sleepdoctor

Sleep Center Accreditation

2009-11-19T15:17:00.000-08:00

Sleep Review magazine's November issue is now available online.
It has an article about accreditation; I agree with every word of it:

http://www.sleepreviewmag.com/issues/articles/2009-11_02.asp

Medpedia

2009-11-12T14:29:00.000-08:00

sleepdoctor is now included in Medpedia's News and Analysis Section.

Here is some more information about Medpedia:

http://www.medpedia.com/press

I encourage you to check out Medpedia:

http://www.medpedia.com/home

Here is the link for their Sleep Disorders Community:

http://www.medpedia.com/communities/148-Sleep-Disorders

SIDS and Slow Wave Sleep

2009-10-29T17:43:00.001-07:00

There's an interesting discussion about the possible relationship between SIDS and Slow Wave sleep here:

http://sleepdoctor.blogspot.com/2009/10/osa-sleep-deprivation-and-alcohol.html

OSA, Sleep Deprivation, and Alcohol

2009-10-11T11:09:00.000-07:00

Once a person has one sleep problem, they are less able to cope with another one. For example, persons with obstructive sleep apnea are less able to cope with the demands of shift work.

A. Vakulin and colleagues pubished "Effects of Alcohol and Sleep Restriction on Simulated Driving Performance in Untreated Patients With Obstructive Sleep Apnea" in this months issue of Annals of Internal Medicine. This study compared patients with untreated OSA and matched controls on a driving simulator. The study found that "Patients with OSA are more vulnerable than healthy persons to the effects of alcohol consumption and sleep restriction on various driving performance variables. "

Alcohol, Sleep, and Pregnancy

2009-10-04T13:31:00.000-07:00

Below is a small excerpt from the article "Sleep disorders associated with alcohol use and abuse," available at Medlink Neurology:

Alcohol use should be avoided during pregnancy. The potential adverse physical and neurocognitive effects, including fetal alcohol syndrome, of maternal alcohol consumption on the developing fetus have been extensively reviewed (Wattendorf and Muenke M 2005). Recent research has clarified the effects of prenatal alcohol consumption on the child’s postnatal sleep. Maternal prenatal consumption of alcohol results in infant postnatal sleep fragmentation as well as the suppression of spontaneous movements during sleep, at 6 to 8 weeks of age (Troese et al 2008). In utero alcohol exposure results in altered neonatal autonomic control during sleep, possibly increasing the risk of Sudden Infant Death Syndrome (Fifer et al 2009).

References:

Wattendorf DJ, Muenke M. Fetal alcohol spectrum disorders. Am Fam Physician 2005;72(2):279-82, 285.

Troese M, Fukumizu M, Sallinen BJ, Gilles AA, Wellman JD, Paul JA, Brown ER, Hayes MJ. Sleep fragmentation and evidence for sleep debt in alcohol-exposed infants. Early Hum Dev 2008;84(9):577-85.

Fifer WP, Fingers ST, Youngman M, Gomez-Gribben E, Myers MM. Effects of alcohol and smoking during pregnancy on infant autonomic control. Dev Psychobiol 2009;51(3):234-42.

It's been a while...

2009-09-29T17:38:00.000-07:00

It's been over a month since I even looked at the comments on this site. Things have been busy at the sleep centers I work at; I am currently reading about 200 sleep studies a month. Also I have been writing an article for Sleep Review , as well as working with some physicians, researchers, and statisticians analyzing data from the Jackson Heart Study.

I do expect things to slow down a little for the rest of the year. My association with Hancock Medical Center is ending. Dr. Brenda Hines is working with me and seeing patients at Somnus Sleep Clinic. She has been a big help.

I do plan on posting more for the rest of the year. I will be reading the comments over the next several days. Thanks for reading sleepdoctor!

Sleep Disorders Linked to Aviation Accidents

2009-07-25T15:41:00.000-07:00

Sleep disorders, especially obstructive sleep apnea, are common among truck drivers. USAToday reports that the National Transportation Safety Board is investigating fatigue as a cause of accidents in the aviation industry:

While efforts to reduce fatigue in aviation have focused on pilots' schedules, federal accident investigators say pilots and other vehicle operators also need to be screened for sleep disorders. The National Transportation Safety Board (NTSB) is preparing to take a stand on the issue within weeks, according to testimony at a recent public meeting.

Preparing for a Sleep Fellowship

2009-06-21T08:24:00.000-07:00

A reader asks:

I'm a current first year (almost second year) internal medicine resident and I'm currently looking into the possibility of sleep medicine as a fellowship choice. Everything I learn about sleep medicine sounds great and I find myself very interested in the subject of sleep and sleep disorders, so I think it would be a great choice for me. I was wondering if you could give me any pointers about the process of applying to sleep fellowships, doing rotations, building my application and so forth. Also, what sort of career options are there for internists who do a fellowship in sleep med? Any good textbooks that you would recommend me starting with?

I previously posted a little about sleep fellowships here.
As an internal medicine resident, elective rotations that would be helpful include pulmonary, psychiatry, neurology, ENT, and sleep medicine (if available). The ENT rotation should include a large outpatient component in which you learn the head and neck exam as well as gain expertise in evaluating and treating sinus problems.
Sleep medicine fellowships are becoming very competitive, especially for those who have only completed a general Internal Medicine residency. Research, especially something related to sleep, would be helpful in getting accepted to a sleep fellowship.

Join the American Academy of Sleep Medicine

Books that I recommend include Sleep Medicine Pearls by Richard Berry, MD. Unfortunately, the current (2002) edition obviously doesn't include the new AASM sleep scoring/staging guidelines.
I also recommend getting The AASM Manual for the Scoring of Sleep and Associated Events.

Principles and Practice of Sleep Medicine is the standard textbook. I would recommend waiting until the new (5th) edition comes out in several months.

Journals you should be reading include Sleep and The Journal of Clinical Sleep Medicine, which are availabe with membership in the American Academy of Sleep Medicine. Non-members can read older articles free on-line.

I have posted regarding career options previously in this blog, and will do so again later this month.

The Future of Sleep Technicians

2009-06-08T07:47:00.000-07:00

I'm in Seattle at the annual Sleep meeting. I'm about to go to the opening session and hear a talk by Dr. Howard Roffwarg on REM sleep.

I have a few minutes before the session starts and will take the time to answer a question from a few weeks ago:

A reader (TimRPSGT) asks:
I have a couple of questions about the future of sleep medicine. First, how do you see the role of the sleep technologist changing over the coming years? I'm also curious bout the new approval for home studies with type 2 and 3 devices. Is there a possible business opportunity here for RPSGT's to do home studies as independent contractors for doctors?

I don't see the role of sleep technologists changing much in sleep centers over the coming years. One trend that has been developing over the last several years is the movement towards certification of sleep technicians. Within several years all new sleep technicians will be required to complete commnunity/vocational college training program to work at an accredited sleep center. I am not totally up to date on RPSGT/AASM sleep tech requirements, but I believe that A-STEP was designed as a transitional program and will be phased out in several years in favor of community/vocational college-based programs (see this page for further details:
http://www.aasmnet.org/astep/RPSGTExam.aspx). On the job training of technicians is on the way out.

I don't see the role of sleep technicians changing much; they will still perform in-lab sleep studies as well as frequently perform administrative duties within the sleep lab.

Type 2 studies (full sleep study done at a patient's home)- I don't think many of this type of study will be done.

Type 3 studies (4-6 channel portable)- Reimbursement for these portable studies remain low.
The 2 ways to make a profit from type 3 studies is 1) use it as a loss leader for a sleep center or 2) do the study very cheaply. As margins at sleep centers are continually squeezed, I don't think it will be possible to portable studies as a loss leader much longer. As far as doing type 3 studies cheaply, the way to do this is to give the patient very little support. The patient picks up the device or has it shipped to them, and is given little instruction from a live person (and if there is any, it is from a secretary rather than a technician).
Neither of the 2 ways is appealing to me; I generally don't do home studies. There are business opportunities out there for entrepeneurial RPSGT's to work with doctors and provide home sleep studies., but I wouldn't recommend it.

Working with the US Sumo Wrestling Team

2009-05-13T13:52:00.000-07:00

A picture of me (the person with a tie), working with the U.S. Sumo team, counseling them about sleep.

Qualifications for Medical Directorship of a sleep center

2009-05-08T12:17:00.000-07:00

A reader asks:

Can a Pulmonologist who is not board certified in sleep be a treating physician for the sleep center? I know the Medical Director and supervising physician has to board certified in sleep medicine.

Any specialty can be a treating physician. According to the AASM, The medical director has to be board certified or board eligible in sleep medicine, unless there is a separate "board-certified (or eligible) sleep specialist" who does the quality control/interreliability scoring.

Per AASM standards, if the doctor who interprets a sleep study isn't bc/be in sleep medicine, it must be overread by a doctor who is.

At the Hancock medical center sleep lab (a hospital-associated sleep lab), there is a general internist who is the medical director; I am the board certified sleep specialist and do all the sleep study interpretations.

For IDTF's each Medicare carrier has it's own standards of who can be medical director; some require that you be a pulmonologist or sleep specialist.

Some insurance companies have standards about which specialty can bill for a sleep study interpretation.

The AASM defines board eligibility in sleep medicine as having been accepted to sit for the sleep board examinations, your eligibility lasts for 2 examination cycles. There are also special BE standards for newly graduated fellows.

Problems with the Respironics Compliance Download Report

2009-04-08T04:15:00.000-07:00

Most sleep professionals are aware that Medicare now requires objective documentation of compliance with CPAP during the first 3 months of use for continued coverage of CPAP. During a consecutive one month period during the first 3 months, the patient needs to use CPAP at least 4 hours per night for 70% of the nights.

When looking at compliance reports from Respironics CPAP machines, I used to look at the % result of "Percent of Days with Usage greater than or equal to 4 hours". However, days in which CPAP is not used at all are not included in calculating this figure.

To get the correct "Medicare %", you need to multiply "Percent Days with Device Usage" by "Percent of Days with Usage greater than or equal to 4 hours."

__________________________________________________________

edit (4/9/09) When doing this calculation, make sure you are using a download report for a 30 day consecutive period (see comments)
_______________________________________________________________

This problem was pointed out to a Respironics representative, and I think we will soon be seeing a more user-friendly compliance download report from Respironics.

A celebrity with non-REM parasomnias

2009-03-31T16:44:00.000-07:00

The model for Lara Croft suffers from sleepwalking and night terrors:

Since she was a small child, Lucy's nights have been blighted by frightening sleepwalking episodes and night terrors, causing her to roam the house screaming in fear while still asleep.
And over the past six months, these episodes have taken a turn for the worse. Lucy Clarkson, 26, has twice woken up to find herself trying to strangle her boyfriend of four years, Michael Parnes

More sleep medicine career advice

2009-03-23T17:31:00.000-07:00

A reader asks:

I am a US citizen- International Medical Graduate- who will start my psychiatry residency and I am interested in pursuing sleep medicine as a fellowship. Please provide me some guidance...

As a psych resident/IMG, you have 2 strikes against you, though IMG status is better than FMG status. If there is a sleep fellowship program at the place where you are doing your psychiatry residency, that sleep program is your best shot. If possible, do electives in sleep, pulmonary, and ENT during your residency (the ENT rotation may be difficult to arrange). Sleep research during residency would also be helpful.

Reader Question About Starting a Career in Sleep Medicine

2009-03-18T19:13:00.001-07:00

A pulmonologist who is becoming certified in sleep and would like to transition to a sleep career asks:
Sleep only jobs seem rare, so realistically incorporating sleep into a primary pulmonary practice is my goal. Is that kind of paradigm possible? On a practical level, how would you see someone trying to do this? Would I work part-time in a sleep lab; would I try to be a director and practice pulmonary (I think that owning my own lab would be a stretch)?

Here are some past posts that may be helpful.

http://sleepdoctor.blogspot.com/2008/08/careers-in-sleep-medicine-for.html

http://sleepdoctor.blogspot.com/2008/04/starting-sleep-lab-part-one.html

http://sleepdoctor.blogspot.com/2008/04/starting-sleep-lab-part-two.html

You could start your own lab if you had access to several hundred thousand dollars; there are companies you can partner with that can help you start the lab. However, this is pretty risky.

One way to transition to sleep is to be in a practice (either solo or group) of your primary specialty. Then advertise your expertise in sleep. Make an agreement with an existing sleep lab that you can read the studies (and bill the interp fee) for the patients you send there for sleep studies- this is easy to do, most labs would be willing to make this arrangement with a BE/BC sleep doc. Gradually increase your sleep work and decrease your primary specialty. Call rural hospitals in your state and offer to go out there and see sleep patients. I made this arrangement with a small hospital about 45 minutes from Jackson MS. At first I sent the patients back to my main sleep lab in Jackson. Now the hospital has a 2 bed sleep lab that I am medical director of.
As you become known as a sleep expert in your state (blogging or posting on sleep discussion forums such as the AASM forums helps), opportunities will open up. You will probably be contacted by sleep labs that will offer you medical directorships and give you a lot of studies to read in exchange for going out there periodically and seeing patients (you might have to drive several hours to outlying sleep labs).

CMS Decision on Home Testing

2009-03-11T18:24:00.000-07:00

Released 3/3/09

Decision Summary
CMS finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.
Therefore:
Type I Polysomnography (PSG) is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.
A Type II or a Type III sleep testing device is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.
A Type IV sleep testing device measuring three or more channels, one of which is airflow, is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.
A sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

Bizkit the Sleepwalking Dog

2009-03-05T12:56:00.000-08:00

Looks more like REM sleep behavior disorder to me.

AASM Limits the Number of Medical Directorships

2009-02-05T23:53:00.000-08:00

The American Academy of Sleep Medicine has limited physicians to being medical director of no more than 3 sleep centers/labs: http://www.aasmnet.org/Resources/PDF/Dec2008CenterStandards.pdf

This requirement is being phased in and appears to take effect July 1,2009.

________________________________

update (2/14/09) It has been clarified by the AASM on their discussion forum that this requirement takes effect July 1, 2009. A physician is limited to 3 medical directorships and/or board-certified sleep specialist positions (the combination can not exceed 3). A PhD. sleep specialist is limited to 3 board-certified sleep specialist positions.

Accreditation and Reimbursement

2009-01-12T18:50:00.000-08:00

A reader asks, via email:
Is Somnus Sleep Clinic accredited by JCAHO and AASM? How do these processes work? Must one occur before the other? Is accreditation required for reimbursment?

Somnus Sleep Clinic is accredited by The American Academy of Sleep Medicine (AASM). In Mississippi and many other states, AASM accreditation is necessary for a sleep center/lab to receive reimbursement for a sleep study from Blue Cross/Blue Shield plans. In some states, other insurance companies also have this restriction.

I don't know too much about JCAHO accreditation of sleep labs/centers. I believe that in some states (not MS), some insurance companies will reimburse for sleep studies at labs/centers accredited by either the AASM or JCAHO. I believe that JCAHO accreditation is mainly for hospital-based sleep labs/centers.

If any reader has more info about JCAHO accreditation for sleep labs/centers, please leave a comment

Sleep and coronary artery calcification

2009-01-02T17:49:00.001-08:00

Several medical bloggers have posted about a recent study in which increased sleep time was associated with a decreased incidence of coronary artery disease (as measured by coronary artery calcification).

The problem with these observational studies looking at sleep duration and mortality/morbidity is that they don't distinguish between 1) voluntary sleep deprivation, 2) primary insomnia, and 3) insomnia secondary to medical/sleep disorders.

How is a doctor to use the data from this study???
I doubt writing a prescription for a sleeping pill would improve someone's coronary artery calcification score. However, advising someone with voluntary sleep deprivation (due to work pressures, etc) to extend their sleep hours might (if they take your advice)- I base this conclusion on prior studies which demonstrated that voluntary sleep restriction does lead to adverse metabolic consequences. And of course, treating any obstructive sleep apnea present is important, especially in patients with pre-existing coronary artery disease, atrial fibrillation, or congestive heart failure.

Sleep and Bipolar Disorder

2008-12-21T16:31:00.000-08:00

Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. The reduced need for sleep can be further defined as the “ability to maintain energy without sufficient sleep” (Plante and Winkelman, 2008). Even when euthymic, sleep disturbance is common (Harvey 2008). In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Both insomnia and hypersomnia have been reported in patients with bipolar depression (Harvey 2008). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Both homeostatic and circadian sleep abnormalities are thought to play a role in bipolar disorder (Plante and Winkelman 2008).

Polysomnographic studies of unmedicated manic panics have found shortened total sleep time, shortened REM latency, and increased time awake in bed (Plante and Winkelman 2008).

**Harvey AG. Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony, and regulation. Am J Psychiatry 2008;165(7):820-9.**

Harvey AG, Schmidt DA, Scarna A, Semler CN, Goodwin GM. Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems. Am J Psychiatry 2005;162(1):50-7.

Mehl RC, O’Brien LM, Jones JH, Dreisbach JK. Correlates of sleep and pediatric bipolar disorder. Sleep 2006;29(2):193-7.

**Plante DT, Winkelman JW. Sleep disturbance in bipolar disorder: therapeutic implications. Am J Psychiatry 2008;165(7):830-43.**

The above is excerpted from an article I wrote on Sleep Disorders and Mental Illness for Medlink Neurology.

Billing for Interrupted Sleep Studies

2008-12-20T06:45:00.000-08:00

This appeared in the current issue of Medical Economics (I am quoting it in full to better illustrate how wrong the answer is):

Q: We perform sleep and polysomnography studies, which are frequently interrupted because the patient repeatedly stops breathing and we need to implement continuous positive airway pressure therapy. Until now, we didn't think we could bill for those interrupted studies, but we were recently told it is appropriate to do so. How do we proceed?
A: There are actually two proper ways to report the service, according to Current Procedural Terminology. The first is to report the appropriate code from the 95803-95811 range with the modifier –52 for reduced services. The second is to report the appropriate code with the modifier –53 for discontinued services.
The modifier selection would be determined by the amount of data collected during the study. If there is sufficient data to form a diagnostic opinion, –52 would seem the appropriate choice. If there is insufficient data, modifier –53 would be appropriate. However, it is a decision that should be made by the physician. As you know, CPT definition does not guarantee coverage by the insurer.

Occasionally a patient comes in for a diagnostic polysomnogram (95810) and due to the severity of the sleep apnea, CPAP is applied (while continuing polysomnographic monitoring). Sometimes patients are scheduled for split-night studies, in which for the first several hours diagnostic polysomnography is performed, and if there appears to be significant sleep apnea, cpap is applied for the rest of the night with continued polysomnographic monitoring. In both of these situations, the correct CPT billing code to use is (95811), the code for a CPAP titration study.

I am not too familiar with the -53 modifier. I use the -52 modifier when a study is terminated prior to 6 hours of recording time. I do plan to look more into the difference between the -52 and -53 modifiers.

On a broader note, this answer in Medical Economics-written by a non-physician- illustrates that the field of Medicine needs physicians with legal and business experience, and perhaps dual degrees (MD/JD and MD/MBA). Non-physicians often have difficulties truly understanding what what is involved in a medical business. For example, sleep labs organized as Independent Diagnostic and Testing Facilities (IDTF's) that have physician ownership or part ownership are limited in the number of referrals that can come from the physician. Say, for example, that an IDTF with a physician owner and several non-physician owners is told by their lawyer that only 40% of the sleep studies can be ordered/referred by the physician owner. Seems simple enough. However, how do you count a cpap titration? If a Primary care doc orders the psg, it shows sleep apnea, the sleep doc - who is a part owner of the IDTF- sees the patient and arranges for the titration study, who is considered to be the referring doc for the cpap titration? Does it make any difference if the original order form signed by the primary care doc has a pre-printed line next to the order for the polysomnogram indicating that a cpap titration will be performed if clinically appropriate? In my experience, many lawyers have difficulties understanding the process by which a patient initially presents with symptoms of OSA and, after seeing several doctors and going through several sleep studies, eventually receives a cpap machine. I think that part of the problem is that Federal regulations are unclear on the matter. We probably need more doctors in government, too.

What I've been up to

2008-12-17T19:03:00.000-08:00

sorry I haven't posted much recently; I have been very busy. I did my last AASM accreditation site visit on the twelfth. I have enjoyed meeting sleep professionals across the country. I learned something about sleep medicine, either about the clinical or business/legal aspects, on each accreditation inspection.
The American Academy of Sleep Medicine is currently recruiting for new Accreditation Site Visitors.
Although I have enjoyed being a site visitor, I am just too busy to continue. Currently I am reading sleep studies for 5 sleep centers/labs: Somnus Sleep Clinic, Forest Sleep Clinic (associated with Lackey Memorial Hospital), Tupelo Sleep Diagnostics, Hancock Medical Center's sleep lab, and Desoto Sleep Diagnostics.
I serve as medical director for the first three. Hancock's sleep center has a local doctor as the medical director, James C. Crittenden, M. D. I am the ABSM diplomate at Hancock.

I'm looking forward to the AASM Business of a Sleep Center Course, which will be in February in Los Angeles. I think that course will inspire me to blog more frequently.

I'm thinking about hiring a nurse practitioner. If they're any interested np's out there, either with a psychiatry or primary care background, please contact me at Somnus Sleep Clinic.

More on Medicare Coverage of CPAP machines

2008-11-24T09:44:00.000-08:00

A few weeks ago I posted on the subject of new medicare requirements for the coverage of a cpap machine.

An interesting part of the new requirements appears to mandate that the physician who will be prescribing the cpap machine see the patient prior to the initial psg:

INITIAL COVERAGE:A single level continuous positive airway pressure (CPAP) device (E0601) is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:
The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.
The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):
The patient and/or their caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.If a claim for a CPAP (E0601) is submitted and all of the criteria above have not been met, it will be denied as not medically necessary.

Currently most of the medicare patients who come through Somnus Sleep Clinic are referred directly for a polysomnogram, I see them after the polysomnogram. If they need cpap, I will typically schedule them for the titration study and then see them back again after that to prescribe cpap. I guess I need to start seeing patients with Medicare prior to their initial psg.

Objective Compliance Documentation for CPAP use

2008-11-13T13:57:00.000-08:00

A member of the AASM discussion boards provide a link to the following info regarding the new CMS requirements for the documentation of benefit of CPAP required for continued coverage of cpap beyond the initial 3 month period:

For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:
Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.

I am planning on asking the durable medical equipment companies I work with to provide me with a compliance download for my Medicare patients. The Medicare patients will bring this printout to their appointments with me.

This LCD applies to most of the southern states, I believe that most other regions have similar LCD's.