, lack of duplication, feasibility, and potential value. See http://www.effectivehealthcare.ahrq.gov/index.cfm/submit-a-suggestion- for-research/how-are-research-topics-chosen/.
c Tufts-New England Medical Center EPC. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Health Technology Assessment Database www.cms.gov/determinationprocess/downloads/id48TA pdf. 2007;2010.
d Type II monitors are portable devices that record all the same information as PSG (Type I monitors).
e Type III monitors are portable devices that contain at least two airflow channels or one airflow and one effort channel.
f Type IV monitors comprise all other devices that fail to fulfill criteria for Type III monitors. They include monitors that record more than two physiological measures as well as single channel monitors.


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But Anyways I prefer not to talk about world first race and talk about people like us who raid for fun, challenge and etc. Both 10m and 25m raids are really hard, but the effort of managing a guild with 25 active raiders needs some more incentives which honestly 10% or 20% better chance on receiving loot is not enough. Everyone gets geared up raiding regularly relatively fast, so lootwise I think quality (ilvl??, rare mounts??) matters not quantity.
Last edited by Marooned; 2013-01-13 at 04:35 PM.
"Blizzard is not incompetent or stupid and they are not intentionally screwing you over"
You guys seriously try to bring in the worlds best raiders into your arguments about 10 vs 25. which the OP said to leave out, and focus on 25 only?
What the Worlds 10 best guilds do has zero value compared to the mainstream of the raiders.
Those 10 guilds are the ones that make the guides and videos for the masses to re-enact and kill anything too, no matter what raid format.
I would like to believe they will implement cauldron again for 25s, mass summon, no res timer on mass rez, etc like perks only, instead of ilvl or tittles mounts etc. I believe 25 man players would agree with me that those 3 perks are really necesary for 25 man.
BTW espe your sig and your posts are retarded period
This thread now seems to have been completely hijacked by 10vs25 arguing, despite the moderator warnings. Why can't you folks just let it go ? You've all already made your points multiple times and no one's mind is being changed. Let it go.
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i agree that wow needs to just switch both 10/25 into a 15 man, but keep the 25 bonuses, for heroic modes, imangine that if we take 15 into normal mode we get the standard loot, but the heroic mode could throw us a bone with additional loot or higher ilvl, furthering itself as the "best" raid option. Anymore these days, despite being much harder, the difference between normal and heroic has shrunk, in terms of slightly better gear in heroic, but you either raid 1 or the other, once you raid heroic modes, you simply use normals just for fun or clear them just for the sake of clearing and getting those last minute upgrades.
I think they need to make the 2 modes more seperated, make 1 clearly stand out as a start for normal, and make heroic better loot, even more difficult, something, once you get the basics down in normal, the only differences in heroic is obviously more health, a few mechanic changes, its been the same format for years, i think heroic mode needs to really stand out, not just the same rehashed and slightly different stuff we get now, but entire new fights, but that goes with my original statement...
the development time it takes for 10 and 25, could be spent on making a single 15 man (with 3 tiers) and the heroic mode could then be further advanced than it currently is, make heroic mode really spectacular, not just meh with heroic loot, its pretty challenging as is, but they could do so much better
in bc the raids and the balancing were perfect, it was a uphill battle on every single boss, and it took WEEKS of raiding to kill ONE boss...it was of course way more epic, and defeating said bosses like kalethas, lady vashj, was the best raiding experiences i've ever had. They need to focus on bringing back that epicness, bringing back that feeling of REAL accomplishment, not just throw-away bosses then 1 last boss that is supposed to be uber hard, and gets killed in 3 days...its just pathetic how raiding has become so weak these days.
hell they could just simply increase health even further, making abilities even more punishing, i think they design these raids and just stop at where they think raiders can kill it, they don't go above and beyond, don't push any further, afraid that no one can ever kill it..they need to have some balls, and make truly insanely hard content again, even if it was just 1 last boss each tier, bring back some pride and real skill again.
There are charts and charts showing 25m and 10m content has equal difficulty. The overwhelming majority of to guilds are 25 man. 10 man you get 2 loots for 10 people. 25 man gets 6 loots. So that's a bit more loot per person. If they increase the item level of 25m without increasing the difficulty substantially, well, it's a sham. Also, about half of my 10m guild would quit and the others would find a 25m. Nevertheless, 25m content has been proven to be equally difficult with 10 mans, just more loot. I think the system is fine how it is.
The point is that you cant look at specific enounters and say that one raid size is always harder, since it depends mainly on the boss mechanics.
Last edited by -Tuigan; 2013-01-13 at 06:14 PM.
The truth hurts. Check my sig for more info.
Last edited by Darsithis; 2013-01-13 at 07:34 PM.
There is a cult of ignorance in the United States, and there always has been. The strain of anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that "my ignorance is just as good as your knowledge." - Isaac Asimov
---------- Post added 2013-01-13 at 07:42 PM ----------
You also said 10 man has tighter enrage timers which is laughable. I gave you numbers and you chose to ignore them.
Luckily devs stated changes that will help revitalizing 25 mans are incoming so we won't have to put up with this any more.
Last edited by Radalek; 2013-01-13 at 06:43 PM.
Ive heard that for a year soon, and it comes back to, "we wanna do something about it but we cant figure out what so will just keep repeating that we wanna fix it".Luckily devs stated changes that will help revitalizing 25 mans are incoming so we won't have to put up with this any more.
Maybe a couple of higher ilvl items per raid. For example 3-4 higher ilvl drops on a tier like t14 size wise or maybe a couple of drops from just the end bosses
Not sure if that will be enough though 25 mans seem kinda desecrated atm my guild is healthy and going strong but around us it looks like scorched earth.
I do not consider 10 man raiding btw never have never will. Its nothing more then a weekend activity for alts. 25 man player quality at least on decent guilds is so much higher then their counterparts (rank wise) on 10 mans that its not even remotely comparable. People that do compare them simply lack raiding or guild leading experience.
Last edited by MarizzaDraenor; 2013-01-13 at 06:48 PM.
Realistically, unless it's a player power increase, and a significant one, they are wasting their time. People have to remember that 25 man raids ALREADY have a loot advantage - they already get a faster gearing path (due to less loot rot) and more loot per person than 10 mans get. 25 man raiders have a 3-5 ilevel advantage and it already isn't close to enough. They probably flat out need to go to having 25 man drop higher ilevel loot, or pre-upgraded loot or something similar for any hope of success.
On top of that, if they were to make 25 mans drop higher ilevel loot, why does everyone assume it would "put us back in Wrath" and "destroy 10 man guilds". Doing that now would not even be comparable to the shared lockouts/shared loot change at the start of Cata. For one thing, 10 man was never considered a viable progression path until the start of Cata. There was really no such thing as a 10 man guild, because 10 mans were seen as an offnight activity for most raiding guilds.
If they were to make 25 man higher ilevel now, I would not be so quick as to say that the majority of 10 man guilds would spontaneously combust. People that still preferred the difficulty and preferred playing with their friends would still probably do so, and I think that 50% or more of the 10 man guilds would still survive. On top of that, as long as they keep the shared lockout in place, it would further prevent the level of extreme exodus some of the 10 man apologists are predicting. With the split lockouts, 25 man guilds felt they had to do offnight 10 mans to maximize gear acquisition, and 10 man guilds felt they had to join with other 10 man guilds to do off night 25 mans for the same reason. That gave 25 mans a huge advantage, because it's a lot easier to do 2-3 in guild 10 man groups than it is to do a 25 man with 1-2 other 10 man guilds. I think that factor alone was probably a bigger hurdle to 10 man being a real viable progression path than the gear itself.
TLDR, I think even if they were to make 25 man a full tier higher in terms of ilevel, you still wouldn't see more than 40-50% of raiders raiding 25 man. Isn't that kind of what you would want to see if the goal is to keep both raid sizes healthy?
lol do not reply or quote that guy, he is just provoking 10vs25 debate by obvious stupid comments from LFR or something which are not related to topic anyways.
Anyways since the new announcement, it triggered something on my mind, maybe since the upgrade guy is leaving in 5.2 patch (they could keep him but having 5.2 raid gear drop non-upgradable normal gear and let ppl still upgrade t14 gear) they want to drop already 1/2 upgraded items for 25 man. They will return the guy back in 5.3 so everyone can upgrade their gear. Although my assumption is probably wrong lol. Lets just wait and see what they will do.
"Blizzard is not incompetent or stupid and they are not intentionally screwing you over"
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When we both of us knew how the end always is...

subset: commoncrawl


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Recipe Box: login | register
Thaw: 40 minutes
Prep: 5 minutes
Bake: 15 minutes
Serves: 25
Sometimes the simplest recipes are the best. Give these sopapillas a try - they combine sugar, cinnamon and a drizzle of honey on crisp and flaky puff pastry squares - simply delicious!
1/2 of a 17.3-ounce package Pepperidge Farm® Puff Pastry Sheets (1 sheet), thawed
3/4 cup sugar
1 tbsp. ground cinnamon
1/4 cup honey
Heat the oven to 400°F. Unfold the pastry sheet on a lightly floured surface. Cut the pastry sheet into 25 (2-inch) squares. Place the sugar and cinnamon into a paper bag and shake to combine.
Bake for 15 minutes or until the pastries are golden brown. Add the hot pastries in batches to the bag and shake until coated with the sugar mixture. Drizzle the pastries with the honey before serving.


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School Production 2009 'Twelfth Night or WHATEVER!'
Twelfth Night or WHATEVER!, our take on one of Shakespeare's best loved comedies was a challenge from start to finish - literally! But, we pulled it off and these beautiful photographs show off what a colourful and imaginative production this was. Our Illyria was a school of the performing arts. Our Orsino and Olivia were lead students in their respective creative disciplines: Orsiono's being music (what else!) and Olivia's being dance. With a magnificent Sir Toby causing mayhem, practically identical sisters as Viola and Sebastian adding to the confusion, and a Malvolio to end all Malvolio's (our 2012 Headgirl, Helen Scott), this was a Shakespeare brought right into the here and now, and connecting with the oldest to the youngest in our audiences - not least when we fed them pizza at the raucous midnight feast held by Sir Toby and Maria. Wonderful stuff.


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Grand Great Lakes Tour
Enjoy the Grand Great Lakes Tour with hot destinations such as the Apostle Islands, the Cana Island Lighthouse, Big Manitou Falls and multiple museums. This seven day trip will wind you along the eastern Wisconsin border through scenic state parks, all while you relax and kick back at some of the finest resorts the state has to offer. Read More


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becuase i am 15 i never get to do anything cool! i'm siting here smacking my self cuase i couldnt go to cel 2 one my perents won't make the long trip up to Indy i can't go alone cuase my perents don't feel right about me going alone so now i'm watching TV looking at how cool it is to be there and i'm still siting here!
they better have a Cel3!


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Agile companies are seizing opportunities around the cloud to create innovative new services and business models that decrease time to market, create operational efficiencies and engage customers in new ways. Cloud services like Infrastructure-as-a-Service (IaaS), Software-as-a-Service (SasS), Platform-as-a-Service (PaaS) and Business Process-as-a-Service (BPaaS) are more than technology delivery paradigms.
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Reinventing Information Technology in the Digital Enterprise: Introducing PwC's New IT PlatformRead more
Clouds in the forecast: Cloud—a necessary component of data center consolidation and IT agilityRead more
On the horizon: Insights into the Cloud for finance and accounting professionalsRead more
PwC: Navigating cloud managementRead more
PwC's Emerging Technology blogRead our views and share yours
Wherever you are in your cloud journey, we have the breadth and depth of experience and global resources to help you create lasting competitive advantage with cloud solutions. From strategy through execution, we help our clients leverage the cloud to transform IT, scale and streamline operations and create new cloud-based businesses. Our strong alliances with HP, Microsoft, Oracle, SAP, Salesforce, and Workday further differentiate our offerings.
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We help companies innovate new products and services to generate additional sources of revenue, to build the business case, and to transform their business models. We also help our clients engage the entire C-suite and foster new ways of customer interaction to strengthen their competitive advantage.


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By Bill Minor
JACKSON – When Gulf Coast Republican neophyte state Rep. Steven Palazzo was suddenly hoisted by the 2010 tea party revolt to a seat in the U.S. House, a veteran Mississippi lawmaker commented that an "empty suit" had just been sent to Congress.
Palazzo, whose short state legislative tenure was, according to some colleagues, marked by his steady stream of preachments about social and fiscal conservatism, but no legislative achievements, last week lived up to his "empty suit" forecast.
The 41-year-old accountant from Gulfport, a city ravaged by Hurricane Katrina in 2005 (and still in recovery mode with bundles of federal aid sent down from Washington) amazingly was among few members of Congress to vote against a $9.7 billion down payment on massive flood insurance relief for homeowners in New York and New Jersey swamped by mega-storm Sandy in August. He callously claimed the money to help Sandy victims should be offset by spending cuts. Funny that nothing was said about offset in 2005 when some $23 billion in federal Katrina relief was funneled into the Mississippi Gulf Coast.
Even two other Republican House members from Mississippi supported the Sandy relief money, although the two – Rep. Alan Nunnelee and Rep. Gregg Harper – two days earlier had refused to join Speaker John Boehner and other GOPers to pass the fiscal cliff package. Harper and Nunnelee showed they had no intention of ending the two-year House gridlock that branded the 112th as the worst legislative body in history.
At least the state's two Republican senators – Thad Cochran and Roger Wicker – who had previously hued to the party line and opposed everything that came out of the Obama White House – voted in the showdown in favor of the cliff package crafted by Vice President Joe Biden and Senate Minority leader Mitch McConnell. As Wicker later admitted, to do nothing and let the Bush-era upper income tax cuts expire would cost taxpayers more than the Biden-McConnell plan.
How the state's Republican-dominated House delegation came to Washington in January, 2011 was actually a major transition in Mississippi political history. Traditionally, the state House delegation, (now only four seats as compared to six seats 40 years ago) was dominated by elected Democrats, some of whom were often not loyal to the party leadership. With momentum from the government-shrinking, anti-incumbency tea party movement, both Palazzo and Nunnalee unseated Democratic incumbents in the First and Fourth districts.
Most notable was upset of Gene Taylor, the maverick and archly conservative Democrat from Bay St. Louis who represented the Mississippi 4th for 21 years. Taylor became a major military defense advocate in Congress, pushing the naval ship-building industry located in his district. Other than spending on national defense, Taylor was among the most fiscally conservative Democrat in Congress. A Catholic, Taylor was staunchly anti-abortion and became a folk hero during Katrina when, though his home was destroyed by the storm, spent hours working on the ground to get food, water and vital help to his constituents.
Obviously Gene, once a controversial reformer of the long-unchanged legislative rules as a state senator, didn't see the tea party revolt coming, and did not wage a full-bore campaign against the well-funded Palazzo.
Nunnelee had unseated freshman Democrat Travis Childers in the First district, branding Childers as not a "true conservative" although he caucused with the conservative Blue Dog Democrats. The National Republican Party saw Childers as vulnerable and poured big money into Nunnelee's campaign to downplay the Tupelo insurance man's negative personality image from when he chaired the state Senate Appropriations Committee before running against Childers.
Harper more or less inherited the Republican-safe 3rd District seat after Chip Pickering unexpectedly resigned in 2007, but had to beat several GOP contenders in 2008. No Democrat has contested him the last four years.
As for Mississippi's lone Democrat left in the U.S. House, 2nd District's Bennie Thompson has become unbeatable for 10 terms in what may be called the state's guaranteed African American/Delta seat to reflect its 65 percent black population.
Columnist Bill Minor has covered Mississippi politics since 1947. Contact him through Ed Inman at email@example.com.


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The Irish on Staten Island
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Join Staten Island Museum Curator of History Patricia M. Salmon for a discussion on Irish immigration, the Quarantine Station, the Draft Riots of 1863 and more. Learn fascinating biographical information on Irish-American residents featuring well known scholars, politicians, authors, and radicals. Registration is required. Cost: Staten Island Museum Members - $5, Non-Members - $7 . For information please call (718)483-7123.
Wednesday, March 14, 2012 - 7:30pm to 9:00pm
History Archives, Building H, Snug Harbor Cultural Center Campus - Staten Island
Staten Island Museum
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An impacted tooth is a tooth that does not break through the gum.
Tooth - unemerged; Unemerged tooth; Dental impaction; Unerupted tooth
Teeth start to pass through the gums (emerge) during infancy, and again when the primary (baby) teeth are replaced by the permanent teeth.
If a tooth fails to come in or emerges only partially, it is considered to be impacted. This most commonly happens with the wisdom teeth (the third set of molars). They are the last teeth to emerge. They usually come in between the ages of 17 and 21.
An impacted tooth remains stuck in gum tissue or bone for various reasons. The area may be overcrowded so there's no room for the teeth to emerge. For example, the jaw may be too small to fit the wisdom teeth. Teeth may also become twisted, tilted, or displaced as they try to emerge. This results in impacted teeth.
Impacted wisdom teeth are very common. They are often painless and do not cause problems. However, some professionals believe an impacted tooth pushes on the next tooth, which pushes the next tooth. Eventually, this can cause a misalignment of the bite. A partially emerged tooth can trap food, plaque, and other debris in the soft tissue around it, which can lead to inflammation and tenderness of the gums and unpleasant mouth odor. This is called pericoronitis. The retained debris may also lead to the decay on the wisdom tooth or the neighboring tooth.
Your dentist will look for swollen tissue over the area where a tooth has not emerged, or has only partially emerged. The impacted tooth may be pressing on nearby teeth. The gums around the area may show signs of infection such as redness, drainage, and tenderness. As gums swell over impacted wisdom teeth and then drain and tighten, it may feel like the tooth came in and then went back down again.
Dental x-rays confirm the presence of one or more teeth that have not emerged.
No treatment may be needed if the impacted tooth is not causing any problems.
Over-the-counter pain relievers may help if the impacted tooth causes discomfort. Warm salt water (one-half teaspoon of salt in one cup of water) or over-the-counter mouthwashes may be soothing to the gums.
Removal of the tooth (extraction) is the usual treatment for an impacted tooth. This is done in the dentist's office. Most often, it will be done by an oral surgeon. Antibiotics may be prescribed before the extraction if the tooth is infected.
Impacted teeth may cause no problems for some people and may not need treatment. Treatment is usually successful when it does cause symptoms.
Wisdom teeth removed before age 20 often have better results. This is because the roots are not fully developed. This allows for an easier removal and better healing. As a person ages, the roots become longer and curved. Bone becomes more rigid and complications can develop.
Complications of an impacted tooth include:
Call your dentist if you have an unemerged tooth (or partially emerged tooth) and you have pain in the gums or other symptoms.
Buttaravoli P, Leffler SM, eds. Dental pain, pericoronitis. Minor Emergencies. 3rd ed. Philadelphia, PA: Elsevier Mosby; 2012:chap 46.
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7th Annual China Gold & Precious Metals Summit 2012, co-hosted by Shanghai Gold & Jewelry Trade Association and IGVision International Corporation Shanghai and jointly endorsed by China Gold Association and Shanghai Gold Exchange, will be held in Shanghai China on December 5-7, 2012. It is China's largest networking and information exchange platform for gold & precious metals industry. The summit has been successfully held for six consecutive years, attracting over 200 senior executives across the value chain arranging from producers, bankers, refiners, bullion dealers, capital managers to traders, brokers, jewelers, advisors and policymakers every year.
Now at its 7th anniversary, the premier event will continue to be committed to delivering exclusive information, intelligence and contacts while gathering over 200 top professionals from across the community including mining companies, commodity & mercantile exchanges, investment & bullion banks, bullion dealers, brokerage firms, refiners & fabricators, traders, fund managers, jewelers, advisors, analysts, regulators and trade associations, etc.
To discern mid- and long-term appeal and fundamental influences of precious metals amid bearish bets, the summit will provide you with a comprehensive picture of prices, market fundamentals, investor sentiment, safe-haven flows, Fed stimulus speculation, disinflationary fears and investment infrastructure development in the context of a weaker economic outlook, Europe's escalating debt mess, global monetary accommodation and a strengthening U.S. dollar. It will highlight the price trends and supply/demand outlook for gold, silver and platinum group metals, gold's correlation with the U.S. dollar, the euro, riskier assets, safe-haven buying interest and macro stresses, the changing investor appetite in response to debt issues, the pace of the U.S. recovery and shifts in monetary policy expectations, the investment and fabrication demand for gold in China and India, China's newly-launched silver futures contracts, the investment appeal of gold-mining shares and the challenges facing producers, and disinflationary worries in the wake of declining commodity and raw material prices.
What Will You Take Away From the Event?
Finding out where gold, silver and PGMs prices are heading amid debt mess, risk-off trade, QE expectations and the risk of a severe global economic decline
Investigating China's economic slowdown, monetary easing to combat faltering growth and their impact on the country's demand for gold and other more industrial precious metals
Discerning stimulus measures to boost growth from both advanced and emerging-market economies and their influences on investor appetite for fiat currencies and precious metals
Examining a slowing in the U.S. economic recovery, the spreading debt, financial and banking crisis in the euro zone and the unpredictable and variable implications for gold's safe-haven appeal and flight-to-safety trades
Scrutinizing the extent and length of sluggish gold demand in India as a result of rupee's weakness, the increase in import duties and a delayed and smaller-than-normal monsoon
Probing into the weakening economic and manufacturing activity out of U.S., Europe and emerging markets and the implications for industrial demand
Looking into the challenge as a combination of rising cash costs, regulatory hurdles, political uncertainty and falling prices faced by mining companies
Assessing the launch of silver futures contracts in China and its effects on the silver market
Analyzing the combined influence of global growth concern, rising scrap supply, mine disruptions, and a "risk-off" mentality on the platinum and palladium markets
Gaining access to a target audience of miners, banks, refiners, bullion dealers, brokerage firms, trading venues, traders, investors, fund managers, consultants, jewelers and regulators, etc
7th China Gold & Precious Metals Summit 2012 is a must choice for decision makers to acquire in-depth insights into the impact and strategy as well as to understand the opportunities and challenges within China's precious metals markets.
Fri, 24/03/2017 - 11:55
Mon, 20/02/2017 - 15:43
Mon, 06/02/2017 - 11:29
Tue, 06/12/2016 - 11:17
Wed, 13/07/2016 - 23:35
Mon, 07/11/2016 - 11:46
Thu, 22/09/2016 - 15:04


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Statement on Lobbying
Applicants and other interested parties must not engage in "lobbying" for or against code change requests. "Lobbying" means unsolicited communications of any kind made at any time (including during Editorial Panel meetings) for the purpose of attempting to improperly influence either:
- CPT/HCPAC Advisors or their societies' evaluation of or comments upon a code change request or
- Voting by members of the Editorial Panel on a code change request
Any communication that can reasonably be interpreted as coercion, intimidation or harassment is strictly prohibited. Violation of the prohibition on lobbying may result in sanctions, such as being suspended or barred from further participation in the CPT process.
Information that accompanies a code change request, presentation or commentary to the Editorial Panel during an open meeting or to a workgroup during a workgroup meeting, and responses to inquiries from a Panel member or a CPT staff member, do not constitute "lobbying."
In order for the CPT Editorial Panel to effectively review and act on proposed changes to the CPT code set, code change applications must be reviewed by CPT/HCPAC Advisors and the Editorial Panel based on the information contained in the application and available clinical literature. CPT staff is responsible for organizing and submitting information to CPT/HCPAC Advisors and the Editorial Panel for consideration. Information relating to a code change application must be submitted to CPT staff no later than 30 days prior to the start of the Editorial Panel meeting at which the code change application will be considered. In some cases, the Chair of the Editorial Panel may establish rules which allow for supplemental submissions of information to workgroups or facilitation sessions established by the Chair or for postponed or appealed agenda items. (A "facilitation session" is an informal meeting requested by the Chair during a CPT Editorial Panel meeting to allow interested parties to confer and attempt to reach a consensus recommendation for presentation at the meeting.)
During development of a code-change application, an applicant may seek input or assistance from a medical specialty society but may not engage, either directly or via proxies, in "lobbying" as defined above. Requests for input or assistance should be directed to the society's staff or leadership as indicated in the society's guidelines. Such requests may not be made after the deadline for submission of applications for an upcoming meeting of the CPT Editorial Panel. Application deadlines are posted on the Calendar for Upcoming Meetings of the CPT® Editorial Panel page.
Medical specialty societies may have their own policies governing interactions with applicants or other interested parties regarding code change requests. The AMA encourages medical societies to work with applicants, from both industry and other medical specialty societies, to assure that code change applications are complete, coherent and consistent with current medical practice and does not discourage specialty society advisors from seeking advice or clarification of information from Panel members on new agenda items or items of old business through the process managed by AMA staff. Contacts with consulting medical societies should be limited to that which is necessary to construct and submit the code change application. After a code change application is submitted to the AMA, contact between an applicant and medical society representatives should be confined to communications managed by the AMA CPT staff unless the medical society is a co-requester on the code change application.
If an entity that does not have a CPT/HCPAC Advisor learns of an application to which it may be an "interested party," the entity may request an opportunity to review the code change application and submit a written comment to the AMA for consideration by CPT/HCPAC Advisors and the CPT Editorial Panel. The entity must deliver such a request to AMA CPT staff and not contact the applicant or CPT/HCPAC Advisors or members of the CPT Editorial Panel. If an applicant or other interested party wishes the CPT/HCPAC Advisors or the Editorial Panel to consider additional information, that information must be submitted to AMA's CPT staff and not directly to CPT/HCPAC Advisors or the Editorial Panel.
Applicants and other interested parties are invited to participate in open CPT Editorial Panel meetings and present their views on code change requests when recognized by the Chair during the course of the meeting. The views of applicants and other interested parties may be sought during work group or facilitation sessions established by the Chair, and participation in a workgroup or a facilitation session is not considered lobbying.
Complaints about lobbying should be reported promptly in writing to the Director, CPT Coding and Regulatory Affairs.
Criteria for Development and Evaluation of CPT Category I and Category III Codes
Application Submission Requirements
All CPT code change applications are reviewed and evaluated by CPT staff, the CPT/HCPAC Advisory Committee, and the CPT Editorial Panel. Strict conformance with the following is required for review of a code change application:
- Submission of a complete application, including all necessary supporting documents
- Adherence to all posted deadlines
- Cooperation with requests from CPT staff and/or Editorial Panel members for clarification and information
- Compliance with CPT Lobbying Policy
General Criteria for Category I and Category III Codes
All Category I or Category III code change applications must satisfy each of the following criteria:
- The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT.
- The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards for maintenance of the code set.
- The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by 1 or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new or revised codes.
- The structure and content of the proposed code descriptor accurately reflects the procedure or service as typically performed. If always or frequently performed with 1 or more other procedures or services, the descriptor structure and content will reflect the typical combination or complete procedure or service.
- The descriptor for the procedure or service is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set.
- The procedure or service satisfies the category-specific criteria set forth below.
Category-Specific Requirements
A. Category I Criteria
A proposal for a new or revised Category I code must satisfy all of the following criteria:
- All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
- The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
- The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
- The procedure or service is consistent with current medical practice.
- The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.
B. Category III Criteria
The following criteria are used by the CPT/HCPAC Advisory Committee and the CPT Editorial Panel for evaluating Category III code applications:
- The procedure or service is currently or recently performed in humans AND
At least 1 of the following additional criteria has been met:
- The application is supported by at least 1 CPT or HCPAC advisor representing practitioners who would use this procedure or service OR
- The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the Editorial Panel OR
- There is (a) at least 1 Institutional Review Board approved protocol of a study of the procedure or service being performed, (b) a description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or (c) other evidence of evolving clinical utilization.
Frequently Asked Questions
View the Frequently Asked Questions regarding the CPT Process.
CPT Process Information and Documents
CPT Code Application Form Instructions
AMA CPT Instructions for submitting a code application.
Category I and Category III Code Application
AMA CPT Application for a Category I or Category III code.
Form updated Feb. 18, 2016
Category I "Short Form" Code Application (DOC)
AMA CPT Code Application for use by Specialty Societies only. Use this form when submitting an application that is required by the Relativity Assessment Workgroup.
Form updated Oct. 15, 2015
Molecular Pathology Multianalyte Assays with Algorithmic Analyses-Genomic Sequencing Procedures Application
Form updated Oct. 21, 2015
CPT Pathology & Laboratory Code Application
AMA CPT Code Application for Pathology and Laboratory codes.
Form updated Feb. 16, 2015
Category II Code Application
AMA CPT Category II Code application and instructions.
CPT Sample Format for Required Clinical Vignette(s)
AMA CPT Sample clinical vignette for CPT process.


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Ice Cube Insights
Why It Matters
If you were an astrophysicist attempting to learn more about the universe, would you place your telescope a mile deep in the Antarctic ice?
Scientists are hoping to learn more about subatomic particles called neutrinos that could give insight into the many unknowns of the universe. Check out Antarctica's Ice Cube Telescope:
Explore More
- What is a neutrino? http://icecube.wisc.edu/info/neutrinos
- Where are they coming from? Why is it important for us to study them?
- Modeling neutrinos with popcorn! http://icecube.wisc.edu/outreach/activity/popcorn_neutrinos
- Collect your own meteorites! http://icecube.wisc.edu/outreach/activity/micrometeorites
Resources Cited
National Science Foundation. http://www.nsf.gov/news/special_reports/science_nation/icecube.jsp
Ice Cube. University of Wisconsin. http://icecube.wisc.edu/info/neutrinos


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By Tiernan Ray
RBC Capital chip analyst Doug Freedman today reiterates a Sector Perform rating on shares of Intel (INTC), and a $24 price target, reflecting on the short list of people who might replace CEO Paul Otellini when he steps down next month, names he's mostly culled from media speculation.
'Currently, the lack of CEO succession is a huge issue for our investment thesis," says Freedman, calling it the company's "most important decision Intel has made since 300mm."
"We need to have a firm grasp on the direction the new CEO is targeting before we are able to offer conviction for large scale investment."
With 14% of total chip sales globally every year, Intel's choice of successor is important for the entire industry, opines Freedman.
He thinks Otellini's replacement must excel at building areas such as mobile and software, to move the company beyond the PC:
The successor to Otellini should have a blueprint in place to grow the newer growth initiatives in a manner to disrupt the areas where Intel feels they are best-positioned; we believe this is in mobile and software. When anointing a CEO this time around, a deep understanding of the PC market no longer gives a candidate an edge, which gave Otellini an advantage in succeeding Craig Barrett in 2005. In our view, the next leader could depend on who is best suited to grow not one, but all, areas of Intel's efforts in mobile, data center, software and foundry (should the company succeed in growing the top line).
The candidates may include outsiders, such as former Motorola Mobility CEO Sanjay Jha, former ARM Holdings (ARMH) CEO Warren East, and VMware (VMW) CEO Pat Gelsinger.
As for insiders, the list includes COO Brian Krzanich; CFO Stacy Smith; chairman Andy Bryant; software lead Renee James; Intel Architecture director David "Dadi" Perlmutter; and PC client technology director Kirk Skaugen.
Following three internal appointments — Otellini, Craig Barrett, and Andy Grove, "this time could be different," thinks Freedman.
Without opining on the merits of the individual candidates, Freedman gives his take on the inside/outside decision:
In our view, an internal candidate pick would likely be viewed as 'steady as she goes'. We surmise that his/her respective group will be validated as an important piece (and perhaps focal point) of Intel's future. Conversely, an external pick would likely come from a mobile or customer-centric background. We highlight that the candidate's age is relevant as Intel implements forced retirement at age 65. That said, market perception of a candidate at or beyond their late-50s may be viewed as less transformational.
Intel shares today are up 61 cents, or 2.8%, at $22.36.


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What are you going to do when they come to take your guns?
What are you going to do when they come to take your guns?
This day I can honestly say I am disappointed with the country I love.I pray it works out but will not at all be surprised when this idiot runs this country into the dirt. Add to that now for the next couple years I have to listen to aassholes like Rev Jackson and Sharpton gloat makes me want to puke!!!!!!!!!!!!!! I will not call him my president.
Well it won't be local LEO's around here since they all hunt and believe in CCW for private citizens. Obama would have to send some federal person.
well Paul - no one has come to the house yet. I offer you my standard deal. For every day after BHO takes office that you still have your guns, you send me a dollar. I'll do the same for every day after he is office after they take your guns.
I believe that the correct term for what you are displaying is called histrionics. It is not appealing, so stop it.
Slow is smooth and smooth is fast.
Well if that happens you'll see many of us on the 6 o clock news
Screw the guns, Raising taxes in a recession (we arent there yet but we will get there); is what turns recessions into depressions.


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Focus on Funds
Pimco High Income Should Cut Distribution: Morningstar
Morningstar's Steven Pikelny lists Pimco High Income (PHK) among closed-end funds where he thinks a distribution cut would be warranted.
From Pikelny's Tuesday article:
PIMCO High Income (PHK)
While this is an easy fund to pick on because of its famously (and consistently) high premium (currently 42.4%), it is also worth picking on for underearning its distribution. Although only 12% of its 2012 distributions were comprised of return of capital, the underlying portfolio is hardly generating enough income to cover the 16.7% distribution rate at NAV. In the same year, the fund only earned 59% of that. Combined with the high premium, the earnings rate per-share price is closer to 6.9%. To reiterate, the overdistribution could be overlooked if shareholders had the chance to reinvest at a discount, but this is obviously not the case.
Unlike the carnage a few months back, when the mere mention of this CEF's extreme premium sent its price lower, PHK's price hasn't reacted. The fund is ahead by a penny at $12.66 on Wednesday after rising by 10 cents on Tuesday.
The other two CEFs on Pikelny's list are DWS Multi-Market Income (KMM) and MFS Intermediate Income (MIN).


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By Parrish Alford/NEMS Daily Journal
OXFORD – Playing one of the later bowl games of the season meant a later start to workout for Ole Miss. But the extra time means first-year coach Hugh Freeze can take a closer look at some of his younger players heading into next season.
Ole Miss takes on Pittsburgh at noon on Jan. 5 in the BBVA Compass Bowl.
It's Pitt's third-straight appearance in the Compass Bowl. Ole Miss will play in its first bowl game since the Cotton Bowl following the 2009 season.
Both teams are 6-6.
Freeze said he is "excited for our fans, our young men, but especially our seniors to get to go out and experience 60 more minutes of football this year."
That excitement extends to his chance to look at young players – or players who have yet to develop significant roles – over the next couple of weeks of practice.
The first name mentioned by Freeze in discussing personnel was junior defensive end Carlos Thompson.
There was a lot of buzz for Thompson – who Freeze redshirted this year as a junior – when he was signed out of Hollandale. Websites Rivals and Scout both ranked him the No. 4 player in Mississippi and among their top 175 players nation-wide.
Former coach Houston Nutt's staff tried to get more weight on Thompson's 6-4 frame. He's currently listed at 243 pounds.
Freeze singled out Temario Strong, Robert Conyers and many other freshmen as well. Bowl practice is often described by coaches as a miniature spring training.
"All those guys need more reps," Freeze said. "We can get in where we're not necessarily game-planning as much and just work on us."
The Rebels will be on the practice field today and three more times this week before taking a week off for Christmas.
They will reconvene Dec. 27 for an evening workout and will practice through Jan. 1 in Oxford. Two practices are scheduled in Birmingham at Birmingham Southern College.
Practices are open this week to the general public and being at 10:30 a.m. each day.