Diagnosis of obstructive sleep apnea in adults: A clinical practice guideline from the American College of Physicians

Annals of Internal Medicine

Volumn 161, Issue 3, 2014, Pages 210-220

  Qaseem, Amir ^a   Dallas, Paul ^b   Owens, Douglas K ^c   Starkey, Melissa ^a   Holty, Jon Erik C ^c   Shekelle, Paul ^d  

^a AMERICAN COLLEGE OF PHYSICIANS   (United States)

^b VIRGINIA TECH CARILION SCHOOL OF MEDICINE   (United States)

^c STANFORD UNIVERSITY   (United States)

^d VETERANS AFFAIRS MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; CARDIOVASCULAR DISEASE; CARDIOVASCULAR MORTALITY; CEREBROVASCULAR ACCIDENT; COMORBIDITY; COMPARATIVE EFFECTIVENESS; CONTROLLED STUDY; DAYTIME SOMNOLENCE; DIAGNOSTIC TEST ACCURACY STUDY; HUMAN; HYPERTENSION; MORTALITY; NON INSULIN DEPENDENT DIABETES MELLITUS; PHYSICIAN; POLYSOMNOGRAPHY; PRACTICE GUIDELINE; PRIORITY JOURNAL; QUALITY OF LIFE; REVIEW; SENSITIVITY AND SPECIFICITY; SLEEP; SLEEP DISORDERED BREATHING;

ADULT; HUMANS; POLYSOMNOGRAPHY; QUESTIONNAIRES; SLEEP APNEA, OBSTRUCTIVE;

EID: 84905651999     PISSN: 00034819     EISSN: 15393704     Source Type: Journal    
DOI: 10.7326/M12-3187     Document Type: Review

References (186)

1. Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999;60:2279-86. [PMID: 10593319]
2. Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004;170:1014-21. [PMID: 15317672]
3. Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999;340:847-51. [PMID: 10080847]
4. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-5. [PMID: 8464434]
5. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-53. [PMID: 15781100]
6. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:136-43. [PMID: 18250205]
7. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163:19-25. [PMID: 11208620]
8. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353:2034-41. [PMID: 16282178]
9. Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283:1829-36. [PMID: 10770144]
10. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000; 342:1378-84. [PMID: 10805822]
11. Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, et al. Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med. 1997;157:1746-52. [PMID: 9250236]
12. Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med. 2005;165:447-52. [PMID: 15738376]
13. Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005;142:187-97. [PMID: 15684207]
14. Gruber A, Horwood F, Sithole J, Ali NJ, Idris I. Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state. Cardiovasc Diabetol. 2006;5:22. [PMID: 17078884]
15. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165: 1217-39. [PMID: 11991871]
16. Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107:1543-63. [PMID: 18931212]
17. Finkel KJ, Searleman AC, Tymkew H, Tanaka CY, Saager L, Safer-Zadeh E, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10:753-8. [PMID: 19186102]
18. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76:897-905. [PMID: 11560300]
19. Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O'Connor GT, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009;6:e1000132. [PMID: 19688045]
20. Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep. 2008;31:1071-8. [PMID: 18714778]
21. Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing in community-dwelling elderly. Sleep. 1991;14:486-95. [PMID: 1798880]
22. Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163:608-13. [PMID: 11254512]
23. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998;157:144-8. [PMID: 9445292]
24. Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163:685-9. [PMID: 11254524]
25. Young T, Shahar E, Nieto FJ, Redline S, Newman AB, Gottlieb DJ, et al; Sleep Heart Health Study Research Group. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med. 2002;162:893-900. [PMID: 11966340]
26. Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005;99:1592-9. [PMID: 16160020]
27. Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540-5. [PMID: 1798888]
28. Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative effectiveness review no. 32. AHRQ publication no. 11-EHC052-EF. (Prepared by Tufts Evidence-based Practice Center under contract 290-2007-100551.) Rockville, MD: Agency for Healthcare Research and Quality; 2011.
29. American Academy of Sleep Medicine. The International Classification of Sleep Disorders, 2nd Edition: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine; 2005.
30. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5:263-76. [PMID: 19960649]
31. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4). Baltimore: Centers for Medicare & Medicaid Services; 2008. Accessed at www.cms.gov/medicare-coverage-database/ details/ncd-details.aspx?NCDId=226&ncdver=3&NCAId=204&NcaName= Continuous±Positive±Airway±Pressure± %28CPAP%29±Therapy±for±Obstructive±Sleep± Apnea±%28OSA%29&IsPopup=y&bc=AAAAAAAAIAAA& on 2 April 2014.
32. Tufts-New England Medical Center EPC. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/ downloads/id48TA.pdf on 19 March 2013.
33. Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P; for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013:159;471-83. [PMID: 24061345]
34. Qaseem A, Snow V, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010;153:194-9. [PMID: 20679562]
35. Iber C, Redline S, Kaplan Gilpin AM, Quan SF, Zhang L, Gottlieb DJ, et al. Polysomnography performed in the unattended home versus the attended laboratory setting-Sleep Heart Health Study methodology. Sleep. 2004;27:536-40. [PMID: 15164911]
36. Mykytyn IJ, Sajkov D, Neill AM, McEvoy RD. Portable computerized polysomnography in attended and unattended settings. Chest. 1999;115:114-22. [PMID: 9925071]
37. Orr WC, Eiken T, Pegram V, Jones R, Rundell OH. A laboratory validation study of a portable system for remote recording of sleep-related respiratory disorders. Chest. 1994;105:160-2. [PMID: 8275725]
38. Portier F, Portmann A, Czernichow P, Vascaut L, Devin E, Benhamou D, et al. Evaluation of home versus laboratory polysomnography in the diagnosis of sleep apnea syndrome. Am J Respir Crit Care Med. 2000;162:814-8. [PMID: 10988088]
39. Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002;121:753-8. [PMID: 11888956]
40. Ferré A, Sampol G, Jurado MJ, Cambrodi R, Lloberes P, Romero O. Neurophysiological two-channel polysomnographic device in the diagnosis of sleep apnea. J Clin Sleep Med. 2012;8:163-8. [PMID: 22505861]
41. Oliveira MG, Nery LE, Santos-Silva R, Sartori DE, Alonso FF, Togeiro SM, et al. Is portable monitoring accurate in the diagnosis of obstructive sleep apnea syndrome in chronic pulmonary obstructive disease? Sleep Med. 2012;13: 1033-8. [PMID: 22841038]
42. Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al; Spanish Sleep Network. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310:2407-15. [PMID: 24327037]
43. Amir O, Barak-Shinar D, Amos Y, MacDonald M, Pittman S, White DP. An automated sleep-analysis system operated through a standard hospital monitor. J Clin Sleep Med. 2010;6:59-63. [PMID: 20191939]
44. García-Díaz E, Quintana-Gallego E, Ruiz A, Carmona-Bernal C, Sánchez-Armengol A, Botebol-Benhamou G, et al. Respiratory polygraphy with actigraphy in the diagnosis of sleep apnea-hypopnea syndrome. Chest. 2007;131:725-32. [PMID: 17356086]
45. Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of Embletta portable diagnostic system for identifying patients with suspected obstructive sleep apnoea syndrome (OSAS). Respirology. 2010;15:336-42. [PMID: 20199644]
46. Planès C, Leroy M, Bouach Khalil N, El Mahmoud R, Digne F, de Roquefeuil F, et al. Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis. Sleep Breath. 2010;14:25-32. [PMID: 19533191]
47. Santos-Silva R, Sartori DE, Truksinas V, Truksinas E, Alonso FF, Tufik S, et al. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep. 2009;32:629-36. [PMID: 19480230]
48. To KW, Chan WC, Chan TO, Tung A, Ngai J, Ng S, et al. Validation study of a portable monitoring device for identifying OSA in a symptomatic patient population. Respirology. 2009;14:270-5. [PMID: 19210658]
49. Tonelli de Oliveira AC, Martinez D, Vasconcelos LF, Gonçalves SC, Lenz MC, Fuchs SC, et al. Diagnosis of obstructive sleep apnea syndrome and its outcomes with home portable monitoring. Chest. 2009;135:330-6. [PMID: 19201709]
50. Redline S, Tosteson T, Boucher MA, Millman RP. Measurement of sleep-related breathing disturbances in epidemiologic studies. Assessment of the validity and reproducibility of a portable monitoring device. Chest. 1991;100:1281-6. [PMID: 1935282]
51. Reichert JA, Bloch DA, Cundiff E, Votteri BA. Comparison of the Nova-Som QSG, a new sleep apnea home-diagnostic system, and polysomnography. Sleep Med. 2003;4:213-8. [PMID: 14592324]
52. White DP, Gibb TJ, Wall JM, Westbrook PR. Assessment of accuracy and analysis time of a novel device to monitor sleep and breathing in the home. Sleep. 1995;18:115-26. [PMID: 7792491]
53. Calleja JM, Esnaola S, Rubio R, Durán J. Comparison of a cardiorespiratory device versus polysomnography for diagnosis of sleep apnoea. Eur Respir J. 2002;20:1505-10. [PMID: 12503711]
54. Carrasco O, Montserrat JM, Lloberes P, Ascasco C, Ballester E, Fornas C, et al. Visual and different automatic scoring profiles of respiratory variables in the diagnosis of sleep apnoea-hypopnoea syndrome. Eur Respir J. 1996;9:125-30. [PMID: 8834345]
55. Dingli K, Coleman EL, Vennelle M, Finch SP, Wraith PK, Mackay TW, et al. Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome. Eur Respir J. 2003;21:253-9. [PMID: 12608438]
56. Ficker JH, Wiest GH, Wilpert J, Fuchs FS, Hahn EG. Evaluation of a portable recording device (Somnocheck) for use in patients with suspected obstructive sleep apnoea. Respiration. 2001;68:307-12. [PMID: 11416253]
57. Fietze I, Glos M, Röttig J, Witt C. Automated analysis of data is inferior to visual analysis of ambulatory sleep apnea monitoring. Respiration. 2002;69:235-41. [PMID: 12097767]
58. Zucconi M, Ferini-Strambi L, Castronovo V, Oldani A, Smirne S. An unattended device for sleep-related breathing disorders: validation study in suspected obstructive sleep apnoea syndrome. Eur Respir J. 1996;9:1251-6. [PMID: 8804946]
59. Yin M, Miyazaki S, Ishikawa K. Evaluation of type 3 portable monitoring in unattended home setting for suspected sleep apnea: factors that may affect its accuracy. Otolaryngol Head Neck Surg. 2006;134:204-9. [PMID: 16455365]
60. Claman D, Murr A, Trotter K. Clinical validation of the Bedbugg in detection of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2001;125:227-30. [PMID: 11555758]
61. Ancoli-Israel S, Mason W, Coy TV, Stepnowsky C, Clausen JL, Dimsdale J. Evaluation of sleep disordered breathing with unattended recording: the Night-watch System. J Med Eng Technol. 1997;21:10-4. [PMID: 9080356]
62. Ballester E, Solans M, Vila X, Hernandez L, Quintó L, Bolivar I, et al. Evaluation of a portable respiratory recording device for detecting apnoeas and hypopnoeas in subjects from a general population. Eur Respir J. 2000;16:123-7. [PMID: 10933097]
63. Emsellem HA, Corson WA, Rappaport BA, Hackett S, Smith LG, Hausfeld JN. Verification of sleep apnea using a portable sleep apnea screening device. South Med J. 1990;83:748-52. [PMID: 2371595]
64. Lloberes P, Montserrat JM, Ascaso A, Parra O, Granados A, Alonso P, et al. Comparison of partially attended night time respiratory recordings and full polysomnography in patients with suspected sleep apnoea/hypopnoea syndrome. Thorax. 1996;51:1043-7. [PMID: 8977607]
65. Man GC, Kang BV. Validation of a portable sleep apnea monitoring device. Chest. 1995;108:388-93. [PMID: 7634872]
66. Marrone O, Salvaggio A, Insalaco G, Bonsignore MR, Bonsignore G. Evaluation of the POLYMESAM system in the diagnosis of obstructive sleep apnea syndrome. Monaldi Arch Chest Dis. 2001;56:486-90. [PMID: 11980277]
67. Parra O, García-Esclasans N, Montserrat JM, García Eroles L, Ruíz J, López JA, et al. Should patients with sleep apnoea/hypopnoea syndrome be diagnosed and managed on the basis of home sleep studies? Eur Respir J. 1997; 10:1720-4. [PMID: 9272909]
68. Quintana-Gallego E, Villa-Gil M, Carmona-Bernal C, Botebol-Benhamou G, Martínez-Martínez A, Sánchez-Armengol A, et al. Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure. Eur Respir J. 2004;24:443-8. [PMID: 15358704]
69. Su S, Baroody FM, Kohrman M, Suskind D. A comparison of polysomnography and a portable home sleep study in the diagnosis of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004;131:844-50. [PMID: 15577778]
70. Verse T, Pirsig W, Junge-Hülsing B, Kroker B. Validation of the POLYMESAM seven-channel ambulatory recording unit. Chest. 2000;117:1613-8. [PMID: 10858392]
71. Whittle AT, Finch SP, Mortimore IL, MacKay TW, Douglas NJ. Use of home sleep studies for diagnosis of the sleep apnoea/hypopnoea syndrome. Thorax. 1997;52:1068-73. [PMID: 9516901]
72. Danzi-Soares NJ, Genta PR, Nerbass FB, Pedrosa RP, Soares FS, César LA, et al. Obstructive sleep apnea is common among patients referred for coronary artery bypass grafting and can be diagnosed by portable monitoring. Coron Artery Dis. 2012;23:31-8. [PMID: 22107804]
73. Cheliout-Heraut F, Senny F, Djouadi F, Ouayoun M, Bour F. Obstructive sleep apnoea syndrome: comparison between polysomnography and portable sleep monitoring based on jaw recordings. Neurophysiol Clin. 2011;41:191-8. [PMID: 22078731]
74. Driver HS, Pereira EJ, Bjerring K, Toop F, Stewart SC, Munt PW, et al. Validation of the MediByte® type 3 portable monitor compared with polysomnography for screening of obstructive sleep apnea. Can Respir J. 2011;18:137-43. [PMID: 21766076]
75. Gjevre JA, Taylor-Gjevre RM, Skomro R, Reid J, Fenton M, Cotton D. Comparison of polysomnographic and portable home monitoring assessments of obstructive sleep apnea in Saskatchewan women. Can Respir J. 2011;18:271-4. [PMID: 21969928]
76. Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernández-Blasco L, et al. Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome. Thorax. 2011;66:567-73. [PMID: 21602541]
77. Abraham WT, Trupp RJ, Phillilps B, Bourge RC, Bailey B, Harding SM, et al. Validation and clinical utility of a simple in-home testing tool for sleep-disordered breathing and arrhythmias in heart failure: results of the Sleep Events, Arrhythmias, and Respiratory Analysis in Congestive Heart Failure (SEARCH) study. Congest Heart Fail. 2006;12:241-7. [PMID: 17033271]
78. Agatsuma T, Fujimoto K, Komatsu Y, Urushihata K, Honda T, Tsukahara T, et al. A novel device (SD-101) with high accuracy for screening sleep apnoea-hypopnoea syndrome. Respirology. 2009;14:1143-50. [PMID: 19818056]
79. Ayappa I, Norman RG, Seelall V, Rapoport DM. Validation of a self-applied unattended monitor for sleep disordered breathing. J Clin Sleep Med. 2008;4:26-37. [PMID: 18350959]
80. Chen H, Lowe AA, Bai Y, Hamilton P, Fleetham JA, Almeida FR. Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea. Sleep Breath. 2009;13:213-9. [PMID: 19052790]
81. Clark AL, Crabbe S, Aziz A, Reddy P, Greenstone M. Use of a screening tool for detection of sleep-disordered breathing. J Laryngol Otol. 2009;123:746-9. [PMID: 19222876]
82. de Almeida FR, Ayas NT, Otsuka R, Ueda H, Hamilton P, Ryan FC, et al. Nasal pressure recordings to detect obstructive sleep apnea. Sleep Breath. 2006; 10:62-9. [PMID: 16502297]
83. Erman MK, Stewart D, Einhorn D, Gordon N, Casal E. Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device. J Clin Sleep Med. 2007;3:387-92. [PMID: 17694728]
84. Goodrich S, Orr WC. An investigation of the validity of the Lifeshirt in comparison to standard polysomnography in the detection of obstructive sleep apnea. Sleep Med. 2009;10:118-22. [PMID: 18083629]
85. Heneghan C, Chua CP, Garvey JF, de Chazal P, Shouldice R, Boyle P, et al. A portable automated assessment tool for sleep apnea using a combined Holter-oximeter. Sleep. 2008;31:1432-9. [PMID: 18853941]
86. Heneghan C, de Chazal P, Ryan S, Chua CP, Doherty L, Boyle P, et al. Electrocardiogram recording as a screening tool for sleep disordered breathing. J Clin Sleep Med. 2008;4:223-8. [PMID: 18595434]
87. Nakano H, Tanigawa T, Ohnishi Y, Uemori H, Senzaki K, Furukawa T, et al. Validation of a single-channel airflow monitor for screening of sleep-disordered breathing. Eur Respir J. 2008;32:1060-7. [PMID: 18480104]
88. Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of a portable recording device (ApneaLink) for identifying patients with suspected obstructive sleep apnoea syndrome. Intern Med J. 2009;39:757-62. [PMID: 19220528]
89. Nigro CA, Aimaretti S, Gonzalez S, Rhodius E. Validation of the WristOx 3100 oximeter for the diagnosis of sleep apnea/hypopnea syndrome. Sleep Breath. 2009;13:127-36. [PMID: 18830731]
90. Pang KP, Gourin CG, Terris DJ. A comparison of polysomnography and the WatchPAT in the diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007;137:665-8. [PMID: 17903588]
91. Pépin JL, Defaye P, Vincent E, Christophle-Boulard S, Tamisier R, Lévy P. Sleep apnea diagnosis using an ECG Holter device including a nasal pressure (NP) recording: validation of visual and automatic analysis of nasal pressure versus full polysomnography. Sleep Med. 2009;10:651-6. [PMID: 19028140]
92. Ragette R, Wang Y, Weinreich G, Teschler H. Diagnostic performance of single airflow channel recording (ApneaLink) in home diagnosis of sleep apnea. Sleep Breath. 2010;14:109-14. [PMID: 19714380]
93. Reda M, Gibson GJ, Wilson JA. Pharyngoesophageal pressure monitoring in sleep apnea syndrome. Otolaryngol Head Neck Surg. 2001;125:324-31. [PMID: 11593166]
94. Schäfer H, Ewig S, Hasper E, Lüderitz B. Predictive diagnostic value of clinical assessment and nonlaboratory monitoring system recordings in patients with symptoms suggestive of obstructive sleep apnea syndrome. Respiration. 1997;64:194-9. [PMID: 9154670]
95. Smith LA, Chong DW, Vennelle M, Denvir MA, Newby DE, Douglas NJ. Diagnosis of sleep-disordered breathing in patients with chronic heart failure: evaluation of a portable limited sleep study system. J Sleep Res. 2007;16:428-35. [PMID: 18036089]
96. Szyszko A, Franceschini C, Gonzalez-Zuelgaray J. Reliability of a Holter-based methodology for evaluation of sleep apnoea syndrome. Europace. 2009;11:94-9. [PMID: 18971289]
97. Watkins MR, Talmage JB, Thiese MS, Hudson TB, Hegmann KT. Correlation between screening for obstructive sleep apnea using a portable device versus polysomnography testing in a commercial driving population. J Occup Environ Med. 2009;51:1145-50. [PMID: 19786903]
98. White JE, Smithson AJ, Close PR, Drinnan MJ, Prichard AJ, Gibson GJ. The use of sound recording and oxygen saturation in screening snorers for obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1994;19:218-21. [PMID: 7923843]
99. Wong KK, Jankelson D, Reid A, Unger G, Dungan G, Hedner JA, et al. Diagnostic test evaluation of a nasal flow monitor for obstructive sleep apnea detection in sleep apnea research. Behav Res Methods. 2008;40:360-6. [PMID: 18411561]
100. Yagi H, Nakata S, Tsuge H, Yasuma F, Noda A, Morinaga M, et al. Significance of a screening device (Apnomonitor 5) for sleep apnea syndrome. Auris Nasus Larynx. 2009;36:176-80. [PMID: 18635324]
101. Nigro CA, Dibur E, Malnis S, Grandval S, Nogueira F. Validation of ApneaLink Ox for the diagnosis of obstructive sleep apnea. Sleep Breath. 2013; 17:259-66. [PMID: 22447171]
102. Morales CR, Hurley S, Wick LC, Staley B, Pack FM, Gooneratne NS, et al. In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep. 2012;35:1491-501. [PMID: 23115398]
103. O'Brien LM, Bullough AS, Shelgikar AV, Chames MC, Armitage R, Chervin RD. Validation of Watch-PAT-200 against polysomnography during pregnancy. J Clin Sleep Med. 2012;8:287-94. [PMID: 22701386]
104. Onder NS, Akpinar ME, Yigit O, Gor AP. Watch peripheral arterial tonometry in the diagnosis of obstructive sleep apnea: influence of aging. Laryngoscope. 2012;122:1409-14. [PMID: 22522750]
105. BaHammam AS, Sharif M, Gacuan DE, George S. Evaluation of the accuracy of manual and automatic scoring of a single airflow channel in patients with a high probability of obstructive sleep apnea. Med Sci Monit. 2011;17:MT13-9. [PMID: 21278698]
106. Chai-Coetzer CL, Antic NA, Rowland LS, Catcheside PG, Esterman A, Reed RL, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax. 2011;66:213-9. [PMID: 21252389]
107. Chouchou F, Sforza E, Celle S, Pichot V, Maudoux D, Garcin A, et al; PROOF Study Group. Pulse transit time in screening sleep disordered breathing in an elderly population: the PROOF-SYNAPSE study. Sleep. 2011;34:1051-9. [PMID: 21804667]
108. Hedner J, White DP, Malhotra A, Herscovici S, Pittman SD, Zou D, et al. Sleep staging based on autonomic signals: a multi-center validation study. J Clin Sleep Med. 2011;7:301-6. [PMID: 21677901]
109. Nigro CA, Dibur E, Aimaretti S, González S, Rhodius E. Comparison of the automatic analysis versus the manual scoring from ApneaLink device for the diagnosis of obstructive sleep apnoea syndrome. Sleep Breath. 2011;15:679-86. [PMID: 20890768]
110. Yang GG, Yang MC, Chung CY, Chen YT, Chang ET. Respiratory-inductive- plethysmography-derived flow can be a useful clinical tool to detect patients with obstructive sleep apnea syndrome. J Formos Med Assoc. 2011;110:642-5. [PMID: 21982468]
111. Alvarez D, Gutierrez GC, Marcos JV, Del Campo F, Hornero R. Spectral analysis of single-channel airflow and oxygen saturation recordings in obstructive sleep apnea detection. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:847-50. [PMID: 21096316]
112. Nigro CA, Serrano F, Aimaretti S, González S, Codinardo C, Rhodius E. Utility of ApneaLink for the diagnosis of sleep apnea-hypopnea syndrome. Medicina (B Aires). 2010;70:53-9. [PMID: 20228025]
113. Yadollahi A, Giannouli E, Moussavi Z. Sleep apnea monitoring and diagnosis based on pulse oximetry and tracheal sound signals. Med Biol Eng Comput. 2010;48:1087-97. [PMID: 20734154]
114. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-21. [PMID: 18431116]
115. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. Validation of the Berlin Questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108:822-30. [PMID: 18431117]
116. Drager LF, Genta PR, Pedrosa RP, Nerbass FB, Gonzaga CC, Krieger EM, et al. Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension. Am J Cardiol. 2010;105:1135-9. [PMID: 20381666]
117. Kapuniai LE, Andrew DJ, Crowell DH, Pearce JW. Identifying sleep apnea from self-reports. Sleep. 1988;11:430-6. [PMID: 3227223]
118. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131:485-91. [PMID: 10507956]
119. Sharma SK, Vasudev C, Sinha S, Banga A, Pandey RM, Handa KK. Validation of the modified Berlin Questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome. Indian J Med Res. 2006;124:281-90. [PMID: 17085831]
120. Geiger-Brown J, Rogers VE, Han K, Trinkoff A, Bausell RB, Scharf SM. Occupational screening for sleep disorders in 12-h shift nurses using the Berlin Questionnaire. Sleep Breath. 2013;17:381-8. [PMID: 22535196]
121. Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med. 2012;8:389-94. [PMID: 22893769]
122. Gjevre JA, Taylor-Gjevre RM, Nair BV, Lim HJ. Do sleepy rheumatoid arthritis patients have a sleep disorder? Musculoskeletal Care. 2012;10:187-95. [PMID: 22577060]
123. Koyama RG, Esteves AM, Oliveira e Silva L, Lira FS, Bittencourt LR, Tufik S, et al. Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Sleep Med. 2012;13:1028-32. [PMID: 22841037]
124. Laporta R, Anandam A, El-Solh AA. Screening for obstructive sleep apnea in veterans with ischemic heart disease using a computer-based clinical decision-support system. Clin Res Cardiol. 2012;101:737-44. [PMID: 22476823]
125. Martinez D, da Silva RP, Klein C, Fiori CZ, Massierer D, Cassol CM, et al. High risk for sleep apnea in the Berlin Questionnaire and coronary artery disease. Sleep Breath. 2012;16:89-94. [PMID: 21210233]
126. Enciso R, Clark GT. Comparing the Berlin and the ARES questionnaire to identify patients with obstructive sleep apnea in a dental setting. Sleep Breath. 2011;15:83-9. [PMID: 20127186]
127. Hrubos-Strøm H, Randby A, Namtvedt SK, Kristiansen HA, Einvik G, Benth J, et al. A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP). J Sleep Res. 2011;20:162-70. [PMID: 20561172]
128. Sert Kuniyoshi FH, Zellmer MR, Calvin AD, Lopez-Jimenez F, Albuquerque FN, van der Walt C, et al. Diagnostic accuracy of the Berlin Questionnaire in detecting sleep-disordered breathing in patients with a recent myocardial infarction. Chest. 2011;140:1192-7. [PMID: 21596794]
129. Sforza E, Chouchou F, Pichot V, Herrmann F, Barthélémy JC, Roche F. Is the Berlin Questionnaire a useful tool to diagnose obstructive sleep apnea in the elderly? Sleep Med. 2011;12:142-6. [PMID: 21227749]
130. Subramanian S, Hesselbacher SE, Aguilar R, Surani SR. The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea. Sleep Breath. 2011;15:819-26. [PMID: 21076972]
131. Thurtell MJ, Bruce BB, Rye DB, Newman NJ, Biousse V. The Berlin Questionnaire screens for obstructive sleep apnea in idiopathic intracranial hypertension. J Neuroophthalmol. 2011;31:316-9. [PMID: 21537196]
132. Vaz AP, Drummond M, Mota PC, Severo M, Almeida J, Winck JC. Translation of Berlin Questionnaire to Portuguese language and its application in OSA identification in a sleep disordered breathing clinic. Rev Port Pneumol. 2011;17:59-65. [PMID: 21477567]
133. Patt BT, Jarjoura D, Lambert L, Roy S, Gordillo G, Schlanger R, et al. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med. 2010;6:541-4. [PMID: 21206743]
134. Sharkey KM, Orff HJ, Tosi C, Harrington D, Roye GD, Millman RP. Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea. Sleep Breath. 2013;17:267-74. [PMID: 22528950]
135. Vana KD, Silva GE, Goldberg R. Predictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea. Res Nurs Health. 2013;36:84-94. [PMID: 23007730]
136. Albuquerque FN, Calvin AD, Sert Kuniyoshi FH, Konecny T, Lopez-Jimenez F, Pressman GS, et al. Sleep-disordered breathing and excessive daytime sleepiness in patients with atrial fibrillation. Chest. 2012;141:967-73. [PMID: 21903736]
137. Asha'ari ZA, Hasmoni MH, Ab Rahman J, Yusof RA, Ahmad RA. The association between sleep apnea and young adults with hypertension. Laryngoscope. 2012;122:2337-42. [PMID: 22753136]
138. Feng J, He QY, Zhang XL, Chen BY; Sleep Breath Disorder Group, Society of Respiratory Medicine. Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea. Sleep Breath. 2012;16:31-40. [PMID: 21243439]
139. Knutson KL, Zhao X, Mattingly M, Galli G, Cizza G. Predictors of sleep-disordered breathing in obese adults who are chronic short sleepers. Sleep Med. 2012;13:484-9. [PMID: 22326831]
140. Morrell MJ, Finn L, McMillan A, Peppard PE. The impact of ageing and sex on the association between sleepiness and sleep disordered breathing. Eur Respir J. 2012;40:386-93. [PMID: 22241742]
141. Nicholl DD, Ahmed SB, Loewen AH, Hemmelgarn BR, Sola DY, Beecroft JM, et al. Clinical presentation of obstructive sleep apnea in patients with chronic kidney disease. J Clin Sleep Med. 2012;8:381-7. [PMID: 22893768]
142. Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld BA, de Vries N. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012;269:1865-71. [PMID: 22310840]
143. Gasa M, Salord N, Fortuna AM, Mayos M, Vilarrasa N, Dorca J, et al. Obstructive sleep apnoea and metabolic impairment in severe obesity. Eur Respir J. 2011;38:1089-97. [PMID: 21622590]
144. Khoo SM, Poh HK, Chan YH, Ngerng WJ, Shi DX, Lim TK. Diagnostic characteristics of clinical prediction models for obstructive sleep apnea in different clinic populations. Sleep Breath. 2011;15:431-7. [PMID: 20440569]
145. Kopitovic I, Trajanovic N, Prodic S, Drvenica MJ, Ilic M, Kuruc V, et al. The Serbian version of the Epworth Sleepiness Scale. Sleep Breath. 2011;15:775-80. [PMID: 21053085]
146. Martinez D, Breitenbach TC, Lumertz MS, Alcântara DL, da Rocha NS, Cassol CM, et al. Repeating administration of Epworth Sleepiness Scale is clinically useful. Sleep Breath. 2011;15:763-73. [PMID: 21063794]
147. Sareli AE, Cantor CR, Williams NN, Korus G, Raper SE, Pien G, et al. Obstructive sleep apnea in patients undergoing bariatric surgery - a tertiary center experience. Obes Surg. 2011;21:316-27. [PMID: 19669842]
148. Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SF. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales. J Clin Sleep Med. 2011;7:467-72. [PMID: 22003341]
149. Tanaka S, Shima M. Assessment of screening tests for sleep apnea syndrome in the workplace. J Occup Health. 2010;52:99-105. [PMID: 20110621]
150. Sharwood LN, Elkington J, Stevenson M, Grunstein RR, Meuleners L, Ivers RQ, et al. Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an "at home" monitoring device. Sleep. 2012;35:469-75. [PMID: 22467984]
151. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, et al. Validation of the Brazilian Portuguese version of the Pittsburgh Sleep Quality Index. Sleep Med. 2011;12:70-5. [PMID: 21145786]
152. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108:768-75. [PMID: 22401881]
153. Farney RJ, Walker BS, Farney RM, Snow GL, Walker JM. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011;7:459-65B. [PMID: 22003340]
154. Ong TH, Raudha S, Fook-Chong S, Lew N, Hsu AA. Simplifying STOPBANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010;14:371-6. [PMID: 20419474]
155. Senchak MA, Frey WC, O'Connor PD. Use of portable sleep monitors to diagnose sleep apnea during predeployment assessment. Mil Med. 2012;177: 1196-201. [PMID: 23113447]
156. Rodrigues MM, Dibbern RS, Goulart CW, Palma RA. Correlation between the Friedman classification and the Apnea-Hypopnea Index in a population with OSAHS. Braz J Otorhinolaryngol. 2010;76:557-60. [PMID: 20963336]
157. Crocker BD, Olson LG, Saunders NA, Hensley MJ, McKeon JL, Allen KM, et al. Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis. 1990;142:14-8. [PMID: 2368960]
158. Gurubhagavatula I, Maislin G, Pack AI. An algorithm to stratify sleep apnea risk in a sleep disorders clinic population. Am J Respir Crit Care Med. 2001;164:1904-9. [PMID: 11734444]
159. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Intern Med. 1997;127:581-7. [PMID: 9341055]
160. Onen SH, Dubray C, Decullier E, Moreau T, Chapuis F, Onen F. Observation-based nocturnal sleep inventory: screening tool for sleep apnea in elderly people. J Am Geriatr Soc. 2008;56:1920-5. [PMID: 18775037]
161. Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004;27:694-9. [PMID: 15283004]
162. Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep. 2000;23:929-38. [PMID: 11083602]
163. Zerah-Lancner F, Lofaso F, d'Ortho MP, Delclaux C, Goldenberg F, Coste A, et al. Predictive value of pulmonary function parameters for sleep apnea syndrome. Am J Respir Crit Care Med. 2000;162:2208-12. [PMID: 11112139]
164. Jauhar S, Orchardson R, Banham SW, Livingston E, Sherriff A, Lyons MF. The Kushida Index as a screening tool for obstructive sleep apnoea-hypopnoea syndrome. Br Dent J. 2012;212:E2. [PMID: 22240714]
165. Su CT, Chen KH, Chen LF, Wang PC, Hsiao YH. Prediagnosis of obstructive sleep apnea via multiclass MTS. Comput Math Methods Med. 2012;2012:212498. [PMID: 22545062]
166. Kolotkin RL, LaMonte MJ, Walker JM, Cloward TV, Davidson LE, Crosby RD. Predicting sleep apnea in bariatric surgery patients. Surg Obes Relat Dis. 2011;7:605-10. [PMID: 21684219]
167. Sun LM, Chiu HW, Chuang CY, Liu L. A prediction model based on an artificial intelligence system for moderate to severe obstructive sleep apnea. Sleep Breath. 2011;15:317-23. [PMID: 20602177]
168. Gurubhagavatula I, Maislin G, Nkwuo JE, Pack AI. Occupational screening for obstructive sleep apnea in commercial drivers. Am J Respir Crit Care Med. 2004;170:371-6. [PMID: 15142866]
169. Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005;172:1447-51. [PMID: 16141444]
170. Botros N, Concato J, Mohsenin V, Selim B, Doctor K, Yaggi HK. Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med. 2009;122:1122-7. [PMID: 19958890]
171. Lavie P, Herer P, Peled R, Berger I, Yoffe N, Zomer J, et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep. 1995;18:149-57. [PMID: 7610310]
172. Lavie P, Lavie L, Herer P. All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age. Eur Respir J. 2005;25:514-20. [PMID: 15738297]
173. O'Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, et al. Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2009;179:1159-64. [PMID: 19264976]
174. Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med. 2005;172:1590-5. [PMID: 16192452]
175. Silva GE, An MW, Goodwin JL, Shahar E, Redline S, Resnick H, et al. Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS). Sleep. 2009;32:1049-57. [PMID: 19725256]
176. Ensrud KE, Blackwell TL, Ancoli-Israel S, Redline S, Cawthon PM, Paudel ML, et al. Sleep disturbances and risk of frailty and mortality in older men. Sleep Med. 2012;13:1217-25. [PMID: 22705247]
177. Chami HA, Resnick HE, Quan SF, Gottlieb DJ. Association of incident cardiovascular disease with progression of sleep-disordered breathing. Circulation. 2011;123:1280-6. [PMID: 21403097]
178. Fung MM, Peters K, Redline S, Ziegler MG, Ancoli-Israel S, Barrett-Connor E, et al; Osteoporotic Fractures in Men Research Group. Decreased slow wave sleep increases risk of developing hypertension in elderly men. Hypertension. 2011;58:596-603. [PMID: 21876072]
179. Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3:737-47. [PMID: 18198809]
180. Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR. Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J. 2006;27:1229-35. [PMID: 16455835]
181. Mitler MM, Gujavarty KS, Browman CP. Maintenance of wakefulness test: a polysomnographic technique for evaluation treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol. 1982;53:658-61. [PMID: 6177511]
182. RTI International. Effectiveness of portable monitoring devices for diagnosing obstructive sleep apnea: update of a systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id24TA.pdf on 1 June 2012.
183. Hallowell PT, Stellato TA, Petrozzi MC, Schuster M, Graf K, Robinson A, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery. 2007;142:608-12. [PMID: 17950355]
184. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;110:629-36. [PMID: 23257990]
185. Kim GH, Lee JJ, Choi SJ, Shin BS, Lee AR, Lee SH, et al. Clinical predictors of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia. Anaesthesia. 2012;67:755-9. [PMID: 22506571]
186. Practice parameters for the indications for polysomnography and related procedures. Polysomnography Task Force, American Sleep Disorders Association Standards of Practice Committee. Sleep. 1997;20:406-22. [PMID: 9302725]