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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">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 href="&#35;bib6" class="elsevierStyleCrossRefs"><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 href="&#35;bib7" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 class="elsevierStylePara">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 class="elsevierStylePara">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&#160;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 href="&#35;t0005" class="elsevierStyleCrossRefs">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 href="&#35;t0010" class="elsevierStyleCrossRefs">Table 2</a>&#41;&#46; More than half of the non-compliant patients &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;11&#59; 55&#37;&#41; needed other therapeutic options&#44; mainly continuous positive airway pressure &#40;CPAP&#41; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;10&#41;&#46; Only 2 compliant patients needed other therapies &#40;1 CPAP and 1 mandibular advancement device&#41;&#46;</p><p class="elsevierStylePara">Table 1&#46; Patients demographic and clinical characteristics related to therapeutic adherence&#46;</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>High adherence</td><td>Low adherence</td><td><span class="elsevierStyleItalic">p</span> value</td></tr><tr align="left"><td>Gender &#40;M&#47;F&#41;</td><td>20&#47;6</td><td>16&#47;4</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Age &#40;yr&#41;</td><td>56&#46;5&#160;&#177;&#160;9&#46;4</td><td>56&#46;1&#160;&#177;&#160;9&#46;1</td><td>NS  <span class="elsevierStyleSup">b</span></td></tr><tr align="left"><td>Body Mass Index &#40;Kg&#47;m<span class="elsevierStyleSup">2</span>&#41;</td><td>28&#46;5&#160;&#177;&#160;3&#46;8</td><td>30&#46;2&#160;&#177;&#160;4&#46;7</td><td>NS  <span class="elsevierStyleSup">b</span></td></tr><tr align="left"><td>Hypertension&#44; n &#40;&#37;&#41;</td><td>15 &#40;57&#46;7&#37;&#41;</td><td>13 &#40;65&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Diabetes mellitus&#44; n &#40;&#37;&#41;</td><td>3 &#40;11&#46;5&#37;&#41;</td><td>6 &#40;30&#37;&#41;</td><td><span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;05  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Ischemic vascular disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>0</td><td>4 &#40;20&#37;&#41;</td><td><span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;05  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Heart Failure&#44; n &#40;&#37;&#41;</td><td>0</td><td>2 &#40;10&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Oncologic disease&#44; n &#40;&#37;&#41;</td><td>0</td><td>2 &#40;10&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr></table><p class="elsevierStylePara">a Chi-square test&#46;<br></br>b Student <span class="elsevierStyleItalic">t</span> test for independent samples&#46;<br></br></p><p class="elsevierStylePara">Table 2&#46; Sleep respiratory variables in baseline and follow-up study&#46;</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>Baseline study</td><td>Follow-up study</td><td><span class="elsevierStyleItalic">p</span> value</td></tr><tr align="left"><td>Epworth sleepiness scale</td><td>11&#46;0&#160;&#177;&#160;3&#46;6</td><td>7&#46;9&#160;&#177;&#160;3&#46;6</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Total AHI &#40;events&#47;h&#41;</td><td>15&#46;0&#160;&#177;&#160;7&#46;6</td><td>9&#46;3&#160;&#177;&#160;7&#46;0</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Supine AHI &#40;events&#47;h&#41;</td><td>34&#46;2&#160;&#177;&#160;18&#46;8</td><td>24&#46;3&#160;&#177;&#160;19&#46;4</td><td>&#60;0&#46;01  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Supine time &#40;&#37;&#41;</td><td>40&#46;0&#160;&#177;&#160;15&#46;5</td><td>17&#46;1&#160;&#177;&#160;14&#46;1</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Oxygen desaturation index &#40;events&#47;h&#41;</td><td>14&#46;8&#160;&#177;&#160;6&#46;6</td><td>8&#46;8&#160;&#177;&#160;6&#46;8</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Minimal SpO<span class="elsevierStyleInf">2</span></td><td>82&#46;2&#160;&#177;&#160;5&#46;1</td><td>85&#46;8&#160;&#177;&#160;3&#46;7</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Mean SpO<span class="elsevierStyleInf">2</span></td><td>93&#46;7&#160;&#177;&#160;1&#46;6</td><td>94&#46;2&#160;&#177;&#160;1&#46;5</td><td>&#60;0&#46;01  <span class="elsevierStyleSup">a</span></td></tr></table><p class="elsevierStylePara">a Student <span class="elsevierStyleItalic">t</span> test for paired samples&#59; AHI&#58; Apnea-hypopnea index&#46;<br></br></p><p class="elsevierStylePara">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 href="&#35;bib8" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 href="&#35;bib9" class="elsevierStyleCrossRefs"><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 href="&#35;bib10" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 class="elsevierStylePara">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><a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara">Corresponding author&#46; pmsotto&#64;hotmail&#46;com</p>"
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Positional sleep apnea: An issue of therapeutic adherence
P.. Matosa,
Corresponding author
pmsotto@hotmail.com

Corresponding author. pmsotto@hotmail.com
, F.. Fradinhoa, A.. Catarinoa, P.. Lopesa, M.J.. Matosa
a Pulmonology Department, Sleep Laboratory, HUC-CHUC, Coimbra, Portugal
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">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 href="&#35;bib6" class="elsevierStyleCrossRefs"><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 href="&#35;bib7" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 class="elsevierStylePara">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 class="elsevierStylePara">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&#160;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 href="&#35;t0005" class="elsevierStyleCrossRefs">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 href="&#35;t0010" class="elsevierStyleCrossRefs">Table 2</a>&#41;&#46; More than half of the non-compliant patients &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;11&#59; 55&#37;&#41; needed other therapeutic options&#44; mainly continuous positive airway pressure &#40;CPAP&#41; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;10&#41;&#46; Only 2 compliant patients needed other therapies &#40;1 CPAP and 1 mandibular advancement device&#41;&#46;</p><p class="elsevierStylePara">Table 1&#46; Patients demographic and clinical characteristics related to therapeutic adherence&#46;</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>High adherence</td><td>Low adherence</td><td><span class="elsevierStyleItalic">p</span> value</td></tr><tr align="left"><td>Gender &#40;M&#47;F&#41;</td><td>20&#47;6</td><td>16&#47;4</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Age &#40;yr&#41;</td><td>56&#46;5&#160;&#177;&#160;9&#46;4</td><td>56&#46;1&#160;&#177;&#160;9&#46;1</td><td>NS  <span class="elsevierStyleSup">b</span></td></tr><tr align="left"><td>Body Mass Index &#40;Kg&#47;m<span class="elsevierStyleSup">2</span>&#41;</td><td>28&#46;5&#160;&#177;&#160;3&#46;8</td><td>30&#46;2&#160;&#177;&#160;4&#46;7</td><td>NS  <span class="elsevierStyleSup">b</span></td></tr><tr align="left"><td>Hypertension&#44; n &#40;&#37;&#41;</td><td>15 &#40;57&#46;7&#37;&#41;</td><td>13 &#40;65&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Diabetes mellitus&#44; n &#40;&#37;&#41;</td><td>3 &#40;11&#46;5&#37;&#41;</td><td>6 &#40;30&#37;&#41;</td><td><span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;05  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Ischemic vascular disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>0</td><td>4 &#40;20&#37;&#41;</td><td><span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;05  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Heart Failure&#44; n &#40;&#37;&#41;</td><td>0</td><td>2 &#40;10&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Oncologic disease&#44; n &#40;&#37;&#41;</td><td>0</td><td>2 &#40;10&#37;&#41;</td><td>NS  <span class="elsevierStyleSup">a</span></td></tr></table><p class="elsevierStylePara">a Chi-square test&#46;<br></br>b Student <span class="elsevierStyleItalic">t</span> test for independent samples&#46;<br></br></p><p class="elsevierStylePara">Table 2&#46; Sleep respiratory variables in baseline and follow-up study&#46;</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>Baseline study</td><td>Follow-up study</td><td><span class="elsevierStyleItalic">p</span> value</td></tr><tr align="left"><td>Epworth sleepiness scale</td><td>11&#46;0&#160;&#177;&#160;3&#46;6</td><td>7&#46;9&#160;&#177;&#160;3&#46;6</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Total AHI &#40;events&#47;h&#41;</td><td>15&#46;0&#160;&#177;&#160;7&#46;6</td><td>9&#46;3&#160;&#177;&#160;7&#46;0</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Supine AHI &#40;events&#47;h&#41;</td><td>34&#46;2&#160;&#177;&#160;18&#46;8</td><td>24&#46;3&#160;&#177;&#160;19&#46;4</td><td>&#60;0&#46;01  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Supine time &#40;&#37;&#41;</td><td>40&#46;0&#160;&#177;&#160;15&#46;5</td><td>17&#46;1&#160;&#177;&#160;14&#46;1</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Oxygen desaturation index &#40;events&#47;h&#41;</td><td>14&#46;8&#160;&#177;&#160;6&#46;6</td><td>8&#46;8&#160;&#177;&#160;6&#46;8</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Minimal SpO<span class="elsevierStyleInf">2</span></td><td>82&#46;2&#160;&#177;&#160;5&#46;1</td><td>85&#46;8&#160;&#177;&#160;3&#46;7</td><td>&#60;0&#46;001  <span class="elsevierStyleSup">a</span></td></tr><tr align="left"><td>Mean SpO<span class="elsevierStyleInf">2</span></td><td>93&#46;7&#160;&#177;&#160;1&#46;6</td><td>94&#46;2&#160;&#177;&#160;1&#46;5</td><td>&#60;0&#46;01  <span class="elsevierStyleSup">a</span></td></tr></table><p class="elsevierStylePara">a Student <span class="elsevierStyleItalic">t</span> test for paired samples&#59; AHI&#58; Apnea-hypopnea index&#46;<br></br></p><p class="elsevierStylePara">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 href="&#35;bib8" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 href="&#35;bib9" class="elsevierStyleCrossRefs"><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 href="&#35;bib10" class="elsevierStyleCrossRefs"><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 class="elsevierStylePara">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 class="elsevierStylePara">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><a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara">Corresponding author&#46; pmsotto&#64;hotmail&#46;com</p>"
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