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of the adult population&#59; insomnia symptoms with distress or impairment &#40;i&#46;e&#46;&#44; general insomnia disorder&#41; in 10&#8211;15&#37;&#59; and specific insomnia disorders in 5&#8211;10&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> Insomnia&#44; a complex and multifactorial entity&#44; has been explained as a psychological process&#44; with a strong physiological component defined as central nervous system activation or increased arousal activity during sleep&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a> Some authors suggest that this arousal behaviour may be innate or genetically determined&#44; serving as a substrate upon which various external factors&#44; such as stress&#44; may act to aggravate sleeplessness&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> Despite the high prevalence of this symptom and its significant psychosocial consequences&#44; little is known about potential interactions or associations between the two disorders &#8211; OSAS and insomnia&#46; Some studies have shown that 40&#8211;50&#37; of patients with sleep-disordered breathing present problematic insomnia symptoms before beginning any type of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;12&#8211;16</span></a> Chung<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> documented a prevalence of 6&#37;&#44; 26&#37; and 19&#37; of initial&#44; intermediate&#44; and final insomnia respectively in patients with OSAS&#44; noting that patients with initial insomnia had significantly lower apnoea&#8211;hypopnoea &#40;AHI&#41; and arousal indices&#46; Although insomnia is a common complaint in patients who are evaluated for OSAS&#44; some believe that these two disorders are not strongly associated&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> However&#44; other studies suggest that co-morbidity of insomnia in OSAS patients may lead to increased severity of OSAS&#44; decrease in OSAS treatment compliance&#44; and that patients with both conditions may experience more symptoms relating to depression&#44; anxiety&#44; and stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19&#8211;21</span></a> Given the substantial overlap in symptoms between insomnia and OSAS&#44; evaluation and treatment of these two conditions can be challenging and will require multidisciplinary collaboration among sleep specialists&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the inconclusive and sometimes contradictory results concerning the relationship between insomnia and OSAS before treatment&#44; there is little doubt that these two disorders can coexist <span class="elsevierStyleItalic">ad initium</span>&#46; However&#44; in clinical practice it has been observed that patients with OSAS and no insomnia at baseline develop this symptom after beginning treatment with nocturnal ventilatory support &#40;NVS&#41;&#46; In this context&#44; we usually consider this complaint as new-onset insomnia &#40;NOI&#41; or <span class="elsevierStyleItalic">de novo</span> insomnia&#46; This is the justification for our aim to evaluate the prevalence of NOI in patients with OSAS under NVS&#44; and to determine its associated risk factors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Subjects</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a descriptive cross-sectional study enrolling 80 patients with OSAS&#44; diagnosed by cardiorespiratory poligraphy and&#47;or polysomnography&#44; who were followed in our Sleep Disordered Breathing Clinic&#46; The severity of OSAS was classified as mild &#40;AHI&#58; 5&#8211;15&#47;h&#41;&#44; moderate &#40;AHI&#58; 15&#8211;30&#47;h&#41;&#44; and severe &#40;AHI &#62;30&#47;h&#41;&#44; according to established criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> All patients were under NVS with auto-adjusting positive airway pressure &#40;APAP&#41;&#44; fixed continuous-PAP &#40;CPAP&#41; or bi-level PAP &#40;BiPAP&#41;&#44; from a variety of models and ventilator manufacturers &#40;Goodknight<span class="elsevierStyleSup">&#174;</span> 420 Evolution &#91;Tyco&#93;&#59; S8 AutoSet Spirit<span class="elsevierStyleSup">&#174;</span> II &#91;ResMed&#93;&#59; REMstar<span class="elsevierStyleSup">&#174;</span> Auto &#91;Respironics&#93;&#59; iSleep20&#43;<span class="elsevierStyleSup">&#174;</span> &#91;Breas&#93;&#59; Goodknight<span class="elsevierStyleSup">&#174;</span> 425 ST &#91;Tyco&#93;&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Exclusion criteria were as follows&#58; patients under anxiolytic and&#47;or antidepressant medication&#59; patients with a weight loss of 10&#37; or greater&#59; and patients with clinical features suggestive of restless legs syndrome &#40;RLS&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our study was approved by the Ethics Committee of Hospital de S&#227;o Jo&#227;o&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">We analyzed demographic variables &#40;gender and age&#41;&#44; baseline and current Epworth Sleepiness Scale &#40;ESS&#41;&#44; OSAS severity&#44; previous insomnia and NOI&#44; subtypes of NOI&#44; treatment duration and compliance&#44; the number of previous and current hours of sleep&#44; and the presence of an anxious&#47;depressive personality in the total sample&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Previous insomnia was considered present if the patient answered the baseline question &#8220;I feel that I have Insomnia&#8221; from the Sleep Disorders Questionnaire &#40;SDQ&#41; &#40;version 1&#46;02&#44; Portuguese&#41;&#44; as &#8220;almost always&#8221; &#40;4&#41; or &#8220;always&#8221; &#40;5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After starting treatment&#44; insomnia was evaluated through the SleepMed Insomnia Index Questionnaire &#40;SMIIQ&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> This is a new diagnostic questionnaire&#44; designed to measure insomnia symptoms rapidly and in a simple standardized way&#46; It has not yet been validated&#44; but has a high degree of reliability&#44; as has been previously shown&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The SMIIQ consists of 10 questions formulated to address important sleep factors&#44; including sleep latency&#44; performance anxiety&#44; first night effect&#44; frequency of awakening&#44; getting back to sleep&#44; total sleep time&#44; perceived sleep quality&#44; and impact on next day function&#46; NOI was considered present when a patient had a SMIIQ score &#62;20 without evidence of previous insomnia&#46; NOI was classified as initial&#44; intermediate&#44; and final&#44; according to the description of symptoms&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment compliance was assessed through NVS equipment software&#44; evaluating the percentage of total days of usage&#44; average number of hours per night&#44; pressure on 90&#37; nighttime &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#41; when applied&#44; and residual AHI&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The SDQ was also used to evaluate the presence of an anxious&#47;depressive personality&#46; A patient was classified as having an anxious&#47;depressive personality if he or she scored 4 or 5 in the questions &#8220;My sleep is disturbed by sadness or depression&#8221; and &#8220;My sleep is disturbed by concerns with life situations&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using the SPSS version 17&#46;0 software &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Data were described as median and interquartile range &#40;IQR&#41; for quantitative variables &#40;non-normally distributed variables&#41; and as counts and proportions for qualitative&#160;variables&#46; Proportions were compared using Chi-square test or Fisher&#39;s exact test whenever appropriate&#46; For comparison between median values in patients with and without NOI the non-parametric Mann&#8211;Whitney and Kruskal&#8211;Wallis tests for independent samples were used&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The median age of patients enrolled was 60&#46;0 &#40;IQR 10&#46;0&#41; years&#44; and 82&#46;5&#37; were male&#46; Median initial AHI was 44&#46;1 &#40;IQR 22&#46;4&#41;&#47;h&#44; reflecting the disease severity &#40;mild&#58; 1&#46;2&#37; &#40;<span class="elsevierStyleItalic">n</span>&#61;1&#41;&#59; moderate&#58; 17&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span>&#61;14&#41;&#59; severe&#58; 81&#46;3&#37; &#40;<span class="elsevierStyleItalic">n</span>&#61;65&#41;&#41;&#46; Median baseline ESS was 12&#46;5 &#40;IQR 9&#46;0&#41;&#44; with minimum and maximum values of 0 and 24&#44; respectively&#46; Most of the patients &#40;91&#46;3&#37;&#59; <span class="elsevierStyleItalic">n</span>&#61;73&#41; were under APAP and the remaining under CPAP &#40;7&#46;5&#37;&#59; <span class="elsevierStyleItalic">n</span>&#61;6&#41; and BiPAP &#40;1&#46;2&#37;&#59; <span class="elsevierStyleItalic">n</span>&#61;1&#41;&#46; The median values of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span> and fixed pressure were 10&#46;2 &#40;IQR 3&#46;2&#41; cmH<span class="elsevierStyleInf">2</span>O and 10&#46;5 &#40;IQR 4&#46;1&#41; cmH<span class="elsevierStyleInf">2</span>O&#44; respectively&#46; Inspiratory-PAP &#40;IPAP&#41; and expiratory-PAP &#40;EPAP&#41; values of the patient under BiPAP were 18 and 12<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; respectively&#46; The median time period with NVS was 26&#46;0 &#40;IQR 34&#46;0&#41; months&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Insomnia at baseline was present in 30&#37; of patients &#40;<span class="elsevierStyleItalic">n</span>&#61;24&#41;&#44; but in 11 of these patients&#44; this symptom disappeared after starting treatment&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">After excluding patients with previous insomnia&#44; we analyzed the remaining 56 patients&#44; divided into two groups according to the presence of NOI&#46; The prevalence of NOI was 21&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span>&#61;12&#41;&#46; Subtypes of NOI are depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The majority of NOI patients were under APAP &#40;<span class="elsevierStyleItalic">n</span>&#61;10&#41;&#44; and 2 were under CPAP and BiPAP&#44; respectively&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">No significant differences were found between the groups&#44; in relation to gender &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;433&#41;&#44; age &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;826&#41;&#44; anxious&#47;depressive personality &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;443&#41;&#44; OSAS severity &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;842&#41;&#44; efficacy of treatment measured by residual AHI &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;596&#41; or previous and current number of hours of sleep &#40;<span class="elsevierStyleItalic">p</span>&#62;0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The median baseline ESS was lower in NOI patients&#44; but the difference was not statistically significant &#40;with NOI&#58; 11&#46;0 &#40;IQR 11&#46;0&#41; versus without NOI&#58; 12&#46;0 &#40;IQR 6&#46;0&#41;&#59; <span class="elsevierStyleItalic">p</span>&#61;0&#46;667&#41;&#46; Also&#44; the variation between current and baseline ESS was not statistically significant in either group &#40;with NOI&#58; &#8722;5&#46;0 &#40;IQR 7&#46;8&#41; versus without NOI&#58; &#8722;6&#46;0 &#40;IQR 7&#46;5&#41;&#59; <span class="elsevierStyleItalic">p</span>&#61;0&#46;502&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to treatment compliance&#44; patients with NOI showed a shorter but non-significant duration of treatment &#40;22&#46;0 &#40;IQR 30&#46;5&#41; months versus 26&#46;0 &#40;IQR 36&#46;8&#41; months&#59; <span class="elsevierStyleItalic">p</span>&#61;0&#46;447&#41; and fewer hours of sleep &#40;6&#46;5 &#40;IQR 2&#46;3&#41;<span class="elsevierStyleHsp" style=""></span>h&#47;night versus 7&#46;0 &#40;IQR 1&#46;5&#41;<span class="elsevierStyleHsp" style=""></span>h&#47;night&#59; <span class="elsevierStyleItalic">p</span>&#61;0&#46;408&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A statistically significant negative relation was found between NOI and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span> &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;040&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#44; although when the different subtypes of NOI were compared by median values of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#44; no statistically significant difference was found &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;067&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Taking previous studies into account&#44; assessment of insomnia should be included in the management of sleep-disordered breathing before starting treatment&#44; mainly because of its high prevalence and its impact on sleep quality&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;17&#44;19&#44;20</span></a> In our OSAS patients&#44; prevalence of previous insomnia was 30&#37;&#44; a slightly lower rate than that described in the literature&#44; which may be the result of the small sample size&#44; a potential limitation of this study&#46; Some authors suggest that further studies on the relationships between insomnia in OSAS patients and NVS are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We also consider that NOI in OSAS patients deserves evaluation&#44; as we observed that some patients&#44; non-insomniacs at the beginning of treatment&#44; developed symptoms of insomnia after starting NVS&#46; In our population&#44; the prevalence of NOI was 21&#46;4&#37;&#46; In order to eliminate the subjective aspect of this self-reported symptom&#44; we evaluated pre- and post-treatment insomnia through reliable tools&#44; such as SDQ and SMIIQ&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Patients under anxiolytic and&#47;or antidepressant medication were excluded&#44; as these medications could themselves influence complaints of insomnia&#44; also excluded were those who had a weight loss of 10&#37; or greater&#44; as this could have affected the severity of their sleep-disordered breathing&#46; In addition we excluded patients with RLS&#44; using the diagnostic criteria of the International Restless Legs Syndrome Study Group&#44; as this condition can induce insomnia complaints&#44; like difficulty in falling asleep and maintaining sleep&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> In this context&#44; we can add that patients did not present any major medical &#40;digestive&#44; genitourinary&#44; endocrine&#44; musculoskeletal&#44; pulmonary&#44; cardiovascular&#44; etc&#46;&#41; or other sleep disorders &#40;periodic limb movement disorder&#44; circadian rhythm sleep disorders&#44; etc&#46;&#41;&#44; and did not have a history of substance abuse&#44; which could have affected the development of insomnia&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The comparative analysis between the two groups&#44; with and without NOI&#44; was based on only 56 patients&#59; we excluded the 24 patients with previous insomnia&#44; as they could have some of the same specific features as NOI patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the general population&#44; insomnia is more common in women and increases with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;27</span></a> In our sample&#44; we did not find a link with gender and age&#59; this may be because there was a predominance of the male gender and homogeneous age in our sample and as stated above&#44; the sample size was small&#46; However&#44; we can develop ideas about different pathogenic mechanisms concerning NOI associated with NVS&#44; like pressure variation related arousals&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Psychological factors and insomnia are interconnected&#59; we know that 40&#37; of insomniacs have a coexisting psychological disorder&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;28</span></a> Anxiety or depression could affect the development of NOI&#44; but in our sample this relationship was not statistically significant&#46; However&#44; as anxiety and depression were not evaluated through specific questionnaires or by a specialist consultant&#44; these personality features could have been underestimated in our study&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Patients with and without NOI had similar baseline ESS values&#46; Also&#44; the variation between post- and pre-treatment values was similar in both groups&#46; It seems that OSAS symptoms&#44; such as hypersomnia&#44; are not related to insomnia&#44; but to the disease itself&#44; as others have shown&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;22&#44;29</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">No differences were found concerning treatment compliance&#44; which was good in both groups&#46; However&#44; NOI group presented shorter treatment duration and fewer hours of sleep per night&#44; compared to the other group&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We can speculate about the adaptation to a new treatment during the night as a factor in the worsening quality of sleep&#46; It is possible that NVS itself becomes a cause of frustration and sleep fragmentation&#44; increasing sleep difficulties&#46; This could also explain the predominance of initial and&#47;or intermediate insomnia subtypes&#44; reflecting the difficulty of NOI group in getting to sleep and maintaining its sleep&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our sample the majority of NOI patients were under APAP &#40;<span class="elsevierStyleItalic">n</span>&#61;10&#41;&#46; APAP devices were designed to continuously adjust the applied pressure to the optimal level throughout the night&#44; according to an algorithm&#44; and therefore minimize the mean overnight pressure requirements of patients with OSAS&#46; Because pressure changes occur throughout the sleep period&#44; some authors have suggested that these devices may actually increase sleep fragmentation&#44; which would explain some of the differences in CPAP and APAP performance&#46; However these are not related to the improvement of OSAS and indexes&#44; such as residual AHI&#44; as observed in the population studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a> Despite the fact that the frequency of microarousals and sleep fragmentation induced by APAP devices appears to be small&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> it might be enough to explain the development of insomnia after treatment had started&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">We found a statistically significant negative relation between NOI and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#46; This finding cannot be explained by the severity of OSAS&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;33</span></a> as there was no difference in initial AHI between the two groups&#46; Also&#44; NOI group was treated effectively&#44; as shown by residual AHI&#44; so we cannot explain this relation by unsolved respiratory events&#46; We can speculate that the number of arousals is the cause of the relationship found&#44; but we did not monitor patients with a polysomnography after treatment had begun&#46; In addition&#44; as insomniacs are awake for longer periods than non-insomniacs&#44; they do not have as many events to solve as the other group&#44; and consequently the pressure on the device can be lower&#46; Although the present work was not designed to study patients with previous insomnia or the influence of NVS on this symptom&#44; we found that median value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span> was higher among those who maintained insomnia &#40;<span class="elsevierStyleItalic">n</span>&#61;13&#41; than in those who resolved it &#40;<span class="elsevierStyleItalic">n</span>&#61;11&#41;&#44; although without statistical significance &#40;data not shown&#41;&#46; This finding that <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span> was higher in insomniac patients may suggest that previous insomnia and NOI have distinct pathogenesis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As limitations of the study&#44; we draw attention to the small sample size and the uneven number of patients observed in the two groups analyzed&#46; The number of OSAS patients enrolled was limited&#44; because the original intention of our study was primarily exploratory&#44; aimed at confirming a clinical suspicion&#44; the development of insomnia associated with OSAS treatment&#44; something which has not been mentioned so far in the literature&#46; Given the present data&#44; we now believe that this is an important area which requires further research in order to pursue other types of potential predictive factors and etiopathogenic mechanisms&#46; Furthermore&#44; we can speculate about the use of different tools for the evaluation of insomnia before and after initiating NVS&#46; Using the same questionnaire would address the lack of uniformity concerning this issue&#46; The idea of using the SMIIQ was to characterize NOI patients better after they had been identified&#46; However&#44; our &#8220;final&#8221; sample had only 56 patients&#44; since 24 had previous insomnia and had to be excluded&#44; leaving only 12 with NOI&#46; This is why we think this investigation of NOI features in this context should be analyzed in a larger group of patients&#46; The use of SMIIQ&#44; without its Sleep Matrix refinement&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> could also be challenged in relation to the differential diagnosis between insomnia and other sleep disorders&#46; Yet&#44; we emphasize that our main aim was to evaluate a type of insomnia that was associated with the use of NVS&#44; and not related to OSAS itself&#46; In this context&#44; we only applied the SMIIQ score as a quick and easy way to screen insomnia &#40;&#62;20&#41;&#44; and because it is known to have high reliability in insomniac patients&#59; the calculation of the Sleep Matrix was really outside our objectives&#44; and would have made the study more complex to interpret&#46; Furthermore&#44; as we can see in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#44; the median baseline ESS in NOI patients was not higher than 11&#44; which could indicate the development of NOI independently of OSAS or other sleep disorders&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Another potential limitation of the study is that the time that elapsed&#44; from the beginning of the NVS to the development of complaints of insomnia&#44; is not specified&#46; However the SMIIQ was applied at the 3-month follow-up visit or later&#44; and we can state that those patients did not present previous insomnia&#44; nor did they develop any co-morbid situation &#40;medical disorder or substance abuse&#41; after initiating NVS which could have affected the insomnia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although we have stressed the lack of a proper instrument for evaluating personality features&#44; such as anxiety or depression&#44; we think that this has been dealt with the exclusion of patients with previous insomnia&#44; who could have presented a co-morbid anxious personality which was not revealed by the answers to the relevant SDQ questions&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">OSAS patients under NVS presented a high prevalence of NOI &#40;21&#46;4&#37;&#41;&#46; Gender&#44; age&#44; OSAS severity&#44; treatment compliance&#44; and the presence of an anxious&#47;depressive personality were not associated with the development of NOI&#46; Patients with NOI presented lower levels of pressure using NVS&#46; Longer and larger studies are needed to determine whether NOI exists as an independent &#8220;entity&#8221; or merely secondary to NVS&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflict of interest"
        ]
        10 => array:2 [
          "identificador" => "xack44905"
          "titulo" => "Acknowledgements"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-12-26"
    "fechaAceptado" => "2011-06-15"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec161756"
          "palabras" => array:6 [
            0 => "New-onset insomnia"
            1 => "Obstructive sleep apnoea syndrome"
            2 => "Nocturnal ventilatory support"
            3 => "Auto-adjusting positive airway pressure"
            4 => "Prevalence"
            5 => "Risk factors"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec161757"
          "palabras" => array:6 [
            0 => "Ins&#243;nia de novo"
            1 => "S&#237;ndrome de apneia obstrutiva do sono"
            2 => "Suporte ventilat&#243;rio nocturno"
            3 => "<span class="elsevierStyleItalic">Auto-adjusting positive airway pressure</span>"
            4 => "Preval&#234;ncia"
            5 => "Factores de risco"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">New-onset insomnia &#40;NOI&#41; associated with nocturnal ventilatory support &#40;NVS&#41; is becoming a reality in clinical practice&#59; however there is a lack of data about its prevalence&#46; Our aim was to determine the prevalence of NOI in patients with obstructive sleep apnoea syndrome &#40;OSAS&#41; under NVS and its associated risk factors&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descriptive cross-sectional study of 80 patients with OSAS under NVS&#46; We compared two groups&#44; with and without NOI&#44; considering demographic characteristics&#44; disease features&#44; and personality&#46; Patients under anxiolytic and&#47;or antidepressant medication&#44; with a weight loss of 10&#37; or greater&#44; and with restless legs symptoms were excluded&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Median age of patients was 60&#46;0 &#40;interquartile range &#40;IQR&#41; 10&#46;0&#41; years&#59; 82&#46;5&#37; were male&#46; Median initial Epworth Sleepiness Scale &#40;ESS&#41; and apnoea&#8211;hypopnoea index &#40;AHI&#41; were 12&#46;5 &#40;IQR 9&#46;0&#41; and 44&#46;1 &#40;IQR 22&#46;4&#41;&#47;h&#44; respectively&#46; The majority of patients &#40;91&#46;3&#37;&#41; were under auto-adjusting positive airway pressure &#40;APAP&#41;&#46; Insomnia at baseline was present in 30&#37; of patients &#40;<span class="elsevierStyleItalic">n</span>&#61;24&#41;&#46; Prevalence of NOI was 21&#46;4&#37; &#40;12&#47;56&#41;&#46; Initial and&#47;or intermediate insomnia were the most frequent subtypes &#40;<span class="elsevierStyleItalic">n</span>&#61;11&#41;&#46; We found a statistically significant negative relation between NOI and pressure on 90&#37; nighttime &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#41; &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;040&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">OSAS patients under NVS presented a high prevalence of NOI&#46; Patients with NOI presented lower levels of pressure using NVS&#44; compared to the others&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A ins&#243;nia de novo &#40;IN&#41; associada ao uso do suporte ventilat&#243;rio nocturno &#40;SVN&#41; tem sido uma realidade constatada na pr&#225;tica cl&#237;nica&#44; contudo &#233; de salientar a escassez de dados referentes &#224; sua preval&#234;ncia&#46; O nosso objectivo consistiu em determinar a preval&#234;ncia de IN e seus factores de risco em doentes com s&#237;ndrome de apneia obstrutiva do sono &#40;SAOS&#41; sob SVN&#46;</p> <span class="elsevierStyleSectionTitle">Material e m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo descritivo transversal que incluiu 80 doentes com SAOS sob SVN&#46; Efectuada compara&#231;&#227;o entre dois grupos&#44; com e sem IN&#44; relativamente a caracter&#237;sticas demogr&#225;ficas&#44; relacionadas com a doen&#231;a&#44; e personalidade&#46; Foram exclu&#237;dos os doentes sob medica&#231;&#227;o ansiol&#237;tica e&#47;ou antidepressiva&#44; com perda ponderal superior ou igual a 10&#37;&#44; e com sintomas da s&#237;ndrome das pernas inquietas&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A mediana de idades dos doentes inclu&#237;dos foi de 60&#44;0 &#40;intervalo interquartil &#40;IIQ&#41; 10&#44;0&#41; anos&#59; 82&#44;5&#37; eram do sexo masculino&#46; Os valores iniciais medianos da escala de sonol&#234;ncia de Epworth &#40;ESE&#41; e do &#237;ndice de apneia-hipopneia &#40;IAH&#41; foram de 12&#44;5 &#40;IIQ 9&#44;0&#41; e de 44&#44;1 &#40;IIQ 22&#44;4&#41;&#47;h&#44; respectivamente&#46; A maioria dos doentes &#40;91&#44;3&#37;&#41; estava sob press&#227;o positiva nas vias a&#233;reas em modo autom&#225;tico &#40;<span class="elsevierStyleItalic">auto-adjusting positive airway pressure</span> &#40;APAP&#41;&#41;&#46; A ins&#243;nia pr&#233;via ao uso de SVN estava presente em 30&#37; &#40;<span class="elsevierStyleItalic">n</span>&#61;24&#41; dos doentes&#46; A preval&#234;ncia de IN foi de 21&#44;4&#37; &#40;12&#47;56&#41; e os subtipos de ins&#243;nia inicial e&#47;ou interm&#233;dia foram os mais frequentes &#40;<span class="elsevierStyleItalic">n</span>&#61;11&#41;&#46; Foi encontrada uma rela&#231;&#227;o negativa estatisticamente significativa entre a IN e a press&#227;o em 90&#37; do tempo de SVN &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#41; &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;040&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os doentes com SAOS sob SVN apresentaram uma preval&#234;ncia elevada de IN&#46; Os doentes com IN apresentaram n&#237;veis inferiores de press&#227;o de SVN comparativamente com os outros&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Caetano Mota&#44; P&#46; Preval&#234;ncia de ins&#243;nia de novo em doentes com s&#237;ndrome de apneia obstrutiva do sono tratados com suporte ventilat&#243;rio nocturno&#46; Rev Port Pneumol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2011.06.016">doi&#58;10&#46;1016&#47;j&#46;rppneu&#46;2011&#46;06&#46;016</span>&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0180" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p> <p id="par0185" class="elsevierStylePara elsevierViewall">Escala&#58;</p> <p id="par0190" class="elsevierStylePara elsevierViewall">0&#61;Sem problemas com o meu sono&#46;</p> <p id="par0195" class="elsevierStylePara elsevierViewall">1&#61;Algum &#40;pouco&#41; problema com o meu sono&#46;</p> <p id="par0200" class="elsevierStylePara elsevierViewall">2&#61;Problema moderado com o meu sono&#46;</p> <p id="par0205" class="elsevierStylePara elsevierViewall">3&#61;Problema moderado&#47;grave com o meu sono&#46;</p> <p id="par0210" class="elsevierStylePara elsevierViewall">4&#61;Problema grave com o meu sono que afecta a minha vida&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "SleepMed Insomnia Index Questionnaire &#40;SMIIQ&#41;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> &#8211; Portuguese translation"
            "identificador" => "sec0050"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 965
            "Ancho" => 2257
            "Tamanyo" => 57800
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of new-onset insomnia &#40;NOI&#41; subtypes&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Quantitative variables are expressed as median &#40;interquartile range&#41;&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AHI&#44; apnoea&#8211;hypopnoea index&#59; NOI&#44; new-onset insomnia&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#44; pressure on 90&#37; nighttime&#59; SMIIQ&#44; SleepMed Insomnia Index Questionnaire&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Residual AHI &#40;events&#47;h&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;5 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;596&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previous hours of sleep &#40;h&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;671&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Current hours of sleep &#40;h&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;599&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Current&#8211;previous hours &#40;h&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;1&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;749&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Treatment</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Duration &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;0 &#40;36&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;0 &#40;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;447&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total days of usage &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;0 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;0 &#40;24&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;976&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hours&#47;night &#40;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5 &#40;2&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span> and fixed pressure &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;9 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;040&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab266523.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of characteristics between patients with and without new-onset insomnia &#40;NOI&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Quantitative variables are expressed as median &#40;interquartile range&#41;&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ESS&#58; Epworth Sleepiness Scale&#59; NOI&#58; new-onset insomnia&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Without NOI <span class="elsevierStyleItalic">n</span>&#61;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">With NOI <span class="elsevierStyleItalic">n</span>&#61;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Baseline ESS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;0 &#40;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;0 &#40;11&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;667&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Current ESS&#8211;baseline ESS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;6&#46;0 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;5&#46;0 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;502&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab266525.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Baseline Epworth Sleepiness Scale &#40;ESS&#41; and its variation in patients with and without new-onset insomnia &#40;NOI&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Quantitative variables are expressed as median &#40;interquartile range&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">NOI&#58; new-onset insomnia&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&#58; pressure on 90&#37; nighttime&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Subtype of NOI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">90</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Without NOI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;9 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;067&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial NOI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate NOI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Final NOI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Initial<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>intermediate NOI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&#46;5 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; No geral&#44; considera que tem problemas com o seu sono&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; &#201; f&#225;cil para si adormecer&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; Sempre que tem preocupa&#231;&#245;es isso traduz-se em problemas no seu sono&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; Acorda facilmente com ru&#237;dos durante a noite&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; Que n&#237;vel de inc&#243;modo sente quando dorme noutro local&#47;cama diferente do habitual&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; O seu sono &#233; perturbado com frequentes despertares durante a noite&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; Adormecer ap&#243;s acordar durante a noite &#233; um problema&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46; Sente-se descansado&#40;a&#41; no dia seguinte&#44; ap&#243;s uma noite de sono&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46; Acha que dorme o n&#250;mero de horas suficientes por noite&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#46; Quanto &#233; que a qualidade do seu sono o&#40;a&#41; afecta nas suas actividades di&#225;rias &#40;fadiga&#44; humor&#44; irritabilidade&#41;&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Total &#40;0&#8211;40&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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