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Ssegonja R, Ljunggren M, Sampaio F, Tegelmo T, Theorell-Haglöw J. Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure. J Sleep Res 2024; 33:e13968. [PMID: 37337981 DOI: 10.1111/jsr.13968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 06/21/2023]
Abstract
Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.
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Affiliation(s)
- Richard Ssegonja
- Department of Medical Sciences, Respiratory, Allergy- and Sleep Medicine Research Unit, Uppsala University, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mirjam Ljunggren
- Department of Medical Sciences, Respiratory, Allergy- and Sleep Medicine Research Unit, Uppsala University, Uppsala, Sweden
| | - Filipa Sampaio
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Tove Tegelmo
- Department of Medical Sciences, Respiratory, Allergy- and Sleep Medicine Research Unit, Uppsala University, Uppsala, Sweden
| | - Jenny Theorell-Haglöw
- Department of Medical Sciences, Respiratory, Allergy- and Sleep Medicine Research Unit, Uppsala University, Uppsala, Sweden
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Ibdah RK, Zaitoun KJ, Altawalbeh RB, Tayyem SH, Nazzal UA, Rawashdeh SI, Khader YS, Al-Mistarehi AHW, Khassawneh BY. Prevalence of Obstructive Sleep Apnea Among Atrial Fibrillation Patients: A Cross-Sectional Study from Jordan. J Multidiscip Healthc 2024; 17:701-710. [PMID: 38375526 PMCID: PMC10875174 DOI: 10.2147/jmdh.s452589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
Background Obstructive Sleep Apnea (OSA) is a common respiratory disorder that causes intermittent upper airway collapse during sleep and can lead to various acute cardiovascular complications. Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with an increased risk of cardiovascular hospitalization and all-cause mortality. Our study aimed to investigate the prevalence of individuals with AF and those considered at high risk for OSA. Methods A cross-sectional study was conducted with a population comprising patients who had visited KAUH cardiology clinics between 2017-2019; subjects were categorized into AF patients and general cardiology patients. Patients were surveyed for OSA using the Berlin Questionnaire to assess the degree of OSA symptoms and to classify patients into high- or low-risk groups based on their responses. Results Of the 656 patients, 545 met our inclusion criteria, of whom 192 were diagnosed with AF. Comparable demographic characteristics were observed between the AF and non-AF groups, barring higher rates of obesity (p=0.001) and smoking (p=0.042) in the AF group. The prevalence of high-risk OSA was significantly higher in AF patients (68.2%) compared to non-AF patients (29.4%), with an adjusted odds ratio of 2.473 times (95% CI: 1.434 -4.266, p=0.001) greater for AF. The age, gender, and BMI categories did not differ significantly between the two groups. Binary logistic regression revealed significant associations between OSA and risk factors such as asthma (OR=4.408, 95% CI: 2.634-7.376, p=0.001). Conclusion These results serve to display a statistically significant increase in high-risk OSA in existing AF patients, irrespective of the presence of conventional OSA risk factors; this could imply a more immediate and direct relationship between both diseases and calls to include routine screening for OSA in patients diagnosed, newly or otherwise, with AF.
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Affiliation(s)
- Rasheed K Ibdah
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Khaled J Zaitoun
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Rana B Altawalbeh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Saad H Tayyem
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ulla A Nazzal
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Sukaina I Rawashdeh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Yousef S Khader
- Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | | | - Basheer Y Khassawneh
- Department of Internal Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
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3
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Di Pumpo M, Nurchis MC, Moffa A, Giorgi L, Sabatino L, Baptista P, Sommella L, Casale M, Damiani G. Multiple-access versus telemedicine home-based sleep apnea testing for obstructive sleep apnea (OSA) diagnosis: a cost-minimization study. Sleep Breath 2022; 26:1641-1647. [PMID: 34826058 PMCID: PMC8617356 DOI: 10.1007/s11325-021-02527-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/28/2021] [Accepted: 11/16/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE The aim of the present study was to compare two clinical pathways: the multiple-access outpatient pathway versus the telemedicine pathway. METHODS The multiple-access outpatient pathway and the telemedicine pathway were both performed with WatchPAT and implemented in a real-life healthcare scenario, adopting a cost-minimization approach. A cost-minimization analysis was undertaken to assess the economic impact of the two alternatives. The cost analyses were performed in euros for the year 2021 adopting the patient, the hospital, and the societal perspectives. Given the chosen perspectives, direct medical costs, direct nonmedical costs, and indirect costs were considered. In addition, a univariate sensitivity analysis was conducted. RESULTS From a hospital perspective, the telemedicine approach was estimated to cost €49 more than the multiple-access alternative. Considering the patient perspective, the telemedicine approach was estimated to cost €167 less than the multiple-access pathway. Considering the societal perspective, the telemedicine approach is estimated to cost €119 less than the multiple-access pathway. CONCLUSION The adoption of telemedicine home sleep apnea testing could improve the efficiency of the healthcare processes if considering the direct and indirect costs incurred by patients and not only by healthcare providers.
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Affiliation(s)
| | - Mario Cesare Nurchis
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Antonio Moffa
- Integrated Therapies in Otolaryngology, Campus Bio-Medico University, Rome, Italy
| | - Lucrezia Giorgi
- Integrated Therapies in Otolaryngology, Campus Bio-Medico University, Rome, Italy
| | - Lorenzo Sabatino
- Integrated Therapies in Otolaryngology, Campus Bio-Medico University, Rome, Italy
| | - Peter Baptista
- Unit of Otolaryngology, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Manuele Casale
- Integrated Therapies in Otolaryngology, Campus Bio-Medico University, Rome, Italy
| | - Gianfranco Damiani
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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4
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Pachito DV, Bagattini ÂM, Drager LF, Eckeli AL, Rocha A. Economic evaluation of CPAP therapy for obstructive sleep apnea: a scoping review and evidence map. Sleep Breath 2022; 26:17-30. [PMID: 33788132 DOI: 10.1007/s11325-021-02362-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of organization of care related to CPAP therapy. METHODS Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps. RESULTS Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving. CONCLUSIONS Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems. CLINICAL TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Daniela V Pachito
- Department of Health Technology Assessment, Hospital Sírio-Libanês, Rua Barata Ribeiro 142, São Paulo, 01308-000, Brazil.
| | - Ângela M Bagattini
- Department of Health Technology Assessment, Hospital Sírio-Libanês, Rua Barata Ribeiro 142, São Paulo, 01308-000, Brazil
| | - Luciano F Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Alan L Eckeli
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
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Cross Sectional Study of the Community Self-Reported Risk of Obstructive Sleep Apnoea (OSA) and Awareness in Thessaly, Greece. Clocks Sleep 2022; 4:16-22. [PMID: 35225950 PMCID: PMC8883944 DOI: 10.3390/clockssleep4010004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to investigate the self-reported risk of obstructive sleep apnea syndrome (OSAS) in the municipality of Thessaly, Greece, and the level of awareness of both the disease and its diagnosis. Inhabitants of Thessaly (254 total; 84 men and 170 women) were studied by means of questionnaires via a telephone-randomized survey. This comprised: (a) the Berlin questionnaire for evaluation of OSAS risk; (b) the evaluation of daytime sleepiness by the Epworth Sleepiness Scale; and (c) demographic and anthropometric data. The percentage of participants at high risk for OSA was 26.77%, and the percentage of people who were at high risk of excessive daytime sleepiness was 10.63%. High risk for OSAS was found to be 3.94%. No significant differences were found between high- and low-risk OSAS participants associated with age, smoking and severity of smoking. Regarding the knowledge of the community about OSAS, the majority of the sample was aware of the entity (64.17%), while fewer had knowledge about the diagnosis (18.50%) and polysomnography (24.80%). The high risk of OSA prevalence and the low awareness of the diagnosis of OSA highlights the need for the development of health promotion programs aiming at increasing the disease awareness in the general population in order to address OSA more effectively.
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Natsky AN, Vakulin A, Chai-Coetzer CL, McEvoy RD, Adams RJ, Kaambwa B. Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea in the adult population: a systematic review. Sleep Med Rev 2022; 62:101608. [DOI: 10.1016/j.smrv.2022.101608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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Santilli M, Manciocchi E, D’Addazio G, Di Maria E, D’Attilio M, Femminella B, Sinjari B. Prevalence of Obstructive Sleep Apnea Syndrome: A Single-Center Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910277. [PMID: 34639577 PMCID: PMC8508429 DOI: 10.3390/ijerph181910277] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 12/15/2022]
Abstract
Obstructive sleep apnea syndrome (OSAS) is a sleep breathing disorder that often remains undiagnosed and untreated. OSAS prevalence is increasing exponentially. Starting on the dentist's role as an epidemiological and diagnostic "sentinel", the purpose of this study was to assess the prevalence of OSAS. The clinical diaries of 4659 patients were reviewed through a single-center retrospective analytic study. Descriptive statistical analysis was performed. Only 0.26% of patients reported to suffer from sleep apnea and were then diagnosed with OSAS. It was found that, out of 4487 patients, 678 suffered from hypertension (14.80%), 188 from gastro-esophageal-reflux-disease (GERD = 4.10%) and 484 from gastritis (10.78%). These results could be related to a difficult diagnosis of OSAS and to the absence of a dedicated section on sleep disorders in medical records. Therefore, the introduction of a question dedicated to sleep disorders, the administration of questionnaires (such as the STOP-BANG questionnaire) for early diagnosis, a multidisciplinary approach and pneumological examination could support the dentist in identifying patients at risk of OSAS.
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Affiliation(s)
- Manlio Santilli
- Unit of Prosthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (M.S.); (E.M.); (G.D.); (B.F.)
| | - Eugenio Manciocchi
- Unit of Prosthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (M.S.); (E.M.); (G.D.); (B.F.)
| | - Gianmaria D’Addazio
- Unit of Prosthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (M.S.); (E.M.); (G.D.); (B.F.)
| | - Erica Di Maria
- Unit of Orthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (E.D.M.); (M.D.)
| | - Michele D’Attilio
- Unit of Orthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (E.D.M.); (M.D.)
| | - Beatrice Femminella
- Unit of Prosthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (M.S.); (E.M.); (G.D.); (B.F.)
| | - Bruna Sinjari
- Unit of Prosthodontics, Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy; (M.S.); (E.M.); (G.D.); (B.F.)
- Correspondence: ; Tel.: +39-392-27471479; Fax: +39-0871-3554070
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Conte L, Greco M, Toraldo DM, Arigliani M, Maffia M, De Benedetto M. A review of the "OMICS" for management of patients with obstructive sleep apnoea. ACTA ACUST UNITED AC 2021; 40:164-172. [PMID: 32773777 PMCID: PMC7416376 DOI: 10.14639/0392-100x-n0409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/21/2019] [Indexed: 12/11/2022]
Abstract
Obstructive sleep apnaea (OSA) syndrome is a condition characterised by the presence of complete or partial collapse of the upper airways during sleep, resulting in fragmentation of sleep associated with rapid episodes of intermittent hypoxia (IH), activation of the sympathetic nervous system and oxidative stress. OSA is associated with a broad spectrum of cardiovascular, metabolic and neurocognitive comorbidities that appear to be particularly evident in obese patients, while affecting both sexes in a different manner and varying in severity according to gender and age. In recent years, studies on OSA have increased considerably, but in clinical practice, it is still a highly underdiagnosed disease. To date, the gold standard for the diagnosis of OSA is nocturnal polysomnography (PSG). However, since it is not well suited for a large number of patients, the Home Sleep Test (HST) is also an accepted diagnostic method. Currently, the major aim of research is to identify non-invasive methods to achieve a highly predictive, non-invasive screening system for these subjects. The most recent reports indicate that research in this field has made significant progress in identifying possible biomarkers in OSA, using -OMIC approaches, particularly in the fields of proteomics and metabolomics. In this review, we analyse these OMIC biomarkers found in the literature.
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Affiliation(s)
- Luana Conte
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), University of Salento, Lecce, Italy.,Laboratory of Advanced Data Analysis for Medicine (ADAM), Department of Mathematics and Physics "E. De Giorgi", University of Salento, Lecce, Italy
| | - Marco Greco
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), University of Salento, Lecce, Italy.,Laboratory of Physiology, Department of Biological and Environmental Sciences and Technologies, University of Salento, Lecce, Italy
| | - Domenico Maurizio Toraldo
- Department Rehabilitation "V. Fazzi" Hospital, Cardio-Respiratory Unit Care, ASL-Lecce, San Cesario di Lecce (LE), Italy
| | | | - Michele Maffia
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), University of Salento, Lecce, Italy.,Laboratory of Physiology, Department of Biological and Environmental Sciences and Technologies, University of Salento, Lecce, Italy.,Laboratory of Clinical Proteomic, "Giovanni Paolo II" Hospital, ASL-Lecce, Italy
| | - Michele De Benedetto
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), University of Salento, Lecce, Italy
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Gonzalez-Vergara D, Marquez-Pelaez S, Alfonso-Arias JD, Perez-Ramos J, Rojas-Box JL, Aumesquet-Nosea M. An alternative model in the provision of CPAP in sleep apnea: a comparative cost analysis. BMC Health Serv Res 2021; 21:469. [PMID: 34006260 PMCID: PMC8130106 DOI: 10.1186/s12913-021-06474-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To conduct a pilot study on an alternative model for the provision of respiratory therapies in sleep apnea-hypopnea syndrome (SAHS) by internalizing the service with the purchase, monitoring and control of continuous positive airway pressure (CPAP) equipment by the hospital. METHODS An observational, prospective pilot study of comparative cost analysis by internalizing the service to include all patients up to a budget limit of 5000 euros. The cost of internalizing the service included the acquisition of CPAP equipment and all the necessary accessories in addition to the nursing days necessary to track the patients. Patient satisfaction was assessed by a survey of the hospital service. RESULTS Twenty-one patients with 23,046 patient-days of follow-up were included. The cost of the internalized system was 6825.11 €. The cost of the outsourced system over the same period would have been 22,781.18 €; thus, the direct saving was 15,956.07 €. The cost per device per day of the internalized system was 0.30 € versus the 0.99 € that the outsourced system would have cost during the study period. In the satisfaction survey, 12 (70.6%) patients indicated that they preferred the service of the hospital over that of the external company. No patient preferred the outsourced system. CONCLUSIONS The internalization of CPAP service represents significant cost savings from a hospital perspective and an improvement in patients' perceptions of the quality of service.
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Affiliation(s)
- Demetrio Gonzalez-Vergara
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot, s/n, 41013, Seville, Spain.
| | | | | | - Julia Perez-Ramos
- Agencia Sanitaria Bajo Guadalquivir, Hospital de Alta Resolución de Constantina, Seville, Spain
| | - Jose Luis Rojas-Box
- Agencia Sanitaria Bajo Guadalquivir, Hospital de Alta Resolución de Constantina, Seville, Spain
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10
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Natsky AN, Vakulin A, Coetzer CLC, McEvoy RD, Adams RJ, Kaambwa B. Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea: a systematic review protocol. Syst Rev 2021; 10:104. [PMID: 33836806 PMCID: PMC8035771 DOI: 10.1186/s13643-021-01651-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is a significant public health problem affecting a large proportion of the population and is associated with adverse health consequences and a substantial economic burden. Despite the existence of effective treatment, undiagnosed OSA remains a challenge. The gold standard diagnostic tool is polysomnography (PSG), yet the test is expensive, labour intensive and time-consuming. Home-based, limited channel sleep study testing (levels 3 and 4) can advance and widen access to diagnostic services. This systematic review aims to summarise available evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home PSG in diagnosing OSA. METHODS Eligible studies will be identified using a comprehensive strategy across the following databases from inception onwards: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane Library, Emcare and Web of Science Core Collection and ProQuest databases. The search will include a full economic evaluation (i.e. cost-effectiveness, cost-utility, cost-benefit, cost-consequences and cost-minimisation analysis) that assesses limited channel tests and PSG. Two reviewers will screen, extract data for included studies and critically appraise the articles for bias and quality. Meta-analyses will be conducted if aggregation of outcomes can be performed. Qualitative synthesis using a dominance ranking matrix will be performed for heterogeneous data. DISCUSSION This systematic review protocol uses a rigorous, reproducible and transparent methodology and eligibility criteria to provide the current evidence relating to the clinical and economic impact of limited channel and full PSG OSA diagnostic tests. Evidence will be examined using standardised tools specific for economic evaluation studies. TRIAL REGISTRATION PROSPERO (CRD42020150130).
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Affiliation(s)
- Andrea N Natsky
- Department of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia. .,National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.
| | - Andrew Vakulin
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Sleep and Circadian Research Group, Woolcock Institute of Medical Research, University of Sydney, Camperdown, New South Wales, Australia
| | - Ching Li Chai Coetzer
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - R D McEvoy
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - Robert J Adams
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - Billingsley Kaambwa
- Department of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia
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11
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Valentim-Coelho C, Vaz F, Antunes M, Neves S, Martins IL, Osório H, Feliciano A, Pinto P, Bárbara C, Penque D. Redox-Oligomeric State of Peroxiredoxin-2 and Glyceraldehyde-3-Phosphate Dehydrogenase in Obstructive Sleep Apnea Red Blood Cells under Positive Airway Pressure Therapy. Antioxidants (Basel) 2020; 9:E1184. [PMID: 33256145 PMCID: PMC7761104 DOI: 10.3390/antiox9121184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022] Open
Abstract
In this study, we examined the effect of six months of positive airway pressure (PAP) therapy on Obstructive Sleep Apnea (OSA) red blood cell (RBC) proteome by two dimensional difference gel electrophoresis (2D-DIGE) - based proteomics followed by Western blotting (WB) validation. The discovered dysregulated proteins/proteoforms are associated with cell death, H2O2 catabolic/metabolic process, stress response, and protein oligomerization. Validation by nonreducing WB was performed for peroxiredoxin-2 (PRDX2) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) by using antibodies against the sulfinylated/sulfonylated cysteine of these proteins to better evaluate their redox-oligomeric states under OSA and/or in response to PAP therapy. The results indicated that the redox-oligomeric state of GAPDH and PRDX2 involving overoxidation by sulfinic/sulfonic acids were differentially modulated in OSA RBC, which might be compromising RBC homeostasis. PAP therapy by restoring this modulation induced a higher oligomerization of overoxidized GAPDH and PRDX2 in some patients that could be associated with eryptosis and the chaperone "gain" of function, respectively. This varied response following PAP may result from the complex interplay between OSA and OSA metabolic comorbidity. Hence, information on the redox status of PRDX2 and GAPDH in RBC will help to better recognize OSA subtypes and predict the therapeutic response in these patients. GAPDH monomer combined with body mass index (BMI) and PRDX2 S-S dimer combined with homeostatic model assessment for insulin resistance (HOMA-IR) showed to be very promising biomarkers to predict OSA and OSA severity, respectively.
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Affiliation(s)
- Cristina Valentim-Coelho
- Laboratório de Proteómica, Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, 1649-016 Lisboa, Portugal; (C.V.-C.); (F.V.); (S.N.); (I.L.M.)
- ToxOmics—Centre of Toxicogenomics and Human Health, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
| | - Fátima Vaz
- Laboratório de Proteómica, Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, 1649-016 Lisboa, Portugal; (C.V.-C.); (F.V.); (S.N.); (I.L.M.)
- ToxOmics—Centre of Toxicogenomics and Human Health, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
| | - Marília Antunes
- Centro de Estatística e Aplicações da Universidade de Lisboa e Departamento de Estatística e Investigação Operacional, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal;
| | - Sofia Neves
- Laboratório de Proteómica, Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, 1649-016 Lisboa, Portugal; (C.V.-C.); (F.V.); (S.N.); (I.L.M.)
- ToxOmics—Centre of Toxicogenomics and Human Health, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
| | - Inês L. Martins
- Laboratório de Proteómica, Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, 1649-016 Lisboa, Portugal; (C.V.-C.); (F.V.); (S.N.); (I.L.M.)
- ToxOmics—Centre of Toxicogenomics and Human Health, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
| | - Hugo Osório
- i3S–Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal;
- Ipatimup–Institute of Molecular Pathology and Immunology of the University of Porto, University of Porto, 4200-135 Porto, Portugal
- Department of Pathology, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Amélia Feliciano
- Serviço de Pneumologia, Centro Hospitalar Lisboa Norte—CHLN, 1649-035 Lisboa, Portugal; (A.F.); (P.P.); (C.B.)
| | - Paula Pinto
- Serviço de Pneumologia, Centro Hospitalar Lisboa Norte—CHLN, 1649-035 Lisboa, Portugal; (A.F.); (P.P.); (C.B.)
- Instituto de Saúde Ambiental—ISAMB, Faculdade de Medicina, Universidade de Lisboa, 1649-026 Lisboa, Portugal
| | - Cristina Bárbara
- Serviço de Pneumologia, Centro Hospitalar Lisboa Norte—CHLN, 1649-035 Lisboa, Portugal; (A.F.); (P.P.); (C.B.)
- Instituto de Saúde Ambiental—ISAMB, Faculdade de Medicina, Universidade de Lisboa, 1649-026 Lisboa, Portugal
| | - Deborah Penque
- Laboratório de Proteómica, Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, 1649-016 Lisboa, Portugal; (C.V.-C.); (F.V.); (S.N.); (I.L.M.)
- ToxOmics—Centre of Toxicogenomics and Human Health, Universidade Nova de Lisboa, 1150-082 Lisboa, Portugal
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İriz A, Şemsi R, Eser B, Arslan B, Dinçel AS. The evaluation of serum tryptophan and kynurenine levels in patients with obstructive sleep apnea syndrome. Sleep Breath 2020; 25:1389-1398. [PMID: 33222028 DOI: 10.1007/s11325-020-02250-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/02/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The kynurenine (Kyn) pathway may play a role in certain physiological functions such as behavior, sleep, thermoregulation, and pregnancy. Tryptophan (Trp) is oxidized with tryptophan 2,3-dioxygenase and indolamine 2,3-dioxygenase (IDO). Under normal conditions, hepatic kynurenine is a transcription factor and IDO expression in healthy tissues is very low. The ratio of Kyn to Trp can be used as an indicator to assess IDO activity. This study aimed to determine the relationship between Kyn/Trp ratio and obstructive sleep apnea syndrome (OSAS) disease activity. METHODS Study participants were categorized in 3 groups: Group 1 included patients with mild OSAS, Group 2, patients with moderate to severe OSAS, and Group 3, individuals considered normal to serve as controls. The demographic characteristics of the patients were recorded. Apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) measurements were performed by diagnostic polysomnography (PSG). Trp and Kyn levels were determined by HPLC-UV method. RESULTS Group 1 included 30 patients (18 men) with mild OSAS; Group 2 included 42 patients (31 men) with moderate to severe OSAS; and Group 3 included 25 controls (13 men). While there was no statistically significant difference between the levels of tryptophan and kynurenine in the groups, a significant difference was found between the Kyn/Trp ratios. A significant correlation was observed in individuals with a body mass index less than 25 with the Kyn/Trp ratio. In individuals with mild OSAS, a significant correlation was observed between ODI and BMI. In individuals with moderate to severe OSAS, there was a significant correlation between ODI, AHI, and BMI. CONCLUSION In this study, there was no relationship between OSAS disease severity and IDO activity as assessed by immunoreactivity via the Kyn/Trp pathway.
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Affiliation(s)
- Ayşe İriz
- Department of Otorhinolaryngology (Ear-Nose-Throat), Gazi University Faculty of Medicine, Ankara, Turkey
| | - Rabia Şemsi
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - Burcu Eser
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
- Gülhane Institute of Health Sciences, R&D Centre, Chromatography Laboratory, The University of Health Sciences, Ankara, Turkey
| | - Burak Arslan
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
- Department of Medical Biochemistry, Ercis State Hospital, Van, Turkey
| | - Aylin Sepici Dinçel
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
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Savini S, Ciorba A, Bianchini C, Stomeo F, Corazzi V, Vicini C, Pelucchi S. Assessment of obstructive sleep apnoea (OSA) in children: an update. ACTA ACUST UNITED AC 2020; 39:289-297. [PMID: 31708576 PMCID: PMC6843580 DOI: 10.14639/0392-100x-n0262] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/11/2019] [Indexed: 02/04/2023]
Abstract
OSA is a condition characterised by episodes of complete or partial obstruction of the upper airway, associated with blood-gas changes and atypical sleep patterns. Early diagnosis of OSA may reduce the occurrence of systemic complications over time, although the diagnosis of OSA is, unfortunately, often late. The aim of the work is to review the current concepts in evaluation of paediatric obstructive sleep apnoea (OSA), with an updated revision of the literature considering risk factors, clinical manifestations, and basic and advanced assessment in the paediatric population. For this narrative review, PubMed, Embase and Cinahl databases were searched for the last 10 years, according to PRISMA criteria/guidelines. Assessment of paediatric OSA remains challenging and paediatric patients should always be carefully evaluated; polysomnography is the gold standard for diagnosis of paediatric OSA.
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Affiliation(s)
- S Savini
- ENT Department, University Hospital of Ferrara, Italy
| | - A Ciorba
- ENT Department, University Hospital of Ferrara, Italy
| | - C Bianchini
- ENT Department, University Hospital of Ferrara, Italy
| | - F Stomeo
- ENT Department, University Hospital of Ferrara, Italy
| | - V Corazzi
- ENT Department, University Hospital of Ferrara, Italy
| | - C Vicini
- Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - S Pelucchi
- ENT Department, University Hospital of Ferrara, Italy
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Management of OSAS: The ELIBA® Device Can Help the Patient? Case Rep Dent 2020; 2020:9873761. [PMID: 32231810 PMCID: PMC7085363 DOI: 10.1155/2020/9873761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/22/2019] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is one of the most challenging diseases to treat in medicine. Here, the authors describe a case of OSAS treated with a lingual elevator of Balercia (ELIBA®). The patient, a forty-five-year-old Caucasian male, had a chief complaint of numerous episodes of nocturnal apnea. After several visits with specialists, a polysomnographic examination was performed, in which the patient's apnea hypopnea index (AHI) was 30.4, and a lingual elevator was prescribed. The lingual elevator helped to keep the patient's tongue in the correct position and prevented the tongue from reverting back to the soft tissue spaces in the mouth. After six months of treatment with the lingual elevator and dietary adjustments, the patient's AHI decreased to 11.6. This simple yet customizable approach is a comfortable and easy option for patients to reduce night apnea episodes.
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MAGLIULO G, IANNELLA G, CIOFALO A, POLIMENI A, DE VINCENTIIS M, PASQUARIELLO B, MONTEVECCHI F, VICINI C. Nasal pathologies in patients with obstructive sleep apnoea. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2019; 39:250-256. [PMID: 30933181 PMCID: PMC6734203 DOI: 10.14639/0392-100x-2173] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/24/2018] [Indexed: 11/23/2022]
Abstract
Nasal obstruction is a frequent condition in patients with obstructive sleep apnoea (OSA). Nasal obstruction leads to mouth breathing, which is thought to destabilise the upper airway and aggravate the condition. Three conditions could be considered as the cause of the nasal breathing obstruction: anatomical conditions of the nose (septum deviation, hypertrophy of the inferior turbinates), chronic rhinosinusitis (CRS) and chronic nasal inflammation caused by allergic rhinitis or non-allergic cellular rhinitis. In this prospective study, we present an evaluation of all these possible rhino-sinusal aspects in OSA patients to correlate different nasal pathologies with nasal obstruction. Fifty patients with a diagnosis of OSA were enrolled in the study. In 70% of OSA patients, nasal obstruction was confirmed by clinical evaluation and rhinomanometry testing. Normal rhino-sinus aspects were present in only 20% of OSA patients, whereas one or more pathological rhino-sinus conditions were present in the remaining 80%. The percentage of OSA patients with a diagnosis of allergic rhinitis and non-allergic rhinitis was 18% and 26% respectively. Non-allergic rhinitis with neutrophils (NARNE) was the most frequent type of cellular rhinitis diagnosed in OSA patients (20% of cases). The results of the present study support and extend the observation that rhinitis is present in OSA patients. Mucosal inflammation caused by these conditions could be the cause of upper airway patency impairment inducing nasal mucosa swelling.
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Affiliation(s)
- G. MAGLIULO
- Department of “Organi di Senso”, University “Sapienza”, Rome, Italy
| | - G. IANNELLA
- Department of “Organi di Senso”, University “Sapienza”, Rome, Italy
| | - A. CIOFALO
- Department of “Organi di Senso”, University “Sapienza”, Rome, Italy
| | - A. POLIMENI
- Department of Oral and Maxillo Facial Sciences, University “Sapienza”, Rome, Italy
| | - M. DE VINCENTIIS
- Department of “Organi di Senso”, University “Sapienza”, Rome, Italy
| | - B. PASQUARIELLO
- Department of “Organi di Senso”, University “Sapienza”, Rome, Italy
| | - F. MONTEVECCHI
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - C. VICINI
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
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Torres-Castro R, Vilaró J, Martí JD, Garmendia O, Gimeno-Santos E, Romano-Andrioni B, Embid C, Montserrat JM. Effects of a Combined Community Exercise Program in Obstructive Sleep Apnea Syndrome: A Randomized Clinical Trial. J Clin Med 2019; 8:jcm8030361. [PMID: 30875753 PMCID: PMC6463021 DOI: 10.3390/jcm8030361] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/09/2019] [Accepted: 03/10/2019] [Indexed: 12/27/2022] Open
Abstract
Physical activity is associated with a decreased prevalence of obstructive sleep apnea and improved sleep efficiency. Studies on the effects of a comprehensive exercise program in a community setting remain limited. Our objective was to investigate the effects of a combined physical and oropharyngeal exercise program on the apnea-hypopnea index in patients with moderate to severe obstructive sleep apnea. This was a randomized clinical trial where the intervention group followed an eight-week urban-walking program, oropharyngeal exercises, and diet and sleep recommendations. The control group followed diet and sleep recommendations. A total of 33 patients were enrolled and randomized and, finally, 27 patients were included in the study (IG, 14; CG, 13) Obstructive sleep apnea patients were analyzed with a median age of 67 (52–74) and median apnea-hypopnea index of 32 events/h (25–41). The apnea-hypopnea index did not differ between groups pre- and post-intervention. However, in intervention patients younger than 60 (n = 6) a reduction of the apnea-hypopnea index from 29.5 (21.8–48.3) to 15.5 (11–34) events/h (p = 0.028) was observed. While a comprehensive multimodal program does not modify the apnea-hypopnea index, it could reduce body weight and increase the walking distance of patients with moderate to severe obstructive sleep apnea. Patients younger than 60 may also present a decreased apnea-hypopnea index after intervention.
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Affiliation(s)
- Rodrigo Torres-Castro
- Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Chile, 8380453 Santiago, Chile.
| | - Jordi Vilaró
- Facultad de Ciencias de la Salud Blanquerna. Global Research on Wellbeing (GRoW)), Universitat Ramon Llull, 08025 Barcelona, Spain.
| | - Joan-Daniel Martí
- Unidad de Cuidados Intensivos en Cirugía Cardiovascular, Instituto Clínico Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
| | - Onintza Garmendia
- Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
| | - Elena Gimeno-Santos
- Respiratory Institute, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain.
| | - Bárbara Romano-Andrioni
- Servicio de Endocrinología y Nutrición, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
| | - Cristina Embid
- Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
| | - Josep M Montserrat
- Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona, 08036 Barcelona, Spain.
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Villa MP, Bellussi LM, De Benedetto M, Garbarino S, Passali D, Sanna A. The "Italian way" to counteract obstructive sleep apnoea syndrome in children. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 38:393-394. [PMID: 30197431 PMCID: PMC6146572 DOI: 10.14639/0392-100x-2157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 11/23/2022]
Affiliation(s)
- M P Villa
- Sant'Andrea Hospital, NESMOS department, Sapienza University of Rome, Italy
| | - L M Bellussi
- ENT Department, University of Siena, Siena, Italy
| | - M De Benedetto
- Department of Otolaryngology Head and Neck Surgery, Hospital Fazzi, Lecce, Italy
| | - S Garbarino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,State Police Health Service Department, Ministry of the Interior, Rome
| | - D Passali
- ENT Department, University of Siena, Siena, Italy
| | - A Sanna
- Azienda USL Toscana Centro, Pneumology Unit, San Jacopo Hospital, Pistoia, Italy
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Morley JE, Sanford A, Bourey R. Sleep Apnea: A Geriatric Syndrome. J Am Med Dir Assoc 2017; 18:899-904. [DOI: 10.1016/j.jamda.2017.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
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