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by recording the patient&#39;s respiratory movements to transform them into a breathing signal that permits to determine episodes of hypopnea and apnea&#46; Its technology is based on the principle that the volume of air that circulates into the lungs is proportional to the thoracic movement that a subject presents while breathing&#46; Furthermore&#44; according to the analysis of the body movements SW can also infer sleep&#47;awake periods&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a previous publication our group compared the diagnostic accuracy of SW and the in-laboratory polysomnography&#44; concluding that Sleepwise determined the diagnosis and the severity of OSA with high reliability&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> We hypothesized that SW testing could also be performed at home&#46; Therefore&#44; the main objective of this study was to evaluate the diagnostic accuracy of SW compared with a home sleep apnea test &#40;HSAT&#41;&#46; As secondary objectives we checked SW reproducibility in different nights and also rated the easiness and comfort of its use&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population of study</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is an observational&#44; prospective&#44; diagnostic accuracy study that included consecutively 38 patients with suspected OSA who had been referred as outpatients to the Sleep Unit of the Hospital Universitari Germans Trias i Pujol &#40;HUGTiP&#41; from September 2016 to September 2017&#46; Male and female patients over 18 years of age were required to sign an informed consent form to participate in the study&#46; OSA suspicion was based on clinical criteria such as usual snoring&#44; witnessed apnea and daytime sleepiness&#46; 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HSAT and SW analyses were carried out independently and blindly by the same certified sleep physician&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main outcome to compare both methods was the apnea&#8211;hypopnea index &#40;AHI&#41;&#46; Based on this&#44; patients were classified as having mild OSA &#40;5<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15&#41;&#44; moderate OSA &#40;15<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#41; or severe OSA &#40;AHI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30&#41;&#44; with an AHI of under 5 being deemed normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;6</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Material</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Sleepwise &#40;SW&#41;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">SW is a non-invasive system for the diagnosis of OSA&#44; which is able to detect respiratory events from the analysis of images provided by a conventional digital video camera equipped with infrared LEDs&#46; This camera must be placed 60<span class="elsevierStyleHsp" style=""></span>cm beside subject&#39;s bed focusing the thorax and the upper abdomen&#46; SW technology is based in the principle that the volume of air that circulates into the lungs is proportional to the chest movement that a subject presents while breathing&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">SW successively analyzes the images captured by the video camera and generates two types of signal&#46; First&#44; the respiratory movement signal that records subtle movements such as the thoracic oscillations that take place during breathing and can be used to infer respiratory flow and detect alterations therein&#46; SW can detect respiratory movements independently of the position while sleeping or even if the patient is covered by a blanket&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Second&#44; the body movement signal that records movements involving a greater degree of motion&#44; such as changes of body position&#46; Based on a similar system to actimetry&#44; this signal differentiates states of sleep&#47;awake and can infer the subject&#39;s sleep time and number of awakenings&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To detect both respiratory events as well as the state of sleep&#47;awake&#44; SW uses numerical thresholds that were calculated empirically by an automatic learning system based on the results of polysomnography as the total number of events and sleep time&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">For the in-laboratory tests&#44; the technician set up both PSG and SW&#46; For the in-home tests&#44; participants were instructed on how to set up both HSAT and the video camera for SW recording by themselves&#46; Participants were advised with verbal and written instructions and were given a brief demonstration&#46; After using SW a self-questionnaire was passed to rate the comprehension and easiness of use&#44; as well as the overall comfort of the system&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Polysomnography &#40;PSG&#41;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">For OSA diagnosis we used gold standard equipment in the form of a 32-channel E-Series polygraph &#40;Compumedics Ltd&#46;&#59; Abbotsford&#44; Victoria&#44; Australia&#41;&#44; to record electroencephalography&#44; electroculography&#44; electromyography and electrocardiography in accordance with AASM criteria &#40;Type I study&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> We monitored respiratory flow by means of a thermistor and a nasal cannula&#46; We recorded thorax and abdomen respiratory movements with two plethysmography bands&#44; and oxygen saturation with a pulse oximeter&#46; We used a video camera equipped with infrared LEDs to record each subject while sleeping&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We defined apnea as the complete cessation of respiratory flow for over 10<span class="elsevierStyleHsp" style=""></span>s&#44; and hypopnea as a reduction in respiratory flow lasting for over 10<span class="elsevierStyleHsp" style=""></span>s and accompanied by oxygen desaturation of at least 3&#37; and&#47;or arousal according to AASM guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> We calculated the AHI as the quotient of the total number of apneas and hypopneas divided by the total number of hours of sleep determined by PSG&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Home sleep apnea test &#40;HSAT&#41;</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">To perform the in-home studies we used Alice PDX &#40;Philips Respironics&#44; Murrysville&#44; PA&#44; USA&#41;&#44; which is a portable monitor for the diagnosis of OSA &#40;Type III study&#41;&#46; It includes oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#44; finger probe&#44; Oximetry board Nonin&#44; Plymouth&#44; MN&#44; USA&#41;&#44; pulse rate &#40;from the oximeter probe&#41;&#44; airflow &#40;pressure-based airflow with snore detection through a nasal cannula and thermistor&#41;&#44; thoracic and abdominal effort &#40;inductance plethysmography&#41;&#44; and body position&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Participants were advised with verbal and written instructions and were given a brief demonstration on how to set up the HSAT at home themselves&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0110" class="elsevierStylePara elsevierViewall">The degree of agreement between procedures for the AHI was assessed by the Lin&#39;s concordance correlation coefficient&#44; and the graphical representation of this agreement was described with the Bland&#8211;Altman method&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The degree of agreement between procedures for the definition of the severity of OSA was assessed by means of Cohen&#39;s kappa &#40;<span class="elsevierStyleItalic">&#954;</span>&#41;&#44; which improves upon simple percentage of agreement by taking into account the agreement occurring by chance&#46; Kappa values range from 0 &#40;when there is no agreement other than what would be expected by chance&#41; to 1 &#40;when the agreement is perfect&#41;&#46; For this study&#44; <span class="elsevierStyleItalic">&#954;</span> values greater than 0&#46;81 were considered to be almost in perfect agreement&#59; 0&#46;61&#8211;0&#46;80 were considered substantial&#59; 0&#46;41&#8211;0&#46;60&#44; moderate&#59; 0&#46;21&#8211;0&#46;40&#44; fair&#59; and 0&#46;00&#8211;0&#46;20 were considered as slight agreement&#46; Ninety-five percent confidence intervals of <span class="elsevierStyleItalic">&#954;</span> were also calculated&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All calculations were conducted in the version 15 of STATA using the <span class="elsevierStyleItalic">agree</span> and the <span class="elsevierStyleItalic">cohenkap</span> command&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">Thirty-eight patients were included in the study and their clinical data are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Agreements between procedures are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The graphical representation of this agreement&#44; described with the Bland&#8211;Altman method can be seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">There was almost perfect agreement between PSG and SW&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;933 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;930 &#40;95&#37; CI 0&#46;867&#8211;0&#46;993&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Between HSAT and SW&#44; agreement was lower&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;917 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;793 &#40;95&#37; CI 0&#46;713&#8211;0&#46;872&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Agreement between two different SW procedures was again almost perfect&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;923 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;837 &#40;95&#37; CI 0&#46;729&#8211;0&#46;944&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">None of the participants reported difficulties in understanding the functioning of SW&#46; The device was considered easy-to-use and comfortable&#46; All the recordings had an adequate quality for their proper analysis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In this present study we found a very high correlation between SW and the gold-standard methods for OSA diagnosis both in-laboratory and in-home&#44; as well as a robust reproducibility of the test&#46; These findings are in line with our previous study&#44; in which we described a good agreement between PSG and SW&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Therefore&#44; we propose SW as an innovative and reliable system for the in-home diagnosis of OSA&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In-laboratory&#44; technician-attended PSG monitoring at least sleep stages and respiration&#44; is accepted as the gold standard for the diagnosis of OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> However&#44; this procedure requires technical expertise&#44; is labor-intensive and time-consuming and together with the high prevalence of OSA and the great demand of examinations results in a problem of long waiting lists&#46; Reliable diagnostic systems that short cut the conventional test are thus a must&#46; Portable monitors are alternative approaches to diagnosis providing an equivalent diagnosis to in-laboratory PSG&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> SW is not just a portable in-home device but more importantly it is also a non-invasive system&#46; SW does not use any sensor attached to patient&#39;s body which implies several advantages compared to other systems for the diagnosis of OSA&#46; First&#44; it is more comfortable for the subject as SW records patient&#39;s sleep without any nuisance and then the quality of sleep is therefore probably improved&#46; SW can detect respiratory movements independently of the position while sleeping or even if the patient is covered by a blanket&#46; Second&#44; it is easier to use as patients can be able to set up the system themselves at home with brief instructions&#46; All participants in our study rated the instructions to set up SW as easy or very easy and expressed their satisfaction to the system comfort&#46; The fact we excluded participants presenting difficulties for the understanding of the set-up of the system could be a selection bias&#46; However&#44; these patients would not have likely been candidates for a HSAT either&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">One of the limitations of HSAT is the absence of sleep staging evaluation that provides a denominator for the AHI&#46; This type of portable monitor provides breathing events quantified per hour of monitoring time as a respiratory disturbance index &#40;RDI&#41; that can underestimate the severity of OSA&#46; Regarding this point&#44; SW offers an undeniable advantage over the rest of the currently available portable diagnostic systems&#46; One SW&#39;s limitation is the absence of cardiorespiratory data registration&#44; such as oxygen saturation&#44; pulse or cardiac rhythm that helps physicians to determine the severity of the apneas and hypopneas and their systemic repercussion&#46; It is technically possible to add the information in question&#44; but that would lead to a drawback of the system ceasing to be noninvasive&#46; However&#44; future SW versions would incorporate these variables obtained in a non-invasive and friendly system&#44; such as it has been agreed with experts as fundamental for the evaluation of OSA&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Although it is difficult to compare two different procedures by simply comparing the kappa index&#44; our findings suggest that SW could be more reliable than HSAT to define OSA&#39;s severity&#46; The explanation for this fact is that SW calculates breathing events based on the time of sleep and not the monitoring time&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">However&#44; we found 3 cases with substantial differences between AHI value determined by PSG and SW&#46; These concrete patients were severe OSA with a BMI over 30 and this findings concur with our previous study&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> SW and PSG presented larger differences in the AHI value in obese patients with severe disease although patients were properly classified as severe OSA by both techniques&#44; thus without implications in the therapeutic decision in any case&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">HSAT use is accepted for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA&#46; On the contrary&#44; polysomnography should be elected in patients with significant cardiorespiratory disease&#44; neuromuscular disease with respiratory impairment&#44; suspicion of hypoventilation&#44; opioid medication use&#44; history of stroke&#44; or severe insomnia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Participants of this study did not presented any major comorbidity to contraindicate a HSAT&#46; In the future it would be interesting to compare SW agreement with PSG in complicated adult patients&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The AASM recommends that the raw data from the HSAT devices must be reviewed and interpreted by a physician who is either board certified in sleep medicine or overseen by a board certified sleep medicine physician&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Although in this study we provided the results of automatic analysis by SW&#44; the system also allows to review the raw data manually&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Even though reproducibility of the two SW procedures was considered to be almost perfect&#44; kappa values were slightly lower than that of the comparison between PSG and SW&#46; The reason for this could be the fact that those procedures were performed in two different nights&#44; with presumably different AHI due to a night-to-night variability&#46; This error could be solved in the future by performing a study comparing two simultaneous SW recordings overnight on the same individual&#46; This would be interesting to evaluate the system repeatability which is currently assumed to be high according to our results&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Other authors have developed various techniques based on motion analysis for diagnosis of OSA&#44; but there are significant differences when compared to SW from the video analysis of breathing to the detection of respiratory events&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;13</span></a> All this studies were performed in an experimental&#44; restricted environment with control subjects&#44; but never tested in real life or compared to other diagnostic techniques&#46; A strength of our study lies in demonstrating the utility and applicability of SW as an in-home diagnosis system of OSAS while previous studies have always been developed in a laboratory environment&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The benefits presented by SW lead us to hypothesize that it could be a useful tool to study pediatric patients&#46; We have analyzed some pediatric patients but preliminary results have not reached the same level of perfect agreement found in the study with adults&#46; The most probable explanation is that children&#39;s respiratory mechanics and body size are different from adults and thus the same algorithm cannot be applied&#46; Further studies are needed to adapt the algorithm and improve the effectiveness of the device in this concrete population group&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Economic analyses have compared the cost-effectiveness of management pathways that incorporate diagnostic strategies using HSAT or PSG&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">14&#8211;16</span></a> Contrary to what one might think&#44; all have concluded that PSG is the preferred diagnostic strategy from an economic perspective for adults suspected to have moderate to severe OSA&#46; The reason for that is the favorable cost-effectiveness of OSA treatment in this group of patients particularly when longer time horizons are considered&#46; HSAT could lead to increase false negatives&#44; and so leave patients untreated&#44; or increase false positives and consequently treat unnecessarily patients&#46; The impact of these errors can be magnified when extrapolated over long time horizons&#46; The HomePAP study concluded that for payers&#44; a home-based diagnostic pathway for OSA with robust patient support incurs fewer costs than a laboratory-based pathway&#44; but for providers&#44; costs are comparable if not higher&#44; resulting in a negative operating margin&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> In that sense&#44; our previous results comparing SW to PSG demonstrated a sensitivity of a 100&#37;&#44; specificity of 87&#37;&#44; a positive predictive value of 97&#37; and a negative predictive value of 100&#37; for the diagnosis of OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> According to that&#44; we believe SW would be a more cost-effective system compared to available HSAT adding also that not consumable material is required and all the automatic analysis is performed digitally&#46; However&#44; this is a hypothesis to be confirmed in further specific cost-effective studies&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0205" class="elsevierStylePara elsevierViewall">In conclusion&#44; SW was found to be highly accurate for non-invasive and automatic diagnosis of OSA in outpatients when compared to standard methods for OSA diagnosis both in-laboratory and in-home&#46; SW proved to be a technique with repeatable and concordant results on different nights for the same patient and resulted easy to set and very comfortable for the patients&#46; According to these results&#44; we conclude SW is a remarkable non-invasive&#44; easy-to-use&#44; portable&#44; effective and highly accurate option for OSA diagnosis at patients&#8217; home&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The research reported in this publication was supported by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Society of Pulmonary Medicine and Thoracic Surgery &#40;SEPAR&#41;</span> with code 030&#47;2015&#46; Esteve-Teijin Healthcare&#44; S&#46;L collaborated disinterestedly with our project instructing the participants in the set-up of both the respiratory polygraph and the camera for the Sleepwise recording for the in-home tests&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authorship</span><p id="par0215" class="elsevierStylePara elsevierViewall">All authors have contributed to the conception and design of the study&#59; analysis and interpretation of data&#59; and revising the article critically for important intellectual content&#46; IAV and CF collected the data&#46; IGO and JA performed the statistical analysis and interpreted the results&#46; AMF wrote the manuscript&#46; All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0220" class="elsevierStylePara elsevierViewall">MAC is Chief Executive Officer &#40;CEO&#41; of Tarsio Medics&#44; S&#46;L&#44; Malgrat de Mar &#40;Barcelona&#41;&#44; Spain&#46; AMF&#44; JRM and JA are minority shareholders of Tarsio Medics&#44; S&#46;L&#44; Malgrat de Mar &#40;Barcelona&#41;&#44; Spain since July 2017 and serve as clinical advisors for this company&#46; The terms of this arrangement have been reviewed and approved by the Fundaci&#243; Institut d&#8217;Investigaci&#243; en Ci&#232;ncies de la Salut Germans Trias i Pujol &#40;IGTP&#41; in accordance with its policy on objectivity in research&#46; IGO&#44; IV&#44; CF and AR declare that there is no conflict of interests regarding the publication of this paper&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Study objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the diagnostic accuracy of a non-invasive technology based on image processing for the identification of obstructive sleep apnea &#40;OSA&#41; and its severity at patients&#8217; home&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; prospective&#44; diagnostic accuracy study to evaluate the degree of measure agreement between Sleepwise &#40;SW&#41;&#44; in-laboratory attended polysomnography &#40;PSG&#41; and a home sleep apnea test &#40;HSAT&#41;&#46; 38 consecutive subjects with suspected OSA referred as outpatients to the sleep unit were recruited from September 2016 to September 2017&#46; All patients underwent in-laboratory attended PSG and image processing with SW simultaneously overnight&#46; Subsequently&#44; a HSAT and image processing with SW were performed simultaneously overnight at patients&#8217; home&#44; and the 2 nights after&#44; patients underwent only image processing with SW consecutively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In-laboratory polysomnography and SW had a Lin&#39;s concordance correlation coefficient of 0&#46;933 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;930&#46; Between HSAT and SW the Lin&#39;s concordance correlation coefficient was 0&#46;842 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;571&#46; Agreement between two consecutive nights with SW recording showed a Lin&#39;s concordance correlation coefficient of 0&#46;923 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46; 837&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SW was highly accurate for non-invasive and automatic diagnosis of OSA in outpatients compared to standard methods for OSA diagnosis either in-laboratory attended PSG or HSAT&#46; SW proved to be a technique with repeatable and concordant results on different nights for the same patient&#46; We conclude SW is a non-invasive&#44; easy-to-use&#44; portable&#44; effective and highly accurate system for the in-home diagnosis of OSA&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Study objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la precisi&#243;n diagn&#243;stica de una tecnolog&#237;a no invasiva basada en el procesamiento de im&#225;genes para la identificaci&#243;n de la apnea obstructiva del sue&#241;o &#40;AOS&#41; y su gravedad en el domicilio de los pacientes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; prospectivo y de precisi&#243;n diagn&#243;stica para evaluar el grado de concordancia entre las mediciones de Sleepwise &#40;SW&#41;&#44; polisomnograf&#237;a &#40;PSG&#41; asistida en el laboratorio y poligraf&#237;a respiratoria domiciliaria &#40;PRD&#41;&#46; Se reclutaron 38 sujetos consecutivos con sospecha de AOS&#44; referidos como pacientes ambulatorios a la unidad de sue&#241;o entre septiembre de 2016 y septiembre de 2017&#46; Se les realiz&#243; a todos una PSG y procesamiento de imagen con SW durante la noche en el laboratorio&#46; Posteriormente&#44; se realiz&#243; una PRD y procesamiento de im&#225;genes con SW de forma simult&#225;nea durante la noche en su domicilio&#44; y las 2 noches siguientes los pacientes se sometieron solo a procesamiento de im&#225;genes con SW&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La polisomnograf&#237;a en el laboratorio y el SW mostraron un coeficiente de correlaci&#243;n de concordancia de Lin de 0&#44;933 y un &#954; de 0&#44;930&#46; Entre la PRD y el SW el coeficiente de correlaci&#243;n de concordancia de Lin fue de 0&#44;842 y un &#954; de 0&#44;571&#46; La concordancia entre las 2 noches consecutivas de grabaci&#243;n con el SW mostr&#243; un coeficiente de correlaci&#243;n de concordancia de Lin de 0&#44;923 y un &#954; de 0&#44;837&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El SW mostr&#243; alta precisi&#243;n para el diagn&#243;stico no invasivo y automatizado de la AOS en pacientes ambulatorios en comparaci&#243;n con los m&#233;todos est&#225;ndar para el diagn&#243;stico de la AOS&#44; ya sean la PSG asistida en el laboratorio o la PRD&#46; El SW demostr&#243; ser una t&#233;cnica con resultados reproducibles y concordantes en diferentes noches para el mismo paciente&#46; Concluimos que la SW es un sistema no invasivo&#44; f&#225;cil de usar&#44; port&#225;til&#44; eficaz y altamente preciso para el diagn&#243;stico domiciliario de la AOS&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0040"
            "titulo" => "Resultados"
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            "identificador" => "abst0045"
            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This study was performed at Hospital Universitari Germans Trias i Pujol &#40;HUGTiP&#41;&#44; Badalona &#40;Barcelona&#41;&#44; Spain&#46;</p>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Bland&#8211;Altman plot for polysomnography &#40;PSG&#41; and Sleepwise &#40;SW&#41; apnea&#8211;hypopnea index &#40;AHI&#41;&#46; Differences between PSG and SW seem to be larger in patients with AHI over 60&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Bland&#8211;Altman plot for home sleep apnea test &#40;HSAT&#41; and Sleepwise &#40;SW&#41; apnea&#8211;hypopnea index &#40;AHI&#41;&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bland&#8211;Altman plot for two different Sleepwise &#40;SW&#41; procedures apnea&#8211;hypopnea index &#40;AHI&#41;&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;8 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoker&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epworth&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Height &#40;cm&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">170 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;6 &#40;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;7 &#40;7&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck &#40;cm&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">39&#46;3 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wrist&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;0 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hip&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">107&#46;6 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Hypertension&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14 &#40;36&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Diabetes&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;13&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Dyslipidemia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischemic cardiopathy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHI&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">36&#46;8 &#40;27&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of severity &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41;&nbsp;\t\t\t\t\t\t\n
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Original Article
In-Home Diagnosis of Obstructive Sleep Apnea Using Automatic Video Analysis
Diagnóstico domiciliario de apnea obstructiva del sueño utilizando el análisis automático de vídeo
Aida Muñoz-Ferrera,b,c,
Corresponding author
amunoz.germanstrias@gencat.cat

Corresponding author.
, Miguel-Ángel Cervantesd, Ignasi Garcia-Olivéa,c,e, Ignacio Vicentea,c, Carlos Folgadoa, Juan Ruiz-Manzanoa, Antoni Rosella,b,c,e, Jorge Abada,b,c,e
a Hospital Universitari Germans Trias i Pujol, Department of Respiratory Medicine, Badalona, Barcelona, Spain
b Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Catalunya, Spain
c Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Department of Respiratory Medicine, Badalona, Catalunya, Spain
d Tarsio Medics, S.L, Malgrat de Mar, Barcelona, Spain
e Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERESP), Department of Respiratory Medicine, Barcelona, Catalunya, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In-laboratory polysomnography &#40;PSG&#41; is the gold standard for the diagnosis of obstructive sleep apnea &#40;OSA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> However&#44; this technique is expensive and time-consuming&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> This condition added to the increasing prevalence of the disease explains the development of new systems for the diagnosis of OSA&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Sleepwise &#40;SW&#41; is a non-invasive technology based on video image processing&#44; by recording the patient&#39;s respiratory movements to transform them into a breathing signal that permits to determine episodes of hypopnea and apnea&#46; Its technology is based on the principle that the volume of air that circulates into the lungs is proportional to the thoracic movement that a subject presents while breathing&#46; Furthermore&#44; according to the analysis of the body movements SW can also infer sleep&#47;awake periods&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a previous publication our group compared the diagnostic accuracy of SW and the in-laboratory polysomnography&#44; concluding that Sleepwise determined the diagnosis and the severity of OSA with high reliability&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> We hypothesized that SW testing could also be performed at home&#46; Therefore&#44; the main objective of this study was to evaluate the diagnostic accuracy of SW compared with a home sleep apnea test &#40;HSAT&#41;&#46; As secondary objectives we checked SW reproducibility in different nights and also rated the easiness and comfort of its use&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population of study</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is an observational&#44; prospective&#44; diagnostic accuracy study that included consecutively 38 patients with suspected OSA who had been referred as outpatients to the Sleep Unit of the Hospital Universitari Germans Trias i Pujol &#40;HUGTiP&#41; from September 2016 to September 2017&#46; Male and female patients over 18 years of age were required to sign an informed consent form to participate in the study&#46; OSA suspicion was based on clinical criteria such as usual snoring&#44; witnessed apnea and daytime sleepiness&#46; Neurological and&#47;or psychiatric disorders or any predictable difficulty with the understanding of HSAT or the video camera use were the only exclusion criteria&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was conducted according to the guidelines and principles of the Declaration of Helsinki and standard ethical conduct for research involving humans&#46; The study also guarantees compliance with Organic Law 3&#47;2018&#44; of December 5&#44; Protection of Personal Data and guarantee of digital rights &#40;Spanish Government&#41; and Regulation &#40;EU&#41; 2016&#47;679 of the European Parliament and of the Council&#44; of April 27 2016&#44; with regard to the processing of personal data and on the free movement of such data&#46; The Ethics Committees for Clinical Research of the participating center approved this study &#40;REF&#46; CEI&#58; PI-15-142&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Protocol</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sociodemographic &#40;age&#44; sex&#41;&#44; anthropometric data &#40;weight&#44; height&#44; neck&#44; hip and waist circumference&#41;&#44; sleep history and Epworth Sleepiness Scale &#40;ESS&#41; were collected for all participants&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients underwent overnight simultaneously PSG and SW recording at the sleep laboratory of the Sleep Unit of &#40;HUGTiP&#41;&#46; Subsequently&#44; in a maximum time of 2 weeks after the in-laboratory test&#44; patients slept at home simultaneously with a cardiorespiratory polygraph and SW recording for one night and the 2 consecutive following nights only with SW recording&#46; PSG and cardiorespiratory polygraphy recordings were analyzed automatically and manually reviewed by the same certified sleep physician&#46; The updated AASM 2007 classification was used to identify stages of sleep&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> The SW analysis was performed automatically&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">PSG&#44; HSAT and SW analyses were carried out independently and blindly by the same certified sleep physician&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main outcome to compare both methods was the apnea&#8211;hypopnea index &#40;AHI&#41;&#46; Based on this&#44; patients were classified as having mild OSA &#40;5<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15&#41;&#44; moderate OSA &#40;15<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#41; or severe OSA &#40;AHI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30&#41;&#44; with an AHI of under 5 being deemed normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;6</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Material</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Sleepwise &#40;SW&#41;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">SW is a non-invasive system for the diagnosis of OSA&#44; which is able to detect respiratory events from the analysis of images provided by a conventional digital video camera equipped with infrared LEDs&#46; This camera must be placed 60<span class="elsevierStyleHsp" style=""></span>cm beside subject&#39;s bed focusing the thorax and the upper abdomen&#46; SW technology is based in the principle that the volume of air that circulates into the lungs is proportional to the chest movement that a subject presents while breathing&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">SW successively analyzes the images captured by the video camera and generates two types of signal&#46; First&#44; the respiratory movement signal that records subtle movements such as the thoracic oscillations that take place during breathing and can be used to infer respiratory flow and detect alterations therein&#46; SW can detect respiratory movements independently of the position while sleeping or even if the patient is covered by a blanket&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Second&#44; the body movement signal that records movements involving a greater degree of motion&#44; such as changes of body position&#46; Based on a similar system to actimetry&#44; this signal differentiates states of sleep&#47;awake and can infer the subject&#39;s sleep time and number of awakenings&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To detect both respiratory events as well as the state of sleep&#47;awake&#44; SW uses numerical thresholds that were calculated empirically by an automatic learning system based on the results of polysomnography as the total number of events and sleep time&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">For the in-laboratory tests&#44; the technician set up both PSG and SW&#46; For the in-home tests&#44; participants were instructed on how to set up both HSAT and the video camera for SW recording by themselves&#46; Participants were advised with verbal and written instructions and were given a brief demonstration&#46; After using SW a self-questionnaire was passed to rate the comprehension and easiness of use&#44; as well as the overall comfort of the system&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Polysomnography &#40;PSG&#41;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">For OSA diagnosis we used gold standard equipment in the form of a 32-channel E-Series polygraph &#40;Compumedics Ltd&#46;&#59; Abbotsford&#44; Victoria&#44; Australia&#41;&#44; to record electroencephalography&#44; electroculography&#44; electromyography and electrocardiography in accordance with AASM criteria &#40;Type I study&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> We monitored respiratory flow by means of a thermistor and a nasal cannula&#46; We recorded thorax and abdomen respiratory movements with two plethysmography bands&#44; and oxygen saturation with a pulse oximeter&#46; We used a video camera equipped with infrared LEDs to record each subject while sleeping&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We defined apnea as the complete cessation of respiratory flow for over 10<span class="elsevierStyleHsp" style=""></span>s&#44; and hypopnea as a reduction in respiratory flow lasting for over 10<span class="elsevierStyleHsp" style=""></span>s and accompanied by oxygen desaturation of at least 3&#37; and&#47;or arousal according to AASM guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> We calculated the AHI as the quotient of the total number of apneas and hypopneas divided by the total number of hours of sleep determined by PSG&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Home sleep apnea test &#40;HSAT&#41;</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">To perform the in-home studies we used Alice PDX &#40;Philips Respironics&#44; Murrysville&#44; PA&#44; USA&#41;&#44; which is a portable monitor for the diagnosis of OSA &#40;Type III study&#41;&#46; It includes oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#44; finger probe&#44; Oximetry board Nonin&#44; Plymouth&#44; MN&#44; USA&#41;&#44; pulse rate &#40;from the oximeter probe&#41;&#44; airflow &#40;pressure-based airflow with snore detection through a nasal cannula and thermistor&#41;&#44; thoracic and abdominal effort &#40;inductance plethysmography&#41;&#44; and body position&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Participants were advised with verbal and written instructions and were given a brief demonstration on how to set up the HSAT at home themselves&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0110" class="elsevierStylePara elsevierViewall">The degree of agreement between procedures for the AHI was assessed by the Lin&#39;s concordance correlation coefficient&#44; and the graphical representation of this agreement was described with the Bland&#8211;Altman method&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The degree of agreement between procedures for the definition of the severity of OSA was assessed by means of Cohen&#39;s kappa &#40;<span class="elsevierStyleItalic">&#954;</span>&#41;&#44; which improves upon simple percentage of agreement by taking into account the agreement occurring by chance&#46; Kappa values range from 0 &#40;when there is no agreement other than what would be expected by chance&#41; to 1 &#40;when the agreement is perfect&#41;&#46; For this study&#44; <span class="elsevierStyleItalic">&#954;</span> values greater than 0&#46;81 were considered to be almost in perfect agreement&#59; 0&#46;61&#8211;0&#46;80 were considered substantial&#59; 0&#46;41&#8211;0&#46;60&#44; moderate&#59; 0&#46;21&#8211;0&#46;40&#44; fair&#59; and 0&#46;00&#8211;0&#46;20 were considered as slight agreement&#46; Ninety-five percent confidence intervals of <span class="elsevierStyleItalic">&#954;</span> were also calculated&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All calculations were conducted in the version 15 of STATA using the <span class="elsevierStyleItalic">agree</span> and the <span class="elsevierStyleItalic">cohenkap</span> command&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">Thirty-eight patients were included in the study and their clinical data are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Agreements between procedures are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The graphical representation of this agreement&#44; described with the Bland&#8211;Altman method can be seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">There was almost perfect agreement between PSG and SW&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;933 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;930 &#40;95&#37; CI 0&#46;867&#8211;0&#46;993&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Between HSAT and SW&#44; agreement was lower&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;917 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;793 &#40;95&#37; CI 0&#46;713&#8211;0&#46;872&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Agreement between two different SW procedures was again almost perfect&#44; with a Lin&#39;s concordance correlation coefficient of 0&#46;923 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;837 &#40;95&#37; CI 0&#46;729&#8211;0&#46;944&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">None of the participants reported difficulties in understanding the functioning of SW&#46; The device was considered easy-to-use and comfortable&#46; All the recordings had an adequate quality for their proper analysis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In this present study we found a very high correlation between SW and the gold-standard methods for OSA diagnosis both in-laboratory and in-home&#44; as well as a robust reproducibility of the test&#46; These findings are in line with our previous study&#44; in which we described a good agreement between PSG and SW&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Therefore&#44; we propose SW as an innovative and reliable system for the in-home diagnosis of OSA&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In-laboratory&#44; technician-attended PSG monitoring at least sleep stages and respiration&#44; is accepted as the gold standard for the diagnosis of OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> However&#44; this procedure requires technical expertise&#44; is labor-intensive and time-consuming and together with the high prevalence of OSA and the great demand of examinations results in a problem of long waiting lists&#46; Reliable diagnostic systems that short cut the conventional test are thus a must&#46; Portable monitors are alternative approaches to diagnosis providing an equivalent diagnosis to in-laboratory PSG&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> SW is not just a portable in-home device but more importantly it is also a non-invasive system&#46; SW does not use any sensor attached to patient&#39;s body which implies several advantages compared to other systems for the diagnosis of OSA&#46; First&#44; it is more comfortable for the subject as SW records patient&#39;s sleep without any nuisance and then the quality of sleep is therefore probably improved&#46; SW can detect respiratory movements independently of the position while sleeping or even if the patient is covered by a blanket&#46; Second&#44; it is easier to use as patients can be able to set up the system themselves at home with brief instructions&#46; All participants in our study rated the instructions to set up SW as easy or very easy and expressed their satisfaction to the system comfort&#46; The fact we excluded participants presenting difficulties for the understanding of the set-up of the system could be a selection bias&#46; However&#44; these patients would not have likely been candidates for a HSAT either&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">One of the limitations of HSAT is the absence of sleep staging evaluation that provides a denominator for the AHI&#46; This type of portable monitor provides breathing events quantified per hour of monitoring time as a respiratory disturbance index &#40;RDI&#41; that can underestimate the severity of OSA&#46; Regarding this point&#44; SW offers an undeniable advantage over the rest of the currently available portable diagnostic systems&#46; One SW&#39;s limitation is the absence of cardiorespiratory data registration&#44; such as oxygen saturation&#44; pulse or cardiac rhythm that helps physicians to determine the severity of the apneas and hypopneas and their systemic repercussion&#46; It is technically possible to add the information in question&#44; but that would lead to a drawback of the system ceasing to be noninvasive&#46; However&#44; future SW versions would incorporate these variables obtained in a non-invasive and friendly system&#44; such as it has been agreed with experts as fundamental for the evaluation of OSA&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Although it is difficult to compare two different procedures by simply comparing the kappa index&#44; our findings suggest that SW could be more reliable than HSAT to define OSA&#39;s severity&#46; The explanation for this fact is that SW calculates breathing events based on the time of sleep and not the monitoring time&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">However&#44; we found 3 cases with substantial differences between AHI value determined by PSG and SW&#46; These concrete patients were severe OSA with a BMI over 30 and this findings concur with our previous study&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> SW and PSG presented larger differences in the AHI value in obese patients with severe disease although patients were properly classified as severe OSA by both techniques&#44; thus without implications in the therapeutic decision in any case&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">HSAT use is accepted for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA&#46; On the contrary&#44; polysomnography should be elected in patients with significant cardiorespiratory disease&#44; neuromuscular disease with respiratory impairment&#44; suspicion of hypoventilation&#44; opioid medication use&#44; history of stroke&#44; or severe insomnia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Participants of this study did not presented any major comorbidity to contraindicate a HSAT&#46; In the future it would be interesting to compare SW agreement with PSG in complicated adult patients&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The AASM recommends that the raw data from the HSAT devices must be reviewed and interpreted by a physician who is either board certified in sleep medicine or overseen by a board certified sleep medicine physician&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Although in this study we provided the results of automatic analysis by SW&#44; the system also allows to review the raw data manually&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Even though reproducibility of the two SW procedures was considered to be almost perfect&#44; kappa values were slightly lower than that of the comparison between PSG and SW&#46; The reason for this could be the fact that those procedures were performed in two different nights&#44; with presumably different AHI due to a night-to-night variability&#46; This error could be solved in the future by performing a study comparing two simultaneous SW recordings overnight on the same individual&#46; This would be interesting to evaluate the system repeatability which is currently assumed to be high according to our results&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Other authors have developed various techniques based on motion analysis for diagnosis of OSA&#44; but there are significant differences when compared to SW from the video analysis of breathing to the detection of respiratory events&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;13</span></a> All this studies were performed in an experimental&#44; restricted environment with control subjects&#44; but never tested in real life or compared to other diagnostic techniques&#46; A strength of our study lies in demonstrating the utility and applicability of SW as an in-home diagnosis system of OSAS while previous studies have always been developed in a laboratory environment&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The benefits presented by SW lead us to hypothesize that it could be a useful tool to study pediatric patients&#46; We have analyzed some pediatric patients but preliminary results have not reached the same level of perfect agreement found in the study with adults&#46; The most probable explanation is that children&#39;s respiratory mechanics and body size are different from adults and thus the same algorithm cannot be applied&#46; Further studies are needed to adapt the algorithm and improve the effectiveness of the device in this concrete population group&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Economic analyses have compared the cost-effectiveness of management pathways that incorporate diagnostic strategies using HSAT or PSG&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">14&#8211;16</span></a> Contrary to what one might think&#44; all have concluded that PSG is the preferred diagnostic strategy from an economic perspective for adults suspected to have moderate to severe OSA&#46; The reason for that is the favorable cost-effectiveness of OSA treatment in this group of patients particularly when longer time horizons are considered&#46; HSAT could lead to increase false negatives&#44; and so leave patients untreated&#44; or increase false positives and consequently treat unnecessarily patients&#46; The impact of these errors can be magnified when extrapolated over long time horizons&#46; The HomePAP study concluded that for payers&#44; a home-based diagnostic pathway for OSA with robust patient support incurs fewer costs than a laboratory-based pathway&#44; but for providers&#44; costs are comparable if not higher&#44; resulting in a negative operating margin&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> In that sense&#44; our previous results comparing SW to PSG demonstrated a sensitivity of a 100&#37;&#44; specificity of 87&#37;&#44; a positive predictive value of 97&#37; and a negative predictive value of 100&#37; for the diagnosis of OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> According to that&#44; we believe SW would be a more cost-effective system compared to available HSAT adding also that not consumable material is required and all the automatic analysis is performed digitally&#46; However&#44; this is a hypothesis to be confirmed in further specific cost-effective studies&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0205" class="elsevierStylePara elsevierViewall">In conclusion&#44; SW was found to be highly accurate for non-invasive and automatic diagnosis of OSA in outpatients when compared to standard methods for OSA diagnosis both in-laboratory and in-home&#46; SW proved to be a technique with repeatable and concordant results on different nights for the same patient and resulted easy to set and very comfortable for the patients&#46; According to these results&#44; we conclude SW is a remarkable non-invasive&#44; easy-to-use&#44; portable&#44; effective and highly accurate option for OSA diagnosis at patients&#8217; home&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The research reported in this publication was supported by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Society of Pulmonary Medicine and Thoracic Surgery &#40;SEPAR&#41;</span> with code 030&#47;2015&#46; Esteve-Teijin Healthcare&#44; S&#46;L collaborated disinterestedly with our project instructing the participants in the set-up of both the respiratory polygraph and the camera for the Sleepwise recording for the in-home tests&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authorship</span><p id="par0215" class="elsevierStylePara elsevierViewall">All authors have contributed to the conception and design of the study&#59; analysis and interpretation of data&#59; and revising the article critically for important intellectual content&#46; IAV and CF collected the data&#46; IGO and JA performed the statistical analysis and interpreted the results&#46; AMF wrote the manuscript&#46; All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0220" class="elsevierStylePara elsevierViewall">MAC is Chief Executive Officer &#40;CEO&#41; of Tarsio Medics&#44; S&#46;L&#44; Malgrat de Mar &#40;Barcelona&#41;&#44; Spain&#46; AMF&#44; JRM and JA are minority shareholders of Tarsio Medics&#44; S&#46;L&#44; Malgrat de Mar &#40;Barcelona&#41;&#44; Spain since July 2017 and serve as clinical advisors for this company&#46; The terms of this arrangement have been reviewed and approved by the Fundaci&#243; Institut d&#8217;Investigaci&#243; en Ci&#232;ncies de la Salut Germans Trias i Pujol &#40;IGTP&#41; in accordance with its policy on objectivity in research&#46; IGO&#44; IV&#44; CF and AR declare that there is no conflict of interests regarding the publication of this paper&#46;</p></span></span>"
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    "fechaRecibido" => "2019-10-14"
    "fechaAceptado" => "2019-11-29"
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            2 => "Procesamiento de im&#225;genes"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Study objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the diagnostic accuracy of a non-invasive technology based on image processing for the identification of obstructive sleep apnea &#40;OSA&#41; and its severity at patients&#8217; home&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; prospective&#44; diagnostic accuracy study to evaluate the degree of measure agreement between Sleepwise &#40;SW&#41;&#44; in-laboratory attended polysomnography &#40;PSG&#41; and a home sleep apnea test &#40;HSAT&#41;&#46; 38 consecutive subjects with suspected OSA referred as outpatients to the sleep unit were recruited from September 2016 to September 2017&#46; All patients underwent in-laboratory attended PSG and image processing with SW simultaneously overnight&#46; Subsequently&#44; a HSAT and image processing with SW were performed simultaneously overnight at patients&#8217; home&#44; and the 2 nights after&#44; patients underwent only image processing with SW consecutively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In-laboratory polysomnography and SW had a Lin&#39;s concordance correlation coefficient of 0&#46;933 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;930&#46; Between HSAT and SW the Lin&#39;s concordance correlation coefficient was 0&#46;842 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46;571&#46; Agreement between two consecutive nights with SW recording showed a Lin&#39;s concordance correlation coefficient of 0&#46;923 and a <span class="elsevierStyleItalic">&#954;</span> of 0&#46; 837&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SW was highly accurate for non-invasive and automatic diagnosis of OSA in outpatients compared to standard methods for OSA diagnosis either in-laboratory attended PSG or HSAT&#46; SW proved to be a technique with repeatable and concordant results on different nights for the same patient&#46; We conclude SW is a non-invasive&#44; easy-to-use&#44; portable&#44; effective and highly accurate system for the in-home diagnosis of OSA&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la precisi&#243;n diagn&#243;stica de una tecnolog&#237;a no invasiva basada en el procesamiento de im&#225;genes para la identificaci&#243;n de la apnea obstructiva del sue&#241;o &#40;AOS&#41; y su gravedad en el domicilio de los pacientes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; prospectivo y de precisi&#243;n diagn&#243;stica para evaluar el grado de concordancia entre las mediciones de Sleepwise &#40;SW&#41;&#44; polisomnograf&#237;a &#40;PSG&#41; asistida en el laboratorio y poligraf&#237;a respiratoria domiciliaria &#40;PRD&#41;&#46; Se reclutaron 38 sujetos consecutivos con sospecha de AOS&#44; referidos como pacientes ambulatorios a la unidad de sue&#241;o entre septiembre de 2016 y septiembre de 2017&#46; Se les realiz&#243; a todos una PSG y procesamiento de imagen con SW durante la noche en el laboratorio&#46; Posteriormente&#44; se realiz&#243; una PRD y procesamiento de im&#225;genes con SW de forma simult&#225;nea durante la noche en su domicilio&#44; y las 2 noches siguientes los pacientes se sometieron solo a procesamiento de im&#225;genes con SW&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La polisomnograf&#237;a en el laboratorio y el SW mostraron un coeficiente de correlaci&#243;n de concordancia de Lin de 0&#44;933 y un &#954; de 0&#44;930&#46; Entre la PRD y el SW el coeficiente de correlaci&#243;n de concordancia de Lin fue de 0&#44;842 y un &#954; de 0&#44;571&#46; La concordancia entre las 2 noches consecutivas de grabaci&#243;n con el SW mostr&#243; un coeficiente de correlaci&#243;n de concordancia de Lin de 0&#44;923 y un &#954; de 0&#44;837&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El SW mostr&#243; alta precisi&#243;n para el diagn&#243;stico no invasivo y automatizado de la AOS en pacientes ambulatorios en comparaci&#243;n con los m&#233;todos est&#225;ndar para el diagn&#243;stico de la AOS&#44; ya sean la PSG asistida en el laboratorio o la PRD&#46; El SW demostr&#243; ser una t&#233;cnica con resultados reproducibles y concordantes en diferentes noches para el mismo paciente&#46; Concluimos que la SW es un sistema no invasivo&#44; f&#225;cil de usar&#44; port&#225;til&#44; eficaz y altamente preciso para el diagn&#243;stico domiciliario de la AOS&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epworth&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Height &#40;cm&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;6 &#40;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;7 &#40;7&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neck &#40;cm&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;3 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wrist&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;0 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hip&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&#46;6 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertension&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;36&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;13&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyslipidemia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischemic cardiopathy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHI&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;8 &#40;27&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2423022.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the 38 patients included in the study&#46;</p>"
        ]
      ]
      4 => array:8 [
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        "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="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of severity &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No OSA&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild OSA&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate OSA&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe OSA&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;52&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Degree of severity of OSA&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CCC&#58; concordance correlation coefficient&#46;</p>"
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            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-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Comparisons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Apnea&#8211;hypopnea index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OSA severity</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">kappa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37;CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PSG-SW0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;933&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;930&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;867&#8211;0&#46;993&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSAT-SW1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;917&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;793&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;713&#8211;0&#46;872&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SW2-SW3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;923&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;837&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;729&#8211;0&#46;944&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2423021.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Degree of agreement between procedures assessed by the Lin&#39;s concordance correlation coefficient and Cohen&#39;s <span class="elsevierStyleItalic">&#954;</span>&#46;</p>"
        ]
      ]
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        "figura" => array:1 [
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:17 [
            0 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice parameters for the indications for polysomnography and related procedures&#58; an update for 2005"
                      "autores" => array:1 [
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Article information
ISSN: 15792129
Original language: English
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