Body size predicts the rate of contemporary morphological change in birds.

Variation in evolutionary rates among species is a defining characteristic of the tree of life and may be an important predictor of species' capacities to adapt to rapid environmental change. It is broadly assumed that generation length is an important determinant of microevolutionary rates, and body size is often used as a proxy for generation length. However, body size has myriad biological correlates that could affect evolutionary rates independently from generation length. We leverage two large, independently collected datasets on recent morphological change in birds (52 migratory species breeding in North America and 77 South American resident species) to test how body size and generation length are related to the rates of contemporary morphological change. Both datasets show that birds have declined in body size and increased in wing length over the past 40 y. We found, in both systems, a consistent pattern wherein smaller species declined proportionally faster in body size and increased proportionally faster in wing length. By contrast, generation length explained less variation in evolutionary rates than did body size. Although the mechanisms warrant further investigation, our study demonstrates that body size is an important predictor of contemporary variation in morphological rates of change. Given the correlations between body size and a breadth of morphological, physiological, and ecological traits predicted to mediate phenotypic responses to environmental change, the relationship between body size and rates of phenotypic change should be considered when testing hypotheses about variation in adaptive responses to climate change.

Targeted Hypoglossal Nerve Stimulation for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial.

Importance: Evidence is lacking from randomized clinical trials of hypoglossal nerve stimulation in obstructive sleep apnea (OSA). Objective: To evaluate the safety and effectiveness of targeted hypoglossal nerve stimulation (THN) of the proximal hypoglossal nerve in patients with OSA. Design, Setting, and Participants: This randomized clinical trial (THN3) was conducted at 20 centers and included 138 patients with moderate to severe OSA with an apnea-hypopnea index (AHI) of 20 to 65 events per hour and body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or less. The trial was conducted from May 2015 through June 2018. Data were analyzed from January 2022 through January 2023. Intervention: Implant with THN system; randomized 2:1 to activation at month 1 (treatment) or month 4 (control). All received 11 months of THN with follow-up at months 12 and 15, respectively. Main Outcomes and Measures: Primary effectiveness end points comprised AHI and oxygen desaturation index (ODI) responder rates (RRs). Treatment responses at months 4 and 12/15 were defined as a 50% or greater reduction in AHI to 20 or less per hour and an ODI decrease of 25% or greater. Coprimary end points comprised (1) month 4 AHI and ODI RR in the treatment greater than the control group and (2) month 12/15 AHI and ODI RR in the entire cohort exceeding 50%. Secondary end points included sleep apnea severity (AHI and ODI) and patient-reported outcomes (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale). Results: Among 138 participants, the mean (SD) age was 56 (9) years, and 19 (13.8%) were women. Month 4 THN RRs were substantially greater in those in the treatment vs control group (AHI, 52.3% vs 19.6%; ODI, 62.5% vs 41.3%, respectively) with treatment-control standardized mean differences of 0.725 (95% CI, 0.360-1.163) and 0.434 (95% CI, 0.070-0.843) for AHI and ODI RRs, respectively. Months 12/15 RRs were 42.5% and 60.4% for AHI and ODI, respectively. Improvements in AHI, ODI, Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale scores were all clinically meaningful (medium to large effect size). Two serious adverse events and 100 nonserious related adverse events were observed from the implant procedure or study protocol. Conclusions and Relevance: This randomized clinical trial found that THN demonstrated improvements in sleep apnea, sleepiness, and quality of life in patients with OSAs over an extended AHI and body mass index range without prior knowledge of pharyngeal collapse pattern. Clinically meaningful improvements in AHI and patient-reported responses compared favorably with those of distal hypoglossal nerve stimulation trials, although clinically meaningful differences were not definitive for ODI. Trial Registration: ClinicalTrials.gov Identifier: NCT02263859.

Temperature, size and developmental plasticity in birds.

As temperatures increase, there is growing evidence that species across much of the tree of life are getting smaller. These climate change-driven size reductions are often interpreted as a temporal analogue of the observation that individuals within a species tend to be smaller in the warmer parts of the species' range. For ectotherms, there has been a broad effort to understand the role of developmental plasticity in temperature-size relationships, but in endotherms, this mechanism has received relatively little attention in favour of selection-based explanations. We review the evidence for a role of developmental plasticity in warming-driven size reductions in birds and highlight insulin-like growth factors as a potential mechanism underlying plastic responses to temperature in endotherms. We find that, as with ectotherms, changes in temperature during development can result in shifts in body size in birds, with size reductions associated with warmer temperatures being the most frequent association. This suggests developmental plasticity may be an important, but largely overlooked, mechanism underlying warming-driven size reductions in endotherms. Plasticity and natural selection have very different constraining forces, thus understanding the mechanism linking temperature and body size in endotherms has broad implications for predicting future impacts of climate change on biodiversity.

"I can't do it": A qualitative study exploring case and contact experiences with COVID-19 contact tracing.

BACKGROUND: Low engagement in contact tracing for COVID-19 dramatically reduces its impact, but little is known about how experiences, environments and characteristics of cases and contacts influence engagement. METHODS: We recruited a convenience sample of COVID-19 cases and contacts from the New Haven Health Department's contact tracing program for interviews about their contact tracing experiences. We analyzed transcripts thematically, organized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model, and identified candidate interventions using the linked Behavior Change Wheel Framework. RESULTS: We interviewed 21 cases and 12 contacts. Many felt physically or psychologically incapable of contact tracing participation due to symptoms or uncertainty about protocols. Environmental factors and social contacts also influenced engagement. Finally, physical symptoms, emotions and low trust in and expectations of public health authorities influenced motivation to participate. CONCLUSION: To improve contact tracing uptake, programs should respond to clients' physical and emotional needs; increase clarity of public communications; address structural and social factors that shape behaviors and opportunities; and establish and maintain trust. We identify multiple potential interventions that may help achieve these goals.

Diversity and extinction risk are inversely related at a global scale.

Increases in biodiversity often lead to greater, and less variable, levels of ecosystem functioning. However, whether species are less likely to go extinct in more diverse ecosystems is unclear. We use comprehensive estimates of avian taxonomic, phylogenetic and functional diversity to characterise the global relationship between multiple dimensions of diversity and extinction risk in birds, focusing on contemporary threat status and latent extinction risk. We find that more diverse assemblages have lower mean IUCN threat status despite being composed of species with attributes that make them more vulnerable to extinction, such as large body size or small range size. Indeed, the reduction in current threat status associated with greater diversity far outweighs the increased risk associated with the accumulation of extinction-prone species in more diverse assemblages. Our results suggest that high diversity reduces extinction risk, and that species conservation targets may therefore best be achieved by maintaining high levels of overall biodiversity in natural ecosystems.

AVONET: morphological, ecological and geographical data for all birds.

Functional traits offer a rich quantitative framework for developing and testing theories in evolutionary biology, ecology and ecosystem science. However, the potential of functional traits to drive theoretical advances and refine models of global change can only be fully realised when species-level information is complete. Here we present the AVONET dataset containing comprehensive functional trait data for all birds, including six ecological variables, 11 continuous morphological traits, and information on range size and location. Raw morphological measurements are presented from 90,020 individuals of 11,009 extant bird species sampled from 181 countries. These data are also summarised as species averages in three taxonomic formats, allowing integration with a global phylogeny, geographical range maps, IUCN Red List data and the eBird citizen science database. The AVONET dataset provides the most detailed picture of continuous trait variation for any major radiation of organisms, offering a global template for testing hypotheses and exploring the evolutionary origins, structure and functioning of biodiversity.

Lessons Learned From COVID-19 Contact Tracing During a Public Health Emergency: A Prospective Implementation Study.

Background: Contact tracing is a core element of the public health response to emerging infectious diseases including COVID-19. Better understanding the implementation context of contact tracing for pandemics, including individual- and systems-level predictors of success, is critical to preparing for future epidemics. Methods: We carried out a prospective implementation study of an emergency volunteer contact tracing program established in New Haven, Connecticut between April 4 and May 19, 2020. We assessed the yield and timeliness of case and contact outreach in reference to CDC benchmarks, and identified individual and programmatic predictors of successful implementation using multivariable regression models. We synthesized our findings using the RE-AIM implementation framework. Results: Case investigators interviewed only 826 (48%) of 1,705 cases and were unable to reach 545 (32%) because of incomplete information and 334 (20%) who missed or declined repeated outreach calls. Contact notifiers reached just 687 (28%) of 2,437 reported contacts, and were unable to reach 1,597 (66%) with incomplete information and 153 (6%) who missed or declined repeated outreach calls. The median time-to-case-interview was 5 days and time-to-contact-notification 8 days. However, among notified contacts with complete time data, 457 (71%) were reached within 6 days of exposure. The least likely groups to be interviewed were elderly (adjusted relative risk, aRR 0.74, 95% CI 0.61-0.89, p = 0.012, vs. young adult) and Black/African-American cases (aRR 0.88, 95% CI 0.80-0.97, pairwise p = 0.01, vs. Hispanic/Latinx). However, ties between cases and their contacts strongly influenced contact notification success (Intraclass Correlation Coefficient (ICC) 0.60). Surging caseloads and high volunteer turnover (case investigator n = 144, median time from sign-up to retirement from program was 4 weeks) required the program to supplement the volunteer workforce with paid public health nurses. Conclusions: An emergency volunteer-run contact tracing program fell short of CDC benchmarks for time and yield, largely due to difficulty collecting the information required for outreach to cases and contacts. To improve uptake, contact tracing programs must professionalize the workforce; better integrate testing and tracing services; capitalize on positive social influences between cases and contacts; and address racial and age-related disparities through enhanced community engagement.

Phylogenetic conservatism drives nutrient dynamics of coral reef fishes.

The relative importance of evolutionary history and ecology for traits that drive ecosystem processes is poorly understood. Consumers are essential drivers of nutrient cycling on coral reefs, and thus ecosystem productivity. We use nine consumer "chemical traits" associated with nutrient cycling, collected from 1,572 individual coral reef fishes (178 species spanning 41 families) in two biogeographic regions, the Caribbean and Polynesia, to quantify the relative importance of phylogenetic history and ecological context as drivers of chemical trait variation on coral reefs. We find: (1) phylogenetic relatedness is the best predictor of all chemical traits, substantially outweighing the importance of ecological factors thought to be key drivers of these traits, (2) phylogenetic conservatism in chemical traits is greater in the Caribbean than Polynesia, where our data suggests that ecological forces have a greater influence on chemical trait variation, and (3) differences in chemical traits between regions can be explained by differences in nutrient limitation associated with the geologic context of our study locations. Our study provides multiple lines of evidence that phylogeny is a critical determinant of contemporary nutrient dynamics on coral reefs. More broadly our findings highlight the utility of evolutionary history to improve prediction in ecosystem ecology.

Trophic complexity alters the diversity-multifunctionality relationship in experimental grassland mesocosms.

Plant diversity has a positive influence on the number of ecosystem functions maintained simultaneously by a community, or multifunctionality. While the presence of multiple trophic levels beyond plants, or trophic complexity, affects individual functions, the effect of trophic complexity on the diversity-multifunctionality relationship is less well known. To address this issue, we tested whether the independent or simultaneous manipulation of both plant diversity and trophic complexity impacted multifunctionality using a mesocosm experiment from Cedar Creek, Minnesota, USA. Our analyses revealed that neither plant diversity nor trophic complexity had significant effects on single functions, but trophic complexity altered the diversity-multifunctionality relationship in two key ways: It lowered the maximum strength of the diversity-multifunctionality effect, and it shifted the relationship between increasing diversity and multifunctionality from positive to negative at lower function thresholds. Our findings highlight the importance to account for interactions with higher trophic levels, as they can alter the biodiversity effect on multifunctionality.

Widespread shifts in bird migration phenology are decoupled from parallel shifts in morphology.

Advancements in phenology and changes in morphology, including body size reductions, are among the most commonly described responses to globally warming temperatures. Although these dynamics are routinely explored independently, the relationships among them and how their interactions facilitate or constrain adaptation to climate change are poorly understood. In migratory species, advancing phenology may impose selection on morphological traits to increase migration speed. Advancing spring phenology might also expose species to cooler temperatures during the breeding season, potentially mitigating the effect of a warming global environment on body size. We use a dataset of birds that died after colliding with buildings in Chicago, IL to test whether changes in migration phenology are related to documented declines in body size and increases in wing length in 52 North American migratory bird species between 1978 and 2016. For each species, we estimate temporal trends in morphology and changes in the timing of migration. We then test for associations between species-specific rates of phenological and morphological changes while assessing the potential effects of migratory distance and breeding latitude. We show that spring migration through Chicago has advanced while the timing of fall migration has broadened as a result of early fall migrants advancing their migrations and late migrants delaying their migrations. Within species, we found that longer wing length was linked to earlier spring migration within years. However, we found no evidence that rates of phenological change across years, or migratory distance and breeding latitude, are predictive of rates of concurrent changes in morphological traits. These findings suggest that biotic responses to climate change are highly multidimensional and the extent to which those responses interact and influence adaptation to climate change requires careful examination.

Implementation of a volunteer contact tracing program for COVID-19 in the United States: A qualitative focus group study.

BACKGROUND: Contact tracing is an important tool for suppressing COVID-19 but has been difficult to adapt to the conditions of a public health emergency. This study explored the experiences and perspectives of volunteer contact tracers in order to identify facilitators, challenges, and novel solutions for implementing COVID-19 contact tracing. METHODS: As part of a study to evaluate an emergently established volunteer contact tracing program for COVID-19 in New Haven, Connecticut, April-June 2020, we conducted focus groups with 36 volunteer contact tracers, thematically analyzed the data, and synthesized the findings using the RE-AIM implementation framework. RESULTS: To successfully reach cases and contacts, participants recommended identifying clients' outreach preferences, engaging clients authentically, and addressing sources of mistrust. Participants felt that the effectiveness of successful isolation and quarantine was contingent on minimizing delays in reaching clients and on systematically assessing and addressing their nutritional, financial, and housing needs. They felt that successful adoption of a volunteer-driven contact tracing model depended on the ability to recruit self-motivated contact tracers and provide rapid training and consistent, supportive supervision. Participants noted that implementation could be enhanced with better management tools, such as more engaging interview scripts, user-friendly data management software, and protocols for special situations and populations. They also emphasized the value of coordinating outreach efforts with other involved providers and agencies. Finally, they believed that long-term maintenance of a volunteer-driven program requires monetary or educational incentives to sustain participation. CONCLUSIONS: This is one of the first studies to qualitatively examine implementation of a volunteer-run COVID-19 contact tracing program. Participants identified facilitators, barriers, and potential solutions for improving implementation of COVID-19 contact tracing in this context. These included standardized communication skills training, supportive supervision, and peer networking to improve implementation, as well as greater cooperation with outside agencies, flexible scheduling, and volunteer incentives to promote sustainability.

The Impact of Social Endorsement Cues and Manipulability Concerns on Perceptions of News Credibility.

Social endorsement cues (SEC) offer information about how online users have engaged and evaluated online content. Some view that SEC thus can serve as useful heuristics when users evaluate the credibility of news content on social media. At the same time, SEC can be manipulated by a variety of commercial and political actors on social media. This study examines whether SEC influence individuals' credibility judgments of political news on social media, and how the salience of concerns that SEC can be manipulated by others can undermine the perceived credibility. Using an experiment, we found that SEC had a negative influence on news credibility, regardless of whether or not SEC manipulability concerns were primed. An independent effect of SEC manipulability concerns was also found, such that priming thoughts about the manipulability of SEC led participants to rate the news post as less credible, regardless of whether that post included SEC. These results suggest a spillover effect whereby concerns over the manipulation of SEC can create doubt about the authenticity of other cues from the news (e.g., source and message), and lead to perceptions that news shared on social media can be manipulated more generally.

Comparison of adult census size and effective population size support the need for continued protection of two Solomon Island endemics.

Because a population's ability to respond to rapid change is dictated by standing genetic variation, we can better predict a population's long-term viability by estimating and then comparing adult census size (N) and effective population size (N e ). However, most studies only measure N or N e , which can be misleading. Using a combination of field and genomic sequence data, we here estimate and compare N and N e in two range-restricted endemics of the Solomon Islands. Two Zosterops White-eye species inhabit the small island of Kolombangara, with a high elevation species endemic to the island (Z. murphyi) and a low elevation species endemic to the Solomon Islands (Z. kulambangrae). Field observations reveal large values of N for both species with Z. kulambangrae numbering at 114,781 ± 32,233 adults, and Z. murphyi numbering at 64,412 ± 15,324 adults. In contrast, genomic analyses reveal that N e was much lower than N, with Z. kulambangrae estimated at 694.5 and Z. murphyi at 796.1 individuals. Further, positive Tajima's D values for both species suggest that they have experienced a demographic contraction, providing a mechanism for low values of N e . Comparison of N and N e suggests that Z. kulambangrae and Z. murphyi are not at immediate threat of extinction but may be at genetic risk. Our results provide important baseline data for long-term monitoring of these island endemics, and argue for measuring both population size estimates to better gauge long-term population viability.

Community Trace: Rapid Establishment of a Volunteer Contact Tracing Program for COVID-19.

Contact tracing was one of the core public health strategies implemented during the first months of the COVID-19 pandemic. In this essay, we describe the rapid establishment of a volunteer contact tracing program in New Haven, Connecticut. We describe successes of the program and challenges that were faced. Going forward, contact tracing efforts can best be supported by increased funding to state and local health departments for a stable workforce and use of evidence-based technological innovations.

The relationship between morphology and behavior in mixed-species flocks of island birds.

Understanding how co-occurring species divide ecological space is a central issue in ecology. Functional traits have the potential to serve as a means for quantitatively assessing niche partitioning by different species based on their ecological attributes, such as morphology, behavior, or trophic habit. This enables testing ecological and evolutionary questions using functional traits at spatio-temporal scales that are not feasible using traditional field methods. Both rapid evolutionary change and inter- and intraspecific competition, however, may limit the utility of morphological functional traits as indicators of how niches are partitioned. To address how behavior and morphology interact, we quantified foraging behavior of mixed-species flocks of birds in the Solomon Islands to test whether behavior and morphology are correlated in these flocks. We find that foraging behavior is significantly correlated with morphological traits (p = .05), but this correlation breaks down after correcting for phylogenetic relatedness (p = .66). These results suggest that there are consistent correlations between aspects of behavior and morphology at large taxonomic scales (e.g., across genera), but the relationship between behavior and morphology depends largely on among-clade differences and may be idiosyncratic at shallower scales (e.g., within genera). As a result, general relationships between behaviors and morphology may not be applicable when comparing close relatives.

Macroevolutionary convergence connects morphological form to ecological function in birds.

Animals have diversified into a bewildering variety of morphological forms exploiting a complex configuration of trophic niches. Their morphological diversity is widely used as an index of ecosystem function, but the extent to which animal traits predict trophic niches and associated ecological processes is unclear. Here we use the measurements of nine key morphological traits for >99% bird species to show that avian trophic diversity is described by a trait space with four dimensions. The position of species within this space maps with 70-85% accuracy onto major niche axes, including trophic level, dietary resource type and finer-scale variation in foraging behaviour. Phylogenetic analyses reveal that these form-function associations reflect convergence towards predictable trait combinations, indicating that morphological variation is organized into a limited set of dimensions by evolutionary adaptation. Our results establish the minimum dimensionality required for avian functional traits to predict subtle variation in trophic niches and provide a global framework for exploring the origin, function and conservation of bird diversity.

Shared morphological consequences of global warming in North American migratory birds.

Increasing temperatures associated with climate change are predicted to cause reductions in body size, a key determinant of animal physiology and ecology. Using a four-decade specimen series of 70 716 individuals of 52 North American migratory bird species, we demonstrate that increasing annual summer temperature over the 40-year period predicts consistent reductions in body size across these diverse taxa. Concurrently, wing length - an index of body shape that impacts numerous aspects of avian ecology and behaviour - has consistently increased across species. Our findings suggest that warming-induced body size reduction is a general response to climate change, and reveal a similarly consistent and unexpected shift in body shape. We hypothesise that increasing wing length represents a compensatory adaptation to maintain migration as reductions in body size have increased the metabolic cost of flight. An improved understanding of warming-induced morphological changes is important for predicting biotic responses to global change.

Nocturnal flight-calling behaviour predicts vulnerability to artificial light in migratory birds.

Understanding interactions between biota and the built environment is increasingly important as human modification of the landscape expands in extent and intensity. For migratory birds, collisions with lighted structures are a major cause of mortality, but the mechanisms behind these collisions are poorly understood. Using 40 years of collision records of passerine birds, we investigated the importance of species' behavioural ecologies in predicting rates of building collisions during nocturnal migration through Chicago, IL and Cleveland, OH, USA. We found that the use of nocturnal flight calls is an important predictor of collision risk in nocturnally migrating passerine birds. Species that produce flight calls during nocturnal migration tended to collide with buildings more than expected given their local abundance, whereas those that do not use such communication collided much less frequently. Our results suggest that a stronger attraction response to artificial light at night in species that produce flight calls may mediate these differences in collision rates. Nocturnal flight calls probably evolved to facilitate collective decision-making during navigation, but this same social behaviour may now exacerbate vulnerability to a widespread anthropogenic disturbance. Our results also suggest that social behaviour during migration may reflect poorly understood differences in navigational mechanisms across lineages of birds.

A long winter for the Red Queen: rethinking the evolution of seasonal migration.

This paper advances an hypothesis that the primary adaptive driver of seasonal migration is maintenance of site fidelity to familiar breeding locations. We argue that seasonal migration is therefore principally an adaptation for geographic persistence when confronted with seasonality - analogous to hibernation, freeze tolerance, or other organismal adaptations to cyclically fluctuating environments. These ideas stand in contrast to traditional views that bird migration evolved as an adaptive dispersal strategy for exploiting new breeding areas and avoiding competitors. Our synthesis is supported by a large body of research on avian breeding biology that demonstrates the reproductive benefits of breeding-site fidelity. Conceptualizing migration as an adaptation for persistence places new emphasis on understanding the evolutionary trade-offs between migratory behaviour and other adaptations to fluctuating environments both within and across species. Seasonality-induced departures from breeding areas, coupled with the reproductive benefits of maintaining breeding-site fidelity, also provide a mechanism for explaining the evolution of migration that is agnostic to the geographic origin of migratory lineages (i.e. temperate or tropical). Thus, our framework reconciles much of the conflict in previous research on the historical biogeography of migratory species. Although migratory behaviour and geographic range change fluidly and rapidly in many populations, we argue that the loss of plasticity for migration via canalization is an overlooked aspect of the evolutionary dynamics of migration and helps explain the idiosyncratic distributions and migratory routes of long-distance migrants. Our synthesis, which revolves around the insight that migratory organisms travel long distances simply to stay in the same place, provides a necessary evolutionary context for understanding historical biogeographic patterns in migratory lineages as well as the ecological dynamics of migratory connectivity between breeding and non-breeding locations.

Hypoglossal Nerve Stimulator Implantation in a Non-Academic Setting: Two-Year Result.

OBJECTIVES/HYPOTHESIS: Upper Airway Stimulation (UAS) is an FDA approved treatment option for patients with moderate-to-severe obstructive sleep apnea (OSA) who could not adhere to continuous positive airway pressure (CPAP). Previous studies have shown UAS reduced apnea-hypopnea index (AHI) in controlled clinical trials and from academic institutions. We report patient outcomes and therapy adherence of UAS in a non-academic hospital and clinic setting. STUDY DESIGN: Case series of consecutive patients. METHODS: Consecutive implants completed at a community hospital between January 2015 to Feb 2017 are included in this report. All patients underwent baseline polysomnography (PSG) recording and drug-induced sleep endoscopy (DISE) prior to the implant. All patients had returned for standard post-implantation titration PSG at a community sleep clinic to validate and adjust the stimulation setting for optimal response. Results were in mean ± SD, and pre- and post-implant data were compared using a paired student t-test. RESULTS: A total 22 patients undergoing UAS implant were overweight (BMI of 28.9 ± 5.0 kg/m2) and middle aged (63.2 ± 11.1 years), and had severe OSA (AHI of 35.9 ± 19.1). The AHI from the entire night of the titration study was 16.0 ± 10.4 (P < .01, compared with baseline), and the treatment AHI from the sleep period when the optimal setting was programmed was 1.2 ± 1.1 (P < .001, compared with baseline), and 90% patients had titrated AHI less than 5. The lowest SpO2 increased from 81% ± 8% at baseline to 91% ± 3% at the titrated setting (P = .001). After an average follow up of 95 ± 28.5 days, the therapy use per night was 7.0 ± 1.9 hours per night. The average postoperative ESS was 6.7 ± 5.3 of 18 patients, a reduction from the baseline of 10.9 ± 4.8. A total of 13 of 18 patients with postoperative ESS < 10, a measure indicated normalization of daytime sleepiness. CONCLUSION: Patients who elected to receive UAS implant surgery at a non-academic hospital and followed at a sleep clinic showed significant reduction in OSA severity with strong adherence to treatment. These results supported that UAS as a valid treatment option for OSA can be successfully implemented in the non-academic hospital and clinic settings. LEVEL OF EVIDENCE: 4.