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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cartwright in 1984 defined positional obstructive sleep apnea &#40;OSA&#41; patients as those in whom the apnea-hypopnea index &#40;AHI&#41; was at least twice as high while sleeping in the supine as in the non-supine position&#46; Several authors intended&#44; since then&#44; to propose better classification systems&#44; but the first &#40;and simplest&#41; is still used nowadays&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In general&#44; the prevalence of positional variant is higher in mild to moderate OSA&#44; where it can reach 65&#8211;69&#37;&#44; but varies from 9 to 69&#37;&#46; It is inversely correlated to OSA severity&#44; body mass index &#40;BMI&#41; and age&#46; This classification intended to better identify whose patients did not require ventilatory support and could be treated with positional therapy &#40;PT&#41;&#44; a more economical and practical treatment&#46; Traditionally&#44; it has been used a tennis ball inside a pocket sewed in the back of a nightshirt as the positional &#8220;device&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Nevertheless&#44; ineffectiveness&#44; backache&#44; discomfort and no improvement in sleep quality or daytime alertness have been responsible for poor compliance and subsequent disappointing long-term results of positional therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">With this in mind&#44; we carried out a study to determine the effectiveness of usual conservative measures and PT with tennis ball technique &#40;TBT&#41; and to verify the compliance to this therapy in our population&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 93 positional OSA patients were retrospectively identified after a cardiorespiratory sleep study with 7 channels in our center&#44; in which the supine AHI was at least twice as high as in a non-supine position&#46; Booklets were provided to patients with information on hygiene&#44; dietary and sleep rules&#44; snoring and TBT&#46; These patients were reassessed in a follow-up visit in average in 3&#8211;6 months&#44; and a follow-up sleep study was then performed&#44; under positional therapy with TBT&#46; Sleep related parameters&#44; subject&#39;s characteristics and Epworth Sleepiness Scale &#40;ESS&#41; were evaluated&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Forty six &#40;49&#46;5&#37;&#41; patients performed the follow-up night study with the TBT&#46; There were 36 men &#40;78&#46;3&#37;&#41;&#44; with average age of 54&#44;8 years and mean BMI of 29&#46;3<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; Of these 46 patients&#44; only 26 &#40;56&#46;5&#37;&#41; said to correctly use the tennis ball every or almost every night&#44; considered as high adherence patients group&#46; We found differences between the two groups of patients &#40;high and low adherence&#41;&#46; They did not significantly differ in parameters such as age&#44; gender&#44; or BMI&#44; however&#44; the low adherence patients had more comorbidities&#58; higher prevalence of diabetes mellitus and ischemic vascular disease &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Results of the follow-up study showed an improvement in all parameters&#44; with mean total AHI decrease from 15&#46;0&#47;h to 9&#46;3&#47;h and mean supine AHI from 34&#46;2&#47;h to 24&#46;3&#47;h&#46; Time spent in supine position fell from 40&#37; to 17&#46;1&#37;&#44; oxygen desaturation index &#40;ODI&#41; from 14&#46;8&#47;h to 8&#46;8&#47;h and minimum SpO2 increased from 82&#46;2&#37; to 85&#46;6&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; More than half of the non-compliant patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#59; 55&#37;&#41; needed other therapeutic options&#44; mainly continuous positive airway pressure &#40;CPAP&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Only 2 compliant patients needed other therapies &#40;1 CPAP and 1 mandibular advancement device&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In our results&#44; PT and other conservative measures were effective&#44; with good clinical outcomes when enforced&#46; There was a significant decrease in sleepiness accessed by ESS&#44; and improvement in the overall sleep respiratory parameters&#46; However&#44; there is a high level of noncompliance with 20 patients &#40;43&#46;5&#37;&#41; reporting low adherence&#46; Nevertheless&#44; these results &#40;56&#46;5&#37; of compliance&#41; seem better than other studies&#46; Oksenberg et al&#46;&#44; reported only 38&#37; of compliance with TBT at six months&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The compliant patients in that study were older&#44; and the main reason for stopping was discomfort&#46; Our results showed no differences in age&#44; but we found non-compliant patients to have more comorbidities and more severe illnesses&#44; as oncologic and cardiovascular diseases&#46; These patients may underestimate the burden of OSA&#44; considering it as a minor health problem&#46; Just half of the low adherent patients accepted CPAP therapy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Results in long-term tend to be even worse&#44; as demonstrated by Bignold et al&#46;&#44; with only 6&#37; of patients still using the TBT after 2&#46;5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> As so&#44; currently&#44; several new devices to replace the TBT are becoming available on the international market&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However the efficacy of these modalities has not been studied in clinical trials on long-term or been patented&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; Data on TBT compliance and patients division in adherence groups was accessed only in a subjective way &#40;interview in follow-up visit&#41;&#46; Validated questionnaires on these topics could have been used in a prospective study&#46; Unfortunately&#44; we could not infer why 47 patients did not attend the follow-up study&#44; however most of them attended to the follow-up visit reporting good results with the recommended measures&#46; We can speculate they were relieved by knowing their OSA was not severe&#44; and&#44; at least&#44; changed their lifestyle&#44; not feeling the need for further examination&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; despite our relatively small sample&#44; we can infer that TBT is a simple&#44; cheap and an effective form of PT when used in selected patients with clear positional OSA&#44; as shown by good disease control in our adherent patients&#46; Compliance remains an issue&#44; even with the development of new devices&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
Positional sleep apnea: An issue of therapeutic adherence
P. Matos
Corresponding author
pmsotto@hotmail.com

Corresponding author.
, F. Fradinho, A. Catarino, P. Lopes, M.J. Matos
Pulmonology Department, Sleep Laboratory, HUC-CHUC, Coimbra, Portugal
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      "titulo" => "Alpha-1 antitrypsin deficiency caused by a novel mutation &#40;p&#46;Leu263Pro&#41;&#58; Pi&#42;ZQ0gaia &#8211; Q0gaia allele"
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            "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Characterization of Q0Gaia allele&#46; &#40;A&#41; Protein gel electrophoresis&#46; Index case ZQ0 displays only a band corresponding to PI&#42;Z allele&#46; &#40;B&#41; Electropherogram of the index case&#46; The arrow shows the region of the T to C mutation in codon 263&#46;</p>"
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    "titulo" => "Positional sleep apnea&#58; An issue of therapeutic adherence"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cartwright in 1984 defined positional obstructive sleep apnea &#40;OSA&#41; patients as those in whom the apnea-hypopnea index &#40;AHI&#41; was at least twice as high while sleeping in the supine as in the non-supine position&#46; Several authors intended&#44; since then&#44; to propose better classification systems&#44; but the first &#40;and simplest&#41; is still used nowadays&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In general&#44; the prevalence of positional variant is higher in mild to moderate OSA&#44; where it can reach 65&#8211;69&#37;&#44; but varies from 9 to 69&#37;&#46; It is inversely correlated to OSA severity&#44; body mass index &#40;BMI&#41; and age&#46; This classification intended to better identify whose patients did not require ventilatory support and could be treated with positional therapy &#40;PT&#41;&#44; a more economical and practical treatment&#46; Traditionally&#44; it has been used a tennis ball inside a pocket sewed in the back of a nightshirt as the positional &#8220;device&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Nevertheless&#44; ineffectiveness&#44; backache&#44; discomfort and no improvement in sleep quality or daytime alertness have been responsible for poor compliance and subsequent disappointing long-term results of positional therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">With this in mind&#44; we carried out a study to determine the effectiveness of usual conservative measures and PT with tennis ball technique &#40;TBT&#41; and to verify the compliance to this therapy in our population&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 93 positional OSA patients were retrospectively identified after a cardiorespiratory sleep study with 7 channels in our center&#44; in which the supine AHI was at least twice as high as in a non-supine position&#46; Booklets were provided to patients with information on hygiene&#44; dietary and sleep rules&#44; snoring and TBT&#46; These patients were reassessed in a follow-up visit in average in 3&#8211;6 months&#44; and a follow-up sleep study was then performed&#44; under positional therapy with TBT&#46; Sleep related parameters&#44; subject&#39;s characteristics and Epworth Sleepiness Scale &#40;ESS&#41; were evaluated&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Forty six &#40;49&#46;5&#37;&#41; patients performed the follow-up night study with the TBT&#46; There were 36 men &#40;78&#46;3&#37;&#41;&#44; with average age of 54&#44;8 years and mean BMI of 29&#46;3<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; Of these 46 patients&#44; only 26 &#40;56&#46;5&#37;&#41; said to correctly use the tennis ball every or almost every night&#44; considered as high adherence patients group&#46; We found differences between the two groups of patients &#40;high and low adherence&#41;&#46; They did not significantly differ in parameters such as age&#44; gender&#44; or BMI&#44; however&#44; the low adherence patients had more comorbidities&#58; higher prevalence of diabetes mellitus and ischemic vascular disease &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Results of the follow-up study showed an improvement in all parameters&#44; with mean total AHI decrease from 15&#46;0&#47;h to 9&#46;3&#47;h and mean supine AHI from 34&#46;2&#47;h to 24&#46;3&#47;h&#46; Time spent in supine position fell from 40&#37; to 17&#46;1&#37;&#44; oxygen desaturation index &#40;ODI&#41; from 14&#46;8&#47;h to 8&#46;8&#47;h and minimum SpO2 increased from 82&#46;2&#37; to 85&#46;6&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; More than half of the non-compliant patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#59; 55&#37;&#41; needed other therapeutic options&#44; mainly continuous positive airway pressure &#40;CPAP&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Only 2 compliant patients needed other therapies &#40;1 CPAP and 1 mandibular advancement device&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In our results&#44; PT and other conservative measures were effective&#44; with good clinical outcomes when enforced&#46; There was a significant decrease in sleepiness accessed by ESS&#44; and improvement in the overall sleep respiratory parameters&#46; However&#44; there is a high level of noncompliance with 20 patients &#40;43&#46;5&#37;&#41; reporting low adherence&#46; Nevertheless&#44; these results &#40;56&#46;5&#37; of compliance&#41; seem better than other studies&#46; Oksenberg et al&#46;&#44; reported only 38&#37; of compliance with TBT at six months&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The compliant patients in that study were older&#44; and the main reason for stopping was discomfort&#46; Our results showed no differences in age&#44; but we found non-compliant patients to have more comorbidities and more severe illnesses&#44; as oncologic and cardiovascular diseases&#46; These patients may underestimate the burden of OSA&#44; considering it as a minor health problem&#46; Just half of the low adherent patients accepted CPAP therapy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Results in long-term tend to be even worse&#44; as demonstrated by Bignold et al&#46;&#44; with only 6&#37; of patients still using the TBT after 2&#46;5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> As so&#44; currently&#44; several new devices to replace the TBT are becoming available on the international market&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However the efficacy of these modalities has not been studied in clinical trials on long-term or been patented&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; Data on TBT compliance and patients division in adherence groups was accessed only in a subjective way &#40;interview in follow-up visit&#41;&#46; Validated questionnaires on these topics could have been used in a prospective study&#46; Unfortunately&#44; we could not infer why 47 patients did not attend the follow-up study&#44; however most of them attended to the follow-up visit reporting good results with the recommended measures&#46; We can speculate they were relieved by knowing their OSA was not severe&#44; and&#44; at least&#44; changed their lifestyle&#44; not feeling the need for further examination&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; despite our relatively small sample&#44; we can infer that TBT is a simple&#44; cheap and an effective form of PT when used in selected patients with clear positional OSA&#44; as shown by good disease control in our adherent patients&#46; Compliance remains an issue&#44; even with the development of new devices&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total AHI &#40;events&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Supine AHI &#40;events&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Supine time &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Oxygen desaturation index &#40;events&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Minimal SpO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mean SpO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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ISSN: 21735115
Original language: English
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