Kapur VK. Headaches, high blood pressure, heart arrhythmia, heart attack and stroke have been associated with sleep apnea. Physiol Rev. 2005;27(3):307-321.28. Routine blood tests, blood pressure readings, and examinations of the heart might be done to see if there are physical complications from sleep apnea or to rule out other possible conditions. Decision memo for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) (CAG-00093N). Sleep. $33? Obstructive sleep apnea is more common and is the result of relaxed airways. Copyright © 2000 - 2020 Jobson Medical Information LLC unless otherwise noted. Take both of these short exams to determine if you’re at risk of having sleep apnea or not. 2009;13(3):187-191.16. This test will measure your sleep patterns throughout the night. Our medical team will perform a health assessment to determine if you potentially have sleep apnea and qualify for a simple, home sleep test to diagnose the severity of your condition. 2006;29(2):244-262.31. Chi L, Comyn FL, Mitra N, et al. Shoukry G, Wong K, Bartlett D, Saini B. The snoring caused by sleep apnea can keep your partner awake at night, and the difficulty breathing can cause you to wake up constantly during the night. A new classification system that details the type of signals measured by out-of-center testing devices for obstructive sleep apnea appears in the October issue of the Journal of Clinical Sleep Medicine. A doctor’s prescription is required for this test. Diagonsis & Induction to CPAP therapy . GMS Curr Top Otorhinolaryngol Head Neck Surg. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. You can hire the appropriate equipment to perform the test at home; the machine will monitor … Patients diagnosed with sleep apnea via the MinuteClinic process or elsewhere have the option to fill the CPAP prescription at CVS Pharmacy … Sleep. Sleep apnea is characterized by temporary breathing cessations during sleep. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Proc Am Thorac Soc. There are 2 scientifically valid tests that you can take at home on your computer to see if you’re at risk for sleep apnea: the Epworth Sleepiness Scale test, and the Berlin Sleep Questionnaire. 2009;5(3):263-276.9. According to the AASM guideline, the main behavioral interventions for management of OSA include weight loss, exercise, positional sleep, and avoidance of alcohol, opiates, and sedatives before sleep.8 There is a linear relationship between obesity and OSA severity.19 Two studies—one of which assigned OSA patients to a low-energy, standardized, liquid-formulation diet for 9 weeks, and a randomized trial that put obese patients on a very-low-calorie diet along with other lifestyle modifications—demonstrated significant symptomatic improvement.32,33, Surgical Interventions: Surgery, which is invasive, is the last resort.19 The most common surgical intervention is uvulopalatopharyngoplasty (UPPP), which involves the removal of excessive tissue at the oropharyngeal tract, often accompanied by tonsillectomy.34 UPPP is shown to improve snoring and other sleep measures.34 Other procedures include palatal advancement, palatal implants, and tongue stabilization.8 Patients considering surgery should be assessed for eligibility based on specific anatomical features, psychological and social factors, and degree of willingness.8 Transient pain, difficulty swallowing, globus sensation, and voice change can occur.35, Adjunctive Therapies: The AASM guideline recommends adjunctive therapies, such as bariatric surgery and medications, in selected patients only.8 Bariatric surgery may be an option for those with a BMI ≥40 kg/m2, or with a BMI ≥35 kg/m2 with significant comorbidities.36 The ACP guideline points out that drug therapy was not shown to be effective in OSA management owing to inconsistent trial outcomes.19, Being a readily accessible healthcare professional, the pharmacist can identify risk factors for OSA. Obstructive sleep apnea (OSA), the most common type of sleep apnea, affects approximately 24% of middle-aged men and 9% of middle-aged women in Canada. Obstructive sleep apnea (OSA) is a common and serious sleep disorder that causes you to slow down or stop breathing during sleep. 2017;1(4):00019.5. If your doctor suspects you have sleep apnea, you may need to undergo a sleep apnea test, either at a lab or at home with a sleep apnea kit. These tests gauge the severity of your snoring, fatigue, and sleep habits. Int J Pharm Pract. 4 . The system categorizes out-of-center devices based on measurements of Sleep, Cardiovascular, Oximetry, Position, Effort and Respiratory (SCOPER) parameters. 1. Your doctor may make an evaluation based on your signs and symptoms and a sleep history, which you can provide with help from someone who shares your bed or your household, if possible.You're likely to be referred to a sleep disorder center. ISRN Otolaryngol. We're here to help. Diagnosing sleep apnea. Counseling services may also include recommendations on lifestyle improvements such as weight loss and medication history. Pharmacists can play an integral role in patient therapy by counseling patients, identifying barriers to therapy, and making referrals to primary care providers upon assessment. Accessed May 21, 2019. Step 1. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. Sleep Apnea Testing at Home: Interview with Laurent Martinot, CEO of Sunrise. This material is provided for educational purposes only … Eckert DJ, Malhotra A. Pathophysiology of adult obstructive sleep apnea. Juro's Pharmacy Health & Wellness offers FREE testing with a prescription from your doctor. This sleep disorder affects approximately 3% of the population. Verse T, Hörmann K. The surgical treatment of sleep-related upper airway obstruction. 2009;32(1):27-36.36. Understand your AHI score Your AHI score shows how severe your sleep apnoea is: AHI of 5 to 14 – mild; AHI of 15 to 30 – moderate; AHI over 30 – severe ; Treatments for sleep apnoea. Learn more Close. 2008;5(2):144-153.2. If you’re not able to get a good night’s sleep, talk to your doctor. If you have sleep apnea in Richardson, our medical team will work with you to create a sleep apnea … 2010;55(9):1155-1167.8. Sleep apnoea does not always need to be treated if it's mild. SAVE 40% OFF. Lewis KE, Seale L, Bartle IE, et al. Sleep apnea is a condition in which disturbed breathing interrupts sleep. The following are just a few examples of how treating sleep apnea can positively affect your overall health. 2011;108:216-221.35. Cawley MJ, Warning WJ II. Your doctor might provide you with simplified tests to be used at home to diagnose sleep apnea. J Clin Sleep Med. Patient education. www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=19&fromdb=true. RERA refers to a series of respiratory cycles of increasing or decreasing effort that cannot be defined as apnea or hypopnea.15 Sleep stage and respiratory-event scoring are further specified in the AASM Manual for the Scoring of Sleep and Associated Events.16. Juro's Pharmacy Health & Wellness provides sleep apnea equipment… Hippokratia. BMJ. Learn more Close. These tests can diagnose many sleep disorders—from sleep apnea to restless legs syndrome to parasomnias—and may even be useful in ruling out other causes of insomnia. Our skilled respiratory therapists and technicians can provide the support you need for a good night's rest. Patil SP, Ayappa IA, Caples SM, et al. End the Test. www.sages.org/publications/guidelines/guidelines-for-clinical-application-of-laparoscopic-bariatric-surgery/. The Epworth Sleepiness Scale is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. Getting a proper diagnosis is hampered by the … During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. Other signs include snoring, dry mouth, and difficulty concentrating due to fatigue. 2014;10(12):1295-1302.27. Ther Adv Chronic Dis. We are proud to offer our patients with a more convenient and less invasive option for diagnosis - a home sleep apnea test (HSAT) instead of an in-lab sleep … 2017;13(3):479-504.12. You may find that you’re not able to get the recommended 7–9 hours of sleep a day 1 or that your sleep is interrupted. This resource helps you identify the common symptoms of sleep apnea. Qaseem A, Holty JE, Owens DK, et al. Dealing with sleep apnea can have many negative repercussions on your health and your lifestyle. It is commonly caused by obesity, high blood pressure, genetics, or chronic sinus issues. Home Sleep Apnea Test. 2010;65(8):726-732.29. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Health & Pharmacy Health & Pharmacy Health & Pharmacy ... To confirm that the condition is sleep apnea, a test called overnight polysomnography may be done. Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. The epidemiology of adult obstructive sleep apnea. If you think you may suffer from obstructive sleep apnea or some other sleep breathing disorder, there are several simple tests you can take that may suggest you should discuss the possibility with your health care provider. Proc Am Thorac Soc. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. The Facts Sleep apnea is a condition in which disturbed breathing interrupts sleep. Guidelines for clinical application of laparoscopic bariatric surgery. ABSTRACT: Obstructive sleep apnea (OSA) is a chronic condition in which the upper airway collapses frequently during sleep and leads to breathing cessation. Aleve Long-Lasting Pain Relief 12 or 24 Tablets . 2003;163(5):565-571.21. Johansson K, Neovius M, Lagerros YT, et al. ARMODAFINIL is used to treat excessive sleepiness caused by certain sleep disorders. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. 2009;179(4):320-327.33. This includes narcolepsy, sleep apnea, and shift work sleep disorder. The International Classification of Sleep Disorders (ICSD), a key reference for diagnoses of sleep disorders, is based on AASM manuals.14 The diagnosis of OSA requires symptoms coupled with five or more obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep as measured by PSG.14 Diagnosis may also be made if the frequency of obstructive respiratory events is 15 or more per hour regardless of symptoms.14 Whereas the ICSD uses the RDI as the index for obstructive respiratory events, the AASM considers the AHI the main index for scoring.11 OSA symptoms include daytime sleepiness, unrefreshing sleep, fatigue, insomnia, gasping or choking at night, loud snoring, and witnessed apneas.14 See TABLE 2. Punjabi NM. If you often feel tired during the day, even if you get a reasonable amount of sleep, this may be a sign of sleep apnea. Ann Intern Med. If left untreated, sleep apnea can contribute to high blood pressure and increase your likelihood of stroke and heart attack. 2014;146(5):1387-1394.15. The good news is that it's easily diagnosed and treated in your home, in your bed, and with your pillow. Your windpipe relaxes and blocks the flow of air to your lungs. Reproduction in whole or in part without permission is prohibited. Richardson Texas Sleep Specialist Doctors physician directory - Learn about sleep apnea, including a description of types of sleep apnea, symptoms, treatment (surgical and nonsurgical), causes, … Failure to address OSA not only compromises the patient’s quality of life but also increases the risk of mortality. The Epworth Sleepiness Scale. Eur Heart J. Home sleep tests. The test can show if you have sleep apnoea and how severe it is. Suspected obstructive sleep apnea patients can now have testing done in the convenience and comfort of their own beds. This session of CareOregon Pharmacy’s MEDS Ed program focuses on clarifying sleep disorder screening and diagnosis; how to help patients through the challenges of CPAP usage and adherence; which medications pose greater risk for Obstructive Sleep Apnea patients. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. 2013;2013:670381.10. A new study by Monash University has found that obstructive sleep apnoea (OSA) has been linked to an increased risk of dementia. Asymptomatic COVID-19 testing available in pharmacies across Ontario. Accessed April 13, 2019.37. Int J Clin Pharm. Effect of CPAP treatment for obstructive sleep apnea hypopnea syndrome on lipid profile: a meta-regression analysis. Chest. The pharmacist can have a significant impact on optimizing CPAP management.38 Early involvement of healthcare providers in difficulties with CPAP therapy is associated with prolonged compliance.39 With patients new to therapy, the pharmacist can discuss patient understanding and concerns regarding CPAP use. Br J Clin Pharmacol. OSA is a common condition involving a range of possible contributors, from structural anomalies to sleep habits. 2009;339:b4609.34. Claustrophobia and adherence to CPAP treatment. 2015;6(5):273-285.23. Stasche N. Selective indication for positive airway pressure (PAP) in sleep-related breathing disorders with obstruction. 2016;38(4):752-760.38. Ramar K, Dort LC, Katz SG, et al. The airway repeatedly becomes blocked, limiting the amount of oxygen that reaches your lungs, putting stress on your heart and body. He or she can help you identify the symptoms by means of a brief … A small booking fee may apply. The scale estimates whether you are experiencing excessive sleepiness that possibly requires medical attention. 2008;5(2):136-143.7. For this test, a variety of measurements are taken while the person sleeps in a specialized sleep laboratory. Arch Intern Med. Tuomilehto HP, Seppä JM, Partinen MM, et al. Higher-risk populations include males, women who have reached menopause, obese individuals, and patients with craniofacial abnormalities. These classes include opiates, benzodiazepines, myorelaxants, and drugs that have the side effect of weight gain (TABLE 1).10, Persons at high risk for OSA should undergo objective testing via polysomnography (PSG) at a facility or by performing a home test with a portable monitor (PM).8 PSG (i.e., sleep study) can help detect anomalies in sleep patterns by recording physiologic signals such as airflow, oxygen saturation, respiratory effort, and heart rate.8 PMs also record parameters such as airflow, respiratory effort, and blood oxygenation but tend to be more limited than PSG.8 Although the main advantage of the PM is that it can be used in an unattended setting, it requires thorough evaluation by a trained clinician to ensure an accurate diagnosis.8, The American Academy of Sleep Medicine (AASM) published a clinical guideline on the selection of diagnostic tools that suggests that PSG or a PM be used for diagnosis in uncomplicated adults at increased risk for OSA.11 No other clinical tools are recommended. Sleep apnea is characterized by temporary breathing cessations during sleep. Epidemiological aspects of obstructive sleep apnea. Early diagnosis can prevent further complications.37 A systematic review assessing the use of pharmacists in screening services for OSA showed that they were able to identify 21.4% to 67% of patients with OSA risk factors and refer them to a physician.37. Obstructive sleep apnea is very common and is associated with a variety of serious health issues, such as cardiovascular disease and diabetes. Upon returning the unit the next day, we will give both you and your doctor the results with your risk rating. CPAP machines and lifestyle changes can help you manage or treat obstructive sleep apnea. Sleep apnea is a serious sleep disorder where your breathing repeatedly stops and starts. Untreated OSA is an independent risk factor for increasedcomorbidities, making it imperative to evaluate common signs andsymptoms such as disruptive snoring, daytime sleepiness, obesity, andlarge neck circumference (>42 cm in men).1,4Diagnosticcriteria for OSA include either an apnea-hypopnea index (AHI) of greaterthan five events per hour plus symptoms of excessive daytime sleepinessor an AHI greater than 15 events per hour regardless of symptoms.Overnight polysomnography is required to mea… The Sparrow Sleep Center acts as a resource for patients who have sleep apnea or other sleep disorders. Obstructive sleep apnea discharge instructions, adult. Chasens ER, Pack AI, Maislin G, et al. Home Sleep Apnea Test Equipment and Machine. 2015;11(7):773-827.19. Orders over $69 eligible for FREE DELIVERY. To learn more, visit the links below or call Juro's Pharmacy Health & Wellness at (406) 869-0123. Tregear S, Reston J, Schoelles K, Phillips B. This gold-standard test … Most people suffering from sleep apnea … Find us on Facebook; Local Care Prescription Transfer … Obstructive sleep apnea, if left untreated can put you at higher risk of a stroke, heart attack or a serious workplace accident – not to mention making you feel worse during the day, both physically and mentally. For an accurate diagnosis of sleep apnea, you need to undergo a sleep study known as a polysomnogram (PSG). 00 ($179.00/Count) FREE Shipping. Sleep apnea is a disorder that causes a person to momentarily stop breathing at points throughout the night. Itamar Medical Announces Additional 16 Million Covered Lives for WatchPAT, the Only Single-Use Sleep Apnea Test that Meets Guidelines Positive … Persons with OSA present with snoring, choking during sleep, nocturia, and excessive daytime sleepiness. Sutherland K, Vanderveken OM, Tsuda H, et al. Madera California Sleep Specialist Doctors physician directory - Learn about sleep apnea, including a description of types of sleep apnea, symptoms, treatment (surgical and nonsurgical), causes, complications, diagnosis, evaluation, and importance of treatment. The AASM published updated guidelines on specific OSA-management considerations in positive airway pressure (PAP) in 2019 and on oral-appliance therapy in 2015.17,18 The ACP guideline describes outcomes of studies that examined the efficacy and limitations of treatment options.19, PAP: Both guidelines agree that for all levels of severity in OSA, PAP is first-line therapy.8,17,19 PAP delivers compressed air to prevent airway closure, and its efficacy has been clinically proven in terms of reduced number of nocturnal obstructive events, reduced incidences of nocturnal arousals, and resolution of daytime symptoms after short-term use.20, 21 Modalities of PAP include continuous PAP (CPAP), bilevel PAP, and autotitrating PAP. Given current high costs and waiting time, sleep apnea syndrome is widely undiagnosed. On the day of your test: Try to follow your regular routine as much as possible. Sleep apnea can be diagnosed via our at-home tests, meaning that you don’t have to disrupt your day to day routine in order to be assessed. Most people suffering from sleep apnea … To confirm that the condition is sleep apnea, a test called overnight polysomnography may be done. Randerath W, Verbraecken J, Andreas S, et al. Berry RB, Brooks R, Gamaldo CE, et al. Download, print and complete this self-assessment tool to discuss your sleep apnea … 2019;15(2):335-343.18. 2004;25(9):728-734.26. Central sleep apnea is the result of a miscommunication between the brain and the muscles that control your breathing. J Clin Sleep Med. By helping to diagnose sleep disorders and making recommendations for treatment, the Sparrow Sleep … Franklin KA, Anttila H, Axelsson S, et al. Respir Care. 2012;8(5):587-596.25. nearest pharmacy. One reason for poor quality sleep could be sleep apnea. This is based on how often your breathing stops while you sleep (AHI score). Obstructive sleep apnea (OSA), a breathing disorder that occurs during sleep, is characterized by a partial or complete blockage of the upper airway. Obstructive sleep apnea is very common and is associated with a variety of serious health issues, such as cardiovascular disease and diabetes. Sleep apnea testing and treatment . Eur Respir J. Pharmacists can assist in the management of OSA by providing counseling regarding therapy and recommending lifestyle changes. To comment on this article, contact rdavidson@uspharmacist.com. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. Garvey JF, Pengo MF, Drakatos P, Kent BD. J Clin Sleep Med. Guidelines for diagnosis and treatment of sleep-related breathing disorders in adults and children. Sleep Apnea is a dangerous condition that affects over 1 million Australians. Sleep Study and Sleep Apnea testing are conducted at Gretna Medical Center on a regular basis. Obstructive sleep apnea and obesity: implications for public health. For more certainty, the Alice NightOne home sleep test at Juro’s can be an ideal preliminary gauge to determine if you are at risk.. To learn more, visit the links below or call Juro's Pharmacy Health & Wellness at (406) 869-0123. Epub October 5, 2006.22. 2011;38(2):348-358.3. Dtsch Arztebl Int. Customer should consult with MinuteClinic for details. Sleep studies Medicare Part B (Medical Insurance) covers Type I, II, III, and IV sleep tests and devices if you have clinical signs and symptoms of sleep apnea. These breathing interruptions or pauses last on average 10 to 60 seconds and occur several times an hour. If you have trouble sleeping, we can help. OSA has become an increasingly prevalent disorder, with current data from the United States and Europe showing that OSA affects between 14% to 49% of middle-aged men.5 OSA is markedly more prevalent in men than in women (24% vs. 9%, respectively).5 OSA with daytime drowsiness also occurred at a higher rate in men than in women (3%-7% vs. 2%-5%, respectively).6 Obesity is a leading risk factor for OSA, and the prevalence of thi… Riverwoods, IL: Wolters Kluwer Health, Inc; Lexicomp. Approximately 22 million Americans suffer from sleep apnea, with 80% of moderate to severe cases of OSA going undiagnosed. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Obstructive sleep apnea (OSA), the most common type of sleep apnea, affects approximately 24% of middle-aged men and 9% of middle-aged women in Canada. At baseline, overall apnea–hypopnea index (AHI) was 25.9 ± 11.3, Epworth Sleepiness Scale (ESS) score was 11.45 ± 3.8, maintenance of wakefulness test (MWT) mean latency was 19.2 ± 11.8 minutes, body … Jehan S, Zizi F, Pandi-Perumal SR, et al. However, it doesn’t have to be this way. Sleep apnea … Call to schedule your test and the Alice NightOne will be checked out to you for the night. The diagnostic test is bulk billed through Medicare for qualifying patients who satisfy the pre-assessment criteria by the Specialist. It may decrease the amount of tissue that blocks your airway and let more air flow through. Thorax. You may have one of two varieties of sleep apnea. Foote’s Pharmacy Redbank Plains; Rosewood Pharmacy; Raceview Pharmacy; Boonah Pharmacy; Grange Road Pharmacy; Sleep Apnea Testing . Kapur VK, Auckley DH, Chowdhuri S, et al. Sateia MJ. Sleep Med Disord. A home sleep apnea test is designed to be a convenient way to collect information about your sleep. Sleep. WatchPAT ®️ is a revolutionary FDA-Cleared portablehome sleep apnea test and diagnostic device that uses innovative technologies to ensure the accurate detection of sleep apnea. Other limitations in use include excessive salivation, dry mouth, and discomfort.29,30 Although MAS may be a feasible alternative to CPAP, evidence of benefit is lacking.19 The ACP states that MAD is an alternative treatment option for patients who fail or cannot tolerate CPAP therapy.19 The AASM guideline suggests that oral appliances may be selected over CPAP in mild-to-moderate disease based on patient preference or intolerance to CPAP.8,18 Tongue-retaining devices, which are designed to shift the tongue forward, have been associated with positive outcomes comparable to those for MAS.31, Behavioral Interventions: Behavioral therapy addresses lifestyle modifications to minimize risk factors for OSA. Treatment experience of people with obstructive sleep apnoea seeking continuous positive airways pressure device provision through community pharmacies—a role for pharmacists? My Pharmacy / Health & Wellness / Sleep apnea risks; Sleep apnea risks. 2015;7(5):920-929.6. Pharmacy services If you think you may be suffering from sleep apnea, speak with your family pharmacist. CPAP, which delivers air at a fixed pressure, is usually administered through the nose.8,22 The most data exist on traditional CPAP, given that it has been in use longest.8 Studies demonstrated a significant reduction in crash risk of drivers with OSA following CPAP treatment.23 Health benefits of CPAP—e.g., lowering of blood pressure, decreases in cardiovascular events and coronary artery disease in adults with OSA, and improvement in lipid profile—have also been documented.24-26 Barriers to adherence include discomfort and claustrophobia.22,27, Oral Appliances: Oral appliances, such as the mandibular advanced splint (MAS)—also called mandibular repositioning appliance or mandibular advancement device (MAD)—are commonly used and may be an alternative to CPAP.8,19 Oral appliances are classified as positional therapy, wherein the mandible and its adjacent muscles are adjusted to widen the airway, thereby securing airflow.28 Studies show positive health outcomes such as decreased blood pressure and improved quality-of-life measures, especially with long-term treatment.29 Oral appliances require device adjustment over time. Test: Try to follow your regular routine as much as possible provide you with simplified tests be! This might not be as accurate, Bartle IE, et al a variety of measurements taken! Instead of in the laboratory, though this might not be as accurate for. And serious sleep disorder billed through Medicare for qualifying patients who satisfy pre-assessment! 5 stars 7 a range of possible contributors, from structural anomalies to sleep habits 's rest a... Diagnosis and treatment of sleep-related breathing disorders in adults: a systematic review and meta-analysis of controlled! High altitude ; Lexicomp Medicine clinical practice guideline daytime sleepiness and/or GI reflux arrhythmia, attack... Sleeps in a specialized sleep laboratory patients who satisfy the pre-assessment criteria by the Specialist lewis KE, L! The unit the next day, we will give both you and your lifestyle a... It 's easily diagnosed and treated in your bed, and even high altitude waiting. 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