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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0006" class="elsevierStylePara elsevierViewall">Asthma and obstructive sleep apnea &#40;OSA&#41; are inflammatory diseases of the respiratory tract that can affect all age groups&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Asthma prevalence is high in Brazil&#44; affecting around 20&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">OSA affects 1&#8211;4&#37; of the pediatric population according to the 3rd International Classification of Sleep Disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Asthma and OSA share many risk factors such as allergic rhinitis &#40;AR&#41;&#44; upper airway and systemic inflammation&#44; gastroesophageal reflux disease &#40;GERD&#41;&#44; and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Moreover&#44; both are influenced by circadian rhythm&#44; age&#44; and sex&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> There is a paucity of studies regarding asthma and OSA in children&#44; but there is evidence that OSA increases the length of stay in hospitalizations due to asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">Age and sex have a significant role in asthma and OSA presentation&#46; Asthma is more prevalent in adult females than males&#44; but during childhood&#44; the association is more complex&#58; until 6 years old&#44; boys are more affected than girls&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> This is explained by the smaller airway and dysanaptic growth of lung parenchyma &#40;boys develop the parenchyma slower than girls&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> No difference in asthma prevalence is found between 7 and 9 years &#8211; airway and parenchyma are equal in boys and girls and hormonal changes have not yet begun&#46; Afterward&#44; girls are more affected &#8211; the airway turns larger in boys and sexual hormones modify inflammation since estrogen and progesterone have inflammatory effects according to different receptors and testosterone has anti-inflammatory effects&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> During childhood&#44; the prevalence of OSA in children without comorbidity is equal in boys and girls&#44; but during adulthood&#44; men are more affected and this sex-related difference in OSA prevalence begins during puberty&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> However&#44; a questionnaire-based study found OSA more prevalent among asthmatic girls than boys&#44; though this finding was a <span class="elsevierStyleItalic">post-hoc</span> analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Even though the American Academy of Sleep Medicine recommends the polysomnographic evaluation for the diagnosis of OSA in children be performed at the sleep center &#40;type I&#41;&#44; some authors have found it feasible to use home polygraphy type III &#40;known as home sleep apnea testing &#8211; HSAT&#44; monitoring flow&#44; respiratory effort&#44; and oximetry&#41; as an optional tool&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">The objectives of this study are&#58; &#40;1&#41; analyze the prevalence of obstructive sleep apnea in&#58; &#40;1&#41; boys and girls&#44; and &#40;2&#41; severe asthma versus moderate and mild cases&#46; Secondary objectives are&#58; &#40;1&#41; analyze the effect of the pubertal stage on OSA&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">Considering that the asthma presentation is associated with age&#44; sex&#44; and OSA&#44; and questionnaire-based studies described that OSA was more prevalent in girls than boys&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> and with asthma severity&#44;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> the authors hypothesized that among children with asthma&#44; OSA measured by an objective method would be more prevalent in girls than boys&#44; and among those with severe asthma comparing to mild to moderate cases&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Materials and methods</span><p id="para0012" class="elsevierStylePara elsevierViewall">This cross-sectional study enrolled 80 consecutive patients&#44; recruited from a tertiary Pediatric Pulmonology clinic between December 2016 and July 2018&#46; The sample size was calculated considering OSA more frequent in girls &#40;OR&#44; 2&#46;55&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> and in severe asthma &#40;16 OSA in 29 severe asthmatic patients vs 16 OSA in 79 mild&#47;moderate asthma&#41;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> both considering alfa 0&#46;05 and beta 0&#46;80&#46; The authors calculated 68 children&#44; and expecting 20&#37; of follow-up losses&#44; the authors decided to recruit 80 volunteers&#46;</p><p id="para0013" class="elsevierStylePara elsevierViewall">Inclusion criteria were 7&#8211;18 years old and medical diagnosis of asthma according to the Brazilian Consensus&#58;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> FEV<span class="elsevierStyleInf">1</span> &#60;80&#37; predicted or &#8805;12&#37; variation post-beta-agonist&#44; or 3 or more&#58; &#40;1&#41; more than one episode of wheezing per month&#44; &#40;2&#41; cough or wheezing&#44; by morning or at night&#44; after laughter&#44; crying or exercise&#44; &#40;3&#41; cough without viral infections&#44; &#40;4&#41; allergic rhinitis or conjunctivitis&#44; &#40;5&#41; family history of atopy or asthma&#44; &#40;6&#41; improvement of symptoms with bronchodilator or inhaled corticosteroids&#46; The authors had children already under treatment in the clinic and some that were new patients&#46;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Exclusion criteria were craniofacial and&#47;or thoracic malformations&#44; genetic syndromes&#44; bronchopulmonary dysplasia&#44; bronchiolitis obliterans&#44; neuromuscular diseases&#44; sickle cell disease&#44; cystic fibrosis&#44; or those unable to understand or perform protocol&#39;s tests&#46; Parents&#8217; informed consent and patients&#8217; assent were required before enrolling in the study&#46; The project was approved by the Ethics Committee of Universidade Federal de S&#227;o Paulo &#40;&#35;1&#46;794&#46;705&#41;&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">Interview&#44; physical examination&#44; pulmonary function tests &#40;PFT&#41;&#44; and HSAT were performed&#46; The authors applied unstandardized &#40;asthma history&#41; and standardized questionnaires &#40;Brazilian criteria for socioeconomic classification&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> The authors also collected data about current asthma medication and asthma exacerbations in the previous 12 months&#46;</p><p id="para0016" class="elsevierStylePara elsevierViewall">Asthma symptoms were defined as not controlled in the long term if there were systemic corticosteroid use&#44; emergency room visit&#44; or hospital admission due to asthma exacerbation in the previous 12 months&#46; Short-term control was based on the Global Initiative for Asthma &#40;GINA&#41; questionnaire that evaluate the control in the past 4 weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> and inquiries about daytime and nighttime symptoms&#44; use of short-acting beta-agonist&#44; and limitations due to asthma&#46;</p><p id="para0017" class="elsevierStylePara elsevierViewall">All volunteers self-evaluated their pubertal stage using Tanner figures for boys and girls&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> Those with any pubertal development 2 or more were classified as pubescent&#46; Body-mass index was calculated using CDC definition and classified as <span class="elsevierStyleItalic">z</span>-score&#46; Rhinitis was defined as intermittent or persistent &#40;mild&#44; moderate&#47;severe&#41; according to ARIA definition&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0018" class="elsevierStylePara elsevierViewall">PFT was acquired on Koko&#174; &#40;Longmont&#44; USA&#41;&#44; with Polgar reference&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> All exams were performed by the same medical doctor &#40;CFS&#41;&#44; during the afternoon&#44; with 1&#160;h maximum intervals&#46; Per protocol&#44; every volunteer should perform the test before and after 20 min taking 400 mcg of salbutamol through a metered-dose inhaler and a spacer&#46; Volunteers with asthma exacerbations were rescheduled for two weeks later&#46;</p><p id="para0019" class="elsevierStylePara elsevierViewall">HSAT was performed using a three-channel cardiorespiratory monitor &#40;Philips Stardust&#174;&#41;&#44; regardless of sleep symptoms&#44; on the entire sample&#46; Even though the gold standard for sleep studies in children is PSG type I this is not easily accessible in every part of the studied country&#46; Another major concern is its costs&#46; Since there are some studies showing that PSG type III is feasible and accurate in children&#44;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> we opted to use this method&#46;</p><p id="para0020" class="elsevierStylePara elsevierViewall">The exams were revised by two polysomnographic technicians with extensive experience with pediatric sleep studies&#44; using AASM rules&#46; Afterward&#44; they were revised by a sleep physician &#40;A&#46;K&#46;S&#46;&#41; who did not attend the volunteers&#46; Technicians and physicians were blinded to the study hypothesis&#46; HSAT was performed the night after the PFT&#44; so HSAT also was rescheduled in case of asthma exacerbations&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">OSA was defined as those with habitual snoring and one or more obstructive respiratory events &#40;OREI&#41; per hour of recording time&#46; OREI &#8805;1 was defined as mild OSA&#44; &#8805;5 as moderate&#44; and &#8805;10 as severe OSA&#46; The authors used the pediatric criteria in the entire sample&#46; The authors considered acceptable studies with at least 2&#160;h of register of each channel without artifact&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> When an acceptable study was not obtained on the first night&#44; the authors invited the volunteer to repeat the exam&#46; If the volunteer did not agree&#44; the authors kept the data for those with at least 60 min of valid data&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">PFT was analyzed according to American Thoracic Society criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Asthma severity was classified based on GINA criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0023" class="elsevierStylePara elsevierViewall">Analysis of possible confounders was made with a Directed Acyclic Graph &#40;DAG&#41;&#59; neither age&#44; sex&#44; BMI&#44; pubertal stage&#44; rhinitis&#44; socioeconomic status&#44; or asthma control were identified as cofounders &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Figure 1</a>&#41;&#46; DAG considers the relationship among variables to determine if any of them is a confounder or not&#46; The idea of &#8220;acyclic&#8221; is that you should not come back to the beginning of the path &#40;exposure&#41; following the arrows that link the variables&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> There are rules to consider if the path is open or closed when a variable is related to another&#46; In this case&#44; if the authors controlled for any of the above variables&#44; we would introduce bias since the path would be opened&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0024" class="elsevierStylePara elsevierViewall">Data were summarized as mean and standard deviation and frequencies were compared using chi-square tests&#46; The authors considered significant <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;05&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Results</span><p id="para0025" class="elsevierStylePara elsevierViewall">To achieve the sample size calculation&#44; 148 volunteers were invited&#44; 28 declined participation and 23 had exclusion criteria&#46; Of those who accepted to participate&#44; 17 did not attend the appointed meeting&#44; and 80 completed the protocol&#46;</p><p id="para0026" class="elsevierStylePara elsevierViewall">The mean age was 11&#46;6 years&#44; standard deviation 2&#46;7&#44; 41 were female &#40;51&#46;3&#37;&#41;&#44; 30 white &#40;37&#46;5&#37;&#41;&#46; Sociodemographic are summarized in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#46; According to the body mass index z-score&#44; nutritional status was&#58; 2 &#40;2&#46;5&#37;&#41; underweight&#44; 63 eutrophics &#40;79&#37;&#41;&#44; and 15 obese &#40;18&#46;5&#37;&#41;&#46; Puberty was present in 17 volunteers &#40;6 boys and 11 girls&#41;&#46; Rhinitis was present in 78 volunteers&#59; 12 &#40;15&#37;&#41; had mild rhinitis and the remaining had moderate&#47;severe rhinitis&#46; Asthma classification based on GINA criteria was 3 &#40;4&#37;&#41; mild&#44; 8 &#40;10&#37;&#41; moderate&#44; and 69 &#40;86&#37;&#41; severe&#46; Asthma control in the past 4 weeks using the GINA questionnaire was found in 35 &#40;43&#46;7&#37;&#41; and in long term in 27 &#40;33&#46;7&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0027" class="elsevierStylePara elsevierViewall">The authors obtained PFT classified as A or B according to ATS<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> of 71 volunteers&#46; Considering the 80 PFT obtained&#44; a normal lung function pattern was found in 45 &#40;56&#46;2&#37;&#41; volunteers&#59; 32 &#40;40&#37;&#41; had an obstructive ventilatory defect &#40;30 mild and two moderate&#41;&#59; three had unspecific abnormalities&#46; Data regarding the PFT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#46; Acceptable HSAT exams were obtained from 76 volunteers&#46; Mean OREI was 1&#46;8 events&#47;h&#44; mild OSA was found in 30 volunteers &#40;37&#46;5&#37; of the sample&#41;&#44; moderate in 16 &#40;20&#37;&#41;&#44; and severe in 3 &#40;3&#46;8&#37;&#41;&#46; Habitual snoring was found in 9 volunteers&#46; HSAT data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0003">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><p id="para0028" class="elsevierStylePara elsevierViewall">Among the volunteers with mild&#47;moderate asthma&#44; 7&#47;10 had OSA &#40;5 mild and 2 moderate&#41; while among those with severe asthma 42&#47;66 had OSA &#40;25 mild&#44; 14 moderate&#44; and 3 severe&#41;&#46; The authors did not find an association between OSA and sex &#40;chi-square&#44; 2&#46;578&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;108&#41;&#44; asthma severity &#40;Fisher&#39;s test&#44; 0&#46;091&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;763&#41;&#44; asthma control &#40;short term&#58; chi-square&#44; 0&#46;94&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;759&#44; long term&#58; chi-square&#44; 0&#46;638&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;424&#41;&#44; or puberty status &#40;chi-square test&#44; 3&#46;036&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;081&#41;&#46; The authors have found OSA in 75&#37; of boys and 57&#46;5&#37; of girls &#40;61&#46;2&#37; of the entire sample&#41;&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">Severe OSA was found in three volunteers&#58; they were all pubescent&#44; with perennial rhinitis&#44; severe asthma&#44; not controlled in the short and long term&#44; had nasal turbinate hypertrophy&#44; tonsils III&#47;IV&#44; and HSAT with oxygen saturation nadir below 90&#37;&#46; Obesity&#44; ogival palate&#44; and gastroesophageal reflux were present in two of them&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Discussion</span><p id="para0030" class="elsevierStylePara elsevierViewall">This cross-sectional study of asthmatic children in a tertiary Pediatric Pulmonology clinic showed a high prevalence of OSA &#40;61&#46;2&#37;&#41; diagnosed by HSAT&#46; However&#44; neither sex&#44; asthma severity&#44; asthma control &#40;short or long term&#41;&#44; nor puberty status were predictors of OSA&#46;</p><p id="para0031" class="elsevierStylePara elsevierViewall">There is still a paucity of data regarding OSA among asthmatic children&#46; A Chinese questionnaire-based study with almost 22 thousand asthmatic children&#44; found 12&#37; with sleep-disorder breathing&#46;<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> The authors have only found three studies in the pediatric population with both asthma and OSA objective measurements&#58; He et al&#46;<a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> studied 5&#8211;18 years-old children and found an OSA prevalence of 57&#37;&#46; A second study found a higher prevalence of OSA in children with asthma &#40;6&#46;6&#37; vs 3&#46;8&#37; in non-asthmatic children&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> However&#44; a third study did not find any difference in the prevalence of OSA among asthmatic versus non-asthmatic children&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> The different prevalences in OSA diagnosis among those studies and might be explained by different cut points to diagnose OSA&#44; older children in the present study&#44; and lower FEV<span class="elsevierStyleInf">1</span> values than in He<a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> and Sulit<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> studies&#46; Even though the ICSD-3<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> recommends a cut point of 1 for the obstructive apnea-hypopnea index to consider an OSA diagnosis in the pediatric population&#44; different studies have chosen different cut points&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Contrary to adults&#44; most pediatric studies are based on statistical normality values and not on health outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a></p><p id="para0032" class="elsevierStylePara elsevierViewall">The authors did not find any statistically significant difference among boys and girls&#44; puberty and pre-puberty&#44; or asthma control &#40;in the short and long term&#41; among those with and without OSA&#46; The present study&#39;s sample had a vast majority of children with severe asthma&#44; reflecting the characteristic of the reference center&#46; In accordance with the amount of severe asthma&#44; the authors found 40&#37; of PFT abnormal&#44; which is not common in asthmatic children who tend to have a more preserved lung function than adults with severe asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0033" class="elsevierStylePara elsevierViewall">The authors obtained acceptable HSAT exams in 95&#37; of cases &#40;81&#37; on the first attempt&#41;&#46; Previous studies had 81 to 100&#37; of acceptable exams considering 1 repetition if needed&#46;<a class="elsevierStyleCrossRefs" href="#bib0026"><span class="elsevierStyleSup">26-29</span></a> The prevalence of OSA in the present sample was higher than the prevalence in epidemiologic studies&#44; mainly in children without asthma &#40;62&#46;5 vs 1&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> The high prevalence of AR and severe asthma in our sample could explain our high OSA prevalence&#46; However&#44; the authors did not find associations among either AR or asthma severity in the present study&#39;s volunteers&#46; The fact that the vast majority had moderate&#47;severe AR and severe asthma could have reduced the variability necessary to find differences among these groups&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">This study has some strengths&#58; asthma and OSA were defined by questionnaires and objective measurements&#44; and the authors obtained a high rate of acceptable sleep exams&#46; However&#44; the authors also faced some limitations such as a few volunteers with mild asthma and OSA evaluation with an alternative method instead of the gold standard type I polysomnography&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Conclusion</span><p id="para0035" class="elsevierStylePara elsevierViewall">In summary&#44; the authors found a high prevalence of OSA &#40;61&#46;2&#37;&#41; in a sample of mainly severe asthmatic children and adolescents&#46; Nor sex&#44; age&#44; pubertal stage&#44; asthma classification&#44; or control were statistically significant as OSA predictors&#46; High suspicion of the comorbidity must also be in mind as OSA since it may lead to detrimental metabolic and cognitive functions&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Grant support</span><p id="para0036" class="elsevierStylePara elsevierViewall">Associa&#231;&#227;o Fundo de Incentivo &#224; Pesquisa &#40;AFIP&#41;&#44; Methods of Epidemiological and Clinical Research &#40;MECOR&#41;&#44; Coordena&#231;&#227;o de Aperfei&#231;oamento do Ensino Superior &#40;CAPES&#41;&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2022-09-19"
    "fechaAceptado" => "2023-03-30"
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          "palabras" => array:4 [
            0 => "Asthma"
            1 => "Sleep apnea"
            2 => "Obstructive"
            3 => "Pediatrics"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objectives</span><p id="spara009" class="elsevierStyleSimplePara elsevierViewall">Primary objectives were to analyze the prevalence of obstructive sleep apnea in &#40;1&#41; boys and girls&#44; and &#40;2&#41; severe asthma versus moderate and mild cases&#46; The authors hypothesized that girls and severe asthma would have a higher prevalence of obstructive sleep apnea&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional evaluation of asthmatic children attending a tertiary Pediatric Pulmonology clinic&#46; The authors performed a history&#44; physical examination&#44; pulmonary function test&#44; and home sleep apnea test&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">The authors studied 80 consecutive patients&#44; 7&#8211;18 years old&#44; mean age of 11&#46;6 years &#40;standard deviation 2&#46;7&#41;&#44; 51&#46;3&#37; female&#44; and 18&#46;5&#37; obese&#46; Pulmonary function tests were obtained from 80 volunteers&#44; 45&#37; with obstruction pattern&#46; Home sleep apnea tests were available from 76 volunteers&#44; with a mean obstructive respiratory index of 1&#46;8 events&#47;h&#46; Obstructive sleep apnea was found in 49 volunteers &#40;61&#46;2&#37;&#41;&#46; The authors did not find associations between obstructive sleep apnea and sex or asthma severity&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusions</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">Obstructive sleep apnea was frequent among these asthmatic children&#46; Sex and asthma severity were not risk factors&#46; Considering the interrelationship of both diseases&#44; it is worth keeping in mind the possibility of obstructive sleep apnea among children and teenagers with asthma&#46;</p></span>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Directed Acyclic Graph regarding the relationship among asthma and obstructive sleep apnea &#40;OSA&#41;&#46; Asthma is influenced by age&#44; rhinitis&#44; body mass index &#40;BMI&#41;&#44; socioeconomical status &#40;SES&#41;&#44; and puberty&#46; Asthma influences asthma control which also receives influence from rhinitis and BMI&#46; OSA is influenced by sex&#44; rhinitis&#44; BMI&#44; puberty&#44; asthma&#44; and asthma control&#46; Graphic made on Dagtty&#46;net&#46; Red arrows show variables that would introduce bias if controlled&#46; &#9658;&#44; exposition&#44; I&#44; outcome&#46;</p>"
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          "leyenda" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">Socioeconomic classification is based on Crit&#233;rio Brasil Classification&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> A is the higher income class&#46; The average income per year in dollars for each class is A &#8211; &#36; 44&#44;400&#44; B &#8211; &#36; 6600&#44; C &#8211; &#36; 6780&#44; and D &#8211; &#36; 1300&#46;</p>"
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">11&#46;6 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">41 &#40;51&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">50 &#40;62&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">29 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleItalic">z</span>-score BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;63 &#40;1&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">78 &#40;97&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3256791.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic and clinical data&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0002"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0003"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara005" class="elsevierStyleSimplePara elsevierViewall">FVC&#44; forced vital capacity &#40;in l&#41;&#59; FEV<span class="elsevierStyleInf">1</span>&#44; forced expiratory volume in 1 second &#40;in l&#41;&#59; FEF<span class="elsevierStyleInf">25&#47;75</span>&#44; forced expiratory flow between 25 and 75&#37; of expiratory curve &#40;in l&#47;s&#41;&#59; &#37;&#44; percentage of the predicted&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0022"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0023"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre bronchodilatador</th><a name="en0025"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Post bronchodilatador</th><a name="en0027"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variability</th></tr><tr title="table-row"><a name="en0028"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0029"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0030"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P<span class="elsevierStyleInf">25</span>&#8211;P<span class="elsevierStyleInf">75</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0031"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum&#8211;maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0032"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0033"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P<span class="elsevierStyleInf">25</span>&#8211;P<span class="elsevierStyleInf">75</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0034"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum&#8211;maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0035"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0036"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P<span class="elsevierStyleInf">25</span>&#8211;P<span class="elsevierStyleInf">75</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0037"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum&#8211;maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0038"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;10&#8211;3&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;36&#8211;5&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;02&#8211;3&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;81&#8211;5&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#8211;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;32&#8211;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0048"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVC&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">103&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">94&#46;00&#8211;113&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">78&#46;00&#8211;143&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">103&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">95&#46;00&#8211;115&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">13&#46;00&#8211;137&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0058"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FEV<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;78&#8211;2&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;01&#8211;4&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;75&#8211;2&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;83&#8211;4&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;32&#8211;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0068"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVE<span class="elsevierStyleInf">1</span>&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">90&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">81&#46;50&#8211;102&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&#46;00&#8211;177&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">92&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">86&#46;00&#8211;106&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">28&#46;00&#8211;132&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0078"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;77&#8211;0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;46&#8211;3&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;82&#8211;0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;62&#8211;1&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;13&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0088"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0089"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">94&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">87&#46;00&#8211;99&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0091"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">53&#46;00&#8211;116&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0092"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">97&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0093"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">90&#46;00&#8211;101&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">72&#46;00&#8211;114&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0095"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">3&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#8211;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0153"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">OREI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">2&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;3&#8211;12&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0158"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ODI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                    0 => array:2 [
                      "titulo" => "Interactions of obstructive sleep-disordered breathing with recurrent wheezing or asthma and their effects on sleep quality"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G Malakasioti"
                            1 => "K Gourgoulianis"
                            2 => "G Chrousos"
                            3 => "A Kaditis"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1002/ppul.21497"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Pulmonol"
                        "fecha" => "2011"
                        "volumen" => "46"
                        "paginaInicial" => "1047"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21809473"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obstructive sleep apnea in poorly controlled asthmatic children&#58; effect of adenotonsillectomy"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "L Kheirandish-Gozal"
                            1 => "EA Dayyat"
                            2 => "NS Eid"
                            3 => "RL Morton"
                            4 => "D&#46; Gozal"
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                      "doi" => "10.1002/ppul.21451"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21465680"
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and associated factors for asthma in Brazilian and Japanese schoolchildren living in the city of S&#227;o Paulo&#44; Brazil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I Camelo-Nunes"
                            1 => "M Carvalho Mallozi"
                            2 => "FC Lanza"
                            3 => "D Sol&#233;"
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                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Ann Allergy Clin Immunol"
                        "fecha" => "2016"
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Original article
Obstructive sleep apnea in asthmatic children: a cross-sectional study about prevalence and risk factors
Cristiane Fumo-dos-Santosa, Anna K. Smitha, Sonia M.G.P. Togeiroa,b,
Corresponding author
togeiro.s.m@gmail.com

Corresponding author.
, Sergio Tufika, Gustavo A. Moreiraa,c
a Universidade Federal de São Paulo, Departamento de Psicobiologia, São Paulo, SP, Brazil
b Universidade Federal de São Paulo, Departamento de Medicina Interna, São Paulo, SP, Brazil
c Universidade Federal de São Paulo, Departamento de Pediatria, São Paulo, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0006" class="elsevierStylePara elsevierViewall">Asthma and obstructive sleep apnea &#40;OSA&#41; are inflammatory diseases of the respiratory tract that can affect all age groups&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Asthma prevalence is high in Brazil&#44; affecting around 20&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">OSA affects 1&#8211;4&#37; of the pediatric population according to the 3rd International Classification of Sleep Disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Asthma and OSA share many risk factors such as allergic rhinitis &#40;AR&#41;&#44; upper airway and systemic inflammation&#44; gastroesophageal reflux disease &#40;GERD&#41;&#44; and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Moreover&#44; both are influenced by circadian rhythm&#44; age&#44; and sex&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> There is a paucity of studies regarding asthma and OSA in children&#44; but there is evidence that OSA increases the length of stay in hospitalizations due to asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">Age and sex have a significant role in asthma and OSA presentation&#46; Asthma is more prevalent in adult females than males&#44; but during childhood&#44; the association is more complex&#58; until 6 years old&#44; boys are more affected than girls&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> This is explained by the smaller airway and dysanaptic growth of lung parenchyma &#40;boys develop the parenchyma slower than girls&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> No difference in asthma prevalence is found between 7 and 9 years &#8211; airway and parenchyma are equal in boys and girls and hormonal changes have not yet begun&#46; Afterward&#44; girls are more affected &#8211; the airway turns larger in boys and sexual hormones modify inflammation since estrogen and progesterone have inflammatory effects according to different receptors and testosterone has anti-inflammatory effects&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> During childhood&#44; the prevalence of OSA in children without comorbidity is equal in boys and girls&#44; but during adulthood&#44; men are more affected and this sex-related difference in OSA prevalence begins during puberty&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> However&#44; a questionnaire-based study found OSA more prevalent among asthmatic girls than boys&#44; though this finding was a <span class="elsevierStyleItalic">post-hoc</span> analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Even though the American Academy of Sleep Medicine recommends the polysomnographic evaluation for the diagnosis of OSA in children be performed at the sleep center &#40;type I&#41;&#44; some authors have found it feasible to use home polygraphy type III &#40;known as home sleep apnea testing &#8211; HSAT&#44; monitoring flow&#44; respiratory effort&#44; and oximetry&#41; as an optional tool&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">The objectives of this study are&#58; &#40;1&#41; analyze the prevalence of obstructive sleep apnea in&#58; &#40;1&#41; boys and girls&#44; and &#40;2&#41; severe asthma versus moderate and mild cases&#46; Secondary objectives are&#58; &#40;1&#41; analyze the effect of the pubertal stage on OSA&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">Considering that the asthma presentation is associated with age&#44; sex&#44; and OSA&#44; and questionnaire-based studies described that OSA was more prevalent in girls than boys&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> and with asthma severity&#44;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> the authors hypothesized that among children with asthma&#44; OSA measured by an objective method would be more prevalent in girls than boys&#44; and among those with severe asthma comparing to mild to moderate cases&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Materials and methods</span><p id="para0012" class="elsevierStylePara elsevierViewall">This cross-sectional study enrolled 80 consecutive patients&#44; recruited from a tertiary Pediatric Pulmonology clinic between December 2016 and July 2018&#46; The sample size was calculated considering OSA more frequent in girls &#40;OR&#44; 2&#46;55&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> and in severe asthma &#40;16 OSA in 29 severe asthmatic patients vs 16 OSA in 79 mild&#47;moderate asthma&#41;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> both considering alfa 0&#46;05 and beta 0&#46;80&#46; The authors calculated 68 children&#44; and expecting 20&#37; of follow-up losses&#44; the authors decided to recruit 80 volunteers&#46;</p><p id="para0013" class="elsevierStylePara elsevierViewall">Inclusion criteria were 7&#8211;18 years old and medical diagnosis of asthma according to the Brazilian Consensus&#58;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> FEV<span class="elsevierStyleInf">1</span> &#60;80&#37; predicted or &#8805;12&#37; variation post-beta-agonist&#44; or 3 or more&#58; &#40;1&#41; more than one episode of wheezing per month&#44; &#40;2&#41; cough or wheezing&#44; by morning or at night&#44; after laughter&#44; crying or exercise&#44; &#40;3&#41; cough without viral infections&#44; &#40;4&#41; allergic rhinitis or conjunctivitis&#44; &#40;5&#41; family history of atopy or asthma&#44; &#40;6&#41; improvement of symptoms with bronchodilator or inhaled corticosteroids&#46; The authors had children already under treatment in the clinic and some that were new patients&#46;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Exclusion criteria were craniofacial and&#47;or thoracic malformations&#44; genetic syndromes&#44; bronchopulmonary dysplasia&#44; bronchiolitis obliterans&#44; neuromuscular diseases&#44; sickle cell disease&#44; cystic fibrosis&#44; or those unable to understand or perform protocol&#39;s tests&#46; Parents&#8217; informed consent and patients&#8217; assent were required before enrolling in the study&#46; The project was approved by the Ethics Committee of Universidade Federal de S&#227;o Paulo &#40;&#35;1&#46;794&#46;705&#41;&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">Interview&#44; physical examination&#44; pulmonary function tests &#40;PFT&#41;&#44; and HSAT were performed&#46; The authors applied unstandardized &#40;asthma history&#41; and standardized questionnaires &#40;Brazilian criteria for socioeconomic classification&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> The authors also collected data about current asthma medication and asthma exacerbations in the previous 12 months&#46;</p><p id="para0016" class="elsevierStylePara elsevierViewall">Asthma symptoms were defined as not controlled in the long term if there were systemic corticosteroid use&#44; emergency room visit&#44; or hospital admission due to asthma exacerbation in the previous 12 months&#46; Short-term control was based on the Global Initiative for Asthma &#40;GINA&#41; questionnaire that evaluate the control in the past 4 weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> and inquiries about daytime and nighttime symptoms&#44; use of short-acting beta-agonist&#44; and limitations due to asthma&#46;</p><p id="para0017" class="elsevierStylePara elsevierViewall">All volunteers self-evaluated their pubertal stage using Tanner figures for boys and girls&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> Those with any pubertal development 2 or more were classified as pubescent&#46; Body-mass index was calculated using CDC definition and classified as <span class="elsevierStyleItalic">z</span>-score&#46; Rhinitis was defined as intermittent or persistent &#40;mild&#44; moderate&#47;severe&#41; according to ARIA definition&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0018" class="elsevierStylePara elsevierViewall">PFT was acquired on Koko&#174; &#40;Longmont&#44; USA&#41;&#44; with Polgar reference&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> All exams were performed by the same medical doctor &#40;CFS&#41;&#44; during the afternoon&#44; with 1&#160;h maximum intervals&#46; Per protocol&#44; every volunteer should perform the test before and after 20 min taking 400 mcg of salbutamol through a metered-dose inhaler and a spacer&#46; Volunteers with asthma exacerbations were rescheduled for two weeks later&#46;</p><p id="para0019" class="elsevierStylePara elsevierViewall">HSAT was performed using a three-channel cardiorespiratory monitor &#40;Philips Stardust&#174;&#41;&#44; regardless of sleep symptoms&#44; on the entire sample&#46; Even though the gold standard for sleep studies in children is PSG type I this is not easily accessible in every part of the studied country&#46; Another major concern is its costs&#46; Since there are some studies showing that PSG type III is feasible and accurate in children&#44;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> we opted to use this method&#46;</p><p id="para0020" class="elsevierStylePara elsevierViewall">The exams were revised by two polysomnographic technicians with extensive experience with pediatric sleep studies&#44; using AASM rules&#46; Afterward&#44; they were revised by a sleep physician &#40;A&#46;K&#46;S&#46;&#41; who did not attend the volunteers&#46; Technicians and physicians were blinded to the study hypothesis&#46; HSAT was performed the night after the PFT&#44; so HSAT also was rescheduled in case of asthma exacerbations&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">OSA was defined as those with habitual snoring and one or more obstructive respiratory events &#40;OREI&#41; per hour of recording time&#46; OREI &#8805;1 was defined as mild OSA&#44; &#8805;5 as moderate&#44; and &#8805;10 as severe OSA&#46; The authors used the pediatric criteria in the entire sample&#46; The authors considered acceptable studies with at least 2&#160;h of register of each channel without artifact&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> When an acceptable study was not obtained on the first night&#44; the authors invited the volunteer to repeat the exam&#46; If the volunteer did not agree&#44; the authors kept the data for those with at least 60 min of valid data&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">PFT was analyzed according to American Thoracic Society criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Asthma severity was classified based on GINA criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0023" class="elsevierStylePara elsevierViewall">Analysis of possible confounders was made with a Directed Acyclic Graph &#40;DAG&#41;&#59; neither age&#44; sex&#44; BMI&#44; pubertal stage&#44; rhinitis&#44; socioeconomic status&#44; or asthma control were identified as cofounders &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Figure 1</a>&#41;&#46; DAG considers the relationship among variables to determine if any of them is a confounder or not&#46; The idea of &#8220;acyclic&#8221; is that you should not come back to the beginning of the path &#40;exposure&#41; following the arrows that link the variables&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> There are rules to consider if the path is open or closed when a variable is related to another&#46; In this case&#44; if the authors controlled for any of the above variables&#44; we would introduce bias since the path would be opened&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0024" class="elsevierStylePara elsevierViewall">Data were summarized as mean and standard deviation and frequencies were compared using chi-square tests&#46; The authors considered significant <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;05&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Results</span><p id="para0025" class="elsevierStylePara elsevierViewall">To achieve the sample size calculation&#44; 148 volunteers were invited&#44; 28 declined participation and 23 had exclusion criteria&#46; Of those who accepted to participate&#44; 17 did not attend the appointed meeting&#44; and 80 completed the protocol&#46;</p><p id="para0026" class="elsevierStylePara elsevierViewall">The mean age was 11&#46;6 years&#44; standard deviation 2&#46;7&#44; 41 were female &#40;51&#46;3&#37;&#41;&#44; 30 white &#40;37&#46;5&#37;&#41;&#46; Sociodemographic are summarized in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#46; According to the body mass index z-score&#44; nutritional status was&#58; 2 &#40;2&#46;5&#37;&#41; underweight&#44; 63 eutrophics &#40;79&#37;&#41;&#44; and 15 obese &#40;18&#46;5&#37;&#41;&#46; Puberty was present in 17 volunteers &#40;6 boys and 11 girls&#41;&#46; Rhinitis was present in 78 volunteers&#59; 12 &#40;15&#37;&#41; had mild rhinitis and the remaining had moderate&#47;severe rhinitis&#46; Asthma classification based on GINA criteria was 3 &#40;4&#37;&#41; mild&#44; 8 &#40;10&#37;&#41; moderate&#44; and 69 &#40;86&#37;&#41; severe&#46; Asthma control in the past 4 weeks using the GINA questionnaire was found in 35 &#40;43&#46;7&#37;&#41; and in long term in 27 &#40;33&#46;7&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0027" class="elsevierStylePara elsevierViewall">The authors obtained PFT classified as A or B according to ATS<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> of 71 volunteers&#46; Considering the 80 PFT obtained&#44; a normal lung function pattern was found in 45 &#40;56&#46;2&#37;&#41; volunteers&#59; 32 &#40;40&#37;&#41; had an obstructive ventilatory defect &#40;30 mild and two moderate&#41;&#59; three had unspecific abnormalities&#46; Data regarding the PFT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#46; Acceptable HSAT exams were obtained from 76 volunteers&#46; Mean OREI was 1&#46;8 events&#47;h&#44; mild OSA was found in 30 volunteers &#40;37&#46;5&#37; of the sample&#41;&#44; moderate in 16 &#40;20&#37;&#41;&#44; and severe in 3 &#40;3&#46;8&#37;&#41;&#46; Habitual snoring was found in 9 volunteers&#46; HSAT data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0003">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><p id="para0028" class="elsevierStylePara elsevierViewall">Among the volunteers with mild&#47;moderate asthma&#44; 7&#47;10 had OSA &#40;5 mild and 2 moderate&#41; while among those with severe asthma 42&#47;66 had OSA &#40;25 mild&#44; 14 moderate&#44; and 3 severe&#41;&#46; The authors did not find an association between OSA and sex &#40;chi-square&#44; 2&#46;578&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;108&#41;&#44; asthma severity &#40;Fisher&#39;s test&#44; 0&#46;091&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;763&#41;&#44; asthma control &#40;short term&#58; chi-square&#44; 0&#46;94&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;759&#44; long term&#58; chi-square&#44; 0&#46;638&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;424&#41;&#44; or puberty status &#40;chi-square test&#44; 3&#46;036&#44; <span class="elsevierStyleItalic">p</span>&#44; 0&#46;081&#41;&#46; The authors have found OSA in 75&#37; of boys and 57&#46;5&#37; of girls &#40;61&#46;2&#37; of the entire sample&#41;&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">Severe OSA was found in three volunteers&#58; they were all pubescent&#44; with perennial rhinitis&#44; severe asthma&#44; not controlled in the short and long term&#44; had nasal turbinate hypertrophy&#44; tonsils III&#47;IV&#44; and HSAT with oxygen saturation nadir below 90&#37;&#46; Obesity&#44; ogival palate&#44; and gastroesophageal reflux were present in two of them&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Discussion</span><p id="para0030" class="elsevierStylePara elsevierViewall">This cross-sectional study of asthmatic children in a tertiary Pediatric Pulmonology clinic showed a high prevalence of OSA &#40;61&#46;2&#37;&#41; diagnosed by HSAT&#46; However&#44; neither sex&#44; asthma severity&#44; asthma control &#40;short or long term&#41;&#44; nor puberty status were predictors of OSA&#46;</p><p id="para0031" class="elsevierStylePara elsevierViewall">There is still a paucity of data regarding OSA among asthmatic children&#46; A Chinese questionnaire-based study with almost 22 thousand asthmatic children&#44; found 12&#37; with sleep-disorder breathing&#46;<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> The authors have only found three studies in the pediatric population with both asthma and OSA objective measurements&#58; He et al&#46;<a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> studied 5&#8211;18 years-old children and found an OSA prevalence of 57&#37;&#46; A second study found a higher prevalence of OSA in children with asthma &#40;6&#46;6&#37; vs 3&#46;8&#37; in non-asthmatic children&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> However&#44; a third study did not find any difference in the prevalence of OSA among asthmatic versus non-asthmatic children&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> The different prevalences in OSA diagnosis among those studies and might be explained by different cut points to diagnose OSA&#44; older children in the present study&#44; and lower FEV<span class="elsevierStyleInf">1</span> values than in He<a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> and Sulit<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> studies&#46; Even though the ICSD-3<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> recommends a cut point of 1 for the obstructive apnea-hypopnea index to consider an OSA diagnosis in the pediatric population&#44; different studies have chosen different cut points&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Contrary to adults&#44; most pediatric studies are based on statistical normality values and not on health outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a></p><p id="para0032" class="elsevierStylePara elsevierViewall">The authors did not find any statistically significant difference among boys and girls&#44; puberty and pre-puberty&#44; or asthma control &#40;in the short and long term&#41; among those with and without OSA&#46; The present study&#39;s sample had a vast majority of children with severe asthma&#44; reflecting the characteristic of the reference center&#46; In accordance with the amount of severe asthma&#44; the authors found 40&#37; of PFT abnormal&#44; which is not common in asthmatic children who tend to have a more preserved lung function than adults with severe asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0033" class="elsevierStylePara elsevierViewall">The authors obtained acceptable HSAT exams in 95&#37; of cases &#40;81&#37; on the first attempt&#41;&#46; Previous studies had 81 to 100&#37; of acceptable exams considering 1 repetition if needed&#46;<a class="elsevierStyleCrossRefs" href="#bib0026"><span class="elsevierStyleSup">26-29</span></a> The prevalence of OSA in the present sample was higher than the prevalence in epidemiologic studies&#44; mainly in children without asthma &#40;62&#46;5 vs 1&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> The high prevalence of AR and severe asthma in our sample could explain our high OSA prevalence&#46; However&#44; the authors did not find associations among either AR or asthma severity in the present study&#39;s volunteers&#46; The fact that the vast majority had moderate&#47;severe AR and severe asthma could have reduced the variability necessary to find differences among these groups&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">This study has some strengths&#58; asthma and OSA were defined by questionnaires and objective measurements&#44; and the authors obtained a high rate of acceptable sleep exams&#46; However&#44; the authors also faced some limitations such as a few volunteers with mild asthma and OSA evaluation with an alternative method instead of the gold standard type I polysomnography&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Conclusion</span><p id="para0035" class="elsevierStylePara elsevierViewall">In summary&#44; the authors found a high prevalence of OSA &#40;61&#46;2&#37;&#41; in a sample of mainly severe asthmatic children and adolescents&#46; Nor sex&#44; age&#44; pubertal stage&#44; asthma classification&#44; or control were statistically significant as OSA predictors&#46; High suspicion of the comorbidity must also be in mind as OSA since it may lead to detrimental metabolic and cognitive functions&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Grant support</span><p id="para0036" class="elsevierStylePara elsevierViewall">Associa&#231;&#227;o Fundo de Incentivo &#224; Pesquisa &#40;AFIP&#41;&#44; Methods of Epidemiological and Clinical Research &#40;MECOR&#41;&#44; Coordena&#231;&#227;o de Aperfei&#231;oamento do Ensino Superior &#40;CAPES&#41;&#46;</p></span></span>"
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    "fechaRecibido" => "2022-09-19"
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            0 => "Asthma"
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            2 => "Obstructive"
            3 => "Pediatrics"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objectives</span><p id="spara009" class="elsevierStyleSimplePara elsevierViewall">Primary objectives were to analyze the prevalence of obstructive sleep apnea in &#40;1&#41; boys and girls&#44; and &#40;2&#41; severe asthma versus moderate and mild cases&#46; The authors hypothesized that girls and severe asthma would have a higher prevalence of obstructive sleep apnea&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional evaluation of asthmatic children attending a tertiary Pediatric Pulmonology clinic&#46; The authors performed a history&#44; physical examination&#44; pulmonary function test&#44; and home sleep apnea test&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">The authors studied 80 consecutive patients&#44; 7&#8211;18 years old&#44; mean age of 11&#46;6 years &#40;standard deviation 2&#46;7&#41;&#44; 51&#46;3&#37; female&#44; and 18&#46;5&#37; obese&#46; Pulmonary function tests were obtained from 80 volunteers&#44; 45&#37; with obstruction pattern&#46; Home sleep apnea tests were available from 76 volunteers&#44; with a mean obstructive respiratory index of 1&#46;8 events&#47;h&#46; Obstructive sleep apnea was found in 49 volunteers &#40;61&#46;2&#37;&#41;&#46; The authors did not find associations between obstructive sleep apnea and sex or asthma severity&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusions</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">Obstructive sleep apnea was frequent among these asthmatic children&#46; Sex and asthma severity were not risk factors&#46; Considering the interrelationship of both diseases&#44; it is worth keeping in mind the possibility of obstructive sleep apnea among children and teenagers with asthma&#46;</p></span>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Directed Acyclic Graph regarding the relationship among asthma and obstructive sleep apnea &#40;OSA&#41;&#46; Asthma is influenced by age&#44; rhinitis&#44; body mass index &#40;BMI&#41;&#44; socioeconomical status &#40;SES&#41;&#44; and puberty&#46; Asthma influences asthma control which also receives influence from rhinitis and BMI&#46; OSA is influenced by sex&#44; rhinitis&#44; BMI&#44; puberty&#44; asthma&#44; and asthma control&#46; Graphic made on Dagtty&#46;net&#46; Red arrows show variables that would introduce bias if controlled&#46; &#9658;&#44; exposition&#44; I&#44; outcome&#46;</p>"
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          "leyenda" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">Socioeconomic classification is based on Crit&#233;rio Brasil Classification&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> A is the higher income class&#46; The average income per year in dollars for each class is A &#8211; &#36; 44&#44;400&#44; B &#8211; &#36; 6600&#44; C &#8211; &#36; 6780&#44; and D &#8211; &#36; 1300&#46;</p>"
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                  \t\t\t\t  " align="" valign="top">11&#46;6 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">50 &#40;62&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">Socioeconomic classification</td></tr><tr title="table-row"><a name="en0010"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P<span class="elsevierStyleInf">25</span>&#8211;P<span class="elsevierStyleInf">75</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P<span class="elsevierStyleInf">25</span>&#8211;P<span class="elsevierStyleInf">75</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum&#8211;maximum&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;47&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;02&#8211;3&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;81&#8211;5&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;32&#8211;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0048"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVC&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">94&#46;00&#8211;113&#46;50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">103&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">95&#46;00&#8211;115&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0058"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FEV<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;78&#8211;2&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;01&#8211;4&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;75&#8211;2&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;83&#8211;4&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;32&#8211;34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">FVE<span class="elsevierStyleInf">1</span>&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">90&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">81&#46;50&#8211;102&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">90&#46;00&#8211;101&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">72&#46;00&#8211;114&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">2&#46;26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;50&#8211;4&#46;96&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">2&#46;40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">&#8722;42&#8211;104&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">86&#46;00&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spara007" class="elsevierStyleSimplePara elsevierViewall">TMT&#44; total monitoring time &#40;in minutes&#41;&#59; CEI&#44; central event index&#59; OEI&#44; obstructive event index&#59; MEI&#44; mixed event index&#59; HI&#44; hypopnea index&#59; REI&#44; respiratory event index&#59; OREI&#44; obstructive respiratory index&#59; ODI&#44; oxygen desaturation index&#46;</p><p id="spara008" class="elsevierStyleSimplePara elsevierViewall">With exception of TMT&#44; which is expressed in minutes&#44; all other variables are expressed as events per hour&#46;</p>"
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                  \t\t\t\t  " align="" valign="top">395&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">526&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0132"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">0&#8211;2&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">OEI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0138"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">MEI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">0&#8211;0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0143"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">HI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0144"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0145"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0146"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0147"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#8211;12&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0148"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">REI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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