Sleep Apnea and Driving. Recommendations for Interpreting Spanish Regulations for Drivers

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Recomendaciones para la interpretación del nuevo Reglamento General de Conductores en España" ] ] "textoCompleto" => "Sleep Apnea and Driving. Scientific EvidenceTraffic accidents are one of the major worldwide causes of death among individuals aged between 5 and 50 years. The death rate on the roads in the European Union (EU) is 52 deaths per million inhabitants, and in economic terms have been estimated to account for 1%–3% of the GDP of the respective countries, representing up to 500 billion dollars on a worldwide level.<a class="elsevierStyleCrossRef" href="#bib0100">1</a>There is clear evidence that sleepiness, irrespective of its cause, is a significant risk factor for traffic accidents, although it is difficult to determine the exact figures. The National Highway Traffic Safety Administration calculates that 2.5% of fatal accidents and 2% of non-fatal accidents are related to sleepiness, although these numbers may be underestimated.<a class="elsevierStyleCrossRef" href="#bib0105">2</a>Sagaspe et al.<a class="elsevierStyleCrossRef" href="#bib0110">3</a> conducted a telephone survey among 4774 drivers, and found that 5.8% of the respondents had had an accident, 3.2% of which were related to sleepiness.In a Spanish study of 4002 vehicle drivers, 3.6% regularly experienced sleepiness when driving; of these, 81% had fallen asleep at the wheel at some time, and 25% regularly did so. One of the main causes of habitual sleepiness while driving was sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0115">4</a>Goncalves et al.<a class="elsevierStyleCrossRef" href="#bib0120">5</a> also provided interesting data associated with the prevalence of sleepiness and driving in Europe: in 12434 questionnaires completed in 19 EU countries, the mean prevalence of “falling asleep at the wheel in the last 2 years” was 17%, and of these, the median accident rate was 7% (3.2% of which were fatal).Sleepiness among professional drivers is a particularly sensitive issue, in view of the possible consequences.<a class="elsevierStyleCrossRef" href="#bib0125">6</a>The population at high risk of experiencing sleepiness at the wheel includes not only professional drivers, due to their longer times of exposure, but also people who work very long shifts or who drive at night, individuals who drive in a state of sleep deprivation, especially young people, or who sleep less than 6h, patients taking hypnotic drugs or other sleep-inducing medications, and finally, individuals with symptoms associated with undiagnosed sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0130">7</a>Various diseases, such as diabetes mellitus, cardiovascular diseases, psychiatric and neurological diseases, obesity or impaired vision, are associated with a higher incidence of traffic accidents,<a class="elsevierStyleCrossRef" href="#bib0135">8</a> but sleep apnea–hypopnea syndrome (SAHS) is the disorder that most frequently causes sleepiness and an increased risk of accidents. Poor sleep hygiene must be added to this group of diseases.A systematic review and metaanalysis<a class="elsevierStyleCrossRef" href="#bib0140">9</a> of the risk of accidents among drivers of commercial vehicles published in 2009 showed that the mean risk was in the range of 1.21–4.89, and that the predictive factors for accidents among drivers with SAHS include body mass index (BMI), apnea–hypopnea index (AHI), oxygen saturation, and possibly daytime sleepiness. Young et al.<a class="elsevierStyleCrossRef" href="#bib0145">10</a> showed that individuals with an AHI>5 were significantly more likely to have at least 1 accident in a 5-year period, and that men and women with AHI>15 had significantly more multiple accidents in the same period (odds ratio: 7.3).Although the published studies differ, most of the evidence suggests that the risk of traffic accidents and sleep apnea is related more closely with sleepiness than with disease severity measured by AHI. The significance of sleepiness as a primary factor contributing to traffic accidents was recently supported by Karimi et al.<a class="elsevierStyleCrossRef" href="#bib0150">11</a> who found that excessive daytime sleepiness (Epworth scale>15) is significantly associated with accident rates. Other studies, meanwhile, such as those of Terán-Santos et al.<a class="elsevierStyleCrossRef" href="#bib0155">12</a> and the European Sleep Apnea Database (ESADA), associate AHI with accident rates.<a class="elsevierStyleCrossRef" href="#bib0160">13</a>Several studies have evaluated the effect of continuous positive airway pressure (CPAP) on reducing motor vehicle accident rates in patients with SAHS, and in most studies, effective treatment will result in a substantial reduction or even normalization of the accident rate.<a class="elsevierStyleCrossRef" href="#bib0165">14</a>The fact that untreated SAHS patients have a higher risk of traffic accidents has prompted some countries in the EU, including Spain, to list this disease among those that must be controlled before a driving license can be obtained or renewed. More recently, the EU Commission Driving License Directive 2014/85,<a class="elsevierStyleCrossRef" href="#bib0170">15</a> modifying Directive 126/2006, has included SAHS among the criteria that appear in Annex III on the criteria for psychophysical aptitudes that must be evaluated in all Member States. This regulation was published in the EU in June 2014 and sets down the minimum criteria that must be applied in all countries.Spain, which already included SAHS in the General Regulations for Drivers, specifically in Annex IV, specifying criteria for psychophysical fitness for obtaining or renewing a driver's license, has updated their criteria in accordance with the European Directive with Royal Decree (RD) 1055/2015, 20 November 2015, modifying the General Regulations for Drivers approved by Royal Decree 818/2009, 8 May 2009, that became effective in January 2016 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The annex regarding obtaining or renewing a driving license now includes criteria for moderate (AHI 15–29) and severe (AHI>30) SAHS, both associated with excessive sleepiness, and establishes that individuals with SAHS (diagnosed in a Sleep Unit [SU]) with an AHI of 15 or more associated with sleepiness cannot obtain or renew their driving license, unless they submit a favorable report from the SU stating that they comply appropriately with treatment and that their disease is clinically controlled to a satisfactory degree, particularly with regard to sleepiness. The period of validity of these licenses is limited to 3 years for group 1, and up to 1 year for group 2.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fitness to Drive in Patients With Sleep ApneaStudies in SAHS and driving show that the risk of a traffic accident in subjects with a diagnosis of SAHS depends not only on the diagnosis of the disease, but also on the different parameters that are also associated with a greater driving risk, and which might affect an individual's fitness to drive.<a class="elsevierStyleCrossRef" href="#bib0160">13</a> This requires a personalized evaluation of the driver in Driving Examination Centers (DACs) and, consequently, the medical staff of these centers must be fully apprised of the impact of the disease on the subject before issuing the psychophysical fitness report.Annex IV of the General Regulations for Drivers, RD 818/2009, modified by RD 1055/2015, states that to obtain or renew a driving license, drivers with a diagnosis of SAHS must provide the DAC with a report from an SU, which is taken into account in the definitive report on the individual's fitness to drive. The aim of the SU report is to inform the DAC physician of the diagnostic details, clinical manifestations of the disease (primarily sleepiness), and efficacy of treatment, so that the impact of the disease on driving can be evaluated and a report on the fitness of the subject to drive issued. Both the patient and doctors working in SUs must be aware of the need to present this report to the DAC at the time of either obtaining or renewing a driving license, since failure to present the report at the time of license renewal will lead to suspension of the process until such time as it is presented, with the consequent personal and professional inconveniences that such a situation may cause the driver.Individuals who need to renew their driving license may face difficulties and variable access to SUs, depending on their healthcare areas, our group recommends that a standardized report template is issued for the purposes of obtaining and renewing a license, and that the patient is informed of the importance of such a report and their obligation to present it to the DAC. This report should be valid for a period of 6 months, unless the DAC detects any changes when administering their standard questionnaire.Specific Recommendations for the Evaluation of Psychophysical Fitness to Drive Motor Vehicles in Patients With Sleep Apnea SyndromeDuring the course of their work, the DAC sees 2 large groups of drivers: those with a diagnosis of SAHS, and those without, but who, after clinical screening, are found to meet the established criteria for a high diagnostic suspicion of SAHS.Drivers Diagnosed With Sleep Apnea–Hypopnea Syndrome in a Sleep UnitProposed recommendations for evaluating fitness to drive motor vehicles in patients with a diagnosis of SAHS are given below.Fit to Drive<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Patients with AHI<15 and/or without excessive sleepiness (Epworth<15), not receiving treatment.</li><li class="elsevierStyleListItem" id="lsti0010">2.Patients with AHI>15<30 without excessive sleepiness (Epworth<15), not requiring treatment.In patients in either group (1 and 2) who do not have sleepiness, whether AHI is higher or lower than 15, there is no absolute evidence of a greater risk of having a traffic accident, so they may be considered fit to drive, with no type of restriction. If, as a result of the diagnostic process, the patient is undergoing regular follow-up in the SU, they must provide follow-up reports when renewing their license with the normal expiry periods, stating that their situation remains unchanged. In these cases, the report may also be issued by the primary care physician, according to the clinical report from the SU.</li><li class="elsevierStyleListItem" id="lsti0015">3.Drivers with no suspicion of SAHS after screening (see criteria in the following sections).</li></ul>Fit to Drive With Restrictions<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">1.Patients with AHI>15 with excessive sleepiness, receiving continuous positive airway pressure (CPAP) treatment.A driver diagnosed with an AHI>15 in a sleep study, who also experiences sleepiness, must provide an SU report to the DAC for the purpose of evaluating their fitness to drive for both group 1 and group 2 licenses.Patients receiving treatment with CPAP must use this report as proof that they are complying appropriately with their treatment, which in the case of CPAP treatment involves at least 4h/night for more than 70% of the week, and that excessive sleepiness has been controlled.The driver who meets these conditions is considered fit to drive, with a reduced period of validity of their license (maximum 3 years for group 1, and 1 year for group 2). Reduction of the period of validity is the mechanism established in Annex IV of the General Regulations for Drivers to ensure that the patient is controlled.</li><li class="elsevierStyleListItem" id="lsti0025">2.Patients with AHI>15 plus excessive sleepiness, receiving treatment other than CPAP: mandibular advancement device, surgery, weight loss, etc.The SU report must confirm reduction of AHI<10 and control of sleepiness.As before, the driver will be considered fit to drive, with a reduced period of validity of their license: maximum 3 years for group 1, and 1 year for group 2.</li></ul>Not Fit to DrivePatients with AHI>15 plus sleepiness who do not comply appropriately with treatment (irrespective of the type of treatment) and/or with uncontrolled symptoms.For patients who are not fit to drive, either due to lack of treatment compliance or recently initiated treatment making it impossible to prove efficacy, a report of fit to drive with reduced period of validity may be issued in the following cases, provided an SU report is available:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">•A driver whose treatment has been successful after a period of 4–6 weeks, with appropriate compliance and control of clinical symptoms. A reduced period of license validity of 1 year followed by evaluation of clinical stability may be established at the criteria of the physician, depending on the time of treatment and the patient's progress.</li></ul>SU considerations:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035">•CPAP adjustments or mandibular advancement devices for treating SAHS in all cases must be regulated with self-adjusting systems or manual polysomnography titration.</li><li class="elsevierStyleListItem" id="lsti0040">•It is always recommended that these procedures are performed in SUs or by specialist physicians qualified in the study and treatment of sleep-disordered breathing.</li><li class="elsevierStyleListItem" id="lsti0045">•In some cases, depending on the criteria of specialists qualified in the study and treatment of sleep-disordered breathing, some objective measurements of sleepiness may be necessary (maintenance of wakefulness test, multiple sleep latency test, or OSLER test).</li><li class="elsevierStyleListItem" id="lsti0050">•For group 2 drivers, a sleep study with adjustment of treatment to reduce AHI to figures lower than 10 and control excessive sleepiness is recommended.</li></ul>Drivers Not Diagnosed With Sleep Apnea–Hypopnea SyndromeProcedure for Sleep Apnea Syndrome Screening and Evaluation of SleepinessIn view of the scientifically proven relationship between sleep apnea and traffic accidents, it is recommended that drivers without a diagnosis be screened for the presence of SAHS.The chosen screening method is the STOP-Bang questionnaire, given its high sensitivity and ease of application in all settings (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), in combination with the Epworth Sleepiness Scale (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), and history of traffic accidents with victims associated with excessive sleepiness when driving in the past 3 years.<a class="elsevierStyleCrossRefs" href="#bib0175">16–19</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The following steps will be taken, depending on the scores obtained in these questionnaires (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>):<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055">•If the person who completes the questionnaire has a STOP-Bang score≥3 and/or has any of the 2 associated criteria (Epworth Sleepiness Scale>15 or a traffic accident with consequences due to sleepiness in the past 3 years), their license will be suspended and they must be referred for an SU study, given their high probability of having moderate/severe SAHS, using the proposed form (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). If applicable, the SU will perform a diagnostic and therapeutic study within 1 month.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0060">•If the STOP-Bang questionnaire score is between 3 and 5 and the additional criteria are negative, the subject may be considered fit to drive and referred to their primary care physician for evaluation.</li><li class="elsevierStyleListItem" id="lsti0065">•If the STOP-Bang questionnaire score is <3 points and the additional criteria are negative, the subject is considered fit to drive.</li><li class="elsevierStyleListItem" id="lsti0070">•If the STOP-Bang questionnaire score is <3 but the subject presents either of the additional criteria, they may be considered fit to drive and must be referred to their primary care physician for evaluation.</li></ul><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The driver must sign the clinical history to attest to the accuracy of the report.A suspicion of SAHS after screening puts the DAC doctor in the delicate position of weighing up the rights of the individual against their personal risk and risk to others. The skill of the SU in managing the study of these patients is essential from a preventive perspective.Content of the Sleep Unit Report Providing Supportive Data to the Driver Assessment CenterThe report from the SU, in accordance with the provisions of Annex iv of the General Regulations for Drivers must cover the following:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0075">-AHI at the time of diagnosis, and the presence or absence of sleepiness and severity (mild, moderate, severe).</li><li class="elsevierStyleListItem" id="lsti0080">-Type of treatment and if therapeutic compliance is adequate (see criteria below).</li><li class="elsevierStyleListItem" id="lsti0085">-Appropriate control of the disease, including control of sleepiness.</li></ul>When the report is given to the patient in the SU, the patient should sign it along with the physician, indicating that they have been appropriately informed and are in agreement with the content of the report.It is recommended that the SU and specialist physicians qualified in the study and treatment of sleep-disordered breathing issue a clinical report stating the level of compliance and clinical control of symptoms. We do not advise SU professionals to include their opinion on the ability of the SAHS patient to drive. Coexistence of other diseases/circumstances might affect the final report issued by the DAC, and a statement in the SU report could cause conflicts between the driver and the DAC professionals.A standard report template (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>) is proposed, to which general criteria on sleep habits and specific criteria on sleep and driving (additional material) will be attached. These messages will support the health advice that will also be provided in the DAC setting.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Recommendations Regarding the Medical Report<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0090">•This questionnaire template should ideally be included in hospital clinical records.</li><li class="elsevierStyleListItem" id="lsti0095">•It will be disseminated via the websites of the scientific societies involved in the diagnosis and treatment of SAHS, thus promoting the use of this standard report.</li></ul>The DAC will also provide a copy to patients with suspected SAHS for completion by the SU physician after the sleep study.ConclusionsExcessive sleepiness affects 5%–20% of the population. This problem, together with fatigue, increases the risk of traffic accidents. In total, 3.6% of drivers habitually experience sleepiness while driving.SAHS is the treatable medical condition most commonly associated with traffic accidents caused by sleepiness.There is an individual relationship between hours slept and the development of excessive daytime sleepiness.The population at high risk of experiencing sleepiness at the wheel includes not only professional drivers who have longer times of exposure, but also people who work very long shifts, individuals who drive in a state of sleep deprivation, especially young people, or who sleep less than 6h, patients who use alcohol, hypnotic drugs or other medications that can cause sleepiness, and finally, individuals with symptoms associated with undiagnosed sleep apnea or other sleep disorders.Every effort should be made to raise awareness of the importance of respecting rest times among professional drivers, so that work interests do not put the safety of drivers or other road users at risk.Treatment of patients with sleep apneas reduces the number of accidents and associated costs.Final ConsiderationThe editorial team of these guidelines on procedures in sleep apnea and driving states that the content of this paper is based on current levels of scientific knowledge and that the rate of accidents caused by sleep apneas depends on multiple variables associated with the presence of comorbidities and lifestyle, among other factors.Conflict of InterestsThe authors state that they have no conflict of interests.Participating Societies and InstitutionsSpanish Sleep Society (SES).Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).Instituto Carlos III, CIBEReS.Spanish Traffic Medicine Society.Spanish Ministry of Health, Social Services and Equality.General Subdepartment of Road Policies, General Department of Traffic." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres867847" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec856904" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres867846" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec856905" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Sleep Apnea and Driving. Scientific Evidence" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Fitness to Drive in Patients With Sleep Apnea" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Specific Recommendations for the Evaluation of Psychophysical Fitness to Drive Motor Vehicles in Patients With Sleep Apnea Syndrome" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Drivers Diagnosed With Sleep Apnea–Hypopnea Syndrome in a Sleep Unit" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Fit to Drive" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Fit to Drive With Restrictions" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Not Fit to Drive" ] ] ] 1 => array:3 [ "identificador" => "sec0040" "titulo" => "Drivers Not Diagnosed With Sleep Apnea–Hypopnea Syndrome" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Procedure for Sleep Apnea Syndrome Screening and Evaluation of Sleepiness" ] ] ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Content of the Sleep Unit Report Providing Supportive Data to the Driver Assessment Center" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Recommendations Regarding the Medical Report" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Final Consideration" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of Interests" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Participating Societies and Institutions" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-09" "fechaAceptado" => "2016-11-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec856904" "palabras" => array:4 [ 0 => "Sleep apnea" 1 => "Sleepiness" 2 => "Driving" 3 => "Accidents" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec856905" "palabras" => array:4 [ 0 => "Apnea del sueño" 1 => "Somnolencia" 2 => "Conducción" 3 => "Accidentes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Road traffic accidents are one of the main causes of death worldwide and are clearly associated with sleepiness. Individuals with undiagnosed sleep apnea–hypopnea syndrome (SAHS) are among the population with a high risk of experiencing sleepiness at the wheel and, consequently, road traffic accidents. Treatment with continuous positive airway pressure (CPAP) has been shown to reduce the risk of accidents among drivers with SAHS. For this reason, the European Union has included this disease in the psychological and physical criteria for obtaining or renewing a driving license. To comply with this European Directive, Spain has updated its driving laws accordingly. To facilitate the implementation of the new regulations, a group of experts from various medical societies and institutions has prepared these guidelines that include questionnaires to screen for SAHS, diagnostic and therapeutic criteria, and physician's report templates." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los accidentes de tráfico son una de las principales causas de mortalidad en todo el mundo, y la somnolencia está claramente relacionada con ello. Entre la población con alto riesgo de padecer somnolencia al volante, y consecuentemente accidentes de tráfico, se encuentran las personas que tienen síndrome de apnea del sueño (SAHS) sin diagnosticar. El tratamiento con CPAP ha demostrado una disminución en el riesgo de accidentabilidad de conductores con SAHS. Es por ello que la Unión Europea ha incluido esta enfermedad entre los requisitos psicofísicos para obtener o mantener el permiso de conducción. Para cumplir con esta Directiva Europea, España ha actualizado el Reglamento de Conductores de manera acorde. Con el fin de facilitar la implementación de la nueva norma, un grupo de expertos de diferentes sociedades médicas e instituciones han elaborado la presente guía, que contiene cuestionarios de cribado de SAHS, criterios de diagnóstico y tratamiento y modelos estandarizados de informes a completar por los médicos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Terán-Santos J, Egea Santaolalla C, Montserrat JM, Masa Jiménez F, Librada Escribano MV, Mirabet E, et al. Apnea del sueño y conducción de vehículos. Recomendaciones para la interpretación del nuevo Reglamento General de Conductores en España. Arch Bronconeumol. 2017;53:336–341." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AHI: apnea–hypopnea index; SU: sleep unit." "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"><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">7. Respiratory system For the purposes of section 7.2, moderate obstructive sleep apnea syndrome is understood to be AHI between 15 and 29, and severe when AHI is 30 or more, and associated in both cases with excessive daytime sleepiness.</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Examination (1) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fitness criteria for obtaining or renewing an ordinary driving permit or license</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adaptations, restrictions, and other limits on individuals, vehicles or traffic in a permit or license subject to restrictive conditions</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1: AM, A1, A2, A, B, B+E and LCC (art. 45.1a) (2) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2: C1, C1+E, C, C+E, D1, D1+E, D, D+E (art. 45.1b) (3) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 (4) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 (5) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7.2 Obstructive sleep apnea syndrome (SAHS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAHS (diagnosed in a sleep study) with AHI of 15 or more, associated with moderate or severe daytime sleepiness is not admitted. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem group 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In the cases indicated in column (2), with a favorable report from the SU confirming an appropriate level of treatment compliance and satisfactory disease control, particularly of daytime sleepiness, the permit or license may be obtained or renewed for a maximum period of validity of 3 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In the cases indicated in column (3), with a favorable report from the SU confirming an appropriate level of treatment compliance and satisfactory disease control, particularly of daytime sleepiness, the license may be obtained or renewed for a maximum period of validity of 1 year \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459566.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Content of Annex IV of the General Regulations for Drivers Approved by Royal Decree 818/2009, modified by RD 1055/2015 (Adapted from the Official State Bulletin)." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Final score: low (<2); intermediate (3–4); high (>5)." "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes (1) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No (0) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do you snore loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do you often feel tired, fatigued, or sleepy during the daytime? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Has anyone told you that you stop breathing during your sleep? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do you have or are you being treated for high blood pressure? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body Mass Index more than 35kg/m2? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age older than 50? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neck size larger than 40cm? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender=male? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459565.png" ] ] ] ] "descripcion" => array:1 [ "en" => "STOP-Bang Questionnaire." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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"><th class="td" title="table-head " colspan="5" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently try to work out how they would have affected you.</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Possibility of falling asleep (mark with an X): \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Never (0) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Some (1) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">A lot (2) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Always (3) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting and reading \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Watching TV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting inactive in a public place (e.g. a theater or a meeting) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">As a passenger in a car for an hour without a break \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lying down in the afternoon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting and talking to someone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting quietly after a lunch without alcohol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In a car, while stopped for a few minutes in traffic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459569.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epworth Sleepiness Scale." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "TA: traffic accidents; Epworth: Epworth sleepiness scale; GP: general practitioner; SU: Sleep Unit." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">STOP-Bang \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">≥3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3–5 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Epworth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Either</td><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Neither</td><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Neither</td><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Either</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TA due to excessive daytime sleepiness in the past 3 years<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Mark with an X</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Criterion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspended: SU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FIT TO DRIVE: GP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FIT TO DRIVE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FIT TO DRIVE: GP \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459564.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Data should be collected only on traffic accidents due to excessive sleepiness in the past 3 years that involved personal injury or injury to others." ] ] ] "descripcion" => array:1 [ "en" => "Screening Criteria According to Questionnaire Results." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">To the attention of the………………………… Sleep Unit Please find enclosed the results of the SAHS screening procedure and evaluation of sleepiness obtained during the evaluation performed in the Driving Examination Center No…… prior to issue/renewal of the driving license of Mr/Mrs/Ms………………… National ID No…………………… STOP-Bang…………………… Epworth……………………… TA involving victims due to excessive daytime sleepiness in the past 3 years…… After application of the criteria recommended for the assessment of driver, results showed a medium-high probability of having SAHS, so I request a priority assessment. In………………………, on………………………………….(date) Signed \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459567.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Proposed Report to be Issued by the Driver Assessment Centers for Referral to the Sleep Unit of Drivers With Suspected SAHS. Driver Code." ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from the National Consensus on sleep apnea–hypopnea syndrome. Spanish Sleep Group 2005." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Institution issuing the report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requesting center \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Full name of patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical Record No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Date \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apnea/hypopnea index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type of treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mandibular advancement devices (MAD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ENT and/or maxillofacial surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Health and dietary measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pharmacological treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Others (specify)……………… \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment compliance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Appropriate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inappropriate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Control of excessive sleepiness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doctor issuing the clinical report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dr. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Signature \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient signature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459568.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Proposed Report to be Issued by Sleep Units to Driver Assessment Centers on the Clinical Status of the Patient's Sleep Disorder (Applicable to SAHS and Other Sleep Disorders)." ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 19951 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: http://ec.europa.eu/transport/road_safety/specialist/statistics/index_en.htm [updated 13.10.14, accessed 12.12.15]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Road safety. 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Special article

Sleep Apnea and Driving. Recommendations for Interpreting Spanish Regulations for Drivers

Apnea del sueño y conducción de vehículos. Recomendaciones para la interpretación del nuevo Reglamento General de Conductores en España

Joaquín Terán-Santosa,

Corresponding author

joaquinteransantos@yahoo.es

Corresponding author.

, Carlos Egea Santaolallab, Jose María Montserratc, Fernando Masa Jiménezd, Maria Villar Librada Escribanoe, Enrique Mirabetf, Elena Valdés Rodríguezg

a Unidad de Sueño, Hospital Universitario de Burgos, CIBERES, Burgos, Spain

b Unidad de Sueño, Hospital Txagorritxu, CIBERES, Vitoria/Gasteiz, Spain

c Servicio de Neumología, Unidad de Sueño, Hospital Clínic de Barcelona, CIBERES, Barcelona, Spain

d Servicio de Neumología, Unidad de Sueño, Hospital San Pedro de Alcántara, CIBERES, Cáceres, Spain

e Ministerio de Sanidad, Servicios Sociales e Igualdad, Spain

f Sociedad Española de Medicina de Tráfico, Spain

g Unidad de Programas de Aptitud Psicofísica, Subdirección General de Políticas Viales, Dirección General de Tráfico, Spain

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        "titulo" => "Apnea del sue&#241;o y conducci&#243;n de veh&#237;culos&#46; Recomendaciones para la interpretaci&#243;n del nuevo Reglamento General de Conductores en Espa&#241;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Sleep Apnea and Driving&#46; Scientific Evidence</span><p id="par0005" class="elsevierStylePara elsevierViewall">Traffic accidents are one of the major worldwide causes of death among individuals aged between 5 and 50 years&#46; The death rate on the roads in the European Union &#40;EU&#41; is 52 deaths per million inhabitants&#44; and in economic terms have been estimated to account for 1&#37;&#8211;3&#37; of the GDP of the respective countries&#44; representing up to 500 billion dollars on a worldwide level&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There is clear evidence that sleepiness&#44; irrespective of its cause&#44; is a significant risk factor for traffic accidents&#44; although it is difficult to determine the exact figures&#46; The National Highway Traffic Safety Administration calculates that 2&#46;5&#37; of fatal accidents and 2&#37; of non-fatal accidents are related to sleepiness&#44; although these numbers may be underestimated&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Sagaspe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> conducted a telephone survey among 4774 drivers&#44; and found that 5&#46;8&#37; of the respondents had had an accident&#44; 3&#46;2&#37; of which were related to sleepiness&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a Spanish study of 4002 vehicle drivers&#44; 3&#46;6&#37; regularly experienced sleepiness when driving&#59; of these&#44; 81&#37; had fallen asleep at the wheel at some time&#44; and 25&#37; regularly did so&#46; One of the main causes of habitual sleepiness while driving was sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Goncalves et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> also provided interesting data associated with the prevalence of sleepiness and driving in Europe&#58; in 12<span class="elsevierStyleHsp" style=""></span>434 questionnaires completed in 19 EU countries&#44; the mean prevalence of &#8220;falling asleep at the wheel in the last 2 years&#8221; was 17&#37;&#44; and of these&#44; the median accident rate was 7&#37; &#40;3&#46;2&#37; of which were fatal&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sleepiness among professional drivers is a particularly sensitive issue&#44; in view of the possible consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The population at high risk of experiencing sleepiness at the wheel includes not only professional drivers&#44; due to their longer times of exposure&#44; but also people who work very long shifts or who drive at night&#44; individuals who drive in a state of sleep deprivation&#44; especially young people&#44; or who sleep less than 6<span class="elsevierStyleHsp" style=""></span>h&#44; patients taking hypnotic drugs or other sleep-inducing medications&#44; and finally&#44; individuals with symptoms associated with undiagnosed sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Various diseases&#44; such as diabetes mellitus&#44; cardiovascular diseases&#44; psychiatric and neurological diseases&#44; obesity or impaired vision&#44; are associated with a higher incidence of traffic accidents&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> but sleep apnea&#8211;hypopnea syndrome &#40;SAHS&#41; is the disorder that most frequently causes sleepiness and an increased risk of accidents&#46; Poor sleep hygiene must be added to this group of diseases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A systematic review and metaanalysis<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> of the risk of accidents among drivers of commercial vehicles published in 2009 showed that the mean risk was in the range of 1&#46;21&#8211;4&#46;89&#44; and that the predictive factors for accidents among drivers with SAHS include body mass index &#40;BMI&#41;&#44; apnea&#8211;hypopnea index &#40;AHI&#41;&#44; oxygen saturation&#44; and possibly daytime sleepiness&#46; Young et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> showed that individuals with an AHI&#62;5 were significantly more likely to have at least 1 accident in a 5-year period&#44; and that men and women with AHI&#62;15 had significantly more multiple accidents in the same period &#40;odds ratio&#58; 7&#46;3&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Although the published studies differ&#44; most of the evidence suggests that the risk of traffic accidents and sleep apnea is related more closely with sleepiness than with disease severity measured by AHI&#46; The significance of sleepiness as a primary factor contributing to traffic accidents was recently supported by Karimi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> who found that excessive daytime sleepiness &#40;Epworth scale&#62;15&#41; is significantly associated with accident rates&#46; Other studies&#44; meanwhile&#44; such as those of Ter&#225;n-Santos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> and the <span class="elsevierStyleItalic">European Sleep Apnea Database</span> &#40;ESADA&#41;&#44; associate AHI with accident rates&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Several studies have evaluated the effect of continuous positive airway pressure &#40;CPAP&#41; on reducing motor vehicle accident rates in patients with SAHS&#44; and in most studies&#44; effective treatment will result in a substantial reduction or even normalization of the accident rate&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The fact that untreated SAHS patients have a higher risk of traffic accidents has prompted some countries in the EU&#44; including Spain&#44; to list this disease among those that must be controlled before a driving license can be obtained or renewed&#46; More recently&#44; the EU Commission Driving License Directive 2014&#47;85&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> modifying Directive 126&#47;2006&#44; has included SAHS among the criteria that appear in Annex III on the criteria for psychophysical aptitudes that must be evaluated in all Member States&#46; This regulation was published in the EU in June 2014 and sets down the minimum criteria that must be applied in all countries&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Spain&#44; which already included SAHS in the General Regulations for Drivers&#44; specifically in Annex IV&#44; specifying criteria for psychophysical fitness for obtaining or renewing a driver&#39;s license&#44; has updated their criteria in accordance with the European Directive with Royal Decree &#40;RD&#41; 1055&#47;2015&#44; 20 November 2015&#44; modifying the General Regulations for Drivers approved by Royal Decree 818&#47;2009&#44; 8 May 2009&#44; that became effective in January 2016 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The annex regarding obtaining or renewing a driving license now includes criteria for moderate &#40;AHI 15&#8211;29&#41; and severe &#40;AHI&#62;30&#41; SAHS&#44; both associated with excessive sleepiness&#44; and establishes that individuals with SAHS &#40;diagnosed in a Sleep Unit &#91;SU&#93;&#41; with an AHI of 15 or more associated with sleepiness cannot obtain or renew their driving license&#44; unless they submit a favorable report from the SU stating that they comply appropriately with treatment and that their disease is clinically controlled to a satisfactory degree&#44; particularly with regard to sleepiness&#46; The period of validity of these licenses is limited to 3 years for group 1&#44; and up to 1 year for group 2&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Fitness to Drive in Patients With Sleep Apnea</span><p id="par0070" class="elsevierStylePara elsevierViewall">Studies in SAHS and driving show that the risk of a traffic accident in subjects with a diagnosis of SAHS depends not only on the diagnosis of the disease&#44; but also on the different parameters that are also associated with a greater driving risk&#44; and which might affect an individual&#39;s fitness to drive&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> This requires a personalized evaluation of the driver in Driving Examination Centers &#40;DACs&#41; and&#44; consequently&#44; the medical staff of these centers must be fully apprised of the impact of the disease on the subject before issuing the psychophysical fitness report&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Annex IV of the General Regulations for Drivers&#44; RD 818&#47;2009&#44; modified by RD 1055&#47;2015&#44; states that to obtain or renew a driving license&#44; drivers with a diagnosis of SAHS must provide the DAC with a report from an SU&#44; which is taken into account in the definitive report on the individual&#39;s fitness to drive&#46; The aim of the SU report is to inform the DAC physician of the diagnostic details&#44; clinical manifestations of the disease &#40;primarily sleepiness&#41;&#44; and efficacy of treatment&#44; so that the impact of the disease on driving can be evaluated and a report on the fitness of the subject to drive issued&#46; Both the patient and doctors working in SUs must be aware of the need to present this report to the DAC at the time of either obtaining or renewing a driving license&#44; since failure to present the report at the time of license renewal will lead to suspension of the process until such time as it is presented&#44; with the consequent personal and professional inconveniences that such a situation may cause the driver&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Individuals who need to renew their driving license may face difficulties and variable access to SUs&#44; depending on their healthcare areas&#44; our group recommends that a standardized report template is issued for the purposes of obtaining and renewing a license&#44; and that the patient is informed of the importance of such a report and their obligation to present it to the DAC&#46; This report should be valid for a period of 6 months&#44; unless the DAC detects any changes when administering their standard questionnaire&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Specific Recommendations for the Evaluation of Psychophysical Fitness to Drive Motor Vehicles in Patients With Sleep Apnea Syndrome</span><p id="par0085" class="elsevierStylePara elsevierViewall">During the course of their work&#44; the DAC sees 2 large groups of drivers&#58; those with a diagnosis of SAHS&#44; and those without&#44; but who&#44; after clinical screening&#44; are found to meet the established criteria for a high diagnostic suspicion of SAHS&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Drivers Diagnosed With Sleep Apnea&#8211;Hypopnea Syndrome in a Sleep Unit</span><p id="par0090" class="elsevierStylePara elsevierViewall">Proposed recommendations for evaluating fitness to drive motor vehicles in patients with a diagnosis of SAHS are given below&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Fit to Drive</span><p id="par0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patients with AHI&#60;15 and&#47;or without excessive sleepiness &#40;Epworth&#60;15&#41;&#44; not receiving treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients with AHI&#62;15&#60;30 without excessive sleepiness &#40;Epworth&#60;15&#41;&#44; not requiring treatment&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In patients in either group &#40;1 and 2&#41; who do not have sleepiness&#44; whether AHI is higher or lower than 15&#44; there is no absolute evidence of a greater risk of having a traffic accident&#44; so they may be considered fit to drive&#44; with no type of restriction&#46; If&#44; as a result of the diagnostic process&#44; the patient is undergoing regular follow-up in the SU&#44; they must provide follow-up reports when renewing their license with the normal expiry periods&#44; stating that their situation remains unchanged&#46; In these cases&#44; the report may also be issued by the primary care physician&#44; according to the clinical report from the SU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Drivers with no suspicion of SAHS after screening &#40;see criteria in the following sections&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fit to Drive With Restrictions</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patients with AHI&#62;15 with excessive sleepiness&#44; receiving continuous positive airway pressure &#40;CPAP&#41; treatment</span>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A driver diagnosed with an AHI&#62;15 in a sleep study&#44; who also experiences sleepiness&#44; must provide an SU report to the DAC for the purpose of evaluating their fitness to drive for both group 1 and group 2 licenses&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Patients receiving treatment with CPAP must use this report as proof that they are complying appropriately with their treatment&#44; which in the case of CPAP treatment involves at least 4<span class="elsevierStyleHsp" style=""></span>h&#47;night for more than 70&#37; of the week&#44; and that excessive sleepiness has been controlled&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The driver who meets these conditions is considered <span class="elsevierStyleSmallCaps">fit to drive</span>&#44; with a reduced period of validity of their license &#40;maximum 3 years for group 1&#44; and 1 year for group 2&#41;&#46; Reduction of the period of validity is the mechanism established in Annex IV of the General Regulations for Drivers to ensure that the patient is controlled&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patients with AHI&#62;15 plus excessive sleepiness&#44; receiving treatment other than CPAP&#58; mandibular advancement device&#44; surgery&#44; weight loss&#44; etc&#46;</span></p><p id="par0150" class="elsevierStylePara elsevierViewall">The SU report must confirm reduction of AHI&#60;10 and control of sleepiness&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">As before&#44; the driver will be considered <span class="elsevierStyleSmallCaps">fit to drive</span>&#44; with a reduced period of validity of their license&#58; maximum 3 years for group 1&#44; and 1 year for group 2&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Not Fit to Drive</span><p id="par0160" class="elsevierStylePara elsevierViewall">Patients with AHI&#62;15 plus sleepiness who do not comply appropriately with treatment &#40;irrespective of the type of treatment&#41; and&#47;or with uncontrolled symptoms&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For patients who are <span class="elsevierStyleSmallCaps">not fit to drive</span>&#44; either due to lack of treatment compliance or recently initiated treatment making it impossible to prove efficacy&#44; a report of <span class="elsevierStyleSmallCaps">fit to drive with reduced period of validity</span> may be issued in the following cases&#44; provided an SU report is available&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">A driver whose treatment has been successful after a period of 4&#8211;6 weeks&#44; with appropriate compliance and control of clinical symptoms&#46; A reduced period of license validity of 1 year followed by evaluation of clinical stability may be established at the criteria of the physician&#44; depending on the time of treatment and the patient&#39;s progress&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">SU considerations&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">CPAP adjustments or mandibular advancement devices for treating SAHS in all cases must be regulated with self-adjusting systems or manual polysomnography titration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">It is always recommended that these procedures are performed in SUs or by specialist physicians qualified in the study and treatment of sleep-disordered breathing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">In some cases&#44; depending on the criteria of specialists qualified in the study and treatment of sleep-disordered breathing&#44; some objective measurements of sleepiness may be necessary &#40;maintenance of wakefulness test&#44; multiple sleep latency test&#44; or OSLER test&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">For group 2 drivers&#44; a sleep study with adjustment of treatment to reduce AHI to figures lower than 10 and control excessive sleepiness is recommended&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Drivers Not Diagnosed With Sleep Apnea&#8211;Hypopnea Syndrome</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Procedure for Sleep Apnea Syndrome Screening and Evaluation of Sleepiness</span><p id="par0200" class="elsevierStylePara elsevierViewall">In view of the scientifically proven relationship between sleep apnea and traffic accidents&#44; it is recommended that drivers without a diagnosis be screened for the presence of SAHS&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The chosen screening method is the STOP-Bang questionnaire&#44; given its high sensitivity and ease of application in all settings &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; in combination with the Epworth Sleepiness Scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; and history of traffic accidents with victims associated with excessive sleepiness when driving in the past 3 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">16&#8211;19</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The following steps will be taken&#44; depending on the scores obtained in these questionnaires &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">If the person who completes the questionnaire has a STOP-Bang score&#8805;3 and&#47;or has any of the 2 associated criteria &#40;Epworth Sleepiness Scale&#62;15 or a traffic accident with consequences due to sleepiness in the past 3 years&#41;&#44; their license will be suspended and they must be referred for an SU study&#44; given their high probability of having moderate&#47;severe SAHS&#44; using the proposed form &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; If applicable&#44; the SU will perform a diagnostic and therapeutic study within 1 month&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">If the STOP-Bang questionnaire score is between 3 and 5 and the additional criteria are negative&#44; the subject may be considered <span class="elsevierStyleSmallCaps">fit to drive</span> and referred to their primary care physician for evaluation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">If the STOP-Bang questionnaire score is &#60;3 points and the additional criteria are negative&#44; the subject is considered <span class="elsevierStyleSmallCaps">fit to drive</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">If the STOP-Bang questionnaire score is &#60;3 but the subject presents either of the additional criteria&#44; they may be considered <span class="elsevierStyleSmallCaps">fit to drive</span> and must be referred to their primary care physician for evaluation&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">The driver must sign the clinical history to attest to the accuracy of the report&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">A suspicion of SAHS after screening puts the DAC doctor in the delicate position of weighing up the rights of the individual against their personal risk and risk to others&#46; The skill of the SU in managing the study of these patients is essential from a preventive perspective&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Content of the Sleep Unit Report Providing Supportive Data to the Driver Assessment Center</span><p id="par0245" class="elsevierStylePara elsevierViewall">The report from the SU&#44; in accordance with the provisions of Annex <span class="elsevierStyleSmallCaps">iv</span> of the General Regulations for Drivers must cover the following&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">AHI at the time of diagnosis&#44; and the presence or absence of sleepiness and severity &#40;mild&#44; moderate&#44; severe&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Type of treatment and if therapeutic compliance is adequate &#40;see criteria below&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0260" class="elsevierStylePara elsevierViewall">Appropriate control of the disease&#44; including control of sleepiness&#46;</p></li></ul></p><p id="par0265" class="elsevierStylePara elsevierViewall">When the report is given to the patient in the SU&#44; the patient should sign it along with the physician&#44; indicating that they have been appropriately informed and are in agreement with the content of the report&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">It is recommended that the SU and specialist physicians qualified in the study and treatment of sleep-disordered breathing issue a clinical report stating the level of compliance and clinical control of symptoms&#46; We do not advise SU professionals to include their opinion on the ability of the SAHS patient to drive&#46; Coexistence of other diseases&#47;circumstances might affect the final report issued by the DAC&#44; and a statement in the SU report could cause conflicts between the driver and the DAC professionals&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">A standard report template &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41; is proposed&#44; to which general criteria on sleep habits and specific criteria on sleep and driving &#40;additional material&#41; will be attached&#46; These messages will support the health advice that will also be provided in the DAC setting&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Recommendations Regarding the Medical Report</span><p id="par0280" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">This questionnaire template should ideally be included in hospital clinical records&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">It will be disseminated via the websites of the scientific societies involved in the diagnosis and treatment of SAHS&#44; thus promoting the use of this standard report&#46;</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">The DAC will also provide a copy to patients with suspected SAHS for completion by the SU physician after the sleep study&#46;</p></span></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0300" class="elsevierStylePara elsevierViewall">Excessive sleepiness affects 5&#37;&#8211;20&#37; of the population&#46; This problem&#44; together with fatigue&#44; increases the risk of traffic accidents&#46; In total&#44; 3&#46;6&#37; of drivers habitually experience sleepiness while driving&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">SAHS is the treatable medical condition most commonly associated with traffic accidents caused by sleepiness&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">There is an individual relationship between hours slept and the development of excessive daytime sleepiness&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">The population at high risk of experiencing sleepiness at the wheel includes not only professional drivers who have longer times of exposure&#44; but also people who work very long shifts&#44; individuals who drive in a state of sleep deprivation&#44; especially young people&#44; or who sleep less than 6<span class="elsevierStyleHsp" style=""></span>h&#44; patients who use alcohol&#44; hypnotic drugs or other medications that can cause sleepiness&#44; and finally&#44; individuals with symptoms associated with undiagnosed sleep apnea or other sleep disorders&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Every effort should be made to raise awareness of the importance of respecting rest times among professional drivers&#44; so that work interests do not put the safety of drivers or other road users at risk&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Treatment of patients with sleep apneas reduces the number of accidents and associated costs&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Final Consideration</span><p id="par0330" class="elsevierStylePara elsevierViewall">The editorial team of these guidelines on procedures in sleep apnea and driving states that the content of this paper is based on current levels of scientific knowledge and that the rate of accidents caused by sleep apneas depends on multiple variables associated with the presence of comorbidities and lifestyle&#44; among other factors&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of Interests</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Participating Societies and Institutions</span><p id="par0340" class="elsevierStylePara elsevierViewall">Spanish Sleep Society &#40;SES&#41;&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41;&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Instituto Carlos III&#44; CIBEReS&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Spanish Traffic Medicine Society&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Spanish Ministry of Health&#44; Social Services and Equality&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">General Subdepartment of Road Policies&#44; General Department of Traffic&#46;</p></span></span>"
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          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Sleep Apnea and Driving&#46; Scientific Evidence"
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          "identificador" => "sec0010"
          "titulo" => "Fitness to Drive in Patients With Sleep Apnea"
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          "identificador" => "sec0015"
          "titulo" => "Specific Recommendations for the Evaluation of Psychophysical Fitness to Drive Motor Vehicles in Patients With Sleep Apnea Syndrome"
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              "identificador" => "sec0020"
              "titulo" => "Drivers Diagnosed With Sleep Apnea&#8211;Hypopnea Syndrome in a Sleep Unit"
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                  "identificador" => "sec0025"
                  "titulo" => "Fit to Drive"
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                  "titulo" => "Fit to Drive With Restrictions"
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                  "titulo" => "Not Fit to Drive"
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              "titulo" => "Drivers Not Diagnosed With Sleep Apnea&#8211;Hypopnea Syndrome"
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                  "identificador" => "sec0045"
                  "titulo" => "Procedure for Sleep Apnea Syndrome Screening and Evaluation of Sleepiness"
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              "identificador" => "sec0050"
              "titulo" => "Content of the Sleep Unit Report Providing Supportive Data to the Driver Assessment Center"
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          "titulo" => "References"
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    "fechaRecibido" => "2016-09-09"
    "fechaAceptado" => "2016-11-16"
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            0 => "Sleep apnea"
            1 => "Sleepiness"
            2 => "Driving"
            3 => "Accidents"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec856905"
          "palabras" => array:4 [
            0 => "Apnea del sue&#241;o"
            1 => "Somnolencia"
            2 => "Conducci&#243;n"
            3 => "Accidentes"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Road traffic accidents are one of the main causes of death worldwide and are clearly associated with sleepiness&#46; Individuals with undiagnosed sleep apnea&#8211;hypopnea syndrome &#40;SAHS&#41; are among the population with a high risk of experiencing sleepiness at the wheel and&#44; consequently&#44; road traffic accidents&#46; Treatment with continuous positive airway pressure &#40;CPAP&#41; has been shown to reduce the risk of accidents among drivers with SAHS&#46; For this reason&#44; the European Union has included this disease in the psychological and physical criteria for obtaining or renewing a driving license&#46; To comply with this European Directive&#44; Spain has updated its driving laws accordingly&#46; To facilitate the implementation of the new regulations&#44; a group of experts from various medical societies and institutions has prepared these guidelines that include questionnaires to screen for SAHS&#44; diagnostic and therapeutic criteria&#44; and physician&#39;s report templates&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los accidentes de tr&#225;fico son una de las principales causas de mortalidad en todo el mundo&#44; y la somnolencia est&#225; claramente relacionada con ello&#46; Entre la poblaci&#243;n con alto riesgo de padecer somnolencia al volante&#44; y consecuentemente accidentes de tr&#225;fico&#44; se encuentran las personas que tienen s&#237;ndrome de apnea del sue&#241;o &#40;SAHS&#41; sin diagnosticar&#46; El tratamiento con CPAP ha demostrado una disminuci&#243;n en el riesgo de accidentabilidad de conductores con SAHS&#46; Es por ello que la Uni&#243;n Europea ha incluido esta enfermedad entre los requisitos psicof&#237;sicos para obtener o mantener el permiso de conducci&#243;n&#46; Para cumplir con esta Directiva Europea&#44; Espa&#241;a ha actualizado el Reglamento de Conductores de manera acorde&#46; Con el fin de facilitar la implementaci&#243;n de la nueva norma&#44; un grupo de expertos de diferentes sociedades m&#233;dicas e instituciones han elaborado la presente gu&#237;a&#44; que contiene cuestionarios de cribado de SAHS&#44; criterios de diagn&#243;stico y tratamiento y modelos estandarizados de informes a completar por los m&#233;dicos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Ter&#225;n-Santos J&#44; Egea Santaolalla C&#44; Montserrat JM&#44; Masa Jim&#233;nez F&#44; Librada Escribano MV&#44; Mirabet E&#44; et al&#46; Apnea del sue&#241;o y conducci&#243;n de veh&#237;culos&#46; Recomendaciones para la interpretaci&#243;n del nuevo Reglamento General de Conductores en Espa&#241;a&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;336&#8211;341&#46;</p>"
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            "etiqueta" => "Appendix A"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">7&#46; Respiratory system<br>For the purposes of section 7&#46;2&#44; moderate obstructive sleep apnea syndrome is understood to be AHI between 15 and 29&#44; and severe when AHI is 30 or more&#44; and associated in both cases with excessive daytime sleepiness&#46;</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Examination &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Fitness criteria for obtaining or renewing an ordinary driving permit or license</span></th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Adaptations&#44; restrictions&#44; and other limits on individuals&#44; vehicles or traffic in a permit or license subject to restrictive conditions</span></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1&#58; AM&#44; A1&#44; A2&#44; A&#44; B&#44; B&#43;E and LCC &#40;art&#46; 45&#46;1a&#41; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2&#58; C1&#44; C1&#43;E&#44; C&#44; C&#43;E&#44; D1&#44; D1&#43;E&#44; D&#44; D&#43;E &#40;art&#46; 45&#46;1b&#41; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46;2 Obstructive sleep apnea syndrome &#40;SAHS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAHS &#40;diagnosed in a sleep study&#41; with AHI of 15 or more&#44; associated with moderate or severe daytime sleepiness is not admitted&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In the cases indicated in column &#40;2&#41;&#44; with a favorable report from the SU confirming an appropriate level of treatment compliance and satisfactory disease control&#44; particularly of daytime sleepiness&#44; the permit or license may be obtained or renewed for a maximum period of validity of 3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In the cases indicated in column &#40;3&#41;&#44; with a favorable report from the SU confirming an appropriate level of treatment compliance and satisfactory disease control&#44; particularly of daytime sleepiness&#44; the license may be obtained or renewed for a maximum period of validity of 1 year&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Content of Annex <span class="elsevierStyleSmallCaps">IV</span> of the General Regulations for Drivers Approved by Royal Decree 818&#47;2009&#44; modified by RD 1055&#47;2015 &#40;Adapted from the Official State Bulletin&#41;&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender&#61;male&#63;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="5" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">How likely are you to doze off or fall asleep in the following situations&#63;<br>Even if you have not done some of these things recently try to work out how they would have affected you&#46;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Possibility of falling asleep &#40;mark with an X&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Never &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Some &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">A lot &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Always &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting and reading&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Watching TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting inactive in a public place &#40;e&#46;g&#46; a theater or a meeting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">As a passenger in a car for an hour without a break&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lying down in the afternoon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting and talking to someone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sitting quietly after a lunch without alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In a car&#44; while stopped for a few minutes in traffic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1459569.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Epworth Sleepiness Scale&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">TA&#58; traffic accidents&#59; Epworth&#58; Epworth sleepiness scale&#59; GP&#58; general practitioner&#59; SU&#58; Sleep Unit&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">STOP-Bang&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8805;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Epworth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Either</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Neither</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Neither</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Either</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TA due to excessive daytime sleepiness in the past 3 years<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top">Mark with an <span class="elsevierStyleSmallCaps">X</span></td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Criterion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suspended&#58; SU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FIT TO DRIVE&#58; GP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FIT TO DRIVE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FIT TO DRIVE&#58; GP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1459564.png"
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          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Data should be collected only on traffic accidents due to excessive sleepiness in the past 3 years that involved personal injury or injury to others&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Screening Criteria According to Questionnaire Results&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">To the attention of the&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230; Sleep Unit<br>Please find enclosed the results of the SAHS screening procedure and evaluation of sleepiness obtained during the evaluation performed in the Driving Examination Center No&#8230;&#8230; prior to issue&#47;renewal of the driving license of Mr&#47;Mrs&#47;Ms&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230; National ID No&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;<br>STOP-Bang&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;<br>Epworth&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;<br>TA involving victims due to excessive daytime sleepiness in the past 3 years&#8230;&#8230;<br>After application of the criteria recommended for the assessment of driver&#44; results showed a medium-high probability of having SAHS&#44; so I request a priority assessment&#46;<br>In&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#44; on&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#46;&#40;date&#41;<br>Signed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1459567.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Proposed Report to be Issued by the Driver Assessment Centers for Referral to the Sleep Unit of Drivers With Suspected SAHS&#46; Driver Code&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Adapted from the National Consensus on sleep apnea&#8211;hypopnea syndrome&#46; Spanish Sleep Group 2005&#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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Institution issuing the report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requesting center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Full name of patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical Record No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apnea&#47;hypopnea index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type of treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mandibular advancement devices &#40;MAD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ENT and&#47;or maxillofacial surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Health and dietary measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pharmacological treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Others &#40;specify&#41;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Appropriate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inappropriate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doctor issuing the clinical report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dr&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Signature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient signature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2016.11.035

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	4	11
2024 October	66	43	109
2024 September	87	45	132
2024 August	73	47	120
2024 July	60	26	86
2024 June	74	39	113
2024 May	92	35	127
2024 April	61	33	94
2024 March	95	20	115
2024 February	74	33	107
2023 November	1	1	2
2023 October	5	1	6
2023 April	2	6	8
2023 March	18	8	26
2023 February	81	26	107
2023 January	61	35	96
2022 December	89	31	120
2022 November	69	35	104
2022 October	93	52	145
2022 September	56	31	87
2022 August	74	48	122
2022 July	49	56	105
2022 June	42	42	84
2022 May	61	47	108
2022 April	57	34	91
2022 March	55	47	102
2022 February	56	38	94
2022 January	67	39	106
2021 December	48	58	106
2021 November	47	50	97
2021 October	64	54	118
2021 September	39	46	85
2021 August	48	40	88
2021 July	34	45	79
2021 June	45	43	88
2021 May	51	47	98
2021 April	103	96	199
2021 March	48	33	81
2021 February	46	39	85
2021 January	37	27	64
2020 December	36	29	65
2020 November	33	23	56
2020 October	45	20	65
2020 September	35	16	51
2020 August	38	26	64
2020 July	28	29	57
2020 June	39	19	58
2020 May	36	11	47
2020 April	52	25	77
2020 March	52	11	63
2020 February	52	28	80
2020 January	42	21	63
2019 December	45	16	61
2019 November	41	32	73
2019 October	23	30	53
2019 September	32	26	58
2019 August	33	20	53
2019 July	29	27	56
2019 June	24	16	40
2019 May	31	22	53
2019 April	38	36	74
2019 March	29	31	60
2019 February	26	23	49
2019 January	31	28	59
2018 December	34	21	55
2018 November	417	30	447
2018 October	121	34	155
2018 September	82	17	99
2018 May	14	1	15
2018 April	28	6	34
2018 March	27	11	38
2018 February	29	9	38
2018 January	16	10	26
2017 December	48	6	54
2017 November	34	10	44
2017 October	25	14	39
2017 September	36	19	55
2017 August	1	0	1

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