Respiratory Polygraphy Research Articles (Page 1)

To assess the effectiveness of an intervention programme combining Oropharyngeal Myofunctional Therapy (OMT) and cervical spine exercises in the general population with mild to moderate Obstructive Sleep Apnoea (OSA), analysing its impact on respiratory variables (AHI, MSatO2, ODI, TC90, Supine AHI), daytime sleepiness and quality of life. A single-blind randomised clinical trial with 32 participants diagnosed with mild to moderate OSA, assigned into two groups: control (n = 16) and intervention (n = 16). Both groups received hygiene- and diet-related recommendations, and the intervention group completed an OMT programme and cervical spine exercises over 20 weeks (May 2023-November 2024). The respiratory variables were evaluated using respiratory polygraphy, and daytime sleepiness and quality of life were measured using the Epworth Sleepiness Scale and EuroQol-5D scales, respectively. No statistically significant differences were found between groups (Median [IQR]): Apnoea-hypopnoea index (2.0 [-6/6], CI 95%, p = 0.86), Mean oxygen saturation (-0.5 [-1/0], CI 95%, p = 0.43), Oxygen Desaturation index (1.0 [-1/5], CI 95%, p = 0.72), Time with oxygen saturation below 90% (1.0 [0/3], CI 95%, p = 0.10), Epworth Sleepiness Scale score (-1.5 [-4/0], CI 95%, p = 0.83), and EuroQol-5D quality of life questionnaire (5.0 [0-10], CI 95% p = 0.08). The comprehensive 20-week OMT programme and cervical spine exercises showed no effectiveness in improving respiratory parameters, daytime sleepiness or quality of life in patients with mild to moderate OSA compared to hygiene- and diet-related measures alone. The null results observed in this study suggest relevant clinical implications, such as the limited efficacy of low-frequency OMT protocols.

Background/Objectives: Heart rate variability (HRV) reflects autonomic nervous system modulation and may be altered in both unexplained syncope and obstructive sleep apnea (OSA). However, the nocturnal autonomic patterns underlying these conditions and their coexistence remain poorly understood. This study aimed to characterize nocturnal autonomic modulation in patients with unexplained syncope, OSA, or both, compared with individuals without these conditions. Methods: In this multicenter, cross-sectional, comparative study, 304 adults were assigned to four groups: controls (no syncope or OSA), OSA without syncope, syncope without OSA, and syncope with OSA. Time- and frequency-domain HRV parameters were derived from overnight respiratory polygraphy and compared across groups. Results: OSA was associated with increased root mean square of successive differences (RMSSD) and reduced low-frequency (LF) power, indicating enhanced vagal activity and lower nocturnal sympathetic tone. Syncope was characterized by further reductions in sympathetic indices (LF and very low frequency, VLF) with increased RMSSD, suggesting blunted sympathetic reserve. Patients with both conditions exhibited a mixed autonomic profile—elevated overall HRV with concurrent reductions in both sympathetic and parasympathetic components—indicating more profound dysautonomia despite milder OSA severity. Conclusions: OSA and syncope show distinct nocturnal autonomic patterns, and their coexistence leads to deeper autonomic imbalance. Incorporating nocturnal HRV analysis into routine polygraphy may improve pathophysiological stratification of unexplained syncope and identify clinically significant OSA.

AimsAnalysis of patient–ventilator interactions in patients on chronic home mechanical ventilation can be time consuming, and the consequences of individual interaction on pulmonary gas exchange are not well understood. The objective was to analyse the relationship between interactions and nocturnal oximetry and arterial blood gases.MethodsA cross-sectional study was carried out in restrictive and neuromuscular patients who underwent respiratory polygraphy with a system that allowed interactions to be correlated with mean saturation in 5-min periods. Unintentional leaks, periodic decreases in flow and primary patient–ventilator asynchronies were analysed. Each interaction was correlated with mean oxygen saturation measured by pulse oximetry (SpO2) and baseline arterial blood gases obtained at the recruitment visit, and the 5-min SpO2 analysis was individualised for each patient based on their mean±sdSpO2 during polygraphy.Results40 patients were included. There was a correlation between interactions and mean SpO2 in periods with mean accidental leak >20 L·min−1 (ANOVA test). After exclusion of periods with leakage above this threshold, a relationship was documented between periodic decreases in flow and asynchronies with mean SpO2 in 5-min periods. However, there was no relationship between patient–ventilator interactions and baseline arterial blood gases at recruitment.ConclusionThe presence of interactions was associated with a decrease in mean SpO2 when 5-min recordings are analysed. Therefore, it seems advisable to systematically detect and correct patient–ventilator interactions in home mechanical ventilated patients.

IntroductionSome studies have indicated a possible association between obstructive sleep apnea (OSA) and restless legs syndrome (RLS). Our aim was to explore this association in a large sample of patients referred to a hospital for suspected OSA.MethodsThe sample included 8,852 patients referred to Haukeland University Hospital with suspicion of OSA between 2011 and 2022. OSA was diagnosed and categorized using standard respiratory polygraphy. Prior to the sleep study the patients completed an extensive questionnaire, including questions to determine if they had RLS. Pearson chi-square tests were used to examine RLS in relation to the presence and severity of OSA. Two separate logistic regression analyses were conducted. The first with moderate-severe OSA as the dependent variable and RLS as predictor, the second with RLS as the dependent variable and OSA severity as predictor. Both were adjusted for sex, age, marital status, alcohol consumption, daily smoking, caffeine after 17:00, and body mass index ≥30.ResultsIn total, 24.0% fulfilled the criteria for RLS, whereas moderate-severe OSA (apnea-hypopnea-index ≥15) occurred in 38.1% of the patients. The proportion of patients with RLS did not differ depending on OSA severity. Furthermore, there was no association between RLS and OSA in either chi-square or logistic regression analyses.ConclusionThe present study did not show increased prevalence of RLS in patients with OSA compared to patients without OSA. Furthermore, we found no increase in prevalence of RLS with increasing OSA severity. This suggests that these two sleep disorders are independent of each other.

Sleep disorders, including snoring and obstructive sleep apnea (OSA), are significant health concerns. OSA affects an estimated 4million (8.5%) individuals in Vietnam, with 2.3million suffering from moderate-to-severe conditions. Despite the high prevalence, underdiagnosis and limited accessibility to sleep diagnostics remain challenges. This study aims to assess the feasibility and effectiveness of a guided, self-administered home sleep study using a level3 diagnostic model. A cross-sectional multicenter survey conducted from September 2023 to March 2024 included healthcare professionals (HCPs) across Vietnam. Participants completed questionnaires (Epworth Sleepiness Scale, STOP-BANG), and high-risk individuals underwent respiratory polygraphy using ApneaLink Air devices. Standardized instructions and technical support were provided remotely by trained technicians. Out of 1721 participants, 21.9% were diagnosed with OSA, comprising mild (32.4%), moderate (19.6%), and severe cases (9.2%). Prevalent symptoms included insomnia (22.2%), daytime sleepiness (40.7%), and memory decline (49.4%). Technical issues were minimal, supporting the feasibility of this approach. A level3home sleep study model is effective for large-scale OSA screening. Integrating such approaches into public health initiatives can enhance early diagnosis and treatment access, reducing OSA-related health and economic burdens. Graphical abstract available for this article.

Among the etiologies of focal epilepsy, mutations of the GATOR1 complex genes-comprising NPRL3, NPRL2, and DEPDC5-are known to result in overactivation of mTORC1. A recent study highlighted an association between ictal and postictal central apnea (ICA) and pathogenic variants of DEPDC5. Here, we analyzed data from 134 patients across two independent cohorts diagnosed with focal epilepsy who underwent video-electroencephalographic long-term monitoring (VLTM) with cardiorespiratory polygraphy. Genetic testing results done for clinical-diagnostic purposes were reviewed in patients with epilepsy of unknown etiology and patients with magnetic resonance imaging (MRI)-defined/suspected focal cortical dysplasia (FCD). In 46 patients, we recorded at least one seizure associated with ICA. Genetic testing was performed in 21 of 22 MRI-negative patients with ICA, revealing variants in mTOR pathway genes in 10 cases (48%), including DEPDC5 (n = 6), NPRL3 (n = 3), and MTOR (n = 1). Regarding MRI-positive patients with ICA (n = 24), an acquired lesional etiology was found in 11. Of 13 patients with MRI-defined FCD, genetic testing was carried out in seven, all of whom had negative results. Moreover, no pathogenic variants were detected in the 14-MRI negative patients without ICA. Our findings confirm that variants in mTOR pathway genes (not only in DEPDC5) are present in patients with ICA and underline the potential risk of sudden unexpected death in epilepsy. These results also highlight the importance of performing respiratory polygraphy during VLTM to document ictal apnea.

Respiratory polygraphy combined with pulse wave amplitude drops for the diagnosis of obstructive sleep apnea in pediatric patients.

Sleepiness, fatigue, and obstructive sleep apnea in stroke patients.

The challenge of assessing upper airway obstruction severity in infants with Robin Sequence.

Background/Objectives: Obstructive sleep apnea is a prevalent, yet often underdiagnosed, condition characterized by recurrent upper airway obstruction during sleep, leading to significant perioperative risks in surgical patients. This systematic review aims to evaluate the incidence and impact of objectively diagnosed obstructive sleep apnea on postoperative outcomes across various surgical specialties-including bariatric, orthopedic, cardiac, and otorhinolaryngologic surgeries-and to assess the effectiveness of preoperative screening and perioperative management strategies. Methods: A comprehensive literature search of PubMed was conducted for studies published between January 2013 and December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies involved adult surgical patients with OSA confirmed by polysomnography or respiratory polygraphy. Studies were assessed for methodological quality using the Oxford Centre for Evidence-Based Medicine Levels of Evidence framework. Results: The findings consistently indicated that obstructive sleep apnea significantly increases the risk of postoperative complications, such as respiratory depression, atrial fibrillation, acute kidney injury, delirium, and prolonged hospital stay. Continuous positive airway pressure therapy demonstrated a protective effect in bariatric and cardiac surgeries, though its effectiveness in orthopedic and otorhinolaryngologic contexts was inconsistent, largely due to adherence variability and limited implementation. Preoperative screening tools such as the STOP-BANG questionnaire were widely used, but their utility depended on integration with confirmatory diagnostics. Conclusions: Obstructive sleep apnea represents a significant, modifiable risk factor in surgical populations. Preoperative identification and risk-adapted perioperative management, including CPAP therapy and multimodal analgesia, may substantially reduce postoperative morbidity. However, further randomized trials and cost-effectiveness studies are needed to optimize care pathways and ensure consistent implementation across surgical disciplines.

Sleep disorders are common yet often underdiagnosed in children with attention deficit/hyperactivity disorder (ADHD). These disturbances can exacerbate ADHD symptoms and negatively affect cognitive, emotional, and behavioral functioning. This study aimed to describe the prevalence of obstructive sleep apnea (OSA) and other sleep disorders in children with ADHD using standardized diagnostic criteria and to identify associated clinical and behavioral factors. A cross-sectional study was conducted on 629 children aged 6-12years (mean age: 7.8 ± 1.5years) who were diagnosed with ADHD. Sleep disturbances were assessed using the Children's Sleep Habits Questionnaire (CSHQ), the Pediatric Sleep Questionnaire (PSQ), and respiratory polygraphy. Sleep disorders were classified on the basis of the International Classification of Sleep Disorders, Third Edition (ICSD-3). Multivariate logistic regression was used to identify associated risk factors. Sleep disorders were diagnosed in 70.0% of children with ADHD. The most common disorders were insomnia (40.2%), OSA (23.4%), parasomnias (27.8%), restless legs syndrome (10.5%), and delayed sleep-wake phase disorder (4.8%). The inattentive ADHD subtype, psychiatric comorbidities, tonsil and adenoid hypertrophy, iron-deficiency anemia, and sleep-related behaviors in children with ADHD were significantly associated with sleep disturbances. Sleep disorders are highly prevalent and diverse in children with ADHD. Early identification and targeted management of sleep disturbances, particularly OSA and insomnia, are essential to improving sleep quality and optimizing ADHD outcomes. Routine sleep screening should be integrated into clinical ADHD evaluations. Graphical abstract available for this article.

Background: Obstructive Sleep Apnea (OSA) is often undiagnosed in heart failure (HF) patients. Early identification using affordable sleep studies could improve patient outcomes in resource-limited clinical settings like Peru. The objective was to determine the frequency of OSA in hospitalized HF patients using respiratory polygraphy (RP) (Sleep Study Type III). Materials and methods: A cross-sectional study was conducted. We included patients >18 years, hospitalized with exacerbated HF, and a STOP-BANG score ≥ 3. Enrolled patients underwent overnight RP using ApneaLink Air™. Data collected included clinical parameters, the Epworth Sleepiness Scale, and echocardiography results. Statistical analysis was carried out using R Studio. Results: Of 46 enrolled patients, 39 underwent successful RP; 84.61% were diagnosed with OSA. Patients exhibited a mean Apnea-Hypopnea Index (AHI) of 14.41 ± 10.08/h with mild (51.28%), moderate (25.64%), and severe (7.69%) cases. Symptoms associated with OSA included a lack of restorative sleep and concentration problems. RP data showed a mean minimum SpO2% of 76.85 ± 9.99% and an Oxygen Desaturation Index (ODI) of 20.01 ± 10.66. Correlation analysis indicated a strong positive correlation between AHI and ODI (r = 0.73, p < 0.001) and a moderate negative correlation between AHI and LVEF (r = - 0.64, p = 0.056). Conclusion: This study reveals a high frequency of previously undiagnosed OSA among hospitalized heart failure patients in our institution, indicating the importance of active screening in this high-risk population.

Severity of obstructive sleep apnea is related to C-reactive protein levels: The influence of comorbidities and self-reported sleep duration.

Effects of Nighttime Eating Behavior on Cardiometabolic Health and Sleep: A Crossover Study.

Sleep apnea is frequently associated with foramen magnum stenosis in patients with achondroplasia and considered a cause of sudden death. The aim of this study was to evaluate the results of respiratory polygraphy (RPG) before and after surgery in patients who underwent foramen magnum decompression (FMD) to elucidate the effectiveness for treatment of sleep apnea. The findings of RPG, MRI, and otolaryngological fibroscopy were retrospectively reviewed in 22 children with achondroplasia who underwent FMD at a single institution from 2016 to 2022. The Mann-Whitney U-test was used to assess the association of sleep apnea to age at FMD; preoperative upper airway stenosis (UAS); preoperative Achondroplasia Foramen Magnum Score (AFMS); concomitance of endoscopic third ventriculostomy, ventriculoperitoneal shunt placement, or adenotonsillectomy after FMD; and type of predominant apnea as determined at the preoperative RPG evaluation. The Wilcoxon signed-rank test was used for comparisons of RPG results. Of 22 patients (median age 8 months) included in the study, the RPG-determined respiratory event index (REI) was within the reference range (REI < 5) for 8 patients and indicated mild sleep apnea (REI 5-15) in 10 patients, moderate sleep apnea (REI 15-30) in 3 patients, and severe sleep apnea (REI ≥ 30) in 1 patient. Postoperatively, 21 patients (95.4%) showed REI improvement. Of the 14 patients with preoperative sleep apnea (REI of ≥ 5), 12 patients (85.7%) had at least 1 level of improvement in sleep apnea. In comparisons between pre-FMD and post-FMD indexes, the REI (p = 0.0009, p < 0.01) and Central Apnea Index (p = 0.03, p < 0.05) showed significant improvement, while the Obstructive Apnea Index (OAI) did not show significant differences. However, the type of predominant apnea according to preoperative RPG had no significant effect on the extent of improvement in the postoperative REI. In 7 patients for whom the predominant type of apnea was obstructive, the OAI improved during the follow-up period. FMD was effective for improving sleep apnea in patients with achondroplasia associated with foramen magnum stenosis. Regardless of the type of sleep apnea, the decompressive surgery could be indicated when the patient has no significant UAS.

Background/Objectives: Aortic stenosis (AS) is the most prevalent valvular disease among older adults. Although obstructive sleep apnea (OSA) has been linked to adverse cardiovascular outcomes, its specific impact on patients with severe AS remains unclear. This study aimed to determine the prevalence of OSA and its influence on postoperative recovery following aortic valve replacement. Methods: A prospective case-control study was conducted at the Instituto Nacional de Cardiología Ignacio Chávez. Patients aged 40-80 years with echocardiographically confirmed severe AS were categorized into groups with and without OSA, based on respiratory polygraphy (Apnea-Hypopnea Index [AHI] threshold of >15 events per hour). Clinical, biochemical, echocardiographic, body composition, and hemodynamic parameters were assessed. Daytime sleepiness and sleep quality were evaluated using validated questionnaires. Inflammatory biomarkers were also analyzed. This study was approved by the institutional ethics committee. Results: Of the 30 patients included, 66.6% were diagnosed with OSA. Compared to non-OSA patients, those with OSA had a higher left ventricular mass index (160 vs. 108; p = 0.001), greater postoperative increases in central venous pressure [8 (8-10) vs. 8 (6-8); p = 0.037], and lower mixed venous oxygen saturation within the first 24 h (69.2 vs. 76; p = 0.027). OSA patients also had longer hospital stays (11 vs. 8 days; p = 0.014). Trends toward a heightened subclinical inflammatory state were noted in the OSA group. Conclusions: OSA is frequent and underdiagnosed in patients with severe AS and is associated with more complicated postoperative recovery. Systematic OSA screening is recommended for candidates undergoing aortic valve surgery.

Abstract Introduction Obstructive Sleep Apnea (OSA) is often undiagnosed in heart failure (HF) patients. Early identification using affordable sleep studies could improve patient outcomes in resource-limited clinical settings like Peru. Therefore, the main objective of this study was to determine the frequency of OSA in hospitalized HF patients using respiratory polygraphy (RP) (Sleep Study Type III). Methods A cross-sectional study was conducted. We included patients &amp;gt;18 years, with exacerbated HF, and STOP-BANG ≥ 3. Enrolled patients underwent overnight RP using ApneaLink Air™. Data collected included clinical parameters, Epworth Sleepiness Scale, and echocardiography results. Statistical analysis was carried out using R Studio. Results From 46 enrolled patients, 39 underwent successful RP; 84.61% were diagnosed with OSA. Patients exhibited a mean Apnea-Hypopnea Index (AHI) of 14.41 ± 10.08/h with mild (51.28%), moderate (25.64%), and severe (7.69%) cases. Symptoms associated with OSA included lack of restorative sleep and concentration problems. RP data showed a mean minimum SpO2% of 76.85 ± 9.99% and an Oxygen Desaturation Index (ODI) of 20.01 ± 10.66. Correlation analysis indicated a strong positive correlation association between AHI and ODI (r = 0.73, p &amp;lt; 0.001) and a moderate negative correlation between AHI and LVEF (r=- 0.64, p= 0.056) Conclusion This study highlights a high frequency of OSA among HF inpatients in our institution, emphasizing its relationship with symptoms and cardiovascular parameters Support (if any)

Abstract Introduction The efficacy of positional therapy with a neck vibrotactile device for positional obstructive sleep apnoea (POSA) has been demonstrated, but its inefficacy in changing body position has not been equally explored. The primary aim of this study was to evaluate the failure rate of the neck vibrotactile positional therapy in POSA. Secondary aims were: to investigate the reliability of a single night sleep study for labelling a supine sleeper, any differences on supine time between the laboratory and the home environment, the impact of the device on snoring and the compliance. Methods A retrospective observational study reviewed patients with a diagnosis of POSA according to Cartwright and who had received monitoring and/or treatment with a Night ShiftTM (NS) Sleep Positioner neck device for 4 nights in Monitor or Therapy mode or both. The diagnosis of POSA was made on respiratory polygraphy or polysomnography and a minimum supine sleep time of 15% was required. A supine sleeper was defined if supine sleep time at home was &amp;gt; 5% at least in 2 nights of neck vibrotactile device in Monitor mode. Failure was defined as continuous vibration time 5 minutes and a supine time &amp;gt; 5% in at least 2 nights. Results Ninety two adult patients were enrolled. The failure rate, restricted to 74 patients who had received the neck vibrotactile device in Therapy mode for 2 nights, was 14.8%, with a compliance rate of 96%. Non-supine sleepers at home were 13/74 (17.5%). A significant reduction of supine sleep time at home was observed in comparison with the diagnostic sleep study (23.9% vs 51%, p &amp;lt; 0.001). Snoring rate was significantly reduced while using the vibrotactile device in Therapy mode versus Monitor mode. Conclusion Considering the failure rate of the device in changing body position, and the rate of patients that at home spontaneously do not sleep in supine position, around 32% of positional therapy prescribed might be inappropriate. An adequate trial with the neck vibrotactile device, in diagnostic and therapeutic modality, might disclose these cases. Main reasons for inefficacy are: sedatives, chronic sleep deprivation, motor limitations and cognitive impairment. Support (if any)

Background: Obstructive sleep apnea (OSA) is increasingly recognized as a chronic condition associated with systemic low-grade inflammation. Elevated levels of inflammatory markers such as C-reactive protein (CRP), fibrinogen, TNF-α, and IL-6 have been observed in OSA patients, independent of obesity. Tobacco use, a known pro-inflammatory factor, may further exacerbate this burden. This study aimed to evaluate whether smoking influences inflammatory markers and OSA severity in newly diagnosed patients. Methods: We conducted a retrospective, observational study on individuals newly diagnosed with OSA between 1 January 2024 and 31 December 2024 at the Clinical Hospital of Pulmonary Diseases Iași. All participants underwent overnight respiratory polygraphy using the SleepDoc Porti 9 system (Löwenstein Medical), with OSA severity classified according to the American Academy of Sleep Medicine (AASM) criteria. Inflammatory status was assessed using CRP and the erythrocyte sedimentation rate (ESR). Smokers were defined as individuals who had smoked within the past year; non-smokers had a lifetime history of fewer than 50 cigarettes. Statistical analysis was performed using IBM SPSS Statistics. Results: Smokers (n = 55) shoation Index (ODI) values, compared to non-smokers (n = 49): AHI 45.29 ± 20.94 vs. 38.40 ± 19.84 events/hour, ODI 45.69 ± 21.05 vs. 38.44 ± 19.40 events/hour (p < 0.05 for both). Mean CRP levels were approximately 3.5 times higher in smokers (10.32 ± 11.69 mg/dL) than in non-smokers (2.97 ± 2.45 mg/dL), indicating a significantly elevated inflammatory burden. Conclusions: The inflammatory burden and clinical severity of OSA may be influenced by smoking. Routine inflammatory marker screening, particularly CRP, may improve risk stratification and treatment planning in OSA patients, especially those who smoke or are obese. Routine assessment of CRP and other inflammatory markers may improve risk stratification and guide personalized treatment strategies, particularly in smokers and obese patients with OSA.

Abstract Background Heart failure (HF) patients suffer from increased respiratory effort at daytime demonstrated by increased negative esophageal pressure (PES)1. PES is the gold standard to estimate respiratory effort2. Its amplitudes are often used as a surrogate for intrathoracic pressure. Negative intrathoracic pressure increases left ventricle transmural pressure, left ventricle afterload and right ventricle preload3. Treatment with positive airway pressure increases reduces left ventricle preload and afterload4, but do not reduce mortality according to previous randomized controlled trials in patients with heart failure and sleep disordered breathing5. Purposes Investigate esophageal pressure amplitudes in patients with heart failure during sleep, and long-term outcomes of increased sleep time with elevated peak to peak esophageal pressure. Methods 16476 patients examined by overnight respiratory polygraphy (PG) with simultaneously peak to peak esophageal pressure measurement at baseline between 2003-2016. Sleep time with increased peak to peak pressure was measured in minutes at different levels of cmH2O. Demographic data and comorbidities were collected from medical records at baseline and matched with data from polygraphies. Follow up period was from baseline to 2024. Mortality data were extracted from the Norwegian death registry. Adjusted Cox proportional hazard models were used to predict mortality. Results Mean age 48 years old. 26% females. Median sleep time with peak-to-peak PES&amp;gt;20cmH2O, at baseline, was longer in patients with HF (97.7 min compared to 59.2 min in non-HF), and it was associated with mortality at the 25th percentile (21minutes) independent of HF, sleep apnea (AHI) and nocturnal mean oxygen saturation (HR 1.298 [1.093-1.541], p0.003). Time with peak-to-peak pressure above 60 cmH2O and 80 cmH2O predicted mortality at 50th percentile (0.8 minutes) (HR 1.409 [1.206-1.647], p&amp;lt;0.001) and (0.2 minutes) (HR 1.384 [1.198-1.598], p&amp;lt;0.001) respectively. Conclusions Respiratory effort is increased in HF-patients also during sleep. Time with increased pressure amplitude in the esophagus was associated with mortality. Selecting patients for positive airway pressure treatment based on esophageal pressure should be considered to improve treatment outcome.Table 1Kaplan-Meier