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Sensibilidad de un modelo secuencial basado en cuestionario (STOP-Bang vs. Dixon) y pulsioximetría nocturna para el screening de apnea obstructiva del sueño en pacientes obesos mórbidos candidatos a cirugía bariátrica
Sensitivity of a sequential model based on a questionnaire (STOP-Bang vs Dixon) and nocturnal pulse oximetry for screening obstructive sleep apnea in patients with morbid obesity candidates for bariatric surgery
Javier Lázaroa,
Autor para correspondencia
javilazarosdr@gmail.com

Autor para correspondencia.
, Paloma Claveríaa, Carmen Cabrejasb, José Fernandoc, Silvia Seguraa, José M. Marínd,e
a Servicio Neumología, Hospital Royo Villanova, Zaragoza, España
b Servicio Endocrinología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
c Servicio de Cirugía General, Hospital Royo Villanova, Zaragoza, España
d Unidad de Investigación Traslacional, Hospital Miguel Servet, IIS Aragón y CIBERES Enfermedades Respiratorias, Madrid, España
e Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Flujograma de selecci&#243;n de pacientes&#46; LEQ&#58; lista de espera quir&#250;rgica&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La obesidad m&#243;rbida &#40;OM&#41;&#44; definida por un &#237;ndice de masa corporal &#40;IMC&#41; &#62;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; es una enfermedad cr&#243;nica que se caracteriza por el ac&#250;mulo desproporcionado de grasa&#46; Las opciones terap&#233;uticas son m&#250;ltiples reserv&#225;ndose la cirug&#237;a bari&#225;trica &#40;CB&#41; para los casos m&#225;s graves &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> o &#62;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> con una o m&#225;s comorbilidades asociadas&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Seg&#250;n la OMS&#44; la prevalencia de la obesidad se ha triplicado a nivel mundial desde el a&#241;o 1975 alcanzando un 13&#37; &#40;11&#37; hombres y 15&#37; mujeres&#41; en el a&#241;o 2016<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">2</span></a>&#46; En Espa&#241;a el 18&#44;2&#37; de los varones y el 16&#44;7&#37; de las mujeres padecen obesidad seg&#250;n la Encuesta Nacional de Salud del a&#241;o 2017<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La incidencia de apnea obstructiva del sue&#241;o &#40;AOS&#41; en pacientes con OM puede alcanzar el 90&#37;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">4</span></a>&#46; Su coexistencia en pacientes candidatos a CB&#44; m&#225;s all&#225; de aumentar el riesgo cardiovascular&#44; incrementa el riesgo perioperatorio de complicaciones cardiorrespiratorias<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">5</span></a>&#46; El tratamiento con presi&#243;n positiva reduce el riesgo de estas complicaciones<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">6</span></a> sin incrementar las quir&#250;rgicas<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">7</span></a>&#46; Se hace necesario&#44; por tanto&#44; un diagn&#243;stico de la AOS en beneficio de los pacientes candidatos a CB&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se han descrito &#237;ndices multicomponente para predecir el riesgo de presentar una AOS&#46; El m&#225;s conocido es el STOP-Bang<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">8&#44;9</span></a>&#44; que analiza la presencia de s&#237;ntomas &#40;roncopat&#237;a&#44; apnea y excesiva somnolencia diurna&#41;&#44; enfermedades asociadas &#40;hipertensi&#243;n arterial &#91;HTA&#93;&#41; y otros factores relacionados &#40;IMC&#44; per&#237;metro cervical&#44; edad y g&#233;nero&#41;&#46; Este cuestionario ha sido validado en individuos con obesidad y OM con una sensibilidad del 100&#37; para AOS grave &#40;&#237;ndice de apnea&#47;hipopnea del sue&#241;o &#91;IAH&#93;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">10</span></a>&#46; Su h&#225;ndicap es su baja especificidad&#58; inferior al 20&#37; en obesidad y 7&#37; en OM&#46; Las medidas antropom&#233;tricas juegan un papel fundamental en la AOS&#44; incluso en la OM&#44; donde la localizaci&#243;n del ac&#250;mulo de grasa determina el IAH<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">11</span></a>&#46; El modelo de Dixon es el que incluye m&#225;s variables relativas a la obesidad central&#46; Descrito en el a&#241;o 2003<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">12</span></a> y modificado en 2011<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">13</span></a>&#44; incluye 9 variables &#40;presi&#243;n arterial sist&#243;lica&#44; &#237;ndice de cintura cadera&#44; per&#237;metro cuello y abdominal&#44; IMC&#44; sexo&#44; edad&#44; roncopat&#237;a y glucosa en ayunas&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">La polisomnograf&#237;a vigilada &#40;PSG&#41; es el <span class="elsevierStyleItalic">gold standard</span> para el diagn&#243;stico de AOS&#46; Una opci&#243;n menos compleja&#44; para su diagn&#243;stico&#44; es la poligraf&#237;a respiratoria domiciliaria &#40;PR&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">14</span></a>&#46; La pulsioximetr&#237;a nocturna &#40;POX&#41;&#44; un dispositivo que solamente analiza SatO<span class="elsevierStyleInf">2</span> y frecuencia cardiaca nocturna&#44; tambi&#233;n han sido estudiados y sugeridos para su uso como <span class="elsevierStyleItalic">screening</span> en pacientes candidatos a CB&#44; reduci&#233;ndose hasta un 40&#37; la realizaci&#243;n de un estudio del sue&#241;o m&#225;s complejo<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a>&#46; El par&#225;metro con mayor concordancia con el IAH es el &#237;ndice de desaturaci&#243;n &#62;<span class="elsevierStyleHsp" style=""></span>3&#37; &#40;IDO&#41;&#46; La sensibilidad de este tipo de dispositivos llega al 100&#37; con una especificidad pr&#243;xima al 70&#37;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a>&#46; Planteamos por tanto un estudio prospectivo con el objetivo de estudiar el <span class="elsevierStyleItalic">screening</span> secuencial en pacientes OM candidatos a CB&#46; Para ello en primer lugar comparamos la rentabilidad de los cuestionarios STOP-Bang&#44; Dixon modificado &#40;DXM&#41; y los par&#225;metros de la POX nocturna&#46; En segundo lugar&#44; aplicar el modelo secuencial &#40;1&#46;<span class="elsevierStyleSup">o</span> cuestionario y 2&#46;<span class="elsevierStyleSup">o</span> POX&#41; a nuestra cohorte de pacientes para dilucidar el n&#250;mero de PR que finalmente hubiesen sido necesarias realizar&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dise&#241;o</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio de cohorte prospectivo&#44; longitudinal&#44; de no intervenci&#243;n de pacientes referidos de la Unidad de Cirug&#237;a Bari&#225;trica &#40;UCB&#41; a la Unidad de Trastornos Respiratorios del Sue&#241;o &#40;UTRS&#41; del Hospital Royo Villanova de Zaragoza entre el 1&#47;07&#47;2014 y el 1&#47;07&#47;2015&#46; El estudio fue aprobado por el Instituto Aragon&#233;s de Ciencias de la Salud &#40;IACS&#41; &#40;CEICA n&#250;mero&#58; 23&#47;2014&#41;&#46; Los resultados que aqu&#237; se presentan se obtuvieron siguiendo el protocolo del estudio <span class="elsevierStyleItalic">Epigenetics dysfunction in Morbid Obesity with or without obstructive sleep apnoea&#58; the EPIMOOSA study</span> &#40;ClinicalTrials&#46;gov identifier&#58; NCT03995836&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">16</span></a>&#46; De acuerdo con las recomendaciones del IACS y la Conferencia de Helsinki&#44; se obtuvo el consentimiento informado antes de entrar en el estudio&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Poblaci&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se remitieron pacientes de entre 18 y 60<span class="elsevierStyleHsp" style=""></span>a&#241;os candidatos a CB bajo los criterios de selecci&#243;n que se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; Los pacientes fueron manejados en la consulta de la UCB de forma habitual y sin que este estudio colateral alterara las decisiones terap&#233;uticas en relaci&#243;n con el tratamiento de la enfermedad diana&#58; la OM&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Procedimientos</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Evaluaci&#243;n cl&#237;nica y cuestionarios<span class="elsevierStyleBold">&#46;</span></span> En la primera visita se registran las siguientes variables cl&#237;nicas y pruebas complementarias&#58; a&#41; datos sociodemogr&#225;ficos&#44; antecedentes m&#233;dico-quir&#250;rgicos y toma regular de f&#225;rmacos&#59; b&#41; nivel de somnolencia diurna mediante escala de somnolencia epworth &#40;ESE&#41;&#59; c&#41; peso &#40;medido en kg&#41;&#44; altura &#40;medida en cm&#41;&#44; IMC &#40;peso &#40;kg&#41;&#47;talla&#40;m&#41;<span class="elsevierStyleSup">2</span>&#41;&#44; per&#237;metro de cuello &#40;cm&#41;&#44; abdomen &#40;cm&#41; y cadera &#40;cm&#41;&#59; d&#41; presi&#243;n arterial seg&#250;n el protocolo de la gu&#237;a de pr&#225;ctica cl&#237;nica europea&#44; y e&#41; espirometr&#237;a posbroncodilatador&#46; Para valorar la probabilidad de AOS se aplicaron los cuestionarios&#58; STOP-Bang<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">8</span></a> y DXM<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">13</span></a>&#44; unificando las variables relativas a la roncopat&#237;a&#44; quedando reducido a 9 variables&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anal&#237;tica sangu&#237;nea</span>&#46; En visita basal se realiz&#243; anal&#237;tica sangu&#237;nea est&#225;ndar&#44; incluyendo bioqu&#237;mica general&#44; colesterol total&#44; triglic&#233;ridos&#44; lipoprote&#237;nas de alta &#40;HDL&#41; y baja densidad &#40;LDL&#41;&#44; hemoglobina glucosilada &#40;HbG&#41; y prote&#237;na C reactiva de alta sensibilidad &#40;PCR&#41;&#46; Al&#237;cuotas de suero&#44; plasma y sangre entera de cada paciente fueron almacenadas a &#8722;80<span class="elsevierStyleHsp" style=""></span>&#176;C para futuras determinaciones&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gasometr&#237;a arterial&#46;</span> Al d&#237;a siguiente de la PR se obtuvo una gasometr&#237;a arterial respirando aire ambiente&#46; Dicha prueba fue realizada en todas las ocasiones por la enfermera de la UTRS&#46; Las muestras fueron analizadas en el mismo d&#237;a&#44; registr&#225;ndose&#58; pH&#44; PaCO<span class="elsevierStyleInf">2</span>&#44; PaO<span class="elsevierStyleInf">2</span> &#40;mmHg&#41; y bicarbonato &#40;mmol&#47;l&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Estudio de sue&#241;o</span>&#46; Se utiliz&#243; el pol&#237;grafo ApneaLink vs10&#46;20 &#40;ResMed&#174;&#44; Sidney&#44; Australia&#41; de la UTRS&#44; que incluye&#58; registro continuo del flujo de aire mediante una c&#225;nula nasal&#44; movimiento tor&#225;cico&#44; SatO<span class="elsevierStyleInf">2</span>&#44; ronquido y posici&#243;n corporal&#46; Un enfermero especializado explic&#243; el uso del sistema y lo recogi&#243; al d&#237;a siguiente&#46; La lectura del registro fue realizada de forma manual por un t&#233;cnico entrenado y desconocedor de la patolog&#237;a del sujeto&#46; Se repitieron los estudios con una duraci&#243;n inferior a 180<span class="elsevierStyleHsp" style=""></span>min tanto para la onda de pulso como para los eventos respiratorios&#46; Definimos una apnea como la ausencia de flujo durante m&#225;s de 10<span class="elsevierStyleHsp" style=""></span>segundos&#59; una hipopnea como la reducci&#243;n discernible &#40;&#62;<span class="elsevierStyleHsp" style=""></span>30&#37; y &#60;<span class="elsevierStyleHsp" style=""></span>90&#37;&#41; de la amplitud de la se&#241;al respiratoria de &#62;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>segundos de duraci&#243;n o una disminuci&#243;n notoria del sumatorio toraco-abdominal que se acompa&#241;a de una desaturaci&#243;n &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>3&#37;&#41;&#46; Se calcul&#243; el IAH como la suma de apneas e hipopneas por hora del periodo de tiempo grabado&#46; Se utiliz&#243; el an&#225;lisis autom&#225;tico de la oximetr&#237;a nocturna incluy&#233;ndose&#58; IDO&#44; SatO<span class="elsevierStyleInf">2</span> media y CT90&#37;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se dividi&#243; la muestra en dos grupos atendiendo&#58; No AOS o AOS leve &#40;IAH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15&#41; y AOS moderada-grave &#40;IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46; Los datos se presentan como media &#40;desviaci&#243;n est&#225;ndar&#41; o porcentaje&#46; No se ha asumido la normalidad&#44; por lo que para la comparaci&#243;n de medias se us&#243; un test no param&#233;trico&#58; U de Mann-Whitney&#46; Para la relaci&#243;n entre las distintas variables y el IAH &#40;cuantitativa&#41; y el diagn&#243;stico de AOS se emplearon modelos de regresi&#243;n lineal y log&#237;stica&#46; La rentabilidad diagn&#243;stica se realiz&#243; mediante la curva <span class="elsevierStyleItalic">receiver operating characteristic</span> &#40;ROC&#41;&#44; los resultados se expresaron mediante el &#225;rea bajo la curva &#40;ABC&#41; y sus intervalos de confianza&#46; Para la elecci&#243;n de los puntos de corte &#243;ptimos para la sensibilidad y especificidad se utiliz&#243; el &#237;ndice de Youden&#46; La comparaci&#243;n de las curvas ROC se realiz&#243; utilizando el paquete estad&#237;stico Epidata 3&#46;1&#46; El an&#225;lisis se llev&#243; a cabo utilizando el paquete estad&#237;stico SPSS 20&#46;0&#44; Microsoft Excel 2016 y el GraphPad Prism 7&#46; Se siguieron las recomendaciones de la gu&#237;a STARD 2015 para pruebas diagn&#243;sticas<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">17</span></a>&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se remitieron 124 pacientes a la UTRS de los cuales 70 se analizaron finalmente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Las caracter&#237;sticas del grupo se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Hubo 42 pacientes &#40;60&#37;&#41; con un IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5&#46; En 26 pacientes &#40;37&#44;1&#37;&#41; se diagnostic&#243; una AOS moderada-grave &#40;IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46; De los 70 estudios se tuvieron que repetir 8&#44; 7 por error en el registro de c&#225;nulas nasales y uno por fallo de la POX&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Las diferencias entre el grupo con&#47;sin AOS se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; En el grupo con AOS hubo una incidencia similar en ambos sexos&#44; con un predominio en los varones con 14 pacientes &#40;53&#44;8&#37;&#41;&#46; En el grupo sin AOS el sexo femenino fue el mayoritario&#46; La incidencia de factores de riesgo cardiovascular &#40;FRCV&#41; fue superior para los AOS&#44; salvo para la diabetes mellitus &#40;DM&#41;&#46; En cuanto a las variables antropom&#233;tricas&#44; el grupo con AOS present&#243; un IMC superior&#44; aunque sin diferencias estad&#237;sticas&#46; Los par&#225;metros relativos a la distribuci&#243;n central de la grasa &#40;per&#237;metro abdominal&#44; cuello e &#237;ndice de cintura cadera&#41; fueron superiores en el grupo con AOS&#46; Se obtuvo una gasometr&#237;a en 63 pacientes &#40;en 7 de ellos la muestra no pudo ser analizada&#41;&#46; Hubo 7 pacientes con una PaCO<span class="elsevierStyleInf">2</span> superior a 45<span class="elsevierStyleHsp" style=""></span>mmHg y que fueron diagnosticados de s&#237;ndrome de hipoventilaci&#243;n obesidad &#40;SHO&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestra el an&#225;lisis de la capacidad diagn&#243;stica de cada uno de los par&#225;metros de la POX y de los cuestionarios&#46; Obtuvieron una mayor AUC los par&#225;metros de la oximetr&#237;a nocturna con unas diferencias estad&#237;sticamente significativas a favor del IDO frente al CT90 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0041&#41; y a los cuestionarios STOP-Bang &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0000&#41; y DXM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0004&#41;&#46; El DXM obtuvo mejor AUC que el STOP-Bang&#44; si bien las diferencias no fueron estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;212&#41;&#46; El punto de corte &#243;ptimo para STOP-Bang &#40;&#62;<span class="elsevierStyleHsp" style=""></span>3&#41; arroj&#243; una sensibilidad del 100&#37;&#44; mientras que DXM &#40;&#62;<span class="elsevierStyleHsp" style=""></span>5&#41; fue del 73&#37;&#46; Con DXM hubo que reducir el punto de corte hasta 3 para alcanzar el 100&#37; de sensibilidad&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">El modelo secuencial que comienza con el STOP-Bang &#62;<span class="elsevierStyleHsp" style=""></span>3 hubiese excluido correctamente a 16 pacientes &#40;22&#44;8&#37;&#41;&#46; Los 54 restantes se hubiesen sometido a una POX&#44; de los cuales 25 &#40;46&#44;2&#37;&#41; hubiesen sido clasificados como de riesgo bajo&#46; Los 29 restantes &#40;41&#44;4&#37;&#41;&#44; de los 70 primeros&#44; ser&#237;an los candidatos finales para someterse a una PR&#47;PSG&#44; evit&#225;ndose 41 &#40;58&#44;5&#37;&#41; &#40;fig&#46; 2&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se analiza el modelo secuencial iniciado con DXM con los puntos de corte &#243;ptimos calculados seg&#250;n el &#237;ndice de Youden &#40;&#62;<span class="elsevierStyleHsp" style=""></span>5&#41; y el que consigue una sensibilidad del 100&#37; &#40;&#62;<span class="elsevierStyleHsp" style=""></span>3&#44;5&#41;&#46; En el primero&#44; tras la aplicaci&#243;n del modelo se etiquet&#243; como de bajo riesgo a 42 pacientes &#40;60&#37;&#41;&#46; De ellos&#44; 7 &#40;16&#44;6&#37;&#41; fueron etiquetados err&#243;neamente como de bajo riesgo&#44; ya que realmente padec&#237;an una AOS&#46; Tras aplicar el punto de corte de la POX nocturna&#44; 20 pacientes &#40;28&#44;5&#37;&#41;&#44; de los 70 primeros&#44; hubiesen precisado una PR&#47;PSG&#44; evit&#225;ndose 50 &#40;71&#44;4&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Utilizando el punto de corte 3 para el modelo DXM&#44; en la primera fase se hubiese excluido a 18 pacientes &#40;25&#44;7&#37;&#41; al ser de bajo riesgo&#44; quedando 52 a los que se hubiese realizado la POX&#46; Dicha prueba hubiese excluido a 23 &#40;44&#44;2&#37;&#41; clasific&#225;ndolos como de bajo riesgo&#44; quedando 29 &#40;41&#44;4&#37;&#41; que ser&#237;an los que se someter&#237;an finalmente a la PR&#47;PSG&#44; evit&#225;ndose 41 &#40;58&#44;5&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">En nuestra cohorte la aplicaci&#243;n de un modelo secuencial con un cuestionario seguido de una POX habr&#237;a reducido considerablemente el n&#250;mero de PR&#46; Hasta la fecha este es el primer estudio que analiza un modelo secuencial para el <span class="elsevierStyleItalic">screening</span> de AOS en una poblaci&#243;n con elevada prevalencia de la misma&#46; El modelo de DXM&#44; con un mayor n&#250;mero de variables antropom&#233;tricas&#44; obtiene una mejor AUC pero no es estad&#237;sticamente superior al cuestionario STOP-Bang como m&#233;todo de <span class="elsevierStyleItalic">screening</span>&#46; El IDO es el que mayor rentabilidad diagn&#243;stica posee y por tanto deber&#237;a incluirse en el protocolo de <span class="elsevierStyleItalic">screening</span> de pacientes OM candidatos a CB&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La prevalencia de AOS en nuestra cohorte de pacientes es del 60&#37;&#44; similar a la descrita en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; con un predominio claro del sexo femenino&#44; si bien la incidencia de AOS es mayor en el sexo masculino&#46; Los FRCV&#58; HTA y dislipemia son superiores en el grupo con AOS moderada-grave&#46; La DM y los antecedentes cardiovasculares&#44; como ocurre en otros estudios<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">20</span></a>&#44; no presentan diferencias significativas entre ambos grupos&#44; posiblemente por la potente se&#241;al cardiovascular de la obesidad&#46; La incidencia de SHO en nuestro estudio fue superior a la descrita en otros estudios<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">21</span></a>&#44; aunque no es habitual que incluyan una gasometr&#237;a para confirmarlo&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La AOS presenta una sintomatolog&#237;a f&#225;cilmente reconocible&#44; como son la roncopat&#237;a&#44; las apneas y la excesiva somnolencia diurna<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">22</span></a>&#46; Este s&#237;ntoma presenta una estrecha relaci&#243;n con la OM independientemente de la presencia de AOS<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">23</span></a>&#46; Los s&#237;ntomas nocturnos&#44; en especial la roncopat&#237;a&#44; son inespec&#237;ficos&#44; y su etiolog&#237;a variable&#46; Desde el punto de vista antropom&#233;trico tambi&#233;n se han encontrado estrechas relaciones entre el IMC&#44; los per&#237;metros abdominal o cervical &#40;entre otras&#41; con el IAH<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; los pacientes que padecen AOS tienen un mayor riesgo de sufrir otros FRCV como la HTA&#44; dislipemia o DM<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Los cuestionarios demostraron relaci&#243;n con el IAH y el diagn&#243;stico de AOS&#46; El DXM present&#243; un mayor poder predictor frente al STOP-Bang&#44; as&#237; como una mayor AUC&#44; aunque sin diferencias significativas&#46; La sensibilidad del STOP-Bang fue mayor que la del modelo de DXM para los puntos de corte &#243;ptimos indicados por el &#237;ndice de Youden&#46; Para obtener la misma sensibilidad en el DXM habr&#237;a que reducir el punto de corte hasta 3&#44; lo que supone un descenso considerable de la especificidad&#46; El cuestionario STOP-Bang se recomienda como <span class="elsevierStyleItalic">screening</span> de AOS en CB<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">7</span></a>&#46; Su sensibilidad para la discriminaci&#243;n de AOS moderada-grave oscila entre el 85 y 100&#37; seg&#250;n el estudio<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">10&#44;25</span></a>&#44; aunque tambi&#233;n ha sido puesta en duda por otros autores al obtener sensibilidades menores<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">26</span></a>&#46; En nuestro an&#225;lisis comparativo entre STOP-Bang y DXM tiene mayor AUC este &#250;ltimo&#44; aunque las diferencias no fueron significativas&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se han analizado otros cuestionarios y modelos matem&#225;ticos como <span class="elsevierStyleItalic">screening</span>&#46; Descartamos la ESE por la elevada incidencia de somnolencia diurna en pacientes con OM&#46; La f&#243;rmula propuesta por Palla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">20</span></a> incorpora la ESE junto a otras 3 variables &#40;sexo&#44; edad y SatO<span class="elsevierStyleInf">2</span> m&#237;nima&#41;&#44; alcanzando sensibilidades pr&#243;ximas al 100&#37;&#46; En un an&#225;lisis de 4 modelos matem&#225;ticos&#44; donde se incorporaban variables como el IMC y el per&#237;metro cervical&#44; aumentaban la precisi&#243;n diagn&#243;stica&#44; pero con una pobre especificidad<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">27</span></a>&#46; Otros cuestionarios como el score <span class="elsevierStyleItalic">multivariate apnea predictor</span> &#40;MAP&#41;&#44; pese a tener una aceptable sensibilidad&#44; se han descartado por su bajo valor predictivo negativo<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Todos esos cuestionarios&#44; realizados en su mayor&#237;a en poblaci&#243;n con obesidad&#44; no incorporan factores determinantes en el desarrollo de AOS en pacientes con OM&#46; Las medidas antropom&#233;tricas son capaces de explicar el 20&#37; del IAH&#44; y dichas medidas deben incluir las referidas a obesidad central&#58; per&#237;metro cervical y abdominal junto con el &#237;ndice de cintura cadera<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">11</span></a>&#46; El &#250;nico modelo encontrado que tenga en cuenta estos 3 par&#225;metros es el modelo desarrollado por Dixon en 2003 y modificado por Kolotkin&#46; El modelo de Kolotkin obtuvo un ABC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;821 con una sensibilidad del 77&#37; y 85&#37; para IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15 e IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#44; respectivamente&#46; La sensibilidad del modelo de Dixon fue superior a la del modelo de Kolotkin&#44; alcanzando el 89&#37; para IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15 y el 96&#37; para el IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Las variables oxim&#233;tricas utilizadas en este estudio fueron el IDO&#44; CT90&#37; y SatO<span class="elsevierStyleInf">2</span> media&#46; El IDO fue el que mejor correlaci&#243;n y precisi&#243;n diagn&#243;stica demostr&#243;&#46; Su utilidad como <span class="elsevierStyleItalic">screening</span> en una cohorte con OM ya ha sido demostrada<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a>&#44; alcanzando un ABC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;950 para el IDO3&#37; y ABC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;910 para el CT90&#37;&#44; con una sensibilidad para ambas del 100&#37;&#44; pero con una especificidad muy baja&#46; Los pulsiox&#237;metros son de f&#225;cil lectura e interpretaci&#243;n y no requieren un an&#225;lisis exhaustivo de los par&#225;metros registrados&#44; facilitando su uso como <span class="elsevierStyleItalic">screening</span>&#46; El uso secuencial de la POX seguida de la PG ha sido estudiado en una cohorte de pacientes con sospecha cl&#237;nica de AOS demostrando su utilidad<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">29</span></a>&#44; si bien el inconveniente de dicha estrategia radica en que todos los pacientes deber&#237;an pasar por el laboratorio del sue&#241;o&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Por ello planteamos un modelo de aplicaci&#243;n en dos niveles&#58; en la consulta con el cuestionario y en el domicilio del paciente con la POX nocturna&#46; Su aplicaci&#243;n hubiese evitado un 59&#37; de PR&#44; por encima de lo publicado por de Vries et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a>&#46; Este modelo ha sido estudiado en poblaci&#243;n general con los cuestionarios OSA-50 y Philips&#44; alcanzando sensibilidades del 91 y 100&#37; y reduciendo significativamente el n&#250;mero de PR a realizar<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">30&#44;31</span></a>&#46; Un an&#225;lisis parecido se llev&#243; a cabo en una cohorte de 141 pacientes candidatos a CB<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">21</span></a>&#44; donde se escogi&#243; como punto de corte para el STOP-Bang<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4&#46; A aquellos pacientes con riesgo elevado se les realiz&#243; una POX&#44; con lo que directamente se daba el diagn&#243;stico de AOS&#46; Este estudio presenta un importante sesgo metodol&#243;gico ya que no se ha comprobado con el <span class="elsevierStyleItalic">gold standard</span> ni con una PR la incidencia de AOS&#46; En nuestro estudio la aplicaci&#243;n del modelo secuencial soluciona el problema de la baja especificidad situ&#225;ndola por encima del 95&#37;&#44; manteniendo la sensibilidad del 100&#37;&#46; Seg&#250;n la literatura revisada&#44; este es el primer estudio en analizar un modelo secuencial para <span class="elsevierStyleItalic">screening</span> de AOS en OM candidatos a CB&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Este estudio presenta limitaciones como su car&#225;cter unic&#233;ntrico afectando su validez externa&#46; Los datos de la POX se han obtenido del registro de PR y no con un dispositivo independiente&#46; No se ha contado con el <span class="elsevierStyleItalic">gold standard</span> para el diagn&#243;stico de los trastornos respiratorios del sue&#241;o&#58; la PSG&#46; Otra de las limitaciones se encuentra en los criterios de exclusi&#243;n&#44; retirando del estudio a los pacientes a quienes ya se les hab&#237;a hecho un estudio del sue&#241;o&#46; Comparando con otros estudios la incidencia de AOS es menor&#44; lo que puede sobreestimar los resultados alcanzados&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusi&#243;n</span><p id="par0135" class="elsevierStylePara elsevierViewall">En definitiva&#44; el modelo secuencial que combina el STOP-Bang en primer lugar seguido de la POX es el que mejores resultados ofrece para discriminar a los pacientes OM con AOS &#40;IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46; Individualmente&#44; ning&#250;n cuestionario fue superior a la POX para el <span class="elsevierStyleItalic">screening</span> de AOS&#46; EL <span class="elsevierStyleItalic">screening</span> secuencial aumenta la especificidad manteniendo una elevada sensibilidad y reduciendo la necesidad de PR&#47;PSG&#46; Se hace necesario un estudio multic&#233;ntrico para la validaci&#243;n de este modelo secuencial&#44; que incluya el cuestionario STOP-Bang y POX&#44; como <span class="elsevierStyleItalic">screening</span> de AOS en OM candidatos a CB&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financiaci&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">Este Proyecto de investigaci&#243;n ha sido becado por FIS &#40;15&#47;01940&#41;&#44; Sociedad Espa&#241;ola de Patolog&#237;a del Aparato Respiratorio &#40;SEPAR-2017&#41; y Sociedad Aragonesa de Aparato Respiratorio &#40;SADAR-2016&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Autor&#237;a</span><p id="par0145" class="elsevierStylePara elsevierViewall">JL y JMM dise&#241;aron el estudio&#59; JL&#44; PC&#44; SS&#44; CC y JF registraron los datos y analizaron las pruebas complementarias&#59; JL y JMM realizaron el an&#225;lisis final de los datos&#59; JL y JMM escribieron el presente manuscrito&#44; que ha sido revisado y aprobado por el resto de los autores&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Ni el autor principal ni el resto de autores declaran tener ning&#250;n conflicto de intereses con el presente art&#237;culo&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La apnea obstructiva del sue&#241;o &#40;AOS&#41; tiene una elevada incidencia en obesos m&#243;rbidos candidatos a cirug&#237;a bari&#225;trica &#40;CB&#41;&#46; Un <span class="elsevierStyleItalic">screening</span> adecuado reducir&#237;a el n&#250;mero de poligraf&#237;as &#40;PR&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizar la utilidad de un modelo secuencial con un cuestionario &#40;Dixon modificado &#91;DXM&#93; vs&#46; STOP-Bang&#41; y pulsioximetr&#237;a nocturna en pacientes candidatos a CB&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; desde el 1 de julio de 2014 hasta el 1 de julio de 2015&#46; Se incluyeron candidatos a CB&#44; excluy&#233;ndose aquellos que ya se hab&#237;an sometido a una PR&#46; Variables&#58; cuestionarios &#40;Epworth&#44; STOP-Bang y DXM&#41;&#44; medidas antropom&#233;tricas&#44; PR y anal&#237;tica de sangre y gases&#46; Se dividi&#243; la muestra entre los que no ten&#237;an AOS o era leve &#40;No AOS&#41; y los que tuvieron una AOS moderada-grave &#40;IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 70 pacientes&#44; de los cuales 46 &#40;65&#44;7&#37;&#41; eran mujeres&#46; Se diagnosticaron 26 &#40;37&#44;1&#37;&#41; de AOS moderada-grave&#46; Comparamos STOP-Bang y DXM mediante curvas ROC con una mayor &#225;rea bajo la curva &#40;AUC&#41; para este &#250;ltimo &#40;0&#44;873 &#91;0&#44;74-0&#44;930&#93; vs&#46; 0&#44;781 &#91;0&#44;673-0&#44;888&#93;&#41;&#46; La sensibilidad fue superior para el STOP-Bang con un 100&#37; vs&#46; 73&#44;1&#37; de DXM&#46; El IDO3&#37; present&#243; mayor rentabilidad diagn&#243;stica AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;982 &#40;0&#44;970-1&#41;&#46; La aplicaci&#243;n del modelo secuencial con STOP-Bang<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#44; DXM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5 y DXM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 hubiese evitado 41 &#40;58&#44;5&#37;&#41;&#44; 50 &#40;71&#44;4&#37;&#41; y 41 &#40;58&#44;5&#37;&#41; PR y 0&#44; 7 &#40;10&#37;&#41; y 0 falsos negativos&#44; respectivamente&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusi&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La aplicaci&#243;n de un modelo secuencial basado en el STOP-Bang y pulsioximetr&#237;a nocturna es una herramienta &#250;til para el <span class="elsevierStyleItalic">screening</span> de AOS en obesos m&#243;rbidos candidatos a CB&#44; reduciendo el n&#250;mero de PR&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n"
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            "titulo" => "Resultados"
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            "titulo" => "Conclusi&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Obstructive sleep apnea &#40;OSA&#41; has a high incidence in patients with morbid obesity who are candidates for bariatric surgery &#40;BS&#41;&#46; Adequate screening would decrease the number of respiratory polygraphies &#40;RPs&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To analyze the value of a sequential model consisting of a questionnaire &#40;modified Dixon &#91;DXM&#93; vs STOP-Bang&#41; and nocturnal pulse oximetry in patients who were candidates for BS&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A prospective study was conducted from July 1&#44; 2014 to July 1&#44; 2015 on candidates for BS&#44; excluding those who have already undergone RP&#46; Variables&#58; questionnaires &#40;Epworth&#44; STOP-Bang&#44; and DXM&#41;&#44; anthropometric measurements&#44; RP&#44; and blood and gas tests&#46; The sample was divided into patients with no or mild OSA &#40;no OSA&#41; and those with moderate to severe OSA &#40;AHI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A total of 70 patients were analyzed&#44; 46 &#40;65&#46;7&#37;&#41; of them females&#46; Moderate to severe OSA was diagnosed in 26 &#40;37&#46;1&#37;&#41; patients&#46; STOP-Bang and DXM were compared using ROC curves&#44; and greater area under the curve &#40;AUC&#41; was found for the latter &#40;0&#46;873 &#91;0&#46;74 -0&#46;930&#93; vs 0&#46;781 &#91;0&#46;673-0&#46;888&#93;&#41;&#46; STOP-Bang had greater sensitivity&#44; 100&#37;&#44; as compared to 73&#46;1&#37; for DXM&#46; ODI3&#37; showed greater diagnostic yield &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;982 &#91;0&#46;970-1&#93;&#41;&#46; Use of the sequential model with STOP-Bang<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#44; DXM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5&#44; and DXM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 would have avoided 41 &#40;58&#46;5&#37;&#41;&#44; 50 &#40;71&#46;4&#37;&#41;&#44; and 41 &#40;58&#46;5&#37;&#41; RPs and 0&#44; 7 &#40;10&#37;&#41;&#44; and 0 false negatives&#44; respectively&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Use of a sequential model based on the STOP-Bang and nocturnal pulse oximetry is a useful tool for screening OSA in patients with morbid obesity candidates for BS&#44; decreasing the number of RPs&#46;</p></span>"
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            "identificador" => "abst0045"
            "titulo" => "Results"
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis del modelo secuencial&#46; A&#41; Modelo secuencial con STOP-Bang y pulsioximetr&#237;a&#46; B&#41; Modelo secuencial con Dixon modificado &#40;punto de corte 5&#41; y pulsioximetr&#237;a&#46; C&#41; Modelo secuencial con Dixon modificado &#40;punto de corte 3&#41; y pulsioximetr&#237;a&#46; D&#41; An&#225;lisis de pruebas diagn&#243;sticas de los distintos modelos secuenciales&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Punto de corte&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable cualitativa&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \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">Cuello&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="left" valign="\n
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                  \t\t\t\t">40<span class="elsevierStyleHsp" style=""></span>cm&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">G&#233;nero masculino&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="left" valign="\n
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                  \t\t\t\t">Hombre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ICD&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;956&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="left" valign="\n
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                  \t\t\t\t">Ronquido&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="left" valign="\n
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                  \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">123<span class="elsevierStyleHsp" style=""></span>mmHg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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">Abdomen&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125<span class="elsevierStyleHsp" style=""></span>cm&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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">Edad&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="left" valign="\n
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                  \t\t\t\t">41<span class="elsevierStyleHsp" style=""></span>a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\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">Criterios de exclusi&#243;n&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">Edad 18-60<span class="elsevierStyleHsp" style=""></span>a&#241;osIMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; mantenido durante 3-5 a&#241;os&#44; tras m&#225;s de un a&#241;o de tratamiento m&#233;dico reglado sin &#233;xitoIMC 35-40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; con comorbilidades asociadas a la OM susceptibles de mejorar con la p&#233;rdida de peso &#40;HTA&#44; DM&#44; dislipemia&#44; AOS&#8230;&#41;&#44; tras m&#225;s de un a&#241;o de tratamiento m&#233;dico reglado sin &#233;xitoFirma del consentimiento informado&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trastorno respiratorio del sue&#241;o ya diagnosticado y&#47;o tratamiento con dispositivos de presi&#243;n positivaDiagn&#243;stico de enfermedad inflamatoria sist&#233;micaEnfermedades neopl&#225;sicas en los &#250;ltimos 5<span class="elsevierStyleHsp" style=""></span>a&#241;osEvento cardiovascular en los &#250;ltimos 6<span class="elsevierStyleHsp" style=""></span>mesesEmbarazo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            "rol" => "short"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Los valores se han expresado en forma de media &#40;desviaci&#243;n est&#225;ndar&#41; para las variables cuantitativas y n&#250;mero &#40;porcentaje&#41; para las cualitativas&#46; Se han estudiado las diferencias con los estad&#237;sticos Chi cuadrado para las variables cualitativas y U de Mann-Whitney para la comparaci&#243;n entre medias&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">AOS&#58; apnea obstructiva del sue&#241;o&#59; CT90&#37;&#58; porcentaje de tiempo con SatO<span class="elsevierStyleInf">2</span>&#59; HTA&#58; hipertensi&#243;n arterial&#59; IAH&#58; &#237;ndice de apnea&#47;hipopnea del sue&#241;o&#59; IDO&#58; &#237;ndice de desaturaci&#243;n de ox&#237;geno&#59; IMC&#58; &#237;ndice de masa corporal&#59; n&#46;s&#46;&#58; no significativo&#59; PA&#58; presi&#243;n arterial&#46;</p>"
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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">Total &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>70&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">Punto de corte IAH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15</th><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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</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
                  \t\t\t\t\t\t</th><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
                  \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">AOS &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&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">No AOS &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;&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"><span class="elsevierStyleBold">p</span>&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"><span class="elsevierStyleItalic">G&#233;nero &#40;femenino&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;65&#44;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;46&#44;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;77&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;008</span>&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"><span class="elsevierStyleItalic">Edad</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;3 &#40;8&#44;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;7&#44;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#44;9 &#40;7&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;000</span>&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"><span class="elsevierStyleItalic">Tabaquismo</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;000</span>&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"><span class="elsevierStyleHsp" style=""></span>Fumador activo&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;21&#44;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;26&#44;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;18&#44;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n&#46;s&#46;</span>&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"><span class="elsevierStyleHsp" style=""></span>Exfumador&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;42&#44;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;69&#44;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;27&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;05</span>&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"><span class="elsevierStyleHsp" style=""></span>Nunca fumador&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;35&#44;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#44;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;54&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n&#46;s&#46;</span>&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"><span class="elsevierStyleItalic">HTA</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;52&#44;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;69&#44;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;43&#44;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;035</span>&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"><span class="elsevierStyleItalic">Dislipemia</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;37&#44;1&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;57&#44;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;25&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;006</span>&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"><span class="elsevierStyleItalic">Diabetes mellitus</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;41&#44;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;53&#44;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;34&#44;1&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;105</span>&nbsp;\t\t\t\t\t\t\n
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            "detalle" => "Tabla "
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Entre par&#233;ntesis se muestran los intervalos de confianza&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">AUC&#58; &#225;rea bajo la curva&#59; CT90&#58; porcentaje de tiempo con SatO<span class="elsevierStyleInf">2</span>&#59; IDO&#58; &#237;ndice de desaturaci&#243;n de ox&#237;geno&#59; LR&#40;&#43;&#41;&#58; tasa de verosimilitud positiva&#59; LR&#40;&#8722;&#41;&#58; tasa de verosimilitud negativa&#59; PPT&#40;&#43;&#41;&#58; probabilidad postest positiva&#59; PPT&#40;&#8722;&#41;&#58; probabilidad postest negativa&#59; VPP&#58; valor predictivo positivo&#59; VPN&#58; valor predictivo negativo&#46;</p>"
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                  \t\t\t\t">0 &#40;0-17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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          "es" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis individualizado de las pruebas diagn&#243;sticas</p>"
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                            0 => "M&#46; Fried"
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                            4 => "A&#46;J&#46; Torres"
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Información del artículo
ISSN: 25300164
Idioma original: Español
DOI:10.1016/j.endinu.2020.03.006
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