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    "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction</span><p class="elsevierStylePara">Obstructive sleep apnea &#40;OSA&#41; is a highly prevalent disorder affecting up to 20&#37; of the general population<a href="&#35;bib30" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> and can occur in all age groups&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a> OSA&#44; even if asymptomatic&#44; is independently associated with increased morbidity and mortality due to cardiovascular and neurovascular diseases&#44; metabolic disorders&#44; and impaired neurocognitive function&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib34" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> Although prevalent&#44; it has been estimated that 82&#37; of men and 92&#37; of women with moderate&#47;severe OSA may be undiagnosed&#46;<a href="&#35;bib35" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a></p><p class="elsevierStylePara">Consequently a simple and reliable method of screening certain populations&#44; namely high-risk groups&#44; is needed&#46; The choice of screening method will depend on its ability to achieve a specific objective&#58; to include patients with OSA for appropriate sleep testing&#59; to detect those with more severe disease prompting diagnosis and treatment&#59; and to exclude patients without OSA or those without moderate&#47;severe OSA whose evaluation and treatment is less pressing&#46; Such screening methods are increasingly important due to the growing number of suspected OSA patients being referred to sleep clinics&#46; Numerous clinical prediction models have been developed based upon self-reported symptoms&#44; demographics&#44; anthropometric variables&#44; and comorbidities&#46;<a href="&#35;bib36" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib37" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> One tool commonly used to identify patients with potential sleep disorders is the Epworth Sleepiness Scale &#40;ESS&#41;&#44; but the ESS was developed to measure propensity for sleep onset rather than the likelihood of sleep disordered breathing&#46;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib39" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> A recently proposed screening method is the STOP-Bang questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> a scoring model consisting of eight Yes&#47;No questions &#40;score&#58; 1&#47;0&#44; with scores ranging from a value of 0 to 8&#41;&#44; which make it a potentially simple and easy to use screening method&#46; A score of &#8805;3 has shown a high sensitivity &#40;83&#46;6&#37;&#41; for detecting OSA in a surgical population&#44; but also in detecting moderate and severe OSA &#40;92&#46;9&#37; and 100&#37;&#44; respectively&#41;&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a></p><p class="elsevierStylePara">We assume that increasing the number of risk factors for OSA&#44; as reflected in the STOP-Bang questionnaire&#44; increases the probability of having OSA but also increases the likelihood of having other severe diseases&#46; We hypothesize that using the STOP-Bang questionnaire in a sleep medicine clinic may show a correlation between the model and the severity of OSA&#44; allowing us to determine a set of predicted probabilities for different disease severities&#46; This could ultimately enable clinicians&#44; in sleep medicine clinics&#44; to make more reasoned decisions about inclusion&#44; exclusion or the prioritization of patients for diagnostic and therapeutic evaluations&#46;</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Methods</span><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">STOP-Bang questionnaire translation</span><p class="elsevierStylePara">The Portuguese version of the STOP-Bang questionnaire was obtained using the following stages&#58; translation&#59; back translation&#59; comparison of the back translation with the original English version by a committee&#59; and usage with bilingual individuals&#46; Two independent translators translated the original questionnaire<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> into Portuguese and two other independent translators did the back translations&#46; A committee whose members were fluent in English fused the back-translated versions into a single one and compared it to the original English version&#46; Every individual question was analyzed according to the methods described&#46;<a href="&#35;bib41" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> The committee made the necessary adjustments and approved a final Portuguese version &#40;<a href="&#35;sec0075" class="elsevierStyleCrossRefs">Annex 1</a>&#41;&#46; In order to evaluate the equivalence between the original English and the Portuguese version&#44; 13 bilingual individuals completed both versions&#44; first the original version and&#44; after a week&#44; the Portuguese version&#46; Questions relating to the STOP portion were read and answered by the individuals&#44; and age&#44; gender&#44; weight&#44; height and neck circumference were measured and recorded in order to fill the Bang portion of the questionnaire&#46; Correlations between the scores obtained by both versions were calculated&#46;</p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Subjects and design</span><p class="elsevierStylePara">During a two-month period&#44; from December 2012&#44; patients referred to the clinic&#44; aged 18 years or older&#44; were asked if they were willing to be included in the study&#44; independently of the reasons for being referred&#44; which included referral for isolated symptoms&#44; clinical suspicion of a specific sleep disorder &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span> insomnia&#44; parasomnia or OSA&#41; or for screening of a sleep breathing disorder due to a recent cardiovascular event&#46; During the clinical consultation&#44; all the patients were asked to complete the STOP questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> and information concerning body mass index &#40;BMI&#41;&#44; age&#44; neck circumference&#44; and gender &#40;Bang&#41;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> was collected by a clinician&#47;research assistant&#46; The research staff gave no help in the interpretation or answering of the questionnaires&#46; A Sleep Disorders Questionnaire and ESS were previously mailed and answered at home&#46; In the following two months&#44; all the patients were invited to undergo a portable or laboratory polysomnography &#40;PSG&#41;&#46; Patients previously diagnosed with OSA or unable to read or write were not included in the study&#46;</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Sleep studies&#44; scoring and diagnosis</span><p class="elsevierStylePara">A laboratory PSG was performed when patients had a low clinical probability of OSA &#40;as judged by the physician&#41; or if there was a clinical suspicion that other sleep disorders might be present &#40;isolated or associated with OSA&#41;&#46; Patients with a moderate to high clinical probability were evaluated with a portable PSG&#46; In cases of technical errors or if the clinical context was not explained by a negative portable PSG a laboratory PSG was ultimately performed&#46;</p><p class="elsevierStylePara">Portable PSG was performed with a level III equipment &#40;Alice PDx&#44; Embletta X100&#44; Nox T3 or Stardust II&#41; that has been shown to be a reliable alternative to standard PSG in the diagnosis of OSA in adult patients&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a> PSG recordings were carried out in the patients&#8217; homes&#46; Recordings included nasal airflow&#44; thoracic and abdominal respiratory effort&#44; pulse oximeter&#44; body position sensor&#44; and lower limb electromyography &#40;EMG&#41; &#40;when available on the device&#41;&#46; The patients and their aides were instructed&#44; by a trained PSG technician&#44; on how to connect and remove the device&#46; The overnight home recordings were unattended&#46; The following morning the patient removed the device and returned it to the sleep clinic&#46; A sleep technician manually scored the recordings and a physician informed the patient of the results&#46; Laboratory PSG was performed overnight and patients went to bed at their usual bedtime&#46; A standard montage obtained with surface electrodes was used consisting of&#58; electroencephalogram&#44; electrooculogram&#44; submental and lower limb EMG&#44; and electrocardiogram&#46; Additional recordings included&#58; oronasal airflow &#40;thermistor and pressure sensor&#41;&#44; thoracic and abdominal respiratory effort&#44; pulse oximeter&#44; snore and body position sensor&#46; A well-trained PSG technician scored the PSG recordings under the supervision of a sleep physician who assessed and approved the reports&#46; The technician and sleep physician were blind to the study information &#40;STOP-Bang score and clinical information&#41;&#46; Manual scoring was performed according to the Manual of the American Academy of Sleep Medicine&#44;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a> and the American Academy of Sleep Medicine Task Force recommendations&#46;<a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> The diagnosis and severity of OSA were classified based on the Apnea-Hypopnea Index values&#58; &#62;5&#8211;15&#47;h as mild&#44; &#62;15&#8211;30&#47;h as moderate&#44; and &#62;30&#47;h as severe&#46;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> Other diagnoses&#44; in accordance with the International Classification of Sleep Disorders&#44;<a href="&#35;bib47" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> were based on&#58; clinical characteristics&#59; minimal follow-up of at least 6 months&#59; and results from laboratory PSG&#44; multiple sleep latency test&#44; or actigraphy&#46;</p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Analysis</span><p class="elsevierStylePara">Statistical analysis was performed using Statistical Package for the Social Sciences &#40;SPSS&#41; version 20 and MedCalc version 12&#46; Patients&#8217; characteristics are presented with the following descriptive statistics&#58; mean and standard deviation were used for normally distributed continuous data&#59; median and inter-quartile range were used for non-normally distributed continuous data&#59; and frequency and percentage were used for categorical data&#46; Reproducibility between the original and Portuguese version was assessed calculating the correlation of the scores from both versions with Pearson&#39;s correlation and using Cronbach&#39;s alpha to obtain intraclass correlation&#46; OSA and non-OSA groups were compared with Student&#39;s <span class="elsevierStyleItalic">t</span>-test for means&#44; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for medians and Chi-square test for proportions&#46; To assess the performance of the STOP-Bang questionnaire and the Epworth Sleepiness Scale in predicting OSA&#44; sensitivity&#44; specificity&#44; positive predictive values &#40;PPVs&#41; and negative predictive values &#40;NPVs&#41; were calculated for each score and for different AHI cut-offs&#46; Area under the receiver-operating curve &#40;ROC&#41; was also calculated to assess the diagnostic ability of the STOP-Bang questionnaire and the Epworth Sleepiness Scale for different AHI cut-offs&#46; Logistic regression was used to compare the severity of the AHI with the STOP-Bang score and to calculate predicted probabilities for different AHI cut-offs at each score&#46;</p><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStylePara">In the group of bilingual individuals&#44; the mean scores on the original STOP-Bang and Portuguese STOP-Bang were 2&#46;4&#160;&#177;&#160;1&#46;7 and 2&#46;3&#160;&#177;&#160;1&#46;7&#44; respectively&#44; showing good reproducibility between the original and the translated questionnaire &#40;intraclass correlation coefficient&#160;&#61;&#160;0&#46;932&#59; Pearson&#39;s <span class="elsevierStyleItalic">r</span>&#160;&#61;&#160;0&#46;928&#59; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#46;</p><p class="elsevierStylePara">A total of 216 patients were observed during the study period&#44; of which 215 &#40;99&#46;5&#37;&#41; completed the STOP-Bang questionnaire and performed a portable or laboratory PSG&#46; Of the 215 patients included in the final analysis&#44; 137 &#40;63&#46;7&#37;&#41; performed a portable PSG and 78 &#40;36&#46;2&#37;&#41; performed a laboratory PSG&#46; Of these 78 patients&#44; 19 had previously performed a portable PSG&#44; but due to technical errors or a clinical context the condition was not explained by a normal or near normal portable PSG&#44; a laboratory PSG was ultimately performed&#46; There were 6 patients in whom a negative portable PSG was not followed by a laboratory PSG because the study had been performed in excellent technical conditions and the patients described a full night&#39;s sleep&#46;</p><p class="elsevierStylePara">Descriptive summary statistics&#44; STOP-Bang characteristics&#44; AHI of the patient population and comparison of OSA and non-OSA groups are displayed in <a href="&#35;t0005" class="elsevierStyleCrossRefs">Table 1</a>&#46; Although greater or more prevalent in the OSA group&#44; Epworth score&#44; tiredness&#44; BMI &#62;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#44; and age &#62;50 years were the only characteristics which were not significantly different between the OSA and non-OSA group&#46; Of the 215 patients included for analysis 168 &#40;78&#37;&#41; had OSA of which&#44; 50 &#40;29&#46;8&#37;&#41;&#44; 56 &#40;33&#46;3&#37;&#41;&#44; and 62 &#40;36&#46;9&#37;&#41; had mild&#44; moderate&#44; and severe OSA&#44; respectively&#46; In the non-OSA group&#44; 3&#46;4&#37; of the patients had no sleep disorder while 9&#46;3&#37; had isolated insomnia&#44; 3&#46;3&#37; had isolated restless legs&#44; 2&#46;3&#37; had central sleep apnea syndromes&#44; 1&#46;7&#37; had idiopathic hypersomnia&#44; 1&#46;0&#37; had narcolepsy&#44; 1&#46;0&#37; had parasomnia and 0&#46;5&#37; had period leg movement disorder &#40;isolated&#41;&#46; The distribution of patients according to their STOP-Bang score is detailed in <a href="&#35;f0010" class="elsevierStyleCrossRefs">Figure 1</a>&#46; Most patients had a STOP-Bang score of 4 &#40;19&#46;5&#37;&#41;&#44; 5 or 6 &#40;both with 20&#46;9&#37;&#41;&#46;</p><p class="elsevierStylePara">Table 1&#46; Summary statistics of the patient population and comparison of OSA and non OSA group&#46;</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>All</td><td>OSA &#40;AHI&#160;&#62;&#160;5&#41;</td><td>Non-OSA &#40;AHI&#160;&#60;&#160;5&#41;</td><td><span class="elsevierStyleItalic">p</span> &#40;OSA <span class="elsevierStyleItalic">vs&#46;</span> nOSA&#41;</td></tr><tr align="left"><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>215</td><td>168 &#40;78&#37;&#41;</td><td>47 &#40;22&#37;&#41;</td><td>&#160;</td></tr><tr align="left"><td>Age &#40;years&#41;</td><td>53&#46;63&#160;&#177;&#160;13&#46;10</td><td>55&#46;14&#160;&#177;&#160;12&#46;98</td><td>48&#46;23&#160;&#177;&#160;12&#46;18</td><td>0&#46;0001</td></tr><tr align="left"><td>BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;</td><td>29&#46;41 &#91;26&#46;85&#59; 33&#46;06&#93;</td><td>30&#46;11 &#91;27&#46;69&#59; 34&#46;13&#93;</td><td>26&#46;91 &#91;25&#46;40&#59; 29&#46;39&#93;</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Neck circumference &#40;cm&#41;</td><td>40&#46;44&#160;&#177;&#160;4&#46;11</td><td>41&#46;32&#160;&#177;&#160;3&#46;75</td><td>37&#46;31&#160;&#177;&#160;3&#46;83</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Epworth&#39;s score</td><td>10&#46;00 &#91;5&#59; 15&#93;</td><td>10 &#91;5&#59; 16&#93;</td><td>8 &#91;4&#59; 14&#93;</td><td>0&#46;237 &#40;NS&#41;</td></tr><tr align="left"><td>Snore &#40;&#37;&#41;</td><td>73&#46;0</td><td>81&#46;5</td><td>42&#46;6</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Tiredness &#40;&#37;&#41;</td><td>61&#46;9</td><td>63&#46;7</td><td>55&#46;3</td><td>0&#46;296 &#40;NS&#41;</td></tr><tr align="left"><td>Observed apnea &#40;&#37;&#41;</td><td>52&#46;6</td><td>58&#46;3</td><td>31&#46;9</td><td>0&#46;0001</td></tr><tr align="left"><td>Pressure &#40;high blood&#41; &#40;&#37;&#41;</td><td>57&#46;2</td><td>63&#46;1</td><td>36&#46;2</td><td>0&#46;0001</td></tr><tr align="left"><td>BMI&#160;&#62;&#160;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span> &#40;&#37;&#41;</td><td>16&#46;3</td><td>17&#46;9</td><td>10&#46;6</td><td>0&#46;236 &#40;NS&#41;</td></tr><tr align="left"><td>Age&#160;&#62;&#160;50 years &#40;&#37;&#41;</td><td>60&#46;5</td><td>62&#46;5</td><td>53&#46;2</td><td>0&#46;249 &#40;NS&#41;</td></tr><tr align="left"><td>Neck circ&#46;&#160;&#62;&#160;40&#160;cm &#40;&#37;&#41;</td><td>56&#46;3</td><td>65&#46;5</td><td>23&#46;4</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Gender &#40;male&#41; &#40;&#37;&#41;</td><td>63&#46;3</td><td>71&#46;4</td><td>34&#46;0</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>STOP-Bang score</td><td>4&#46;41&#160;&#177;&#160;1&#46;70</td><td>4&#46;84&#160;&#177;&#160;1&#46;45</td><td>2&#46;87&#160;&#177;&#160;1&#46;66</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>AHI &#40;h&#41;</td><td>16&#46;7 &#91;7&#46;8&#59; 32&#46;9&#93;</td><td>21&#46;75 &#91;13&#46;52&#59; 38&#46;92&#93;</td><td>1&#46;6 &#91;0&#46;4&#59; 4&#46;0&#93;</td><td>&#60;0&#46;0001</td></tr></table><p class="elsevierStylePara">BMI&#58; body mass index&#59; AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#59; NS&#58; not significant&#46;<br></br></p><a name="f0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig1.jpg" alt="Distribution of patients according to their STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 1&#46; Distribution of patients according to their STOP-Bang score&#46;</p><p class="elsevierStylePara">Using the STOP-Bang model for the prediction of all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA&#44; the area under the ROC was 0&#46;806 &#40;95&#37; CI&#58; 0&#46;730&#8211;0&#46;881&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; 0&#46;730 &#40;95&#37; CI&#58; 0&#46;661&#8211;0&#46;798&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; and 0&#46;728 &#40;95&#37; CI&#58; 0&#46;655&#8211;0&#46;801&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; respectively&#44; confirming the diagnostic ability of the STOP-Bang model in all OSA severities&#46; Using the ESS as predictor&#44; the area under the ROC was 0&#46;556 &#40;95&#37; CI&#58; 0&#46;461&#8211;0&#46;652&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;238&#41;&#44; 0&#46;606 &#40;95&#37; CI&#58; 0&#46;529&#8211;0&#46;682&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;008&#41;&#44; and 0&#46;614 &#40;95&#37; CI&#58; 0&#46;533&#8211;0&#46;696&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;009&#41;&#44; for all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA&#44; respectively&#44; reflecting the inferior discriminative power of the ESS for the diagnosis of OSA&#46;</p><p class="elsevierStylePara">The sensitivity&#44; specificity&#44; PPV&#44; and NPV for all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA are summarized in <a href="&#35;t0010" class="elsevierStyleCrossRefs">Table 2</a>&#46; With a STOP-Bang score &#8805;3 the sensitivity and PPV were 93&#46;4&#37; and 86&#46;6&#37; for all OSA&#44; 95&#46;7&#37; and 62&#46;4&#37; for moderate&#47;severe OSA and 98&#46;4&#37; and 33&#46;7&#37; for severe OSA&#44; respectively&#46; With the same cut-off the negative predictive value for moderate&#47;severe and severe OSA were 85&#46;3&#37; and 97&#46;1&#37;&#44; respectively&#46; As the STOP-Bang score increased from 3 to 7&#44; the specificity and PPV increased continuously from 48&#46;9&#37; to 97&#46;9&#37; and 86&#46;6&#37; to 95&#46;0&#37; for all OSA&#59; 29&#46;9&#37; to 95&#46;5&#37; and 62&#46;4&#37; to 80&#37; for moderate&#47;severe OSA&#59; and 21&#46;9&#37; to 95&#46;4&#37; and 33&#46;7&#37; to 63&#46;9&#37; for severe OSA&#44; respectively&#46;</p><p class="elsevierStylePara">Table 2&#46; Predictive parameters of each STOP-Bang score cut-offs for different AHI levels &#40;<span class="elsevierStyleItalic">n</span>&#44; number of patients in the AHI group who scored the STOP-Bang score indicated or higher&#59; percentage out of the 215 patients&#41;&#46;</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>STOP-Bang score cut-off</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Sensitivity</td><td>Specificity</td><td>PPV</td><td>NPV</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">All OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">5&#41;</span></td></tr><tr align="left"><td>1</td><td>168 &#40;78&#46;1&#41;</td><td>100&#46;0</td><td>2&#46;1</td><td>78&#46;4</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>167 &#40;77&#46;8&#41;</td><td>99&#46;4</td><td>23&#46;4</td><td>82&#46;1</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>157 &#40;73&#46;0&#41;</td><td>93&#46;4</td><td>48&#46;9</td><td>86&#46;6</td><td>67&#46;8</td></tr><tr align="left"><td>4</td><td>136 &#40;63&#46;2&#41;</td><td>81&#46;0</td><td>66&#46;0</td><td>89&#46;4</td><td>49&#46;4</td></tr><tr align="left"><td>5</td><td>102 &#40;47&#46;4&#41;</td><td>60&#46;7</td><td>83&#46;0</td><td>92&#46;7</td><td>37&#46;3</td></tr><tr align="left"><td>6</td><td>61 &#40;28&#46;4&#41;</td><td>36&#46;3</td><td>91&#46;5</td><td>93&#46;8</td><td>28&#46;8</td></tr><tr align="left"><td>7</td><td>19 &#40;8&#46;8&#41;</td><td>11&#46;3</td><td>97&#46;9</td><td>95&#46;0</td><td>23&#46;7</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>1&#46;79</td><td>100&#46;0</td><td>100&#46;0</td><td>22&#46;3</td></tr><tr align="left"><td colspan="6">&#160;</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Moderate&#47;severe OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">15&#41;</span></td></tr><tr align="left"><td>1</td><td>118 &#40;54&#46;9&#41;</td><td>100&#46;0</td><td>1&#46;0</td><td>55&#46;2</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>117 &#40;54&#46;4&#41;</td><td>99&#46;2</td><td>11&#46;3</td><td>57&#46;7</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>113 &#40;52&#46;6&#41;</td><td>95&#46;7</td><td>29&#46;9</td><td>62&#46;4</td><td>85&#46;3</td></tr><tr align="left"><td>4</td><td>102 &#40;47&#46;4&#41;</td><td>86&#46;5</td><td>48&#46;4</td><td>67&#46;1</td><td>74&#46;6</td></tr><tr align="left"><td>5</td><td>78 &#40;36&#46;3&#41;</td><td>66&#46;1</td><td>67&#46;0</td><td>70&#46;9</td><td>61&#46;9</td></tr><tr align="left"><td>6</td><td>49 &#40;22&#46;8&#41;</td><td>41&#46;5</td><td>83&#46;5</td><td>75&#46;4</td><td>54&#46;0</td></tr><tr align="left"><td>7</td><td>16 &#40;7&#46;4&#41;</td><td>13&#46;6</td><td>95&#46;9</td><td>80&#46;0</td><td>47&#46;7</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>2&#46;5</td><td>100&#46;0</td><td>100&#46;0</td><td>45&#46;7</td></tr><tr align="left"><td colspan="6">&#160;</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Severe OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">30&#41;</span></td></tr><tr align="left"><td>1</td><td>62 &#40;28&#46;8&#41;</td><td>100&#46;0</td><td>0&#46;7</td><td>28&#46;9</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>61 &#40;28&#46;4&#41;</td><td>98&#46;4</td><td>7&#46;2</td><td>30&#46;0</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>61 &#40;28&#46;4&#41;</td><td>98&#46;4</td><td>21&#46;9</td><td>33&#46;7</td><td>97&#46;1</td></tr><tr align="left"><td>4</td><td>55 &#40;25&#46;6&#41;</td><td>88&#46;7</td><td>36&#46;8</td><td>36&#46;3</td><td>89&#46;0</td></tr><tr align="left"><td>5</td><td>46 &#40;21&#46;4&#41;</td><td>74&#46;2</td><td>57&#46;9</td><td>41&#46;7</td><td>84&#46;7</td></tr><tr align="left"><td>6</td><td>34 &#40;15&#46;8&#41;</td><td>54&#46;8</td><td>79&#46;6</td><td>52&#46;1</td><td>81&#46;3</td></tr><tr align="left"><td>7</td><td>13 &#40;6&#46;0&#41;</td><td>21&#46;0</td><td>95&#46;4</td><td>63&#46;9</td><td>74&#46;9</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>4&#46;8</td><td>100&#46;0</td><td>100&#46;0</td><td>72&#46;2</td></tr></table><p class="elsevierStylePara">AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#59; PPV&#58; positive predictive value&#59; NPV&#58; negative predictive value&#46;<br></br></p><p class="elsevierStylePara">The predicted probabilities of having OSA&#44; moderate&#47;severe OSA&#44; and severe OSA are shown in <a href="&#35;t0015" class="elsevierStyleCrossRefs">Table 3</a>&#46; As the STOP-Bang score increased from 2 to 8&#44; the probability of having OSA&#44; moderate&#47;severe OSA&#44; and severe OSA increased continuously from 44&#37; to 99&#37;&#44; 24&#37; to 90&#37; and 7&#37; to 73&#37;&#44; respectively&#46; This trend&#44; present in all groups is illustrated in <a href="&#35;f0015" class="elsevierStyleCrossRefs">Figure 2</a>&#46; The predicted probabilities of having OSA of a specific severity are illustrated in <a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#46; With each incremental increase in the score from 0 to 4&#44; the probability of having no sleep apnea diminished&#44; while the probability of having mild&#44; moderate&#44; or severe sleep apnea increased&#46; With any score greater than 4&#44; only the probability of having severe sleep apnea increased continuously&#46;</p><p class="elsevierStylePara">Table 3&#46; Predicted probabilities of each STOP-Bang score for different AHI levels &#40;<span class="elsevierStyleItalic">n</span>&#44; number of patients in the AHI group who scored the STOP-Bang score indicated&#59; percentage out of the 215 patients&#41;&#46;</p><a name="t0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Score</td><td colspan="2">All OSA &#40;AHI&#160;&#62;&#160;5&#41;</td><td colspan="2">Mod&#46;&#47;severe OSA &#40;AHI&#160;&#62;&#160;15&#41;</td><td colspan="2">Severe OSA &#40;AHI&#160;&#62;&#160;30&#41;</td></tr><tr align="left"><td>&#160;</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td></tr><tr align="left"><td>1</td><td>1 &#40;0&#46;6&#41;</td><td>0&#46;26</td><td>1 &#40;0&#46;8&#41;</td><td>0&#46;15</td><td>1 &#40;1&#46;6&#41;</td><td>0&#46;04</td></tr><tr align="left"><td>2</td><td>10 &#40;6&#46;0&#41;</td><td>0&#46;44</td><td>4 &#40;3&#46;4&#41;</td><td>0&#46;24</td><td>0 &#40;0&#46;0&#41;</td><td>0&#46;07</td></tr><tr align="left"><td>3</td><td>21 &#40;12&#46;5&#41;</td><td>0&#46;64</td><td>11 &#40;9&#46;3&#41;</td><td>0&#46;36</td><td>6 &#40;9&#46;7&#41;</td><td>0&#46;13</td></tr><tr align="left"><td>4</td><td>34 &#40;20&#46;2&#41;</td><td>0&#46;80</td><td>24 &#40;20&#46;3&#41;</td><td>0&#46;50</td><td>9 &#40;14&#46;5&#41;</td><td>0&#46;21</td></tr><tr align="left"><td>5</td><td>41 &#40;24&#46;2&#41;</td><td>0&#46;90</td><td>29 &#40;24&#46;6&#41;</td><td>0&#46;64</td><td>12 &#40;19&#46;4&#41;</td><td>0&#46;32</td></tr><tr align="left"><td>6</td><td>42 &#40;25&#46;0&#41;</td><td>0&#46;95</td><td>33 &#40;28&#46;0&#41;</td><td>0&#46;75</td><td>21 &#40;33&#46;9&#41;</td><td>0&#46;46</td></tr><tr align="left"><td>7</td><td>16 &#40;9&#46;5&#41;</td><td>0&#46;98</td><td>13 &#40;11&#46;0&#41;</td><td>0&#46;84</td><td>10 &#40;16&#46;1&#41;</td><td>0&#46;61</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;8&#41;</td><td>0&#46;99</td><td>3 &#40;2&#46;5&#41;</td><td>0&#46;90</td><td>3 &#40;4&#46;8&#41;</td><td>0&#46;73</td></tr></table><p class="elsevierStylePara">AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#46;<br></br></p><a name="f0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig2.jpg" alt="Plot of predicted probabilities for different AHI levels with the corresponding STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 2&#46; Plot of predicted probabilities for different AHI levels with the corresponding STOP-Bang score&#46;</p><a name="f0020" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig3.jpg" alt="Plot of predicted probabilities for different OSA severities with the corresponding STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 3&#46; Plot of predicted probabilities for different OSA severities with the corresponding STOP-Bang score&#46;</p><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara">This study shows that&#44; in a population referred to a sleep medicine clinic&#44; a STOP-Bang score &#8805;3 has high sensitivity &#40;93&#46;4&#37;&#41; and PPV &#40;86&#46;6&#37;&#41; for the diagnosis of OSA and that the greater the STOP-Bang score&#44; reflecting a higher cumulative score of known risk factors&#44; the greater the probability of sleep apnea&#44; particularly severe sleep apnea &#40;<a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#41;&#46; The probability of OSA for score of 3 is of 64&#37; and increases continuously to 80&#37;&#44; 90&#37; and 95&#37; with a stepwise increase of the STOP-Bang score to 4&#44; 5&#44; and 6&#46; This performance is due to the continuously increasing probability of severe OSA for each score above 4&#44; reaching a predicted probability of 46&#37;&#44; 61&#37; and 73&#37; for a score of 6&#44; 7 and 8 &#40;<a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#41;&#44; respectively&#46; Moreover&#44; a score lower than 3 showed high discriminative power to exclude moderate to severe OSA&#44; as reflected by a negative predictive value of 85&#46;3&#37; and 91&#46;7&#37; for a score of 3 and 2&#44; respectively&#46; The area under the ROC curve was consistently high for the diagnostic ability of the STOP-Bang questionnaire for all OSA severities&#46; On the contrary&#44; the ESS&#44; as expected&#44; showed inferior ability for the prediction of moderate to severe and severe OSA and was non-significant for the prediction of all OSA&#46; Furthermore&#44; the ESS and tiredness &#40;as assessed by question T of the STOP-Bang questionnaire&#41; were statistically similar between the OSA and non-OSA groups&#44; albeit tending to be greater and more prevalent in the OSA group&#44; reflecting excessive daytime sleepiness and tiredness as similarly common complaints among patients with various sleep disorders&#46; Two other STOP-Bang characteristics&#44; BMI&#160;&#62;&#160;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span> and age &#62;&#160;50 years&#44; were also statistically not different&#44; although tending to be more prevalent in the OSA group&#46; This might be related to the specific cut-off values of the questionnaire&#44; as the OSA group was statistically more obese and older&#46;</p><p class="elsevierStylePara">Due to the relatively high prevalence of undiagnosed OSA and its short and long-term complications&#44; a reliable screening tool is required for a quick prediction of OSA&#46; A fast and reliable screening test can enable clinicians within a given clinical context to make more reasoned diagnostic decisions&#44; namely in stratifying patients for unrecognized OSA and triage for further diagnostic assessment and&#47;or treatment&#46; Questionnaires can be appropriate tools for that purpose since they can be applied and scored easily as part of routine daily practice&#46; Furthermore&#44; analysis of the questionnaire&#39;s performance in specific populations can provide clinicians with a set of predictive parameters for various levels of OSA severity&#44; which can be used as a valuable guide for diagnostic or therapeutic decisions&#46; In our study the present results show that the STOP-Bang questionnaire&#44; in the context of a sleep medicine clinic&#44; can be a very useful tool for triaging patients into three groups depending on their score&#58; score of 0&#8211;2 &#8211; low probability of OSA and very low probability of moderate&#47;severe OSA&#59; score of 3&#8211;4 &#8211; probable OSA&#59; score of 5&#8211;8 &#8211; high probability of moderate&#47;severe OSA&#46;</p><p class="elsevierStylePara">Several questionnaires and other clinical screening tests for obstructive sleep apnea have been analyzed&#46; In the meta-analysis by Ramachandran and Josephs<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> that included the American Society of Anesthesiologists &#40;ASA&#41; checklist&#44;<a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a> the Berlin questionnaire&#44;<a href="&#35;bib50" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a> the Sleep Questionnaire&#44;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a> the Sleep Disorders Questionnaire &#40;SDQ&#41;&#44;<a href="&#35;bib52" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">23</span></a> and the STOP and STOP-Bang questionnaires&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> the authors concluded that the Berlin questionnaire and the SDQ were the most accurate questionnaires overall to screen OSA&#44; while the ESS was the least accurate&#46; The authors identified the STOP-Bang questionnaire as an inferior screening tool but an excellent method for predicting severe OSA due to its simplicity and relative ease of use&#46; Another systematic review&#44; by Abrishami et al&#46;<a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> reported that the Wisconsin<a href="&#35;bib54" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> and the Berlin questionnaires had the highest sensitivity and specificity&#44; respectively&#46; However&#44; the authors argue that the validity of the studies was unclear due to potential selection bias as subjects in the Berlin study were pre-screened for the presence of snoring&#44; wake-time sleepiness or fatigue&#44; and history of obesity or hypertension&#46; In terms of predicting moderate or severe OSA&#44; the authors concluded that the STOP-Bang and the Berlin questionnaires were found to have the highest sensitivity and specificity&#44; respectively&#46; They also noted that the Berlin questionnaire&#44; which was shown to have high sensitivity for detecting OSA &#40;69&#8211;86&#37;&#41;&#44; was found to be relatively less sensitive in detecting moderate and severe cases&#44; while the STOP-Bang questionnaire was shown to have consistently high sensitivity for detecting OSA at different severity levels&#46; For these reasons&#44; Abrishami et al&#46;<a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> and Ramachandran and Josephs<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> recommended the STOP-Bang questionnaire for OSA screening due to its high-quality methodology and reasonably accurate results&#46; However&#44; in both reviews there were discrepancies between the analyzed populations and there was only one study included that evaluated the STOP-Bang questionnaire in surgical patients&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a></p><p class="elsevierStylePara">Recently&#44; there have been two studies of the STOP-Bang questionnaire performance in patients referred to a sleep medicine clinic&#44;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> and an additional study by Chung et al&#46;<a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> in a surgical population&#46; Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> showed an 85&#46;1&#37; probability of OSA for a score of 3 or greater&#46; This was consistent with the papers by Chung et al&#46;&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> in surgical populations&#44; which reported a 75&#46;3&#37; probability and 84&#37; sensitivity for OSA with a score of 3 or greater&#46; For the same score&#44; we show better results as reflected by the 86&#46;6&#37; probability and 93&#46;4&#37; sensitivity for OSA&#46; Compared to the study by Chung et al&#46;&#44;<a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> our better results could be related with the greater prevalence of OSA in our population &#40;78&#37; <span class="elsevierStyleItalic">vs&#46;</span> 68&#46;4&#37;&#41; and by a greater proportion of moderate&#47;severe OSA patients &#40;70&#46;0&#37; <span class="elsevierStyleItalic">vs&#46;</span> 56&#46;3&#37;&#41;&#46; Also&#44; Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> reported&#44; as we do&#44; that with any score greater than 4&#44; the probability of severe sleep apnea increases continuously&#46; Silva et al&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> compared the performance of the STOP-Bang questionnaire&#44; in a sleep medicine clinic&#44; with the STOP questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> the ESS&#44;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a> and a 4-variable screening tool&#46;<a href="&#35;bib58" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a> They concluded that the STOP-Bang tool identified more subjects with moderate-to-severe OSA and severe OSA while the ESS was the least capable tool for this purpose as it focuses on sleep propensity rather than OSA&#46; For a score cut-off of 3&#44; the reported sensitivities were of 87&#37; and 70&#46;4&#37; for moderate to severe and severe OSA&#44; respectively&#46; Chung et al&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> showed&#44; for that cut-off&#44; similar sensitivities for moderate to severe OSA &#40;68&#46;4&#37; and 92&#46;9&#37;&#41; but better results for severe OSA &#40;94&#46;8&#37; and 100&#37;&#41;&#46; In our study&#44; the corresponding sensitivities were of 95&#46;7&#37; and 98&#46;4&#37; for moderate to severe and severe OSA&#44; respectively&#46; Our results and those described before confirm the high performance of the STOP-Bang for diagnosing OSA but especially moderate to severe and severe OSA&#46;</p><p class="elsevierStylePara">The studies by Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> and Silva et al&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> were cross-sectional analysis of patients who had undergone diagnostic PSG for several reasons and whose STOP-Bang responses were retrospectively derived from answers to other questionnaires that the authors defined as similar to those in the STOP-Bang questionnaire&#46; Our cross-sectional analysis has some advantages here&#44; as it was designed specifically for the present analysis&#44; conducted prospectively and had a high rate of patients with both a complete STOP-Bang questionnaire and sleep study &#40;99&#46;5&#37;&#41;&#46; Furthermore&#44; during the study&#44; the technicians and clinical personnel validating the sleep studies were blind to the results of the STOP-Bang questionnaire and there was only a short waiting time between the answering of the questionnaires and the execution of the sleep study&#46; There are some potential disadvantages&#44; as our study has a smaller population compared to the studies of Farney et al&#46; and Silva et al&#46;&#44; and includes results from both laboratory and portable &#40;level III&#41; PSG&#46; The use of level III devices could mean some underestimation in the measured AHI&#46; Also&#44; 6 patients &#40;2&#46;8&#37; of the total&#41; had a negative portable PSG&#44; which was not confirmed by performing a laboratory PSG&#46; This was a small percentage of patients and&#44; although unlikely&#44; it is possible that a false positive could have occurred&#46; Moreover&#44; only those performed in excellent technical conditions and with a patients&#8217; description of a full night of sleep were not reevaluated and&#44; as previously stated&#44; level III portable sleep devices have been shown to be a reliable alternative to a standard PSG in the diagnosis of OSA in adult patients&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a></p><p class="elsevierStylePara">We conclude that the STOP-Bang questionnaire can be a powerful tool in the assessment of patients referred to a sleep medicine clinic as it shows a high level of performance in the diagnosis of OSA and detection of moderate to severe OSA&#44; but also in the exclusion of moderate to severe disease&#46; These characteristics may help to define the STOP-Bang questionnaire as an interesting triage tool in the context of a sleep medicine clinic as it can&#58; include patients with probable OSA for diagnostic evaluation&#59; predict those with more severe disease&#44; who are in greater need of therapy and may be more quickly diagnosed with simpler sleep studies&#59; and virtually exclude patients from a moderate&#47;severe OSA diagnosis&#46;</p><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Funding</span><p class="elsevierStylePara">This study received no industry support&#46; The authors have no financial conflicts of interest to report&#46;</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that no experiments were performed on humans or animals for this study&#46;</p><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors declare that no patient data appear in this article&#46;</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Annex 1&#46; </span><p class="elsevierStylePara"><a name="f0005" class="elsevierStyleCrossRefs"></a></p><p class="elsevierStylePara"><img src="320v21n02-90393304figfx1.jpg"></img></p><p class="elsevierStylePara"></p><p class="elsevierStylePara">Received 8 January 2014 <br></br>Accepted 20 April 2014 </p><p class="elsevierStylePara">Corresponding author&#46; ricardomcreis&#64;gmail&#46;com</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><br/><p class="elsevierStylePara">Screening methods have become increasingly important owing to the growing number of patients suspected of obstructive sleep apnea &#40;OSA&#41; being referred for sleep consultation&#46; The STOP-Bang questionnaire has been validated as a screening tool for OSA in surgical patients&#46;</p><span class="elsevierStyleSectionTitle">Objectives</span><br/><p class="elsevierStylePara">To evaluate the performance of a Portuguese version of the STOP-Bang questionnaire for the diagnosis of OSA in a sleep clinic&#46;</p><span class="elsevierStyleSectionTitle">Methods</span><br/><p class="elsevierStylePara">Prospectively&#44; for 2 months&#44; all patients referred to our clinic for clinical evaluation completed a translated version of the STOP-Bang questionnaire in Portuguese and underwent a sleep study&#46;</p><span class="elsevierStyleSectionTitle">Results</span><br/><p class="elsevierStylePara">We observed 216 patients and 215 &#40;99&#46;5&#37;&#41; were included&#46; Age was 53&#46;63&#160;&#177;&#160;13&#46;10 years&#44; 63&#46;3&#37; were male patients&#44; neck circumference was 40&#46;4&#160;&#177;&#160;44&#46;11&#160;cm and BMI was 29&#46;41 &#91;26&#46;85&#59; 33&#46;06&#93;&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#46; OSA was present in 78&#37; of the patients&#44; of whom&#44; 33&#37; had moderate and 37&#37; had severe OSA&#46; A STOP-Bang score &#8805;3 had a sensitivity and positive predictive value &#40;PPV&#41; for OSA of 93&#46;4&#37; and 86&#46;6&#37;&#44; respectively&#46; Each increase in the STOP-Bang score was associated with an increase in the probability of OSA and severe OSA&#59; reaching a 95&#37; OSA probability&#44; for a score of 6&#44; and a 73&#37; severe OSA probability&#44; for a score of 8&#46; A score of 3 and 2 had a negative predictive value for moderate&#47;severe OSA of 85&#46;3&#37; and 91&#46;7&#37;&#44; respectively&#46;</p><span class="elsevierStyleSectionTitle">Conclusions</span><br/><p class="elsevierStylePara">The STOP-Bang questionnaire showed high sensitivity and PPV for OSA with the probability of severe OSA steadily increasing&#44; the higher the scores&#46; Furthermore&#44; a low score showed high predictive value for the exclusion of moderate&#47;severe OSA&#46; The STOP-Bang questionnaire can be a powerful tool for stratifying patients in the diagnosis of OSA&#46;</p>"
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Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic
R.. Reisa,
Corresponding author
ricardomcreis@gmail.com

Corresponding author. ricardomcreis@gmail.com
, F.. Teixeirab, V.. Martinsb, L.. Sousab, L.. Batatab, C.. Santosb, J.. Moutinhob
a Respiratory Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Portugal
b Sleep Medicine Center, Centro Hospitalar e Universitário de Coimbra, Portugal
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        "descripcion" => array:1 [
          "en" => "Distribution of patients according to their STOP-Bang score&#46;"
        ]
      ]
    ]
    "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction</span><p class="elsevierStylePara">Obstructive sleep apnea &#40;OSA&#41; is a highly prevalent disorder affecting up to 20&#37; of the general population<a href="&#35;bib30" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> and can occur in all age groups&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a> OSA&#44; even if asymptomatic&#44; is independently associated with increased morbidity and mortality due to cardiovascular and neurovascular diseases&#44; metabolic disorders&#44; and impaired neurocognitive function&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib34" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> Although prevalent&#44; it has been estimated that 82&#37; of men and 92&#37; of women with moderate&#47;severe OSA may be undiagnosed&#46;<a href="&#35;bib35" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a></p><p class="elsevierStylePara">Consequently a simple and reliable method of screening certain populations&#44; namely high-risk groups&#44; is needed&#46; The choice of screening method will depend on its ability to achieve a specific objective&#58; to include patients with OSA for appropriate sleep testing&#59; to detect those with more severe disease prompting diagnosis and treatment&#59; and to exclude patients without OSA or those without moderate&#47;severe OSA whose evaluation and treatment is less pressing&#46; Such screening methods are increasingly important due to the growing number of suspected OSA patients being referred to sleep clinics&#46; Numerous clinical prediction models have been developed based upon self-reported symptoms&#44; demographics&#44; anthropometric variables&#44; and comorbidities&#46;<a href="&#35;bib36" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib37" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> One tool commonly used to identify patients with potential sleep disorders is the Epworth Sleepiness Scale &#40;ESS&#41;&#44; but the ESS was developed to measure propensity for sleep onset rather than the likelihood of sleep disordered breathing&#46;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib39" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> A recently proposed screening method is the STOP-Bang questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> a scoring model consisting of eight Yes&#47;No questions &#40;score&#58; 1&#47;0&#44; with scores ranging from a value of 0 to 8&#41;&#44; which make it a potentially simple and easy to use screening method&#46; A score of &#8805;3 has shown a high sensitivity &#40;83&#46;6&#37;&#41; for detecting OSA in a surgical population&#44; but also in detecting moderate and severe OSA &#40;92&#46;9&#37; and 100&#37;&#44; respectively&#41;&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a></p><p class="elsevierStylePara">We assume that increasing the number of risk factors for OSA&#44; as reflected in the STOP-Bang questionnaire&#44; increases the probability of having OSA but also increases the likelihood of having other severe diseases&#46; We hypothesize that using the STOP-Bang questionnaire in a sleep medicine clinic may show a correlation between the model and the severity of OSA&#44; allowing us to determine a set of predicted probabilities for different disease severities&#46; This could ultimately enable clinicians&#44; in sleep medicine clinics&#44; to make more reasoned decisions about inclusion&#44; exclusion or the prioritization of patients for diagnostic and therapeutic evaluations&#46;</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Methods</span><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">STOP-Bang questionnaire translation</span><p class="elsevierStylePara">The Portuguese version of the STOP-Bang questionnaire was obtained using the following stages&#58; translation&#59; back translation&#59; comparison of the back translation with the original English version by a committee&#59; and usage with bilingual individuals&#46; Two independent translators translated the original questionnaire<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> into Portuguese and two other independent translators did the back translations&#46; A committee whose members were fluent in English fused the back-translated versions into a single one and compared it to the original English version&#46; Every individual question was analyzed according to the methods described&#46;<a href="&#35;bib41" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> The committee made the necessary adjustments and approved a final Portuguese version &#40;<a href="&#35;sec0075" class="elsevierStyleCrossRefs">Annex 1</a>&#41;&#46; In order to evaluate the equivalence between the original English and the Portuguese version&#44; 13 bilingual individuals completed both versions&#44; first the original version and&#44; after a week&#44; the Portuguese version&#46; Questions relating to the STOP portion were read and answered by the individuals&#44; and age&#44; gender&#44; weight&#44; height and neck circumference were measured and recorded in order to fill the Bang portion of the questionnaire&#46; Correlations between the scores obtained by both versions were calculated&#46;</p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Subjects and design</span><p class="elsevierStylePara">During a two-month period&#44; from December 2012&#44; patients referred to the clinic&#44; aged 18 years or older&#44; were asked if they were willing to be included in the study&#44; independently of the reasons for being referred&#44; which included referral for isolated symptoms&#44; clinical suspicion of a specific sleep disorder &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span> insomnia&#44; parasomnia or OSA&#41; or for screening of a sleep breathing disorder due to a recent cardiovascular event&#46; During the clinical consultation&#44; all the patients were asked to complete the STOP questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> and information concerning body mass index &#40;BMI&#41;&#44; age&#44; neck circumference&#44; and gender &#40;Bang&#41;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> was collected by a clinician&#47;research assistant&#46; The research staff gave no help in the interpretation or answering of the questionnaires&#46; A Sleep Disorders Questionnaire and ESS were previously mailed and answered at home&#46; In the following two months&#44; all the patients were invited to undergo a portable or laboratory polysomnography &#40;PSG&#41;&#46; Patients previously diagnosed with OSA or unable to read or write were not included in the study&#46;</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Sleep studies&#44; scoring and diagnosis</span><p class="elsevierStylePara">A laboratory PSG was performed when patients had a low clinical probability of OSA &#40;as judged by the physician&#41; or if there was a clinical suspicion that other sleep disorders might be present &#40;isolated or associated with OSA&#41;&#46; Patients with a moderate to high clinical probability were evaluated with a portable PSG&#46; In cases of technical errors or if the clinical context was not explained by a negative portable PSG a laboratory PSG was ultimately performed&#46;</p><p class="elsevierStylePara">Portable PSG was performed with a level III equipment &#40;Alice PDx&#44; Embletta X100&#44; Nox T3 or Stardust II&#41; that has been shown to be a reliable alternative to standard PSG in the diagnosis of OSA in adult patients&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a> PSG recordings were carried out in the patients&#8217; homes&#46; Recordings included nasal airflow&#44; thoracic and abdominal respiratory effort&#44; pulse oximeter&#44; body position sensor&#44; and lower limb electromyography &#40;EMG&#41; &#40;when available on the device&#41;&#46; The patients and their aides were instructed&#44; by a trained PSG technician&#44; on how to connect and remove the device&#46; The overnight home recordings were unattended&#46; The following morning the patient removed the device and returned it to the sleep clinic&#46; A sleep technician manually scored the recordings and a physician informed the patient of the results&#46; Laboratory PSG was performed overnight and patients went to bed at their usual bedtime&#46; A standard montage obtained with surface electrodes was used consisting of&#58; electroencephalogram&#44; electrooculogram&#44; submental and lower limb EMG&#44; and electrocardiogram&#46; Additional recordings included&#58; oronasal airflow &#40;thermistor and pressure sensor&#41;&#44; thoracic and abdominal respiratory effort&#44; pulse oximeter&#44; snore and body position sensor&#46; A well-trained PSG technician scored the PSG recordings under the supervision of a sleep physician who assessed and approved the reports&#46; The technician and sleep physician were blind to the study information &#40;STOP-Bang score and clinical information&#41;&#46; Manual scoring was performed according to the Manual of the American Academy of Sleep Medicine&#44;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a> and the American Academy of Sleep Medicine Task Force recommendations&#46;<a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> The diagnosis and severity of OSA were classified based on the Apnea-Hypopnea Index values&#58; &#62;5&#8211;15&#47;h as mild&#44; &#62;15&#8211;30&#47;h as moderate&#44; and &#62;30&#47;h as severe&#46;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> Other diagnoses&#44; in accordance with the International Classification of Sleep Disorders&#44;<a href="&#35;bib47" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> were based on&#58; clinical characteristics&#59; minimal follow-up of at least 6 months&#59; and results from laboratory PSG&#44; multiple sleep latency test&#44; or actigraphy&#46;</p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Analysis</span><p class="elsevierStylePara">Statistical analysis was performed using Statistical Package for the Social Sciences &#40;SPSS&#41; version 20 and MedCalc version 12&#46; Patients&#8217; characteristics are presented with the following descriptive statistics&#58; mean and standard deviation were used for normally distributed continuous data&#59; median and inter-quartile range were used for non-normally distributed continuous data&#59; and frequency and percentage were used for categorical data&#46; Reproducibility between the original and Portuguese version was assessed calculating the correlation of the scores from both versions with Pearson&#39;s correlation and using Cronbach&#39;s alpha to obtain intraclass correlation&#46; OSA and non-OSA groups were compared with Student&#39;s <span class="elsevierStyleItalic">t</span>-test for means&#44; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for medians and Chi-square test for proportions&#46; To assess the performance of the STOP-Bang questionnaire and the Epworth Sleepiness Scale in predicting OSA&#44; sensitivity&#44; specificity&#44; positive predictive values &#40;PPVs&#41; and negative predictive values &#40;NPVs&#41; were calculated for each score and for different AHI cut-offs&#46; Area under the receiver-operating curve &#40;ROC&#41; was also calculated to assess the diagnostic ability of the STOP-Bang questionnaire and the Epworth Sleepiness Scale for different AHI cut-offs&#46; Logistic regression was used to compare the severity of the AHI with the STOP-Bang score and to calculate predicted probabilities for different AHI cut-offs at each score&#46;</p><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStylePara">In the group of bilingual individuals&#44; the mean scores on the original STOP-Bang and Portuguese STOP-Bang were 2&#46;4&#160;&#177;&#160;1&#46;7 and 2&#46;3&#160;&#177;&#160;1&#46;7&#44; respectively&#44; showing good reproducibility between the original and the translated questionnaire &#40;intraclass correlation coefficient&#160;&#61;&#160;0&#46;932&#59; Pearson&#39;s <span class="elsevierStyleItalic">r</span>&#160;&#61;&#160;0&#46;928&#59; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#46;</p><p class="elsevierStylePara">A total of 216 patients were observed during the study period&#44; of which 215 &#40;99&#46;5&#37;&#41; completed the STOP-Bang questionnaire and performed a portable or laboratory PSG&#46; Of the 215 patients included in the final analysis&#44; 137 &#40;63&#46;7&#37;&#41; performed a portable PSG and 78 &#40;36&#46;2&#37;&#41; performed a laboratory PSG&#46; Of these 78 patients&#44; 19 had previously performed a portable PSG&#44; but due to technical errors or a clinical context the condition was not explained by a normal or near normal portable PSG&#44; a laboratory PSG was ultimately performed&#46; There were 6 patients in whom a negative portable PSG was not followed by a laboratory PSG because the study had been performed in excellent technical conditions and the patients described a full night&#39;s sleep&#46;</p><p class="elsevierStylePara">Descriptive summary statistics&#44; STOP-Bang characteristics&#44; AHI of the patient population and comparison of OSA and non-OSA groups are displayed in <a href="&#35;t0005" class="elsevierStyleCrossRefs">Table 1</a>&#46; Although greater or more prevalent in the OSA group&#44; Epworth score&#44; tiredness&#44; BMI &#62;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#44; and age &#62;50 years were the only characteristics which were not significantly different between the OSA and non-OSA group&#46; Of the 215 patients included for analysis 168 &#40;78&#37;&#41; had OSA of which&#44; 50 &#40;29&#46;8&#37;&#41;&#44; 56 &#40;33&#46;3&#37;&#41;&#44; and 62 &#40;36&#46;9&#37;&#41; had mild&#44; moderate&#44; and severe OSA&#44; respectively&#46; In the non-OSA group&#44; 3&#46;4&#37; of the patients had no sleep disorder while 9&#46;3&#37; had isolated insomnia&#44; 3&#46;3&#37; had isolated restless legs&#44; 2&#46;3&#37; had central sleep apnea syndromes&#44; 1&#46;7&#37; had idiopathic hypersomnia&#44; 1&#46;0&#37; had narcolepsy&#44; 1&#46;0&#37; had parasomnia and 0&#46;5&#37; had period leg movement disorder &#40;isolated&#41;&#46; The distribution of patients according to their STOP-Bang score is detailed in <a href="&#35;f0010" class="elsevierStyleCrossRefs">Figure 1</a>&#46; Most patients had a STOP-Bang score of 4 &#40;19&#46;5&#37;&#41;&#44; 5 or 6 &#40;both with 20&#46;9&#37;&#41;&#46;</p><p class="elsevierStylePara">Table 1&#46; Summary statistics of the patient population and comparison of OSA and non OSA group&#46;</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>&#160;</td><td>All</td><td>OSA &#40;AHI&#160;&#62;&#160;5&#41;</td><td>Non-OSA &#40;AHI&#160;&#60;&#160;5&#41;</td><td><span class="elsevierStyleItalic">p</span> &#40;OSA <span class="elsevierStyleItalic">vs&#46;</span> nOSA&#41;</td></tr><tr align="left"><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>215</td><td>168 &#40;78&#37;&#41;</td><td>47 &#40;22&#37;&#41;</td><td>&#160;</td></tr><tr align="left"><td>Age &#40;years&#41;</td><td>53&#46;63&#160;&#177;&#160;13&#46;10</td><td>55&#46;14&#160;&#177;&#160;12&#46;98</td><td>48&#46;23&#160;&#177;&#160;12&#46;18</td><td>0&#46;0001</td></tr><tr align="left"><td>BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;</td><td>29&#46;41 &#91;26&#46;85&#59; 33&#46;06&#93;</td><td>30&#46;11 &#91;27&#46;69&#59; 34&#46;13&#93;</td><td>26&#46;91 &#91;25&#46;40&#59; 29&#46;39&#93;</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Neck circumference &#40;cm&#41;</td><td>40&#46;44&#160;&#177;&#160;4&#46;11</td><td>41&#46;32&#160;&#177;&#160;3&#46;75</td><td>37&#46;31&#160;&#177;&#160;3&#46;83</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Epworth&#39;s score</td><td>10&#46;00 &#91;5&#59; 15&#93;</td><td>10 &#91;5&#59; 16&#93;</td><td>8 &#91;4&#59; 14&#93;</td><td>0&#46;237 &#40;NS&#41;</td></tr><tr align="left"><td>Snore &#40;&#37;&#41;</td><td>73&#46;0</td><td>81&#46;5</td><td>42&#46;6</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Tiredness &#40;&#37;&#41;</td><td>61&#46;9</td><td>63&#46;7</td><td>55&#46;3</td><td>0&#46;296 &#40;NS&#41;</td></tr><tr align="left"><td>Observed apnea &#40;&#37;&#41;</td><td>52&#46;6</td><td>58&#46;3</td><td>31&#46;9</td><td>0&#46;0001</td></tr><tr align="left"><td>Pressure &#40;high blood&#41; &#40;&#37;&#41;</td><td>57&#46;2</td><td>63&#46;1</td><td>36&#46;2</td><td>0&#46;0001</td></tr><tr align="left"><td>BMI&#160;&#62;&#160;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span> &#40;&#37;&#41;</td><td>16&#46;3</td><td>17&#46;9</td><td>10&#46;6</td><td>0&#46;236 &#40;NS&#41;</td></tr><tr align="left"><td>Age&#160;&#62;&#160;50 years &#40;&#37;&#41;</td><td>60&#46;5</td><td>62&#46;5</td><td>53&#46;2</td><td>0&#46;249 &#40;NS&#41;</td></tr><tr align="left"><td>Neck circ&#46;&#160;&#62;&#160;40&#160;cm &#40;&#37;&#41;</td><td>56&#46;3</td><td>65&#46;5</td><td>23&#46;4</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>Gender &#40;male&#41; &#40;&#37;&#41;</td><td>63&#46;3</td><td>71&#46;4</td><td>34&#46;0</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>STOP-Bang score</td><td>4&#46;41&#160;&#177;&#160;1&#46;70</td><td>4&#46;84&#160;&#177;&#160;1&#46;45</td><td>2&#46;87&#160;&#177;&#160;1&#46;66</td><td>&#60;0&#46;0001</td></tr><tr align="left"><td>AHI &#40;h&#41;</td><td>16&#46;7 &#91;7&#46;8&#59; 32&#46;9&#93;</td><td>21&#46;75 &#91;13&#46;52&#59; 38&#46;92&#93;</td><td>1&#46;6 &#91;0&#46;4&#59; 4&#46;0&#93;</td><td>&#60;0&#46;0001</td></tr></table><p class="elsevierStylePara">BMI&#58; body mass index&#59; AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#59; NS&#58; not significant&#46;<br></br></p><a name="f0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig1.jpg" alt="Distribution of patients according to their STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 1&#46; Distribution of patients according to their STOP-Bang score&#46;</p><p class="elsevierStylePara">Using the STOP-Bang model for the prediction of all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA&#44; the area under the ROC was 0&#46;806 &#40;95&#37; CI&#58; 0&#46;730&#8211;0&#46;881&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; 0&#46;730 &#40;95&#37; CI&#58; 0&#46;661&#8211;0&#46;798&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; and 0&#46;728 &#40;95&#37; CI&#58; 0&#46;655&#8211;0&#46;801&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;0001&#41;&#44; respectively&#44; confirming the diagnostic ability of the STOP-Bang model in all OSA severities&#46; Using the ESS as predictor&#44; the area under the ROC was 0&#46;556 &#40;95&#37; CI&#58; 0&#46;461&#8211;0&#46;652&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;238&#41;&#44; 0&#46;606 &#40;95&#37; CI&#58; 0&#46;529&#8211;0&#46;682&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;008&#41;&#44; and 0&#46;614 &#40;95&#37; CI&#58; 0&#46;533&#8211;0&#46;696&#41; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;009&#41;&#44; for all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA&#44; respectively&#44; reflecting the inferior discriminative power of the ESS for the diagnosis of OSA&#46;</p><p class="elsevierStylePara">The sensitivity&#44; specificity&#44; PPV&#44; and NPV for all OSA&#44; moderate&#47;severe OSA&#44; and severe OSA are summarized in <a href="&#35;t0010" class="elsevierStyleCrossRefs">Table 2</a>&#46; With a STOP-Bang score &#8805;3 the sensitivity and PPV were 93&#46;4&#37; and 86&#46;6&#37; for all OSA&#44; 95&#46;7&#37; and 62&#46;4&#37; for moderate&#47;severe OSA and 98&#46;4&#37; and 33&#46;7&#37; for severe OSA&#44; respectively&#46; With the same cut-off the negative predictive value for moderate&#47;severe and severe OSA were 85&#46;3&#37; and 97&#46;1&#37;&#44; respectively&#46; As the STOP-Bang score increased from 3 to 7&#44; the specificity and PPV increased continuously from 48&#46;9&#37; to 97&#46;9&#37; and 86&#46;6&#37; to 95&#46;0&#37; for all OSA&#59; 29&#46;9&#37; to 95&#46;5&#37; and 62&#46;4&#37; to 80&#37; for moderate&#47;severe OSA&#59; and 21&#46;9&#37; to 95&#46;4&#37; and 33&#46;7&#37; to 63&#46;9&#37; for severe OSA&#44; respectively&#46;</p><p class="elsevierStylePara">Table 2&#46; Predictive parameters of each STOP-Bang score cut-offs for different AHI levels &#40;<span class="elsevierStyleItalic">n</span>&#44; number of patients in the AHI group who scored the STOP-Bang score indicated or higher&#59; percentage out of the 215 patients&#41;&#46;</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>STOP-Bang score cut-off</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Sensitivity</td><td>Specificity</td><td>PPV</td><td>NPV</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">All OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">5&#41;</span></td></tr><tr align="left"><td>1</td><td>168 &#40;78&#46;1&#41;</td><td>100&#46;0</td><td>2&#46;1</td><td>78&#46;4</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>167 &#40;77&#46;8&#41;</td><td>99&#46;4</td><td>23&#46;4</td><td>82&#46;1</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>157 &#40;73&#46;0&#41;</td><td>93&#46;4</td><td>48&#46;9</td><td>86&#46;6</td><td>67&#46;8</td></tr><tr align="left"><td>4</td><td>136 &#40;63&#46;2&#41;</td><td>81&#46;0</td><td>66&#46;0</td><td>89&#46;4</td><td>49&#46;4</td></tr><tr align="left"><td>5</td><td>102 &#40;47&#46;4&#41;</td><td>60&#46;7</td><td>83&#46;0</td><td>92&#46;7</td><td>37&#46;3</td></tr><tr align="left"><td>6</td><td>61 &#40;28&#46;4&#41;</td><td>36&#46;3</td><td>91&#46;5</td><td>93&#46;8</td><td>28&#46;8</td></tr><tr align="left"><td>7</td><td>19 &#40;8&#46;8&#41;</td><td>11&#46;3</td><td>97&#46;9</td><td>95&#46;0</td><td>23&#46;7</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>1&#46;79</td><td>100&#46;0</td><td>100&#46;0</td><td>22&#46;3</td></tr><tr align="left"><td colspan="6">&#160;</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Moderate&#47;severe OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">15&#41;</span></td></tr><tr align="left"><td>1</td><td>118 &#40;54&#46;9&#41;</td><td>100&#46;0</td><td>1&#46;0</td><td>55&#46;2</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>117 &#40;54&#46;4&#41;</td><td>99&#46;2</td><td>11&#46;3</td><td>57&#46;7</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>113 &#40;52&#46;6&#41;</td><td>95&#46;7</td><td>29&#46;9</td><td>62&#46;4</td><td>85&#46;3</td></tr><tr align="left"><td>4</td><td>102 &#40;47&#46;4&#41;</td><td>86&#46;5</td><td>48&#46;4</td><td>67&#46;1</td><td>74&#46;6</td></tr><tr align="left"><td>5</td><td>78 &#40;36&#46;3&#41;</td><td>66&#46;1</td><td>67&#46;0</td><td>70&#46;9</td><td>61&#46;9</td></tr><tr align="left"><td>6</td><td>49 &#40;22&#46;8&#41;</td><td>41&#46;5</td><td>83&#46;5</td><td>75&#46;4</td><td>54&#46;0</td></tr><tr align="left"><td>7</td><td>16 &#40;7&#46;4&#41;</td><td>13&#46;6</td><td>95&#46;9</td><td>80&#46;0</td><td>47&#46;7</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>2&#46;5</td><td>100&#46;0</td><td>100&#46;0</td><td>45&#46;7</td></tr><tr align="left"><td colspan="6">&#160;</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Severe OSA &#40;AHI</span>&#160;<span class="elsevierStyleItalic">&#62;</span>&#160;<span class="elsevierStyleItalic">30&#41;</span></td></tr><tr align="left"><td>1</td><td>62 &#40;28&#46;8&#41;</td><td>100&#46;0</td><td>0&#46;7</td><td>28&#46;9</td><td>100&#46;0</td></tr><tr align="left"><td>2</td><td>61 &#40;28&#46;4&#41;</td><td>98&#46;4</td><td>7&#46;2</td><td>30&#46;0</td><td>91&#46;7</td></tr><tr align="left"><td>3</td><td>61 &#40;28&#46;4&#41;</td><td>98&#46;4</td><td>21&#46;9</td><td>33&#46;7</td><td>97&#46;1</td></tr><tr align="left"><td>4</td><td>55 &#40;25&#46;6&#41;</td><td>88&#46;7</td><td>36&#46;8</td><td>36&#46;3</td><td>89&#46;0</td></tr><tr align="left"><td>5</td><td>46 &#40;21&#46;4&#41;</td><td>74&#46;2</td><td>57&#46;9</td><td>41&#46;7</td><td>84&#46;7</td></tr><tr align="left"><td>6</td><td>34 &#40;15&#46;8&#41;</td><td>54&#46;8</td><td>79&#46;6</td><td>52&#46;1</td><td>81&#46;3</td></tr><tr align="left"><td>7</td><td>13 &#40;6&#46;0&#41;</td><td>21&#46;0</td><td>95&#46;4</td><td>63&#46;9</td><td>74&#46;9</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;4&#41;</td><td>4&#46;8</td><td>100&#46;0</td><td>100&#46;0</td><td>72&#46;2</td></tr></table><p class="elsevierStylePara">AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#59; PPV&#58; positive predictive value&#59; NPV&#58; negative predictive value&#46;<br></br></p><p class="elsevierStylePara">The predicted probabilities of having OSA&#44; moderate&#47;severe OSA&#44; and severe OSA are shown in <a href="&#35;t0015" class="elsevierStyleCrossRefs">Table 3</a>&#46; As the STOP-Bang score increased from 2 to 8&#44; the probability of having OSA&#44; moderate&#47;severe OSA&#44; and severe OSA increased continuously from 44&#37; to 99&#37;&#44; 24&#37; to 90&#37; and 7&#37; to 73&#37;&#44; respectively&#46; This trend&#44; present in all groups is illustrated in <a href="&#35;f0015" class="elsevierStyleCrossRefs">Figure 2</a>&#46; The predicted probabilities of having OSA of a specific severity are illustrated in <a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#46; With each incremental increase in the score from 0 to 4&#44; the probability of having no sleep apnea diminished&#44; while the probability of having mild&#44; moderate&#44; or severe sleep apnea increased&#46; With any score greater than 4&#44; only the probability of having severe sleep apnea increased continuously&#46;</p><p class="elsevierStylePara">Table 3&#46; Predicted probabilities of each STOP-Bang score for different AHI levels &#40;<span class="elsevierStyleItalic">n</span>&#44; number of patients in the AHI group who scored the STOP-Bang score indicated&#59; percentage out of the 215 patients&#41;&#46;</p><a name="t0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Score</td><td colspan="2">All OSA &#40;AHI&#160;&#62;&#160;5&#41;</td><td colspan="2">Mod&#46;&#47;severe OSA &#40;AHI&#160;&#62;&#160;15&#41;</td><td colspan="2">Severe OSA &#40;AHI&#160;&#62;&#160;30&#41;</td></tr><tr align="left"><td>&#160;</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td><td><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td><td>Probability</td></tr><tr align="left"><td>1</td><td>1 &#40;0&#46;6&#41;</td><td>0&#46;26</td><td>1 &#40;0&#46;8&#41;</td><td>0&#46;15</td><td>1 &#40;1&#46;6&#41;</td><td>0&#46;04</td></tr><tr align="left"><td>2</td><td>10 &#40;6&#46;0&#41;</td><td>0&#46;44</td><td>4 &#40;3&#46;4&#41;</td><td>0&#46;24</td><td>0 &#40;0&#46;0&#41;</td><td>0&#46;07</td></tr><tr align="left"><td>3</td><td>21 &#40;12&#46;5&#41;</td><td>0&#46;64</td><td>11 &#40;9&#46;3&#41;</td><td>0&#46;36</td><td>6 &#40;9&#46;7&#41;</td><td>0&#46;13</td></tr><tr align="left"><td>4</td><td>34 &#40;20&#46;2&#41;</td><td>0&#46;80</td><td>24 &#40;20&#46;3&#41;</td><td>0&#46;50</td><td>9 &#40;14&#46;5&#41;</td><td>0&#46;21</td></tr><tr align="left"><td>5</td><td>41 &#40;24&#46;2&#41;</td><td>0&#46;90</td><td>29 &#40;24&#46;6&#41;</td><td>0&#46;64</td><td>12 &#40;19&#46;4&#41;</td><td>0&#46;32</td></tr><tr align="left"><td>6</td><td>42 &#40;25&#46;0&#41;</td><td>0&#46;95</td><td>33 &#40;28&#46;0&#41;</td><td>0&#46;75</td><td>21 &#40;33&#46;9&#41;</td><td>0&#46;46</td></tr><tr align="left"><td>7</td><td>16 &#40;9&#46;5&#41;</td><td>0&#46;98</td><td>13 &#40;11&#46;0&#41;</td><td>0&#46;84</td><td>10 &#40;16&#46;1&#41;</td><td>0&#46;61</td></tr><tr align="left"><td>8</td><td>3 &#40;1&#46;8&#41;</td><td>0&#46;99</td><td>3 &#40;2&#46;5&#41;</td><td>0&#46;90</td><td>3 &#40;4&#46;8&#41;</td><td>0&#46;73</td></tr></table><p class="elsevierStylePara">AHI&#58; Apnea-Hypopnea Index&#59; OSA&#58; obstructive sleep apnea&#46;<br></br></p><a name="f0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig2.jpg" alt="Plot of predicted probabilities for different AHI levels with the corresponding STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 2&#46; Plot of predicted probabilities for different AHI levels with the corresponding STOP-Bang score&#46;</p><a name="f0020" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393304fig3.jpg" alt="Plot of predicted probabilities for different OSA severities with the corresponding STOP-Bang score&#46;"></img></p><p class="elsevierStylePara">Figure 3&#46; Plot of predicted probabilities for different OSA severities with the corresponding STOP-Bang score&#46;</p><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara">This study shows that&#44; in a population referred to a sleep medicine clinic&#44; a STOP-Bang score &#8805;3 has high sensitivity &#40;93&#46;4&#37;&#41; and PPV &#40;86&#46;6&#37;&#41; for the diagnosis of OSA and that the greater the STOP-Bang score&#44; reflecting a higher cumulative score of known risk factors&#44; the greater the probability of sleep apnea&#44; particularly severe sleep apnea &#40;<a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#41;&#46; The probability of OSA for score of 3 is of 64&#37; and increases continuously to 80&#37;&#44; 90&#37; and 95&#37; with a stepwise increase of the STOP-Bang score to 4&#44; 5&#44; and 6&#46; This performance is due to the continuously increasing probability of severe OSA for each score above 4&#44; reaching a predicted probability of 46&#37;&#44; 61&#37; and 73&#37; for a score of 6&#44; 7 and 8 &#40;<a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 3</a>&#41;&#44; respectively&#46; Moreover&#44; a score lower than 3 showed high discriminative power to exclude moderate to severe OSA&#44; as reflected by a negative predictive value of 85&#46;3&#37; and 91&#46;7&#37; for a score of 3 and 2&#44; respectively&#46; The area under the ROC curve was consistently high for the diagnostic ability of the STOP-Bang questionnaire for all OSA severities&#46; On the contrary&#44; the ESS&#44; as expected&#44; showed inferior ability for the prediction of moderate to severe and severe OSA and was non-significant for the prediction of all OSA&#46; Furthermore&#44; the ESS and tiredness &#40;as assessed by question T of the STOP-Bang questionnaire&#41; were statistically similar between the OSA and non-OSA groups&#44; albeit tending to be greater and more prevalent in the OSA group&#44; reflecting excessive daytime sleepiness and tiredness as similarly common complaints among patients with various sleep disorders&#46; Two other STOP-Bang characteristics&#44; BMI&#160;&#62;&#160;35&#160;kg&#47;m<span class="elsevierStyleSup">2</span> and age &#62;&#160;50 years&#44; were also statistically not different&#44; although tending to be more prevalent in the OSA group&#46; This might be related to the specific cut-off values of the questionnaire&#44; as the OSA group was statistically more obese and older&#46;</p><p class="elsevierStylePara">Due to the relatively high prevalence of undiagnosed OSA and its short and long-term complications&#44; a reliable screening tool is required for a quick prediction of OSA&#46; A fast and reliable screening test can enable clinicians within a given clinical context to make more reasoned diagnostic decisions&#44; namely in stratifying patients for unrecognized OSA and triage for further diagnostic assessment and&#47;or treatment&#46; Questionnaires can be appropriate tools for that purpose since they can be applied and scored easily as part of routine daily practice&#46; Furthermore&#44; analysis of the questionnaire&#39;s performance in specific populations can provide clinicians with a set of predictive parameters for various levels of OSA severity&#44; which can be used as a valuable guide for diagnostic or therapeutic decisions&#46; In our study the present results show that the STOP-Bang questionnaire&#44; in the context of a sleep medicine clinic&#44; can be a very useful tool for triaging patients into three groups depending on their score&#58; score of 0&#8211;2 &#8211; low probability of OSA and very low probability of moderate&#47;severe OSA&#59; score of 3&#8211;4 &#8211; probable OSA&#59; score of 5&#8211;8 &#8211; high probability of moderate&#47;severe OSA&#46;</p><p class="elsevierStylePara">Several questionnaires and other clinical screening tests for obstructive sleep apnea have been analyzed&#46; In the meta-analysis by Ramachandran and Josephs<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> that included the American Society of Anesthesiologists &#40;ASA&#41; checklist&#44;<a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a> the Berlin questionnaire&#44;<a href="&#35;bib50" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a> the Sleep Questionnaire&#44;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a> the Sleep Disorders Questionnaire &#40;SDQ&#41;&#44;<a href="&#35;bib52" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">23</span></a> and the STOP and STOP-Bang questionnaires&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> the authors concluded that the Berlin questionnaire and the SDQ were the most accurate questionnaires overall to screen OSA&#44; while the ESS was the least accurate&#46; The authors identified the STOP-Bang questionnaire as an inferior screening tool but an excellent method for predicting severe OSA due to its simplicity and relative ease of use&#46; Another systematic review&#44; by Abrishami et al&#46;<a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> reported that the Wisconsin<a href="&#35;bib54" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> and the Berlin questionnaires had the highest sensitivity and specificity&#44; respectively&#46; However&#44; the authors argue that the validity of the studies was unclear due to potential selection bias as subjects in the Berlin study were pre-screened for the presence of snoring&#44; wake-time sleepiness or fatigue&#44; and history of obesity or hypertension&#46; In terms of predicting moderate or severe OSA&#44; the authors concluded that the STOP-Bang and the Berlin questionnaires were found to have the highest sensitivity and specificity&#44; respectively&#46; They also noted that the Berlin questionnaire&#44; which was shown to have high sensitivity for detecting OSA &#40;69&#8211;86&#37;&#41;&#44; was found to be relatively less sensitive in detecting moderate and severe cases&#44; while the STOP-Bang questionnaire was shown to have consistently high sensitivity for detecting OSA at different severity levels&#46; For these reasons&#44; Abrishami et al&#46;<a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> and Ramachandran and Josephs<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> recommended the STOP-Bang questionnaire for OSA screening due to its high-quality methodology and reasonably accurate results&#46; However&#44; in both reviews there were discrepancies between the analyzed populations and there was only one study included that evaluated the STOP-Bang questionnaire in surgical patients&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a></p><p class="elsevierStylePara">Recently&#44; there have been two studies of the STOP-Bang questionnaire performance in patients referred to a sleep medicine clinic&#44;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> and an additional study by Chung et al&#46;<a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> in a surgical population&#46; Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> showed an 85&#46;1&#37; probability of OSA for a score of 3 or greater&#46; This was consistent with the papers by Chung et al&#46;&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> in surgical populations&#44; which reported a 75&#46;3&#37; probability and 84&#37; sensitivity for OSA with a score of 3 or greater&#46; For the same score&#44; we show better results as reflected by the 86&#46;6&#37; probability and 93&#46;4&#37; sensitivity for OSA&#46; Compared to the study by Chung et al&#46;&#44;<a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> our better results could be related with the greater prevalence of OSA in our population &#40;78&#37; <span class="elsevierStyleItalic">vs&#46;</span> 68&#46;4&#37;&#41; and by a greater proportion of moderate&#47;severe OSA patients &#40;70&#46;0&#37; <span class="elsevierStyleItalic">vs&#46;</span> 56&#46;3&#37;&#41;&#46; Also&#44; Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> reported&#44; as we do&#44; that with any score greater than 4&#44; the probability of severe sleep apnea increases continuously&#46; Silva et al&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> compared the performance of the STOP-Bang questionnaire&#44; in a sleep medicine clinic&#44; with the STOP questionnaire&#44;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> the ESS&#44;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a> and a 4-variable screening tool&#46;<a href="&#35;bib58" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a> They concluded that the STOP-Bang tool identified more subjects with moderate-to-severe OSA and severe OSA while the ESS was the least capable tool for this purpose as it focuses on sleep propensity rather than OSA&#46; For a score cut-off of 3&#44; the reported sensitivities were of 87&#37; and 70&#46;4&#37; for moderate to severe and severe OSA&#44; respectively&#46; Chung et al&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> showed&#44; for that cut-off&#44; similar sensitivities for moderate to severe OSA &#40;68&#46;4&#37; and 92&#46;9&#37;&#41; but better results for severe OSA &#40;94&#46;8&#37; and 100&#37;&#41;&#46; In our study&#44; the corresponding sensitivities were of 95&#46;7&#37; and 98&#46;4&#37; for moderate to severe and severe OSA&#44; respectively&#46; Our results and those described before confirm the high performance of the STOP-Bang for diagnosing OSA but especially moderate to severe and severe OSA&#46;</p><p class="elsevierStylePara">The studies by Farney et al&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> and Silva et al&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> were cross-sectional analysis of patients who had undergone diagnostic PSG for several reasons and whose STOP-Bang responses were retrospectively derived from answers to other questionnaires that the authors defined as similar to those in the STOP-Bang questionnaire&#46; Our cross-sectional analysis has some advantages here&#44; as it was designed specifically for the present analysis&#44; conducted prospectively and had a high rate of patients with both a complete STOP-Bang questionnaire and sleep study &#40;99&#46;5&#37;&#41;&#46; Furthermore&#44; during the study&#44; the technicians and clinical personnel validating the sleep studies were blind to the results of the STOP-Bang questionnaire and there was only a short waiting time between the answering of the questionnaires and the execution of the sleep study&#46; There are some potential disadvantages&#44; as our study has a smaller population compared to the studies of Farney et al&#46; and Silva et al&#46;&#44; and includes results from both laboratory and portable &#40;level III&#41; PSG&#46; The use of level III devices could mean some underestimation in the measured AHI&#46; Also&#44; 6 patients &#40;2&#46;8&#37; of the total&#41; had a negative portable PSG&#44; which was not confirmed by performing a laboratory PSG&#46; This was a small percentage of patients and&#44; although unlikely&#44; it is possible that a false positive could have occurred&#46; Moreover&#44; only those performed in excellent technical conditions and with a patients&#8217; description of a full night of sleep were not reevaluated and&#44; as previously stated&#44; level III portable sleep devices have been shown to be a reliable alternative to a standard PSG in the diagnosis of OSA in adult patients&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a></p><p class="elsevierStylePara">We conclude that the STOP-Bang questionnaire can be a powerful tool in the assessment of patients referred to a sleep medicine clinic as it shows a high level of performance in the diagnosis of OSA and detection of moderate to severe OSA&#44; but also in the exclusion of moderate to severe disease&#46; These characteristics may help to define the STOP-Bang questionnaire as an interesting triage tool in the context of a sleep medicine clinic as it can&#58; include patients with probable OSA for diagnostic evaluation&#59; predict those with more severe disease&#44; who are in greater need of therapy and may be more quickly diagnosed with simpler sleep studies&#59; and virtually exclude patients from a moderate&#47;severe OSA diagnosis&#46;</p><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Funding</span><p class="elsevierStylePara">This study received no industry support&#46; The authors have no financial conflicts of interest to report&#46;</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that no experiments were performed on humans or animals for this study&#46;</p><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors declare that no patient data appear in this article&#46;</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Annex 1&#46; </span><p class="elsevierStylePara"><a name="f0005" class="elsevierStyleCrossRefs"></a></p><p class="elsevierStylePara"><img src="320v21n02-90393304figfx1.jpg"></img></p><p class="elsevierStylePara"></p><p class="elsevierStylePara">Received 8 January 2014 <br></br>Accepted 20 April 2014 </p><p class="elsevierStylePara">Corresponding author&#46; ricardomcreis&#64;gmail&#46;com</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><br/><p class="elsevierStylePara">Screening methods have become increasingly important owing to the growing number of patients suspected of obstructive sleep apnea &#40;OSA&#41; being referred for sleep consultation&#46; The STOP-Bang questionnaire has been validated as a screening tool for OSA in surgical patients&#46;</p><span class="elsevierStyleSectionTitle">Objectives</span><br/><p class="elsevierStylePara">To evaluate the performance of a Portuguese version of the STOP-Bang questionnaire for the diagnosis of OSA in a sleep clinic&#46;</p><span class="elsevierStyleSectionTitle">Methods</span><br/><p class="elsevierStylePara">Prospectively&#44; for 2 months&#44; all patients referred to our clinic for clinical evaluation completed a translated version of the STOP-Bang questionnaire in Portuguese and underwent a sleep study&#46;</p><span class="elsevierStyleSectionTitle">Results</span><br/><p class="elsevierStylePara">We observed 216 patients and 215 &#40;99&#46;5&#37;&#41; were included&#46; Age was 53&#46;63&#160;&#177;&#160;13&#46;10 years&#44; 63&#46;3&#37; were male patients&#44; neck circumference was 40&#46;4&#160;&#177;&#160;44&#46;11&#160;cm and BMI was 29&#46;41 &#91;26&#46;85&#59; 33&#46;06&#93;&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#46; OSA was present in 78&#37; of the patients&#44; of whom&#44; 33&#37; had moderate and 37&#37; had severe OSA&#46; A STOP-Bang score &#8805;3 had a sensitivity and positive predictive value &#40;PPV&#41; for OSA of 93&#46;4&#37; and 86&#46;6&#37;&#44; respectively&#46; Each increase in the STOP-Bang score was associated with an increase in the probability of OSA and severe OSA&#59; reaching a 95&#37; OSA probability&#44; for a score of 6&#44; and a 73&#37; severe OSA probability&#44; for a score of 8&#46; A score of 3 and 2 had a negative predictive value for moderate&#47;severe OSA of 85&#46;3&#37; and 91&#46;7&#37;&#44; respectively&#46;</p><span class="elsevierStyleSectionTitle">Conclusions</span><br/><p class="elsevierStylePara">The STOP-Bang questionnaire showed high sensitivity and PPV for OSA with the probability of severe OSA steadily increasing&#44; the higher the scores&#46; Furthermore&#44; a low score showed high predictive value for the exclusion of moderate&#47;severe OSA&#46; The STOP-Bang questionnaire can be a powerful tool for stratifying patients in the diagnosis of OSA&#46;</p>"
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